Bilateral Posterior Uveitis and Retinal Detachment During Immunotherapy: A Case Report and Literature Review

Ocular side effects of oncological therapies: Review

With the advance of cancer therapy in recent years, the knowledge of the mechanisms involved in this disease has increased, which has meant an increase in the quality of life and survival of patients with tumor pathologies previously considered incurable or refractory to treatment. The number of drugs used has increased exponentially in number, and although the implicit toxicity is lower than that of conventional antineoplastic therapy, they lead to the appearance of new associated adverse effects that the ophthalmologist must recognize and manage.

Diagnosing and Managing Uveitis Associated with Immune Checkpoint Inhibitors: A Review

This review aims to provide an understanding of the diagnostic and therapeutic challenges of uveitis associated with immune checkpoint inhibitors (ICI). In the wake of these molecules being increasingly employed as a treatment against different cancers, cases of uveitis post-ICI therapy have also been increasingly reported in the literature, warranting an extensive exploration of the clinical presentations, risk factors, and pathophysiological mechanisms of ICI-induced uveitis. This review further provides an understanding of the association between ICIs and uveitis, and assesses the efficacy of current diagnostic tools, underscoring the need for advanced techniques to enable early detection and accurate assessment. Further, it investigates the therapeutic strategies for ICI-related uveitis, weighing the benefits and limitations of existing treatment regimens, and discussing current challenges and emerging therapies in the context of their potential efficacy and side effects. Through an overview of the short-term and long-term outcomes, this article suggests recommendations and emphasizes the importance of multidisciplinary collaboration between ophthalmologists and oncologists. Finally, the review highlights promising avenues for future research and development in the field, potentially informing transformative approaches in the ocular assessment of patients under immunotherapy and the management of uveitis following ICI therapy.

Ocular adverse events associated with immune checkpoint inhibitors, a scoping review

INTRODUCTION

Immune checkpoint inhibitors (ICIs) have become an important part of the treatment of multiple cancers, especially for advanced melanoma and non-small cell lung cancer. Some tumors are capable of escaping immunosurveillance by stimulating checkpoints on T-cells. ICIs prevent activation of these checkpoints and thereby stimulate the immune system and indirectly the anti-tumor response. However, the use of ICIs is associated with various adverse events. Ocular side effects are rare but may have a major impact on the quality of life of the patient.

METHODS

A comprehensive literature search of the medical databases Web of Science, Embase and PubMed was performed. Articles that provided a comprehensive description of a case report containing 1) cancer patient(s) treated with (a combination of) immune checkpoint inhibitors, and 2) assessed occurrence of ocular adverse events, were included. A total of 290 case reports were included.

RESULTS

Melanoma (n = 179; 61.7%) and lung cancer (n = 56; 19.3%) were the most frequent reported malignancies. The primary used ICIs were nivolumab (n = 123; 42.5%) and ipilimumab (n = 116; 40.0%). Uveitis was most the common adverse event (n = 134; 46.2%) and mainly related to melanoma. Neuro-ophthalmic disorders, including myasthenia gravis and cranial nerve disorders, were the second most common adverse events (n = 71; 24.5%), mainly related to lung cancer. Adverse events affecting the orbit and the cornea were reported in 33 (11.4%) and 30 cases (10.3%) respectively. Adverse events concerning the retina were reported in 26 cases (9.0%).

CONCLUSION

The aim of this paper is to provide an overview of all reported ocular adverse events related to the use of ICIs. The insights retrieved from this review might contribute to a better understanding of the underlying mechanisms of these ocular adverse events. Particularly, the difference between actual immune-related adverse events and paraneoplastic syndromes might be relevant. These findings might be of great value in establishing guidelines on how to manage ocular adverse events related to ICIs.

Emerging Trends in Radionuclide Imaging of Infection and Inflammation in Pediatrics: Focus on FDG PET/CT and Immune Reactivity

The most common indication for ¹⁸F-FDG PET/CT is tumor imaging, which may be performed for initial diagnosis, staging, therapeutic response monitoring, surveillance, or suspected recurrence. In the routine practice of pediatric nuclear medicine, most infectious, inflammatory, and autoimmune processes that are detected on ¹⁸F-FDG PET/CT imaging - except for imaging in fever or inflammation of unknown origin - are coincidental and not the main indication for image acquisition. However, interpreting these "coincidental" findings is of utmost importance to avoid erroneously attributing these findings to a neoplastic process. We review the recent literature on fever of unknown origin as well as inflammation of unknown origin in pediatrics and then focus on the ¹⁸F FDG PET/CT imaging findings seen in two specific entities with increased immune reactivity: hemophagocytic lymphohistiocytosis syndrome and the immune-related adverse events associated with checkpoint inhibitors. We will subsequently close with two sections highlighting related topics and relevant references for further reading.

Ocular Inflammation Induced by Immune Checkpoint Inhibitors

Ocular immunotherapy-related adverse events (IRAEs), although rare, can be sight-threatening. Our objective was to analyze ocular IRAEs diagnosed in France from the marketing of immune checkpoint inhibitors (ICPIs) until June 2021 and to review the literature. We collected the cases of 28 patients (36 ocular IRAEs), occurring after an average of 17 weeks (±19). Forty-six percent of patients were treated for metastatic melanoma. Anti-PD1 agents were responsible for 57% of the IRAEs. Anterior uveitis was the most common (44%), followed by panuveitis (28%). Of 25 uveitis cases, 80% were bilateral and 60% were granulomatous. We found one case with complete Vogt-Koyanagi–Harada syndrome and one case of birdshot retinochoroidopathy. The other IRAEs were eight ocular surface disorders, one optic neuropathy, and one inflammatory orbitopathy. Seventy percent of the IRAEs were grade 3 according to the common terminology of AEs. ICPIs were discontinued in 60% of patients and 50% received local corticosteroids alone. The literature review included 230 uveitis cases, of which 7% were granulomatous. The distributions of ICPIs, cancer, and type of uveitis were similar to our cohort. Ocular IRAEs appeared to be easily controlled by local or systemic corticosteroids and did not require routine discontinuation of ICPIs. Further work is still warranted to define the optimal management of ocular IRAEs.

Cancer Immunotherapy and Uveitis: Balancing Anti-Tumor Immunity and Ocular Autoimmunity

Immune checkpoint inhibitors and targeted therapies are two classes of pharmacologic therapies used to treat metastatic malignancy by amplifying the immune system activity against cancerous cells. However, these drugs can consequently cause immune-related adverse events (irAEs). Albeit rare, cases of ocular IRAEs occurring among patients taking these drugs have been documented in literature, including a spectrum of uveitis findings. The classes of immune checkpoint inhibitors explored here include anti-CTLA4 (ipilimumab), anti-PD-1 (pembrolizumab, nivolumab) and anti-PDL-1 (atezolizumab, avelumab, durvalumab). Targeted therapies include the MEK inhibitors (trametinib) and BRAF enzyme inhibitors (dabrafenib, vemurafenib), both of which are involved in the MAPK/ERK signaling pathway responsible for cell proliferation. Reported cases of ocular irAEs caused by these drugs include anterior uveitis, posterior uveitis, panuveitis, and Vogt-Koyanagi-Harada (VKH)-like syndrome. Treatment can be determined on a case-by-case basis and depending on the severity of the irAE, may include temporary cessation of the offending drug, local corticosteroids, or systemic corticosteroids. Although the mechanism by which these ocular toxicities occur is not clearly elucidated, it is hypothesized that they are secondary to increased activity of auto-reactive T-cells. Further investigation into mechanisms underlying these inflammatory findings are relevant for cancer targeting, as well as insights into ocular autoimmune diseases.

A real-world pharmacovigilance study of axitinib: data mining of the public version of FDA adverse event reporting system

BACKGROUND

Axitinib was approved for treatment of advanced renal cell carcinoma (RCC). The current study was to assess axitinib-related adverse events (AEs) through data mining of the US Food and Drug Administration Adverse Event Reporting System (FAERS).

METHODS

Disproportionality analyses, including the reporting odds ratio (ROR), the proportional reporting ratio (PRR), the Bayesian confidence propagation neural network (BCPNN), and the multi-item gamma Poisson shrinker (MGPS) algorithms, were employed to quantify the signals of axitinib-associated AEs.

RESULTS

Out of 10,703,806 reports collected from the FAERS database, 9044 reports of axitinib as the 'primary suspected (PS)' AEs were identified. Axitinib induced AEs occurrence targeted 26 organ systems. A total of 95 significant disproportionality PTs conforming to the four algorithms were simultaneously retained. Rare reports and significant signals of aortic disease have emerged. Unexpected significant AEs such as scrotal swelling, scrotal ulcers, infections, and infestations might also occur. The median onset time of axitinib-associated AEs was 63.5 days (interquartile range [IQR] 20-182 days), and most of the cases occurred within the first one and 2 months after axitinib initiation.

CONCLUSION

Our study found potential new AEs signals and might provide important support for clinical monitoring and risk identification of axitinib.