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Hartmann GG, Sage J. Small Cell Lung Cancer Neuronal Features and Their Implications for Tumor Progression, Metastasis, and Therapy. Mol Cancer Res 2024; 22:787-795. [PMID: 38912893 PMCID: PMC11374474 DOI: 10.1158/1541-7786.mcr-24-0265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/30/2024] [Accepted: 06/20/2024] [Indexed: 06/25/2024]
Abstract
Small cell lung cancer (SCLC) is an epithelial neuroendocrine form of lung cancer for which survival rates remain dismal and new therapeutic approaches are greatly needed. Key biological features of SCLC tumors include fast growth and widespread metastasis, as well as rapid resistance to treatment. Similar to pulmonary neuroendocrine cells, SCLC cells have traits of both hormone-producing cells and neurons. In this study, we specifically discuss the neuronal features of SCLC. We consider how neuronal G protein-coupled receptors and other neuronal molecules on the surface of SCLC cells can contribute to the growth of SCLC tumors and serve as therapeutic targets in SCLC. We also review recent evidence for the role of neuronal programs expressed by SCLC cells in the fast proliferation, migration, and metastasis of these cells. We further highlight how these neuronal programs may be particularly relevant for the development of brain metastases and how they can assist SCLC cells to functionally interact with neurons and astrocytes. A greater understanding of the molecular and cellular neuronal features of SCLC is likely to uncover new vulnerabilities in SCLC cells, which may help develop novel therapeutic approaches. More generally, the epithelial-to-neuronal transition observed during tumor progression in SCLC and other cancer types can contribute significantly to tumor development and response to therapy.
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Affiliation(s)
- Griffin G Hartmann
- Department of Pediatrics, Stanford University, Stanford, California
- Department of Genetics, Stanford University, Stanford, California
| | - Julien Sage
- Department of Pediatrics, Stanford University, Stanford, California
- Department of Genetics, Stanford University, Stanford, California
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2
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McKeon A, Pittock SJ. Overview and Diagnostic Approach in Autoimmune Neurology. Continuum (Minneap Minn) 2024; 30:960-994. [PMID: 39088285 DOI: 10.1212/con.0000000000001447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
OBJECTIVE The field of autoimmune neurology is rapidly evolving. This article reviews the epidemiology and pathophysiology as well as current approaches to clinical and paraclinical assessment, testing paradigms, and general principles of treatment. LATEST DEVELOPMENTS Improved recognition of autoimmune diagnoses among patients who have phenotypically diverse, subacute onset neurologic presentations is facilitated by disease-specific antibody biomarker discovery. These antibodies have varying associations with paraneoplastic causation (from no association to greater than 70% positive predictive value), immunotherapy responses, and outcomes. To simplify assessment in an increasingly complex discipline, neurologic phenotype-specific serum and CSF antibody evaluations are recommended. Clinical trials have led to the approval of monoclonal therapies for neuromyelitis optica spectrum disorder (NMOSD) and are underway for N-methyl-d-aspartate (NMDA) receptor and leucine-rich glioma inactivated protein 1 (LGI1) encephalitides. ESSENTIAL POINTS Autoimmune neurology is now a mainstream subspecialty, consisting of disorders with diverse presentations detectable using antibody testing of serum and CSF. Early and sustained immunotherapy (eg, corticosteroids, intravenous immunoglobulin [IVIg], plasma exchange) is recommended and may be supplemented by immune suppressants (eg, rituximab or cyclophosphamide) to sustain responses and optimize outcomes.
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Zekeridou A. Paraneoplastic Neurologic Disorders. Continuum (Minneap Minn) 2024; 30:1021-1051. [PMID: 39088287 DOI: 10.1212/con.0000000000001449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
OBJECTIVE This article reviews the clinical presentations, neural antibody associations, and oncologic accompaniments of paraneoplastic neurologic syndromes and neurologic autoimmunity in the context of immune checkpoint inhibitor (ICI) cancer immunotherapy. LATEST DEVELOPMENTS Neural antibody discovery has improved the diagnosis of paraneoplastic neurologic syndromes. Neural antibodies also delineate the underlying disease pathophysiology and thus inform outcomes and treatments. Neural antibodies specific for extracellular proteins have pathogenic potential, whereas antibodies specific for intracellular targets are biomarkers of a cytotoxic T-cell immune response. A recent update in paraneoplastic neurologic syndrome criteria suggests high- and intermediate-risk phenotypes as well as neural antibodies to improve diagnostic accuracy in patients with paraneoplastic neurologic syndromes; a score was created based on this categorization. The introduction of ICI cancer immunotherapy has led to an increase in cancer-related neurologic autoimmunity with distinct clinical phenotypes. ESSENTIAL POINTS Paraneoplastic neurologic syndromes reflect an ongoing immunologic response to cancer mediated by effector T cells or antibodies. Paraneoplastic neurologic syndromes can present with manifestations at any level of the neuraxis, and neural antibodies aid diagnosis, focus cancer screening, and inform prognosis and therapy. In patients with high clinical suspicion of a paraneoplastic neurologic syndrome, cancer screening and treatment should be undertaken, regardless of the presence of a neural antibody. ICI therapy has led to immune-mediated neurologic complications. Recognition and treatment lead to improved outcomes.
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Malvaso A, Giglio P, Diamanti L, Gastaldi M, Vegezzi E, Pace A, Bini P, Marchioni E. Unravelling the Acute, Chronic and Steroid-Refractory Management of High-Grade Neurological Immune-Related Adverse Events: A Call to Action. Brain Sci 2024; 14:764. [PMID: 39199458 PMCID: PMC11352216 DOI: 10.3390/brainsci14080764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Revised: 07/17/2024] [Accepted: 07/25/2024] [Indexed: 09/01/2024] Open
Abstract
Rare side effects of immune-checkpoint inhibitors (ICIs) are known as neurological immune-related adverse events (n-irAEs). Typically, n-irAEs affect the peripheral nervous system, primarily presenting as myositis, polyradiculoneuropathy, or cranial neuropathy. Less commonly, they impact the central nervous system, resulting in encephalitis, meningitis, or myelitis. High-grade n-irAEs managing and recognizing remains challenging, considering the risk of mortality and long-term disability. To date, strong scientific data are lacking to support the management of high-grade clinical forms. We performed a systematic literature search, selecting all articles describing high-grade steroid-resistance n-irAEs. and we reported them in a practical review. Specifically, current recommendations advise stopping ICI use and beginning corticosteroid treatment. Our findings highlighted that in steroid-resistant n-irAEs, it should be recommended to quickly escalate to plasma exchange (PLEX) and/or intravenously immunoglobulins (IVIg), usually in association with other immunosuppressants. Furthermore, newer evidence supports the use of drugs that may specifically block inflammation without reducing the anti-tumour effect of ICIs. In this practical review, we provide new evidence regarding the therapeutic approach of high-grade n-irAEs, particularly in steroid-resistant cases. We would also stress the importance of informing the scientific community of the discrepancy between current guidelines and clinical evidence in these rare forms of pathology.
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Affiliation(s)
- Antonio Malvaso
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy; (A.M.); (P.G.)
- Neuroimmunology Research Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy;
| | - Pierpaolo Giglio
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy; (A.M.); (P.G.)
| | - Luca Diamanti
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
| | - Matteo Gastaldi
- Neuroimmunology Research Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy;
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
| | - Elisa Vegezzi
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
| | - Andrea Pace
- IRCCS Regina Elena, Istituto Nazionale Tumori, 00144 Rome, Italy;
| | - Paola Bini
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
| | - Enrico Marchioni
- Neuroncology Unit, IRCCS Mondino Foundation—National Neurological Institute, 27100 Pavia, Italy; (L.D.); (E.V.); (P.B.)
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Jovanovski A, Mengert L, Lukacs M, Wagner JN. Anti-Hu associated paraneoplastic upper and lower motor neuropathy triggered by atezolizumab. Neurol Sci 2024:10.1007/s10072-024-07666-7. [PMID: 39023708 DOI: 10.1007/s10072-024-07666-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 06/15/2024] [Indexed: 07/20/2024]
Affiliation(s)
- Aleksandar Jovanovski
- Department of Neurology, Evangelisches Klinikum Gelsenkirchen, Teaching Hospital University Duisburg-Essen, Munckelstr. 27, 45879, Gelsenkirchen, Germany.
| | - Leonie Mengert
- Department of Neurology, Evangelisches Klinikum Gelsenkirchen, Teaching Hospital University Duisburg-Essen, Munckelstr. 27, 45879, Gelsenkirchen, Germany
| | - Miklos Lukacs
- Department of Neurology, Evangelisches Klinikum Gelsenkirchen, Teaching Hospital University Duisburg-Essen, Munckelstr. 27, 45879, Gelsenkirchen, Germany
| | - Judith N Wagner
- Department of Neurology, Evangelisches Klinikum Gelsenkirchen, Teaching Hospital University Duisburg-Essen, Munckelstr. 27, 45879, Gelsenkirchen, Germany
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Stavropoulou De Lorenzo S, Andravizou A, Alexopoulos H, Michailidou I, Bokas A, Kesidou E, Boziki MK, Parissis D, Bakirtzis C, Grigoriadis N. Neurological Immune-Related Adverse Events Induced by Immune Checkpoint Inhibitors. Biomedicines 2024; 12:1319. [PMID: 38927526 PMCID: PMC11202292 DOI: 10.3390/biomedicines12061319] [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: 04/29/2024] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
The use of immune checkpoint inhibitors (ICIs) for the treatment of various advanced and aggressive types of malignancy has significantly increased both survival and long-term remission rates. ICIs block crucial inhibitory pathways of the immune system, in order to trigger an aggravated immune response against the tumor. However, this enhanced immune activation leads to the development of numerous immune-related adverse events (irAEs), which may affect any system. Although severe neurological irAEs are relatively rare, they carry a high disability burden, and they can be potentially life-threatening. Therefore, clinicians must be alert and act promptly when individuals receiving ICIs present with new-onset neurological symptoms. In this narrative review, we have collected all the currently available data regarding the epidemiology, pathogenesis, clinical manifestations, diagnosis, and treatment of post-ICI neurological irAEs. This review aims to raise physicians' awareness, enrich their knowledge regarding disease pathogenesis, and guide them through the diagnosis and management of post-ICI neurological irAEs.
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Affiliation(s)
- Sotiria Stavropoulou De Lorenzo
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Athina Andravizou
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Harry Alexopoulos
- Department of Cell Biology and Biophysics, Faculty of Biology, National and Kapodistrian University of Athens, University Campus, 15784 Athens, Greece;
| | - Iliana Michailidou
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Alexandros Bokas
- Department of Medical Oncology, Theageneio Cancer Hospital, 54639 Thessaloniki, Greece;
| | - Evangelia Kesidou
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Marina-Kleopatra Boziki
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Dimitrios Parissis
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Christos Bakirtzis
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
| | - Nikolaos Grigoriadis
- Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (S.S.D.L.); (A.A.); (I.M.); (E.K.); (M.-K.B.); (D.P.); (N.G.)
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Mikkelsen AW, Nilsson AC, Tenstad HB, Lillevang ST, Asgari N. Initial screening for neuronal autoantibodies and their putative impact on survival in patients with small-cell lung cancer. Thorac Cancer 2024; 15:1350-1356. [PMID: 38703039 PMCID: PMC11168912 DOI: 10.1111/1759-7714.15318] [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: 01/17/2024] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 05/06/2024] Open
Abstract
INTRODUCTION Small-cell lung cancer (SCLC) may be associated with neuronal autoantibodies and paraneoplastic neurological syndromes. It has been suggested that neuronal autoantibodies, especially antineuronal nuclear antibody type 1 (Hu) autoantibodies, are associated with longer survival of patients with SCLC. The objective of this study was to determine the frequency and distribution of neuronal autoantibodies at the time of diagnosis of SCLC patients and assess survival rates in relation to autoimmunity. METHODS In this retrospective study, serum from 40 patients with biopsy-proven SCLC at the time of diagnosis was studied prior to treatment. The sera originated from a cancer registry at the Oncology Department, Vejle Hospital from 2007 to 2010. The sera were analyzed blindly to clinical status for the presence of neuronal autoantibodies. Medical records were reviewed for neurological symptoms. RESULTS Neuronal autoantibodies were detected in 22/40 (55%) of the SCLC patients. A broad range of neurological symptoms was recorded in 28/40 (70%) patients, of which 14/28 (50%) were positive for neuronal autoantibodies. The most frequently detected autoantibodies were Hu (7/40, 17.5%) followed by GAD65 (6/22, 15.0%). Striational and P/Q- or N-type voltage-gated calcium channel antibodies were less common, with each found in five patients (12.5%). Eight patients (20%) had coexisting autoantibodies. Autoantibody-positivity was not associated with survival. CONCLUSION Neuronal autoantibodies were at time of diagnosis found in approximately half of the treatment-naïve SCLC patients. Neither autoantibody positivity at diagnosis nor neurological manifestations correlated with survival and their clinical importance requires further studies in larger, prospective cohorts.
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Affiliation(s)
| | - Anna Christine Nilsson
- Department of Clinical ImmunologyOdense University HospitalOdenseDenmark
- Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Helene Broch Tenstad
- Department of Clinical ImmunologyOdense University HospitalOdenseDenmark
- Department of RheumatologyOdense University HospitalOdenseDenmark
| | | | - Nasrin Asgari
- Department of NeurologySlagelse HospitalSlagelseDenmark
- Institute of Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark
- Department of NeurobiologyInstitute of Molecular Medicine, University of Southern DenmarkOdenseDenmark
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Tominaga K, Toda E, Takeuchi K, Takakuma S, Sakamoto E, Kuno H, Kajimoto Y, Terasaki Y, Kunugi S, Mii A, Sakai Y, Terasaki M, Shimizu A. Predominant CD8 + cell infiltration and low accumulation of regulatory T cells in immune checkpoint inhibitor-induced tubulointerstitial nephritis. Pathol Int 2024; 74:317-326. [PMID: 38634742 DOI: 10.1111/pin.13428] [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: 01/10/2024] [Revised: 03/05/2024] [Accepted: 04/03/2024] [Indexed: 04/19/2024]
Abstract
Immune checkpoint inhibitors (ICIs) can provide survival benefits to cancer patients; however, they sometimes result in the development of renal immune-related adverse events (irAEs). Tubulointerstitial nephritis (TIN) is the most representative pathological feature of renal irAEs. However, the clinicopathological entity and underlying pathogenesis of ICI-induced TIN are unclear. Therefore, we compared the clinical and histological features of this condition with those of non-ICI drug-induced TIN. Age and C-reactive protein levels were significantly higher in ICI-induced TIN, but there were no significant differences in renal function. Immunophenotyping of ICI-induced TIN showed massive T cell and macrophage infiltration with fewer B cells, plasma cells, neutrophils, and eosinophils. Compared with those in non-ICI drug-induced TIN, CD4+ cell numbers were significantly lower in ICI-induced TIN but CD8+ cell numbers were not significantly different. However, CD8/CD3 and CD8/CD4 ratios were higher in ICI-induced TIN. Moreover, CD25+ and FOXP3+ cells, namely regulatory T cells, were less abundant in ICI-induced TIN. In conclusion, T cell, B cell, plasma cell, neutrophil, and eosinophil numbers proved useful for differentiating ICI-induced and non-ICI drug-induced TIN. Furthermore, the predominant distribution of CD8+ cells and low accumulation of regulatory T cells might be associated with ICI-induced TIN development.
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Affiliation(s)
- Kenta Tominaga
- Department of Analytic Human Pathology, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Etsuko Toda
- Department of Analytic Human Pathology, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Kazuhiro Takeuchi
- Department of Analytic Human Pathology, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Shoichiro Takakuma
- Department of Analytic Human Pathology, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Emi Sakamoto
- Department of Analytic Human Pathology, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Hideaki Kuno
- Division of Nephrology and Hypertension, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Yusuke Kajimoto
- Department of Analytic Human Pathology, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Yasuhiro Terasaki
- Department of Analytic Human Pathology, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
- Division of Pathology, Nippon Medical School Hospital, Bunkyo-ku, Tokyo, Japan
| | - Shinobu Kunugi
- Department of Analytic Human Pathology, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Akiko Mii
- Department of Nephrology, Nippon Medical School Musashi Kosugi Hospital, Kawasaki-shi, Kanagawa, Japan
| | - Yukinao Sakai
- Department of Endocrinology, Metabolism and Nephrology, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Mika Terasaki
- Department of Analytic Human Pathology, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
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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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Nassar AH, El Zarif T, Khalid AB, Rahme S, Zhong C, Kwak L, Salame M, Farhat EB, Freeman D, El-Am E, Ravishankar A, Ahmad B, Nana FA, Kaldas D, Naqash AR, Sharon E, LeBoeuf NR, Cortellini A, Malgeri A, Gupta S, Al-Hader A, Sparks JA, Linnoila J, Hamnvik OPR, Mouhieddine TH, Marron T, Parikh K, McKay RR, Dilling T, Choueiri TK, Adib E, Najem E, Kim SY, Sonpavde G. Clinical outcomes and safety of immune checkpoint inhibitors in patients with solid tumors and paraneoplastic syndromes. J Immunother Cancer 2024; 12:e008724. [PMID: 38448038 PMCID: PMC10916116 DOI: 10.1136/jitc-2023-008724] [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] [Accepted: 02/05/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Patients with paraneoplastic syndromes (PNS) are excluded from clinical trials involving immune checkpoint inhibitors (ICIs) due to safety concerns. Moreover, real-world data on efficacy and safety is scarce. METHODS In this retrospective study, data were collected on patients with PNS and solid tumors receiving ICI between 2015 and 2022 at nine institutions. Patients were classified into: Cohort 1 (pre-existing PNS before ICI initiation), cohort 2 (PNS during ICI treatment), and cohort 3 (PNS after ICI discontinuation). Patients with metastatic non-small cell lung cancer (NSCLC) (mNSCLC) from cohort 1 were matched to patients who were PNS-free at each institution up to a 1:3 ratio for age, sex, type of ICI, use of concurrent chemotherapy, and number of lines of systemic therapy prior to ICI initiation. Kaplan-Meier method was used to assess overall survival (OS) and time-to-next treatment (TTNT). RESULTS Among 109 patients with PNS treated with ICIs, median age at ICI initiation was 67 years (IQR: 58-74). The most represented cancer type was NSCLC (n=39, 36%). In cohort 1 (n=55), PNS exacerbations occurred in 16 (29%) patients with median time to exacerbation after ICI of 1.1 months (IQR: 0.7-3.3). Exacerbation or de novo PNS prompted temporary/permanent interruption of ICIs in 14 (13%) patients. For cohort 2 (n=16), median time between ICI initiation and de novo PNS was 1.2 months (IQR: 0.4-3.5). Treatment-related adverse events (trAEs) occurred in 43 (39%) patients. Grade ≥3 trAEs occurred in 18 (17%) patients. PNS-directed immunosuppressive therapy was required in 55 (50%) patients. We matched 18 patients with mNSCLC and PNS (cohort 1) to 40 without PNS, treated with ICIs. There was no significant difference in OS or TTNT between patients with mNSCLC with and without PNS, although a trend was seen towards worse outcomes in patients with PNS. TrAEs occurred in 6/18 (33%) and 14/40 (35%), respectively. Grade ≥3 trAEs occurred in 4 (22%) patients with PNS and 7 (18%) patients without PNS. CONCLUSIONS Exacerbations of pre-existing PNS occurred in 29% of patients treated with ICIs and both exacerbations and de novo PNS occur early in the ICI course. TrAE from ICIs were similar between patients with and without PNS. Our data suggest that pre-existing PNS should not preclude consideration of ICI therapy although patients may not derive the same clinical benefit compared with patients without PNS.
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Affiliation(s)
| | - Talal El Zarif
- Yale University, New Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Ahmed Bilal Khalid
- Indiana Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, Indiana, USA
| | - Serena Rahme
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, New York, USA
| | - Caiwei Zhong
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lucia Kwak
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Elias Bou Farhat
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Dory Freeman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Arjun Ravishankar
- Yale University, New Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Bachar Ahmad
- Yale University, New Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Frank Aboubakar Nana
- Division of Pneumology, CHU UCL Namur, Yvoir, Namur, Belgium
- Division of Pneumology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - David Kaldas
- Department of Internal Medicine, University of South Florida, Tampa, Florida, USA
- Department of Clinical Oncology, Cairo University, Giza, Egypt
| | - Abdul Rafeh Naqash
- Medical Oncology/TSET Phase 1 Program, The University of Oklahoma Stephenson Cancer Center, Oklahoma City, Oklahoma, USA
| | - Elad Sharon
- National Cancer Institute, Bethesda, Maryland, USA
| | | | - Alessio Cortellini
- Medical Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Andrea Malgeri
- Medical Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Shruti Gupta
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ahmad Al-Hader
- Indiana Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, Indiana, USA
| | | | - Jenny Linnoila
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | - Thomas Marron
- Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Rana R McKay
- Division of Medical Oncology, University of California San Diego, La Jolla, California, USA
| | - Thomas Dilling
- Department of Internal Medicine, University of South Florida, Tampa, Florida, USA
| | - Toni K Choueiri
- Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, UK
| | - Elio Adib
- Harvard Medical School, Boston, Massachusetts, USA
| | - Elie Najem
- Department of Radiology, Harvard Medical School, Boston, Massachusetts, USA
| | - So Yeon Kim
- Yale University, New Haven, Connecticut, USA
| | - Guru Sonpavde
- Medical Oncology, AdventHealth Central Florida, Orlando, Florida, USA
- AdventHealth Cancer Institute, AdventHealth, Altamonte Springs, Florida, USA
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McCombe JA, Sechi E, Zekeridou A. Neurologic manifestations of autoimmunity with immune checkpoint inhibitors. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:449-465. [PMID: 38494296 DOI: 10.1016/b978-0-12-823912-4.00024-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Immune checkpoint inhibitors (ICIs) are cancer immunotherapies that enhance the body's own immune system to treat cancer. ICI treatment, however, can cause immune-related adverse events (irAEs) that can affect any organ, resulting in significant morbidity and mortality. Neurologic irAEs (nirAEs) are rare and can affect the peripheral nervous system more commonly than the central nervous system. Treatment is dependent on the severity of the neurologic manifestations and often includs discontinuation of the ICI and initiation of steroid therapy as the first line; other treatments have also been used. NirAEs and cardiac irAEs have higher fatality rates underlying the importance of early recognition and appropriate management. This chapter reviews the clinical manifestations of neurologic immune-related adverse events associated with ICI treatment as well as diagnostic and therapeutic modalities.
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Affiliation(s)
- Jennifer A McCombe
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Elia Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Center of MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States.
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12
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Kerstens J, Titulaer MJ. Overview of treatment strategies in paraneoplastic neurological syndromes. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:97-112. [PMID: 38494299 DOI: 10.1016/b978-0-12-823912-4.00015-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Treatment strategies in paraneoplastic neurological syndromes rely on the three pillars of tumor treatment, immunotherapy, and symptomatic treatment, the first one being by far the most important in the majority of patients and syndromes. Classically, antibodies against extracellular antigens are directly pathogenic, and patients with these syndromes are more responsive to immunomodulatory or immunosuppressive treatments than the ones with antibodies against intracellular targets. This chapter first discusses some general principles of tumor treatment and immunotherapy, followed by a closer look at specific treatment options for different clinical syndromes, focusing on symptomatic treatments.
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Affiliation(s)
- Jeroen Kerstens
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maarten J Titulaer
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands.
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13
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Montalvo M, Flanagan EP. Paraneoplastic/autoimmune myelopathies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:193-201. [PMID: 38494277 DOI: 10.1016/b978-0-12-823912-4.00017-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Paraneoplastic myelopathies are a rare but important category of myelopathy. They usually present with an insidious or subacute progressive neurologic syndrome. Risk factors include tobacco use and family history of cancer. Cerebrospinal fluid analysis usually shows lymphocytic pleocytosis with elevated protein. MRI findings suggest that paraneoplastic myelopathies include longitudinally extensive T2 hyperintensities that are tract-specific and accompanied by enhancement, but spinal MRIs can also be normal. The most commonly associated neural antibodies include amphiphysin and collapsin-response-mediator-protein-5 (CRMP5/anti-CV2) antibodies with lung and breast cancers being the most frequent oncologic accompaniments. The differential diagnosis of paraneoplastic myelopathies includes nutritional deficiency myelopathy (B12, copper) as well as autoimmune/inflammatory conditions such as primary progressive multiple sclerosis or spinal cord sarcoidosis. Patients treated with immune checkpoint inhibitors for cancer may develop myelitis, that can be considered along the spectrum of paraneoplastic myelopathies. Management of paraneoplastic myelopathy includes oncologic treatment and immunotherapy. Despite these treatments, the prognosis is poor and the majority of patients eventually become wheelchair-dependent.
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Affiliation(s)
- Mayra Montalvo
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
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14
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Rosenberg MI, Greenstein E, Buchkovich M, Peres A, Santoni-Rugiu E, Yang L, Mikl M, Vaksman Z, Gibbs DL, Reshef D, Salovin A, Irwin MS, Naranjo A, Ulitsky I, de Alarcon PA, Matthay KK, Weigman V, Yaari G, Panzer JA, Friedman N, Maris JM. Polyclonal lymphoid expansion drives paraneoplastic autoimmunity in neuroblastoma. Cell Rep 2023; 42:112879. [PMID: 37537844 PMCID: PMC10551040 DOI: 10.1016/j.celrep.2023.112879] [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: 04/14/2022] [Revised: 04/25/2023] [Accepted: 07/13/2023] [Indexed: 08/05/2023] Open
Abstract
Neuroblastoma is a lethal childhood solid tumor of developing peripheral nerves. Two percent of children with neuroblastoma develop opsoclonus myoclonus ataxia syndrome (OMAS), a paraneoplastic disease characterized by cerebellar and brainstem-directed autoimmunity but typically with outstanding cancer-related outcomes. We compared tumor transcriptomes and tumor-infiltrating T and B cell repertoires from 38 OMAS subjects with neuroblastoma to 26 non-OMAS-associated neuroblastomas. We found greater B and T cell infiltration in OMAS-associated tumors compared to controls and showed that both were polyclonal expansions. Tertiary lymphoid structures (TLSs) were enriched in OMAS-associated tumors. We identified significant enrichment of the major histocompatibility complex (MHC) class II allele HLA-DOB∗01:01 in OMAS patients. OMAS severity scores were associated with the expression of several candidate autoimmune genes. We propose a model in which polyclonal auto-reactive B lymphocytes act as antigen-presenting cells and drive TLS formation, thereby supporting both sustained polyclonal T cell-mediated anti-tumor immunity and paraneoplastic OMAS neuropathology.
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Affiliation(s)
- Miriam I Rosenberg
- Hebrew University of Jerusalem, Edmond Safra Campus, Givat Ram, Jerusalem 91904, Israel.
| | - Erez Greenstein
- Department of Immunology, Weizmann Institute of Science, Rehovot 7610001, Israel
| | | | - Ayelet Peres
- Bio-engineering, Faculty of Engineering, Bar Ilan University, Ramat Gan, Israel; Bar Ilan Institute of Nanotechnologies and Advanced Materials, Bar Ilan University, Ramat Gan, Israel
| | - Eric Santoni-Rugiu
- Department of Pathology, Rigshospitalet, Copenhagen University Hospital and Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Lei Yang
- Pacific Northwest Research Institute, Seattle, WA 98122, USA
| | - Martin Mikl
- Department of Human Biology, Faculty of Natural Sciences, University of Haifa, Mount Carmel, Haifa 31905, Israel
| | | | - David L Gibbs
- Institute for Systems Biology, 401 Terry Avenue N, Seattle, WA 98109, USA
| | - Dan Reshef
- Department of Immunology, Weizmann Institute of Science, Rehovot 7610001, Israel
| | - Amy Salovin
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Meredith S Irwin
- Department of Pediatrics and Division of Hematology-Oncology, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G1X8, Canada
| | - Arlene Naranjo
- Department of Biostatistics, University of Florida, Children's Oncology Group Statistics & Data Center, Gainesville, FL, USA
| | - Igor Ulitsky
- Department of Immunology & Regenerative Biology, Weizmann Institute of Science, Rehovot 7610001, Israel
| | - Pedro A de Alarcon
- Department of Pediatrics, Hematology/Oncology, University of Illinois College of Medicine Peoria, Peoria, IL 61605, USA
| | - Katherine K Matthay
- Department of Pediatrics, UCSF School of Medicine, San Francisco, CA 94143, USA
| | | | - Gur Yaari
- Bio-engineering, Faculty of Engineering, Bar Ilan University, Ramat Gan, Israel; Bar Ilan Institute of Nanotechnologies and Advanced Materials, Bar Ilan University, Ramat Gan, Israel
| | - Jessica A Panzer
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Nir Friedman
- Department of Immunology, Weizmann Institute of Science, Rehovot 7610001, Israel
| | - John M Maris
- Department of Pediatrics and Division of Oncology, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
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15
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Khalid F, Gupta R, Gor R, Gor D, Singh V, Eltoukhy H. Neurological Adverse Effects of Immune Checkpoint Inhibitors and Chimeric Antigen Receptor T-Cell Therapy. World J Oncol 2023; 14:109-118. [PMID: 37188042 PMCID: PMC10181423 DOI: 10.14740/wjon1575] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/20/2023] [Indexed: 05/17/2023] Open
Abstract
Immune checkpoint inhibitors (ICPIs) and chimeric antigen receptor (CAR) T-cell constitute recently approved novel therapies targeted to treat a wide number of malignancies. Both the treatments modulate the immune system and can cause a number of immune-related adverse events (irAEs), including polyendocrinopathies, gastrointestinal and neurological complications. This literature review focuses on the neurological side effects of these therapies as these are uncommon and alter the course of the treatment. Neurological complications involve the peripheral and central nervous system, including polyneuropathy, myositis, myasthenia gravis, demyelinating polyradiculopathy, myelitis, and encephalitis. If early recognized, the neurological complications can be treated effectively with steroids to reduce the potential of short-term and long-term complications. Therefore, early identification and treatment of irAEs are needed to optimize the outcomes associated with ICPI and CAR T-cell therapies.
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Affiliation(s)
- Farhan Khalid
- Department of Medicine, Monmouth Medical Center, Long Branch, NJ 07740, USA
- Corresponding Author: Farhan Khalid, Department of Medicine, Monmouth Medical Center, Long Branch, NJ 07740, USA.
| | - Rajshree Gupta
- Department of Medicine, JJM Medical College, Devnagree, Karnataka 577004, India
| | - Rajvi Gor
- Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, USA
| | - Dairya Gor
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ 07753, USA
| | - Vinit Singh
- Department of Medicine, Monmouth Medical Center, Long Branch, NJ 07740, USA
| | - Hussam Eltoukhy
- Section of Hematology-Oncology, Department of Medicine, Monmouth Medical Center, Long Branch, NJ 07740, USA
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16
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Miske R, Scharf M, Borowski K, Rieckhoff N, Teegen B, Denno Y, Probst C, Guthke K, Didrihsone I, Wildemann B, Ruprecht K, Komorowski L, Jarius S. Septin-3 autoimmunity in patients with paraneoplastic cerebellar ataxia. J Neuroinflammation 2023; 20:88. [PMID: 36997937 PMCID: PMC10061979 DOI: 10.1186/s12974-023-02718-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/03/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Septins are cytoskeletal proteins with filament forming capabilities, which have multiple roles during cell division, cellular polarization, morphogenesis, and membrane trafficking. Autoantibodies against septin-5 are associated with non-paraneoplastic cerebellar ataxia, and autoantibodies against septin-7 with encephalopathy with prominent neuropsychiatric features. Here, we report on newly identified autoantibodies against septin-3 in patients with paraneoplastic cerebellar ataxia. We also propose a strategy for anti-septin autoantibody determination. METHODS Sera from three patients producing similar immunofluorescence staining patterns on cerebellar and hippocampal sections were subjected to immunoprecipitation followed by mass spectrometry. The identified candidate antigens, all of which were septins, were expressed recombinantly in HEK293 cells either individually, as complexes, or combinations missing individual septins, for use in recombinant cell-based indirect immunofluorescence assays (RC-IIFA). Specificity for septin-3 was further confirmed by tissue IIFA neutralization experiments. Finally, tumor tissue sections were analyzed immunohistochemically for septin-3 expression. RESULTS Immunoprecipitation with rat cerebellum lysate revealed septin-3, -5, -6, -7, and -11 as candidate target antigens. Sera of all three patients reacted with recombinant cells co-expressing septin-3/5/6/7/11, while none of 149 healthy control sera was similarly reactive. In RC-IIFAs the patient sera recognized only cells expressing septin-3, individually and in complexes. Incubation of patient sera with five different septin combinations, each missing one of the five septins, confirmed the autoantibodies' specificity for septin-3. The tissue IIFA reactivity of patient serum was abolished by pre-incubation with HEK293 cell lysates overexpressing the septin-3/5/6/7/11 complex or septin-3 alone, but not with HEK293 cell lysates overexpressing septin-5 as control. All three patients had cancers (2 × melanoma, 1 × small cell lung cancer), presented with progressive cerebellar syndromes, and responded poorly to immunotherapy. Expression of septin-3 was demonstrated in resected tumor tissue available from one patient. CONCLUSIONS Septin-3 is a novel autoantibody target in patients with paraneoplastic cerebellar syndromes. Based on our findings, RC-IIFA with HEK293 cells expressing the septin-3/5/6/7/11 complex may serve as a screening tool to investigate anti-septin autoantibodies in serological samples with a characteristic staining pattern on neuronal tissue sections. Autoantibodies against individual septins can then be confirmed by RC-IIFA expressing single septins.
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Affiliation(s)
- Ramona Miske
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Madeleine Scharf
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany.
| | - Kathrin Borowski
- Clinical Immunological Laboratory Prof. Dr. med. Winfried Stöcker, Lübeck, Germany
| | - Nicole Rieckhoff
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Bianca Teegen
- Clinical Immunological Laboratory Prof. Dr. med. Winfried Stöcker, Lübeck, Germany
| | - Yvonne Denno
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Christian Probst
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Kersten Guthke
- Department of Neurology, Städtisches Klinikum Görlitz, Görlitz, Germany
| | - Ieva Didrihsone
- Department of Neurology, Hermann-Josef-Krankenhaus, Erkelenz, Germany
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lars Komorowski
- Institute for Experimental Immunology, affiliated to EUROIMMUN AG, Lübeck, Germany
| | - Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany.
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17
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Laumont CM, Nelson BH. B cells in the tumor microenvironment: Multi-faceted organizers, regulators, and effectors of anti-tumor immunity. Cancer Cell 2023; 41:466-489. [PMID: 36917951 DOI: 10.1016/j.ccell.2023.02.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/11/2023] [Accepted: 02/12/2023] [Indexed: 03/14/2023]
Abstract
Our understanding of tumor-infiltrating lymphocytes (TILs) is rapidly expanding beyond T cell-centric perspectives to include B cells and plasma cells, collectively referred to as TIL-Bs. In many cancers, TIL-Bs carry strong prognostic significance and are emerging as key predictors of response to immune checkpoint inhibitors. TIL-Bs can perform multiple functions, including antigen presentation and antibody production, which allow them to focus immune responses on cognate antigen to support both T cell responses and innate mechanisms involving complement, macrophages, and natural killer cells. In the stroma of the most immunologically "hot" tumors, TIL-Bs are prominent components of tertiary lymphoid structures, which resemble lymph nodes structurally and functionally. Additionally, TIL-Bs participate in a variety of other lympho-myeloid aggregates and engage in dynamic interactions with the tumor stroma. Here, we summarize our current understanding of TIL-Bs in human cancer, highlighting the compelling therapeutic opportunities offered by their unique tumor recognition and effector mechanisms.
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Affiliation(s)
- Céline M Laumont
- Deeley Research Centre, BC Cancer, Victoria, BC V8R 6V5, Canada; Department of Medical Genetics, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - Brad H Nelson
- Deeley Research Centre, BC Cancer, Victoria, BC V8R 6V5, Canada; Department of Medical Genetics, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; Department of Biochemistry and Microbiology, University of Victoria, Victoria, BC V8P 3E6, Canada.
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18
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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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19
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Fidahussain AA, Abid A, Paracha AA, Jeevan VE, Rueve J, Engelhardt M, Schrock C, Ghani S, Nair HK. An Etiological Investigation of Paraneoplastic Cerebellar Degeneration in Ovarian Cancer Patients: A Systematic Review. Cureus 2022; 14:e31154. [PMID: 36483902 PMCID: PMC9724195 DOI: 10.7759/cureus.31154] [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: 11/05/2022] [Indexed: 11/07/2022] Open
Abstract
Paraneoplastic syndromes (PNS) are uncommon, distinct clinical complications of a primary tumor. Paraneoplastic cerebellar degeneration (PCD) is a PNS that is described as an autoimmune response targeting Purkinje cells in the cerebellum. Ovarian cancer (OC) is one of the most prevalent causes of cancer-related deaths in women. Anti-Yo is the most common onconeural antibody produced in the PCD immune response and is most typically found in ovarian and breast cancer patients. While the current literature highlights the predisposing genetic factors, diagnostic workflows, and treatment options, the pathophysiology of PCD, among other considerations, remains largely unestablished. This review aimed to systematically observe procedural solutions to facilitate an early diagnosis and improve the prognosis of patients with OC-associated PCD. To that end, we examined literature published from 01/01/2015-11/10/2022 indexed in PubMed by using the keywords "paraneoplastic, cerebellar degeneration" combined with "ovarian cancer." Inclusion criteria were met if PCD and OC diagnoses were made and if studies provided adequate patient information. After screening and assessing records for eligibility using the inclusion and exclusion criteria, 18 articles involving 102 patients were included. The typical patient observed in this sample was diagnosed with International Federation of Gynecology and Obstetrics (FIGO) Stage III, high-grade serous carcinoma. The diagnostic workup typically included a clinical evaluation for dysarthria (50%), ataxia (60%), and gait abnormalities (50%), along with multiple imaging modalities and serological findings (90%). Genetic screening for human leukocyte antigen (HLA) haplotype susceptibility for PCD and immune tolerance modulators regulation may also be recommended prior to starting treatment. Findings support the use of corticosteroids (35%) and intravenous immunoglobulin (IVIg) (40%) as viable treatment options for managing PCD in conjunction with systemic therapy for the primary malignancy. A diagnosis of PCD should be considered if a patient has had a malignancy in the past five years with the presence of explicit cerebellar symptoms. This clinical diagnosis can be further supplemented by serologic and radiologic findings. Recognizing PCD symptoms and scheduling genetic and proteomic testing may help with early diagnosis and better prognosis.
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Affiliation(s)
| | - Ali Abid
- Biology, Saint Louis University, St. Louis, USA
| | - Awais A Paracha
- Hematology and Oncology, Saint Louis University School of Medicine, St. Louis, USA
| | - Varun E Jeevan
- Neurology, University of Missouri School of Medicine, Columbia, USA
| | | | | | - Cody Schrock
- Neuroscience, Saint Louis University, St. Louis, USA
| | - Sofia Ghani
- Hematology and Oncology, Saint Louis University School of Medicine, St. Louis, USA
| | - Hari K Nair
- Hematology and Oncology, Saint Louis University School of Medicine, St. Louis, USA
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20
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Cacciaguerra L, Sechi E, Rocca MA, Filippi M, Pittock SJ, Flanagan EP. Neuroimaging features in inflammatory myelopathies: A review. Front Neurol 2022; 13:993645. [PMID: 36330423 PMCID: PMC9623025 DOI: 10.3389/fneur.2022.993645] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022] Open
Abstract
Spinal cord involvement can be observed in the course of immune-mediated disorders. Although multiple sclerosis (MS) represents the leading cause of inflammatory myelopathy, an increasing number of alternative etiologies must be now considered in the diagnostic work-up of patients presenting with myelitis. These include antibody-mediated disorders and cytotoxic T cell-mediated diseases targeting central nervous system (CNS) antigens, and systemic autoimmune conditions with secondary CNS involvement. Even though clinical features are helpful to orient the diagnostic suspicion (e.g., timing and severity of myelopathy symptoms), the differential diagnosis of inflammatory myelopathies is often challenging due to overlapping features. Moreover, noninflammatory etiologies can sometimes mimic an inflammatory process. In this setting, magnetic resonance imaging (MRI) is becoming a fundamental tool for the characterization of spinal cord damage, revealing a pictorial scenario which is wider than the clinical manifestations. The characterization of spinal cord lesions in terms of longitudinal extension, location on axial plane, involvement of the white matter and/or gray matter, and specific patterns of contrast enhancement, often allows a proper differentiation of these diseases. For instance, besides classical features, such as the presence of longitudinally extensive spinal cord lesions in patients with aquaporin-4-IgG positive neuromyelitis optica spectrum disorder (AQP4+NMOSD), novel radiological signs (e.g., H sign, trident sign) have been recently proposed and successfully applied for the differential diagnosis of inflammatory myelopathies. In this review article, we will discuss the radiological features of spinal cord involvement in autoimmune disorders such as MS, AQP4+NMOSD, myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), and other recently characterized immune-mediated diseases. The identification of imaging pitfalls and mimics that can lead to misdiagnosis will also be examined. Since spinal cord damage is a major cause of irreversible clinical disability, the recognition of these radiological aspects will help clinicians achieve a correct and prompt diagnosis, treat early with disease-specific treatment and improve patient outcomes.
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Affiliation(s)
- Laura Cacciaguerra
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Elia Sechi
- Neurology Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Maria A. Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sean J. Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Eoin P. Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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21
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Abstract
Despite advances in surgery and chemotherapy, ovarian cancer remains one of the most lethal malignancies. Hence, the implementation of novel treatment approaches is required to improve the outcomes of the disease. Immunotherapy has been proven to be effective in many tumors and has already been incorporated into clinical practice. In this review, we describe key strategies in immunotherapy of ovarian cancer and summarize data from clinical studies assessing immunological prospects which could improve ovarian cancer treatment approaches in the future. The most notable current strategies include checkpoint blockade agents, the use of vaccines, adoptive cell transfer, as well as various combinations of these methods. While several of these options are promising, large controlled randomized studies are still needed to implement new immunotherapeutic options into clinical practice.
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22
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Katsumoto TR, Wilson KL, Giri VK, Zhu H, Anand S, Ramchandran KJ, Martin BA, Yunce M, Muppidi S. Plasma Exchange for Severe Immune-Related Adverse Events from Checkpoint Inhibitors: An Early Window of Opportunity? IMMUNOTHERAPY ADVANCES 2022; 2:ltac012. [PMID: 35814850 PMCID: PMC9257781 DOI: 10.1093/immadv/ltac012] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/24/2022] [Indexed: 11/29/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of several advanced malignancies leading to durable remission in a subset of patients. Their rapidly expanding use has led to an increased frequency of immune-related adverse events (irAEs). The pathogenesis of irAEs is poorly understood but may involve aberrant activation of T cells leading to inflammatory cytokine release or production of pathogenic antibodies leading to organ damage. Severe irAEs can be extremely debilitating and, in some cases, life threatening. IrAEs may not always be corticosteroid responsive or may require excessively high, often toxic, corticosteroid doses. Therapeutic plasma exchange (PLEX) is a treatment modality that has shown promising results for the management of certain severe irAEs, including irAEs that are not mentioned in current treatment guidelines. PLEX may attenuate ongoing irAEs and prevent delayed irAEs by accelerating clearance of the ICI, or by acutely removing pathogenic antibodies, cytokines, and chemokines. Here, we summarize examples from the literature in which PLEX was successfully used for the treatment of irAEs. We posit that timing may be a critical factor and that earlier utilization of PLEX for life-threatening irAEs may result in more favorable outcomes. In individuals at high risk for irAEs, the availability of PLEX as a potential therapeutic mitigation strategy may encourage life-saving ICI use or rechallenge. Future research will be critical to better define which indications are most amenable to PLEX, particularly to establish the optimal place in the sequence of irAE therapies and to assess the ramifications of ICI removal on cancer outcomes.
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Affiliation(s)
- Tamiko R Katsumoto
- Department of Medicine, Division of Immunology and Rheumatology, Stanford University School of Medicine , Stanford, CA, USA
| | - Kalin L Wilson
- Department of Medicine, Stanford University School of Medicine, Stanford , CA, USA
| | - Vinay K Giri
- Department of Medicine, Stanford University School of Medicine, Stanford , CA, USA
| | - Han Zhu
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine , Stanford, CA, USA
| | - Shuchi Anand
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine , Stanford, CA, USA
| | - Kavitha J Ramchandran
- Department of Medicine, Division of Oncology, Stanford Cancer Institute , Stanford University School of Medicine, Stanford, CA, USA
| | - Beth A Martin
- Department of Medicine, Division of Hematology, Stanford University School of Medicine , Stanford, CA, USA
| | - Muharrem Yunce
- Department of Pathology, Stanford University School of Medicine, Stanford , CA, USA
| | - Srikanth Muppidi
- Department of Neurology and Neurosciences, Stanford University School of Medicine, Stanford , CA, USA
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23
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Gastaldi M, Scaranzin S, Pietro B, Lechiara A, Pesce G, Franciotta D, Lorusso L. Paraneoplastic Neurological Syndromes: Transitioning Between the Old and the New. Curr Oncol Rep 2022; 24:1237-1249. [PMID: 35476177 DOI: 10.1007/s11912-022-01279-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Paraneoplastic neurological syndromes (PNS) are caused by nervous system-targeting aberrant anti-tumoral immune responses. We review the updated criteria for PNS diagnosis, incorporating novel information on clinical phenotypes, neuronal autoantibodies (Nabs), and tumors. The impact of the oncologic use of immune checkpoint inhibitors (ICI) on PNS occurrence is also addressed. RECENT FINDINGS Clinical phenotypes and Nabs are redefined as "high/intermediate/low" risk, following the frequency of cancer association. Nabs, the diagnostic hallmark of PNS, can target intracellular or surface neuronal proteins, with important prognostic and pathogenic implications. Many novel assays have been incorporated into laboratory diagnostics, that is becoming increasingly complex. ICI fight tumors, but favor autoimmunity, thus increasing the incidence of PNS-like disorders. Overcoming the old PNS criteria, the new ones are centered around the presence of tumor. Clinical presentation, Nabs, and tumor findings are translated in diagnostic scores, providing a useful tool for PNS diagnosis and management.
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Affiliation(s)
- Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy.
| | - Silvia Scaranzin
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | | | - Anastasia Lechiara
- Autoimmunology Laboratory, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Giampaola Pesce
- Autoimmunology Laboratory, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine (Dimi), University of Genova, Genova, Italy
| | - Diego Franciotta
- Autoimmunology Laboratory, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Lorenzo Lorusso
- Neurology and Stroke Unit, Neuroscience Department, A.S.S.T.-Lecco, Merate (LC), Italy
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24
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Duong SL, Prüss H. Paraneoplastic Autoimmune Neurological Syndromes and the Role of Immune Checkpoint Inhibitors. Neurotherapeutics 2022; 19:848-863. [PMID: 35043373 PMCID: PMC9294109 DOI: 10.1007/s13311-022-01184-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 12/14/2022] Open
Abstract
The introduction of immune checkpoint inhibitors (ICIs) in oncologic therapies has led to a paradigm shift in cancer treatment. ICIs have increased the overall survival in patients with malignant melanoma, small-cell lung cancer, and many other tumor entities. Despite their clinical benefits, these novel cancer immunotherapies can induce neurological immune-related adverse events (irAEs). Such immune-mediated complications can manifest within the spectrum of paraneoplastic neurological syndromes (PNSs). PNSs are rare immune-mediated complications of systemic cancers that can involve every aspect of the nervous system. The emergence of PNSs with ICI treatment opens further pathways to study the complex immunopathological interplay of cancer immunity, cross-reactive neurological autoimmune phenomena, and effects of ICIs on the immune system. ICI-induced PNSs comprise a diverse antibody repertoire and phenotypic spectrum with severe and life-threatening disease progression in some cases. Timely diagnosis and urgent interventions are pivotal for a favorable neurologic and oncologic outcome. This review focuses on the pathogenesis of cancer immunotherapy and the disruption of immune tolerance in PNSs and provides an overview of the most pertinent clinical manifestations and principles of diagnostic and therapeutic managements in light of the expected increase in PNSs due to the widespread use of ICIs in clinical practice. This review further discusses potential and evolving concepts of therapeutic monoclonal antibodies for the treatment of PNSs.
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Affiliation(s)
- Sophie L Duong
- Department of Neurology and Experimental Neurology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE) Berlin, 10117, Berlin, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
- German Center for Neurodegenerative Diseases (DZNE) Berlin, 10117, Berlin, Germany.
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25
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Neurotoxicity and safety of the rechallenge of immune checkpoint inhibitors: a growing issue in neuro-oncology practice. Neurol Sci 2022; 43:2339-2361. [DOI: 10.1007/s10072-022-05920-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
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26
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Greenlee JE, Carlson NG, Abbatemarco JR, Herdlevær I, Clardy SL, Vedeler CA. Paraneoplastic and Other Autoimmune Encephalitides: Antineuronal Antibodies, T Lymphocytes, and Questions of Pathogenesis. Front Neurol 2022; 12:744653. [PMID: 35111121 PMCID: PMC8801577 DOI: 10.3389/fneur.2021.744653] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/26/2021] [Indexed: 01/14/2023] Open
Abstract
Autoimmune and paraneoplastic encephalitides represent an increasingly recognized cause of devastating human illness as well as an emerging area of neurological injury associated with immune checkpoint inhibitors. Two groups of antibodies have been detected in affected patients. Antibodies in the first group are directed against neuronal cell surface membrane proteins and are exemplified by antibodies directed against the N-methyl-D-aspartate receptor (anti-NMDAR), found in patients with autoimmune encephalitis, and antibodies directed against the leucine-rich glioma-inactivated 1 protein (anti-LGI1), associated with faciobrachial dystonic seizures and limbic encephalitis. Antibodies in this group produce non-lethal neuronal dysfunction, and their associated conditions often respond to treatment. Antibodies in the second group, as exemplified by anti-Yo antibody, found in patients with rapidly progressive cerebellar syndrome, and anti-Hu antibody, associated with encephalomyelitis, react with intracellular neuronal antigens. These antibodies are characteristically found in patients with underlying malignancy, and neurological impairment is the result of neuronal death. Within the last few years, major advances have been made in understanding the pathogenesis of neurological disorders associated with antibodies against neuronal cell surface antigens. In contrast, the events that lead to neuronal death in conditions associated with antibodies directed against intracellular antigens, such as anti-Yo and anti-Hu, remain poorly understood, and the respective roles of antibodies and T lymphocytes in causing neuronal injury have not been defined in an animal model. In this review, we discuss current knowledge of these two groups of antibodies in terms of their discovery, how they arise, the interaction of both types of antibodies with their molecular targets, and the attempts that have been made to reproduce human neuronal injury in tissue culture models and experimental animals. We then discuss the emerging area of autoimmune neuronal injury associated with immune checkpoint inhibitors and the implications of current research for the treatment of affected patients.
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Affiliation(s)
- John E Greenlee
- Neurology Service, George E. Wahlen Veterans Affairs Health Care System, Salt Lake City, UT, United States.,Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Noel G Carlson
- Department of Neurology, University of Utah, Salt Lake City, UT, United States.,Geriatric Research, Education, and Clinical Center (GRECC), George E. Wahlen Veterans Affairs Health Care System, Salt Lake City, UT, United States.,Department of Neurobiology, University of Utah, Salt Lake City, UT, United States
| | - Justin R Abbatemarco
- Department of Neurology, University of Utah, Salt Lake City, UT, United States.,Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Ida Herdlevær
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Stacey L Clardy
- Neurology Service, George E. Wahlen Veterans Affairs Health Care System, Salt Lake City, UT, United States.,Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Christian A Vedeler
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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27
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Valencia-Sanchez C, Flanagan EP. Uncommon inflammatory/immune-related myelopathies. J Neuroimmunol 2021; 361:577750. [PMID: 34715593 DOI: 10.1016/j.jneuroim.2021.577750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/16/2021] [Accepted: 10/10/2021] [Indexed: 01/03/2023]
Abstract
The differential diagnosis for immune-mediated myelopathies is broad. Although clinical manifestations overlap, certain presentations are suggestive of a particular myelopathy etiology. Spine MRI lesion characteristics including the length and location, and the pattern of gadolinium enhancement, help narrow the differential diagnosis and exclude an extrinsic compressive cause. The discovery of specific antibodies that serve as biomarkers of myelitis such as aquaporin-4-IgG and myelin-oligodendrocyte -glycoprotein-IgG (MOG-IgG), has improved our understanding of myelitis pathophysiology and facilitated diagnosis. In this review we will focus on the pathophysiology, clinical presentation, imaging findings and treatment and outcomes of uncommon immune-mediated myelopathies.
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28
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How to diagnose and manage neurological toxicities of immune checkpoint inhibitors: an update. J Neurol 2021; 269:1701-1714. [PMID: 34708250 DOI: 10.1007/s00415-021-10870-6] [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: 08/11/2021] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 12/19/2022]
Abstract
As the use of cancer immunotherapy with immune checkpoint inhibitors (ICIs) is expanding rapidly for the treatment of many tumor types, it is crucial that both neurologists and oncologists become familiar with the diagnosis and treatment of neurological immune-related adverse events (n-irAEs). These are rare complications, developing in their severe forms in only 1-3% of the patients, but are highly relevant due to their mortality and morbidity burden. The diagnosis of n-irAEs is-however-challenging, as many alternative diagnoses need to be considered in the complex scenario of a patient with advanced cancer developing neurological problems. A tailored diagnostic approach is advisable according to the presentation, clinical history, and known specificities of n-irAEs. Several patterns characterized by distinct clinical, immunological, and prognostic characteristics are beginning to emerge. For example, myasthenia gravis is more likely to develop after anti-programmed cell death protein 1 (PD-1) or anti-programmed cell death ligand 1 (PD-L1) treatment, while meningitis appears more frequently after anti-cytotoxic T lymphocyte antigen-4 (CTLA-4) therapy. Also, peripheral neuropathy and Guillain-Barré syndrome seem to be more common in patients with an underlying melanoma. Central nervous system disorders (CNS) are less frequent and are more often associated with lung cancer, and some of them (especially those with limbic encephalitis and positive onconeural antibodies) have a poor prognosis. Herein, we provide an update of the recent advances in the diagnosis and treatment of neurological toxicities related to ICI use, focusing on the exclusion of alternative diagnoses, diagnostic specificities, and treatment of n-irAEs.
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29
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Minami S, Okada H, Ihara S, Tsuji H, Yamadera M, Yasuoka H. Pembrolizumab-Induced Meningoencephalitis: A Brain Autopsy Case. J Med Cases 2021; 12:359-365. [PMID: 34527106 PMCID: PMC8425809 DOI: 10.14740/jmc3748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 08/03/2021] [Indexed: 02/07/2023] Open
Abstract
Encephalitis is very rare, but often fatal immune-related adverse event (irAE) of immune checkpoint inhibitors (ICIs). A 65-year-old Japanese woman was admitted to our hospital because of general fatigue, chillness and high-grade fever for 4 days, 8 months after the initiation of the first-line pembrolizumab monotherapy for metastatic pulmonary adenocarcinoma. On the hospital day 3, she suddenly presented delirium and uncontrollable impaired consciousness. Although the magnetic resonance imaging (MRI) did not suggest a diagnosis of encephalitis and meningitis, the spinal fluid showed abnormally elevated levels of protein (317.6 mg/L) and cell count (197 cells/µL) with increased mononuclear cells (93%). An empirical and intravenous administration of acyclovir in doses of 10 mg/kg body weight every 8 h and steroid pulse therapy in dose of 1 g/body/day from the hospital day 5 until her death failed to improve her conditions. She died on the hospital day 8. The postmortem autopsy showed viable cancer cells in the metastatic tumor in the left occipital lobe and in the spinal fluids. However, many inflammatory cells infiltration in the meninges and perivascular cuffing were prominent especially in the brain stem and medial part of the temporal lobe. Infiltrating lymphocytes in the meninges and parenchyma of the brain stem were mainly composed of cluster of differentiation (CD)8-positive lymphocytes. For irAE encephalitis, early recognition of early signs and symptoms and subsequent early therapeutic intervention are necessary. It is important for oncologists to keep in mind of the possible adverse effects of immunotherapies on the nervous system.
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Affiliation(s)
- Seigo Minami
- Department of Respiratory Medicine, Osaka Police Hospital, 10-31 Kitayama-cho, Tennoji-ku, Osaka City, Osaka 543-0035, Japan
| | - Hideyasu Okada
- Department of Respiratory Medicine, Osaka Police Hospital, 10-31 Kitayama-cho, Tennoji-ku, Osaka City, Osaka 543-0035, Japan
| | - Shoichi Ihara
- Department of Respiratory Medicine, Osaka Police Hospital, 10-31 Kitayama-cho, Tennoji-ku, Osaka City, Osaka 543-0035, Japan
| | - Hiromi Tsuji
- Department of Pathology, Osaka Police Hospital, 10-31 Kitayama-cho, Tennoji-ku, Osaka City, Osaka 543-0035, Japan
| | - Misaki Yamadera
- Department of Pathology, National Hospital Organization Osaka Toneyama Medical Center, Toyonaka, Osaka, Japan
| | - Hironao Yasuoka
- Department of Pathology, Osaka Police Hospital, 10-31 Kitayama-cho, Tennoji-ku, Osaka City, Osaka 543-0035, Japan
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30
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Paraneoplastic myelitis associated with durvalumab treatment for extensive-stage small cell lung cancer. Invest New Drugs 2021; 40:151-156. [PMID: 34287773 PMCID: PMC8763935 DOI: 10.1007/s10637-021-01154-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/14/2021] [Indexed: 11/01/2022]
Abstract
Paraneoplastic neurologic syndromes(PNSs) caused by immune checkpoint inhibitors(ICIs) is rare and requires clinicians to differentiate between disease progression and immune-related adverse effects(irAEs). We hereby report the case of immune-related myelitis accompanied by positive paraneoplastic autoantibodies following durvalumab treatment for extensive-stage small cell lung cancer (ES-SCLC). A 70-year-old Chinese woman with ES-SCLC was administered durvalumab with etoposid-platinum(EP) as first-line treatment. Four cycles after treatment with EP plus ICI, she developed immune-related myelitis with positive paraneoplastic autoantibodies (CV2, SOX1, ZIC4). Spinal MRI showed diffuse abnormal signal shadow in the cervicothoracic spinal cord. She was discontinued for chemotherapy, and treated with high-dose steroids, intravenous immunoglobulin and plasmapheresis, maintenance therapy with steroids resulted in a favorable neurologic outcome. This is the first report of durvalumab-related PNSs. We supposed that the development of paraneoplastic myelitis was causally related to immune activation by durvalumab. Prompt diagnosis and therapeutic intervention are essential for the effective treatment of paraneoplastic myelitis.
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