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Vu T, O'Brien SR, Ma SX, Sundaram KM, Pantel AR. Pembrolizumab-induced vasculitis demonstrated by FDG-PET/CT. Radiol Case Rep 2024; 19:3959-3961. [PMID: 39050646 PMCID: PMC11266975 DOI: 10.1016/j.radcr.2024.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 06/08/2024] [Accepted: 06/10/2024] [Indexed: 07/27/2024] Open
Abstract
A 76-year-old man with a history of malignant pleural mesothelioma treated with pembrolizumab underwent FDG-PET/CT for restaging. The images demonstrated FDG uptake overlying the right hepatic and splenic artery, which were new from the previous FDG-PET/CT 2.5 years prior before the patient started pembrolizumab, suspicious for vasculitis. A follow-up MRI supported the diagnosis with evidence of celiac, splenic, common hepatic, and right hepatic artery involvement. Pembrolizumab was discontinued and the patient received a short course of oral glucocorticoids. Subsequent FDG-PET/CT performed 14 months after initiation of treatment for vasculitis demonstrated resolution of vasculitis. Immune checkpoint inhibitors can cause vasculitis, which can be recognized on FDG-PET/CT and lead to appropriate treatment.
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Affiliation(s)
- Tuan Vu
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19147, USA
- Pennsylvania State College of Medicine, 700 HMC Cres Rd, Hershey, PA 17033, USA
| | - Sophia R. O'Brien
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19147, USA
| | - Shawn X. Ma
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19147, USA
| | - Karthik M. Sundaram
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19147, USA
| | - Austin R. Pantel
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19147, USA
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2
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Keam S, Turner N, Kugeratski FG, Rico R, Colunga-Minutti J, Poojary R, Alekseev S, Patel AB, Li YJ, Sheshadri A, Loghin ME, Woodman K, Aaroe AE, Hamidi S, Iyer PC, Palaskas NL, Wang Y, Nurieva R. Toxicity in the era of immune checkpoint inhibitor therapy. Front Immunol 2024; 15:1447021. [PMID: 39247203 PMCID: PMC11377343 DOI: 10.3389/fimmu.2024.1447021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 07/23/2024] [Indexed: 09/10/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) reinvigorate anti-tumor immune responses by disrupting co-inhibitory immune checkpoint molecules such as programmed cell death 1 (PD-1) and cytotoxic T lymphocyte antigen 4 (CTLA-4). Although ICIs have had unprecedented success and have become the standard of care for many cancers, they are often accompanied by off-target inflammation that can occur in any organ system. These immune related adverse events (irAEs) often require steroid use and/or cessation of ICI therapy, which can both lead to cancer progression. Although irAEs are common, the detailed molecular and immune mechanisms underlying their development are still elusive. To further our understanding of irAEs and develop effective treatment options, there is pressing need for preclinical models recapitulating the clinical settings. In this review, we describe current preclinical models and immune implications of ICI-induced skin toxicities, colitis, neurological and endocrine toxicities, pneumonitis, arthritis, and myocarditis along with their management.
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Affiliation(s)
- Synat Keam
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Naimah Turner
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Fernanda G Kugeratski
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Rene Rico
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jocelynn Colunga-Minutti
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- The University of Texas MD Anderson Cancer Center University of Texas Health (UTHealth) Houston Graduate School of Biomedical Sciences (GSBS), Houston, TX, United States
| | | | - Sayan Alekseev
- College of Sciences, The University of Texas at San Antonio, San Antonio, TX, United States
- The Cancer Prevention and Research Institute of Texas (CPRIT)-CURE Summer Undergraduate Program, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Anisha B Patel
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Yuanteng Jeff Li
- Department of General Internal Medicine, Section of Rheumatology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ajay Sheshadri
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Monica E Loghin
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Karin Woodman
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ashley E Aaroe
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Sarah Hamidi
- Department of Endocrine Neoplasia and HD, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Priyanka Chandrasekhar Iyer
- Department of Endocrine Neoplasia and HD, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Nicolas L Palaskas
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Roza Nurieva
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- The University of Texas MD Anderson Cancer Center University of Texas Health (UTHealth) Houston Graduate School of Biomedical Sciences (GSBS), Houston, TX, United States
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3
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Pozzessere C, Mazini B, Omoumi P, Jreige M, Noirez L, Digklia A, Fasquelle F, Sempoux C, Dromain C. Immune-Related Adverse Events Induced by Immune Checkpoint Inhibitors and CAR-T Cell Therapy: A Comprehensive Imaging-Based Review. Cancers (Basel) 2024; 16:2585. [PMID: 39061225 PMCID: PMC11274393 DOI: 10.3390/cancers16142585] [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: 05/07/2024] [Revised: 07/09/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024] Open
Abstract
Immunotherapy has revolutionized oncology care, improving patient outcomes in several cancers. However, these therapies are also associated with typical immune-related adverse events due to the enhanced inflammatory and immune response. These toxicities can arise at any time during treatment but are more frequent within the first few months. Any organ and tissue can be affected, ranging from mild to life-threatening. While some manifestations are common and more often mild, such as dermatitis and colitis, others are rarer and more severe, such as myocarditis. Management depends on the severity, with treatment being held for >grade 2 toxicities. Steroids are used in more severe cases, and immunosuppressive treatment may be considered for non-responsive toxicities, along with specific organ support. A multidisciplinary approach is mandatory for prompt identification and management. The diagnosis is primarily of exclusion. It often relies on imaging features, and, when possible, cytologic and/or pathological analyses are performed for confirmation. In case of clinical suspicion, imaging is required to assess the presence, extent, and features of abnormalities and to evoke and rule out differential diagnoses. This imaging-based review illustrates the diverse system-specific toxicities associated with immune checkpoint inhibitors and chimeric antigen receptor T-cells with a multidisciplinary perspective. Clinical characteristics, imaging features, cytological and histological patterns, as well as the management approach, are presented with insights into radiological tips to distinguish these toxicities from the most important differential diagnoses and mimickers-including tumor progression, pseudoprogression, inflammation, and infection-to guide imaging and clinical specialists in the pathway of diagnosing immune-related adverse events.
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Affiliation(s)
- Chiara Pozzessere
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), CH-1011 Lausanne, Switzerland
| | - Bianca Mazini
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), CH-1011 Lausanne, Switzerland
| | - Patrick Omoumi
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), CH-1011 Lausanne, Switzerland
| | - Mario Jreige
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital (CHUV), CH-1011 Lausanne, Switzerland
| | - Leslie Noirez
- Department of Pulmonology, Lausanne University Hospital (CHUV), CH-1011 Lausanne, Switzerland
| | - Antonia Digklia
- Department of Oncology, Lausanne University Hospital (CHUV), CH-1011 Lausanne, Switzerland
| | - François Fasquelle
- Department of Pathology, Lausanne University Hospital (CHUV), CH-1011 Lausanne, Switzerland
| | - Christine Sempoux
- Department of Pathology, Lausanne University Hospital (CHUV), CH-1011 Lausanne, Switzerland
| | - Clarisse Dromain
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), CH-1011 Lausanne, Switzerland
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Speranza D, Santarpia M, Luppino F, Omero F, Maiorana E, Cavaleri M, Sapuppo E, Cianci V, Pugliese A, Racanelli V, Camerino GM, Rodolico C, Silvestris N. Immune checkpoint inhibitors and neurotoxicity: a focus on diagnosis and management for a multidisciplinary approach. Expert Opin Drug Saf 2024:1-14. [PMID: 38819976 DOI: 10.1080/14740338.2024.2363471] [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: 03/22/2024] [Accepted: 05/28/2024] [Indexed: 06/02/2024]
Abstract
INTRODUCTION Although immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment, the consequential over activation of the immune system is often complicated by adverse events that can affect several organs and systems, including the nervous system. The precise pathophysiology underlying neurological irAEs (n-irAEs) is not completely known. Around 3.8% of patients receiving anti-CTLA-4 agents, 6.1% of patients receiving anti-PD-1/PD-L1, and 12% of patients receiving combination therapies have n-irAEs. Most n-irAEs are low-grade, while severe toxicities have rarely been reported. in this article, we performed an updated literature search on immuno-related neurotoxicity on main medical research database, from February 2017 to December 2023. AREAS COVERED We have also compared the latest national and international guidelines on n-irAEs management with each other in order to better define patient management. EXPERT OPINION A multidisciplinary approach appears necessary in the management of oncological patients during immunotherapy. Therefore, in order to better manage these toxicities, we believe that it is essential to collaborate with neurologists specialized in the diagnosis and treatment of n-irAEs, and that a global neurological assessment, both central and peripheral, is necessary before starting immunotherapy, with regular reassessment during treatment.
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Affiliation(s)
- Desirèe Speranza
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina, Italy
| | - Mariacarmela Santarpia
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina, Italy
| | - Francesco Luppino
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Fausto Omero
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina, Italy
| | - Enrica Maiorana
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina, Italy
| | - Mariacarmela Cavaleri
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina, Italy
| | - Elena Sapuppo
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina, Italy
| | - Vincenzo Cianci
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Alessia Pugliese
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Vito Racanelli
- Centre for Medical Sciences (CISMed), University of Trento and Internal Medicine Department, Trento, Italy
| | | | - Carmelo Rodolico
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Nicola Silvestris
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina, Italy
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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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Brown SR, Vomhof-DeKrey EE. Current Immunotherapy Treatments of Primary Breast Cancer Subtypes. Biomedicines 2024; 12:895. [PMID: 38672249 PMCID: PMC11048522 DOI: 10.3390/biomedicines12040895] [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: 02/27/2024] [Revised: 04/02/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Breast cancer receives the most funding when compared to any other cancer type, according to a global study conducted by The Lancet. Nevertheless, this malignancy remains the most diagnosed cancer among women and relies heavily on a neoadjuvant treatment regimen of chemotherapy and targeted therapy. After standard treatment, 25-30% of breast cancer patients still develop disease recurrence and must undergo cytoreductive debulking surgery followed by intensive chemotherapy. An array of targeted therapies are currently being utilized and developed to alleviate negative side effects, eradicate cancer growth, and diminish disease recurrence. Immunotherapy is a promising cancer therapy that upregulates one's immune system to stimulate a therapeutic effect and is utilized for cancer management among other ailments such as immunodeficiencies, hypersensitivity reactions, autoimmune diseases, inflammatory disorders, tissue and organ transplantation, and infectious diseases. This review highlights the five primary subtypes of breast cancer, provides a brief history of immunotherapy, evaluates the current landscape of treating breast cancer with immunotherapy, analyzes selected ongoing or recently completed immunotherapy clinical trials for hormone receptor-positive, HER2-enriched, and triple-negative breast cancer, and examines future trends for the treatment of breast cancer with immunotherapeutic techniques. This review provides a formal summary categorized by breast cancer subtype rather than types of immunotherapeutic treatment.
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Affiliation(s)
- Savannah R. Brown
- Department of Pathology, School of Medicine and the Health Sciences, University of North Dakota, Grand Forks, ND 58202, USA;
| | - Emilie E. Vomhof-DeKrey
- Department of Pathology, School of Medicine and the Health Sciences, University of North Dakota, Grand Forks, ND 58202, USA;
- Department of Surgery, School of Medicine and the Health Sciences, University of North Dakota, Grand Forks, ND 58202, USA
- Department of Biomedical Sciences, School of Medicine and the Health Sciences, University of North Dakota, Grand Forks, ND 58202, USA
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7
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Bonilla CE, Ávila V. Immune-Related Peripheral Neuropathy Associated with Immune Checkpoint Inhibitors: Case Report and Review of Literature. Case Rep Oncol Med 2024; 2024:8212943. [PMID: 38596399 PMCID: PMC11003791 DOI: 10.1155/2024/8212943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/09/2024] [Accepted: 03/11/2024] [Indexed: 04/11/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) are a group of drugs that have improved outcomes for patients with various cancers. Generally considered safe and well tolerated, these drugs are occasionally linked to immune-mediated or immune-related adverse events. Among these, autoimmune neurological events are rare, displaying varying incidence rates across different studies. Peripheral neuropathy, although one of the more common neurological immune-related events, is at times underestimated. This case report highlights an adult patient diagnosed with metastatic intrahepatic cholangiocarcinoma. Initially, the patient underwent chemoimmunotherapy with gemcitabine, cisplatin, and durvalumab for eight cycles, achieving partial response without significant toxicity. Following this, the patient continued with maintenance monotherapy with durvalumab every 28 days. After completing six cycles of maintenance therapy, the patient suddenly experienced paresthesia and hypoesthesia in four limbs, accompanied by apraxia in the hands that was more pronounced on the right side. Additionally, the patient reported neuropathic pain in the right arm and encountered limitations in certain instrumental activities of daily living. Diagnostic studies, including laboratory and electrophysiological studies, combined with the clinical presentation, identified immune-related peripheral polyneuropathy. Durvalumab was suspended and prednisolone therapy was initiated, resulting in a rapid resolution of all neuropathic symptoms. In addition to the clinical case, this article reviews the literature on immunotherapy-associated peripheral neuropathy.
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Affiliation(s)
- Carlos Eduardo Bonilla
- Unidad Funcional de Tumores Gastrointestinales, Centro de Tratamiento e Investigación sobre Cáncer Luis Carlos Sarmiento Angulo (CTIC), Bogotá, Colombia
- Grupo de Investigación GIGA, CTIC/Universidad El Bosque, Bogotá, Colombia
| | - Vaneza Ávila
- Grupo de Investigación GIGA, CTIC/Universidad El Bosque, Bogotá, Colombia
- Unidad Funcional Asistencial Hospitalización, Centro de Tratamiento e Investigación sobre Cáncer Luis Carlos Sarmiento Angulo (CTIC), Bogotá, Colombia
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8
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Selamet U, Ahdoot RS, Salasnek R, Abdelnour L, Hanna RM. Onconephrology: mitigation of renal injury in chemotherapy administration. Curr Opin Nephrol Hypertens 2024; 33:257-266. [PMID: 38095483 DOI: 10.1097/mnh.0000000000000960] [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: 01/23/2024]
Abstract
PURPOSE OF REVIEW Onconephrology was first coined as a name for the intersection of cancer medicine and nephrology in the early 2010s. It was recognized then that beyond and understanding of kidney physiology, a new generation of nephrologists skilled in both molecular biology and precision medicine were needed to deal with the challenges of emerging cancer therapies. Stem cell transplants, biologic agents, adjuvants blocking basic cellular signaling pathways, immunotherapy were found to promote novel anticancer outcomes, but also to pose new risks to the kidneys. The field rapidly overlapped with emerging expertise in vascular glomerular disease, glomerular disease, and the same biologic agents now applied to auto immune systemic and kidney diseases. RECENT FINDINGS Many categories of chemotherapeutic agents have been discovered to have adverse renal side effects. In this review, we address classic chemotherapeutic nephrotoxicity and oncologic clinical situations leading to acute kidney injury. We also review the frontiers of nephrotoxicity reported with cell cycle inhibitors, diverse classes of tyrosine kinase inhibitors, immune checkpoint inhibitors, chimeric antigen receptor T-cell therapy, anticancer vaccines, and thrombotic microangiopathies triggered by malignancy and chemotherapy. The aim will be to focus on published strategies to mitigate nephrotoxicity. SUMMARY As onconephrology expands into its own field, it gives birth to new subdisciplines. An understanding that patient populations want the benefits of chemotherapy without the renal (and other) systemic toxicities is emerging. A need to develop a new class of molecular and genetic experts in onconephrology to mitigate nephrotoxicity from chemotherapy is apparent and urgent.
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Affiliation(s)
- Umut Selamet
- Department of Medical Oncology of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Rebecca S Ahdoot
- Department of Medicine- Division of Nephrology, University of California-Irvine, Irvine
| | - Reed Salasnek
- Department of Medicine- Division of Nephrology, University of California-Irvine, Irvine
| | - Lama Abdelnour
- Department of Medicine-Division of Nephrology, University of California Los Angeles, Los Angeles, CA, USA
| | - Ramy M Hanna
- Department of Medicine- Division of Nephrology, University of California-Irvine, Irvine
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Hung SC, Guimaraes C. Imaging of Childhood Cerebral Vasculitis. Neuroimaging Clin N Am 2024; 34:149-166. [PMID: 37951700 DOI: 10.1016/j.nic.2023.07.005] [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] [Indexed: 11/14/2023]
Abstract
Childhood cerebral vasculitis is a condition that affects the blood vessels in the brain of children and is rare but life-threatening. Imaging plays a crucial role in the diagnosis and monitoring of the disease. This article describes the classification, diagnostic algorithm, and various imaging modalities used in the evaluation of childhood cerebral vasculitis and the imaging findings associated with primary and secondary vasculitis. Understanding the imaging features of this condition can assist in early diagnosis, effective treatment, and improve outcomes.
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Affiliation(s)
- Sheng-Che Hung
- Department of Radiology, University of North Carolina, 2000 Old Clinic, CB# 7510, Chapel Hill, NC 27599, USA.
| | - Carolina Guimaraes
- Department of Radiology, University of North Carolina, 2000 Old Clinic, CB# 7510, Chapel Hill, NC 27599, USA
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10
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Rahnea-Nita RA, Rebegea LF, Toma RV, Mocanu H, Soare I, Mihailov R, Nechifor A, Guliciuc M, Constantin GB, Rahnea-Nita G. Immunotherapy Combined with Radiation in Malignant Melanoma without BRAF Mutations Brain Metastases-Favorable Response after Immunotherapy Continued beyond Progression. J Pers Med 2024; 14:86. [PMID: 38248787 PMCID: PMC10817469 DOI: 10.3390/jpm14010086] [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: 11/27/2023] [Accepted: 01/10/2024] [Indexed: 01/23/2024] Open
Abstract
We present the case of a patient who was diagnosed in 2018 with nodular Malignant Melanoma (MM) without BRAF V 600 mutations stage 3 C (pT4b pN1a M0), and who underwent adjuvant citokines treatment with Interferon alpha 2b-48 weeks. Immunotherapy was initiated in January 2021 for lung and lymph node metastases. In June 2021, there was a partial response of the lung and lymph node metastases, but there was also progression to brain metastases. Immunotherapy was continued and Whole Brain Radiotherapy (WBRT) was performed. In September 2023, the imaging investigations revealed a favorable response, with no lesions suggestive of secondary determinations. The combination of Radiotherapy (RT) and Immunotherapy (IT) with Immune Checkpoint Inhibitors (ICI) has an abscopal effect. There is a coordinated action in the combination of RT and IT in order to obtain a common result, with the antitumor effect being greater than if RT or IT acted separately.
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Affiliation(s)
- Roxana-Andreea Rahnea-Nita
- The Clinical Department, The Faculty of Medicine, The University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania; (R.-A.R.-N.); (R.-V.T.)
- The Oncology-Palliative Care Department, “Sf. Luca” Chronic Disease Hospital, 041915 Bucharest, Romania;
| | - Laura-Florentina Rebegea
- The Clinical Department, The Faculty of Medicine and Pharmacy, “Dunarea de Jos” University in Galati, 800008 Galati, Romania; (L.-F.R.); (R.M.); (A.N.); (M.G.)
- The Radiotherapy Department, “Sf. Ap. Andrei” County Emergency Clinical Hospital, 800579 Galati, Romania
- The Research Center in the Field of Medical and Pharmaceutical Sciences, ReFORM-UDJ, 800010 Galati, Romania
| | - Radu-Valeriu Toma
- The Clinical Department, The Faculty of Medicine, The University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania; (R.-A.R.-N.); (R.-V.T.)
- The Radiotherapy Department, The Oncological Institute, 022328 Bucharest, Romania
| | - Horia Mocanu
- The Clinical Department, The Faculty of Medicine, “Titu Maiorescu” University, 040051 Bucharest, Romania; (H.M.); (I.S.)
- The E.N.T Department, Gaesti City Hospital, 135200 Gaesti, Romania
| | - Ioana Soare
- The Clinical Department, The Faculty of Medicine, “Titu Maiorescu” University, 040051 Bucharest, Romania; (H.M.); (I.S.)
| | - Raul Mihailov
- The Clinical Department, The Faculty of Medicine and Pharmacy, “Dunarea de Jos” University in Galati, 800008 Galati, Romania; (L.-F.R.); (R.M.); (A.N.); (M.G.)
| | - Alexandru Nechifor
- The Clinical Department, The Faculty of Medicine and Pharmacy, “Dunarea de Jos” University in Galati, 800008 Galati, Romania; (L.-F.R.); (R.M.); (A.N.); (M.G.)
| | - Mădălin Guliciuc
- The Clinical Department, The Faculty of Medicine and Pharmacy, “Dunarea de Jos” University in Galati, 800008 Galati, Romania; (L.-F.R.); (R.M.); (A.N.); (M.G.)
- The Urology Department, “Sf. Ap. Andrei” County Emergency Clinical Hospital, 800579 Galati, Romania
| | - Georgiana Bianca Constantin
- The Morphological and Functional Sciences Department, The Faculty of Medicine and Pharmacy, “Dunarea de Jos” University in Galati, 800008 Galati, Romania
| | - Gabriela Rahnea-Nita
- The Oncology-Palliative Care Department, “Sf. Luca” Chronic Disease Hospital, 041915 Bucharest, Romania;
- The Clinical Department, The Faculty of Midwifery and Nursing, The University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
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11
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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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Brahmbhatt S, Overfield CJ, Rhyner PA, Bhatt AA. Imaging of the Posttreatment Head and Neck: Expected Findings and Potential Complications. Radiol Imaging Cancer 2024; 6:e230155. [PMID: 38276904 PMCID: PMC10825710 DOI: 10.1148/rycan.230155] [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: 09/08/2023] [Revised: 12/11/2023] [Accepted: 12/15/2023] [Indexed: 01/27/2024]
Abstract
Interpretation of posttreatment imaging findings in patients with head and neck cancer can pose a substantial challenge. Malignancies in this region are often managed through surgery, radiation therapy, chemotherapy, and newer approaches like immunotherapy. After treatment, patients may experience various expected changes, including mucositis, soft-tissue inflammation, laryngeal edema, and salivary gland inflammation. Imaging techniques such as CT, MRI, and PET scans help differentiate these changes from tumor recurrence. Complications such as osteoradionecrosis, chondroradionecrosis, and radiation-induced vasculopathy can arise because of radiation effects. Radiation-induced malignancies may occur in the delayed setting. This review article emphasizes the importance of posttreatment surveillance imaging to ensure proper care of patients with head and neck cancer and highlights the complexities in distinguishing between expected treatment effects and potential complications. Keywords: CT, MR Imaging, Radiation Therapy, Ear/Nose/Throat, Head/Neck, Nervous-Peripheral, Bone Marrow, Calvarium, Carotid Arteries, Jaw, Face, Larynx © RSNA, 2024.
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Affiliation(s)
- Sneh Brahmbhatt
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd,
Cannaday Building and Davis Building, Jacksonville, FL 32224
| | - Cameron J. Overfield
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd,
Cannaday Building and Davis Building, Jacksonville, FL 32224
| | - Patricia A. Rhyner
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd,
Cannaday Building and Davis Building, Jacksonville, FL 32224
| | - Alok A. Bhatt
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd,
Cannaday Building and Davis Building, Jacksonville, FL 32224
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13
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Miao YD, Quan WX, Tang XL, Shi WW, Li Q, Li RJ, Wang JT, Gan J, Dong X, Hao L, Luan WY, Zhang F. Uncovering the flip side of immune checkpoint inhibitors: a comprehensive review of immune-related adverse events and predictive biomarkers. Int J Biol Sci 2024; 20:621-642. [PMID: 38169638 PMCID: PMC10758091 DOI: 10.7150/ijbs.89376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/25/2023] [Indexed: 01/05/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) have generated considerable excitement as a novel class of immunotherapeutic agents due to their remarkable efficacy in treating various types of cancer. However, the widespread use of ICIs has brought about a number of safety concerns, especially the development of immune-related adverse events (irAEs). These serious complications could result in treatment discontinuation and even life-threatening consequences, making it critical to identify high-risk groups and predictive markers of irAEs before initiating therapy. To this end, the current article examines several potential predictive markers of irAEs in important organs affected by ICIs. While retrospective studies have yielded some promising results, limitations such as small sample sizes, variable patient populations, and specific cancer types and ICIs studied make it difficult to generalize the findings. Therefore, prospective cohort studies and real-world investigations are needed to validate the potential of different biomarkers in predicting irAEs risk. Overall, identifying predictive markers of irAEs is a crucial step towards improving patient safety and enhancing the management of irAEs. With ongoing research efforts, it is hoped that more accurate and reliable biomarkers will be identified and incorporated into clinical practice to guide treatment decisions and prevent the development of irAEs in susceptible patients.
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Affiliation(s)
- Yan-Dong Miao
- Cancer Center, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Wu-Xia Quan
- Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Xiao-Long Tang
- The First Clinical Medical College, Lanzhou University, Lanzhou 730000, China
| | - Wei-Wei Shi
- Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Qing Li
- Cancer Center, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Rui Jian Li
- Cancer Center, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Jiang-Tao Wang
- Department of Thyroid and Breast Surgery, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Jian Gan
- Department of Gastroenterology, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Xin Dong
- Cancer Center, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Liang Hao
- Cancer Center, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Wen-Yu Luan
- Cancer Center, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
| | - Fang Zhang
- Cancer Center, Yantai Affiliated Hospital of Binzhou Medical University, The 2 nd Medical College of Binzhou Medical University, Yantai 264100, China
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14
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Khurana A, Dubey H, Arora MK. Assessment of Neurologic Safety Profile of Immune Checkpoint Inhibitors: Evaluation of Adverse Drug Reaction Reports. Curr Drug Saf 2024; 19:382-394. [PMID: 38310553 DOI: 10.2174/0115748863273507231116112824] [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: 07/29/2023] [Revised: 10/05/2023] [Accepted: 10/12/2023] [Indexed: 02/06/2024]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) used in immunotherapy have revolutionized cancer management. However, ICI therapy can come with serious neurologic risks. OBJECTIVE The objective of our study is to analyze the occurrence of neurologic events with ICIs. METHODS We referred to EudraVigilance (EV) and VigiAccess to evaluate the frequency of individual case safety reports (ICSRs), including neurologic events with ICIs. Data was gathered for a period from the date of ICI's marketing authorization till 30 January 2023. The computational assessment was conducted with the help of reporting odds ratio (ROR) and its 95% confidence interval (CI). RESULTS Overall, 8181 ICSRs in EV and 15905 ICSRs from VigiAccess were retrieved for neurologic events, with at least one ICI as the suspected drug. The majority of the ICSRs were reported for nivolumab, pembrolizumab, and ipilimumab, whereas frequently reported events were neuropathy peripheral, myasthenia gravis, seizure, Guillain-Barre syndrome, paraesthesia, syncope, encephalopathy, somnolence. Under EV, 92% of ICSRs were reported as serious, 10% included fatal outcomes, and nearly 61% cited patient recovery. Atezolizumab (ROR 1.64, 95% CI 1.75- 1.52), cemiplimab (ROR 1.61, 95% CI 1.98-1.3), and nivolumab (ROR 1.38, 95% CI 1.44-1.31) had a considerable increase in the frequency of ICSR reporting. Cerebrovascular accident, posterior reversible encephalopathy syndrome, tremor, and somnolence were identified as potential signals. CONCLUSION ICIs were significantly associated with neurologic risks, which cannot be generalized. A considerable increase in ICSR reporting frequency was observed with atezolizumab, cemiplimab, and nivolumab, while avelumab, pembrolizumab, durvalumab, and cemiplimab were linked with four potential signals. These findings suggest the consideration of a revision of the neurologic safety profile of ICIs. Furthermore, the necessity for additional ad-hoc research is emphasized.
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Affiliation(s)
- Atul Khurana
- School of Pharmaceutical and Population Health Informatics, DIT University, Dehradun, India
| | - Harikesh Dubey
- The Institute for Quantitative Health Science and Engineering, Michigan State University, East Lansing, United States of America
| | - Mandeep Kumar Arora
- School of Pharmaceutical and Population Health Informatics, DIT University, Dehradun, India
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15
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Simao P, Almeida MJ, Catela J, Matias F. Convexal subarachnoid haemorrhage in a patient under pembrolizumab-lenvatinib combination therapy. BMJ Case Rep 2023; 16:e256100. [PMID: 38081747 PMCID: PMC10728919 DOI: 10.1136/bcr-2023-256100] [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] [Indexed: 12/18/2023] Open
Abstract
A woman in her 60s was brought to the emergency department due to a new-onset seizure. She was drowsy on arrival and unable to provide a clinical history. She had a medical history of advanced endometrial cancer, for which she was under the therapeutic protocol pembrolizumab plus lenvatinib. Laboratorial investigations were unremarkable. The brain CT angiography provided further insight into the case by detecting a bilateral convexal subarachnoid haemorrhage with discrete bilateral opercular vasogenic oedema, without other noticeable structural changes. Cerebrospinal fluid analysis was macroscopically haemorrhagic, but otherwise unremarkable. The brain MRI did not provide additional information. Although considered a rare adverse reaction, cerebral haemorrhage has been described for both pembrolizumab and lenvatinib. We cautiously assumed a probable drug aetiology after a thorough review of potential causes. Following discontinuation of these drugs and under anti-convulsive therapy, the patient remained asymptomatic and was discharged home.
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Affiliation(s)
- Paulo Simao
- Internal Medicine, Centro Hospitalar e Universitario de Coimbra EPE Campus dos Hospitais da Universidade de Coimbra, Coimbra, Portugal
- Internal Medicine, Centro Hospitalar e Universitário Cova da Beira EPE, Covilhã, Portugal
| | - Marco José Almeida
- Neurology, Centro Hospitalar e Universitario de Coimbra EPE Campus dos Hospitais da Universidade de Coimbra, Coimbra, Portugal
| | - João Catela
- Neurosurgery, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Fernando Matias
- Neurology, Centro Hospitalar e Universitario de Coimbra EPE Campus dos Hospitais da Universidade de Coimbra, Coimbra, Portugal
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Luciano A, Liguori L, Polcaro G, Sabbatino F, Pepe S. Evaluation of Potential Predictive Biomarkers for Defining Brain Radiotherapy Efficacy in Non-Small Cell Lung Cancer Patients with Brain Metastases: A Case Report and a Narrative Review. Clin Pract 2023; 13:1549-1560. [PMID: 38131685 PMCID: PMC10742049 DOI: 10.3390/clinpract13060136] [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: 09/24/2023] [Revised: 11/16/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023] Open
Abstract
Non-small cell lung cancer (NSCLC) is the second most common cancer worldwide, resulting in 1.8 million deaths per year. Most patients are diagnosed with a metastatic disease. Brain metastases are one of the most common metastatic sites and are associated with severe neurological symptoms, shorter survival, and the worst clinical outcomes. Brain radiotherapy and systemic oncological therapies are currently used for controlling both cancer progression and neurological symptoms. Brain radiotherapy includes stereotactic brain ablative radiotherapy (SBRT) or whole brain radiotherapy (WBRT). SBRT is applied for single or multiple (up to ten) small (diameter less than 4 cm) lesions, whereas WBRT is usually applied for multiple (more than ten) and large (diameter greater than 4 cm) brain metastases. In both cases, radiotherapy application may be viewed as an overtreatment which causes severe toxicities without achieving a significant clinical benefit. Thus far, a number of scoring systems to define the potential clinical benefits derived from brain radiotherapy have been proposed. However, most are not well established in clinical practice. In this article, we present a clinical case of a patient with advanced NSCLC carrying a BRAFV600E mutation and brain metastases. We review the variables in addition to applicable scoring systems considered to have potential for predicting clinical outcomes and benefits of brain radiotherapy in patients with advanced NSCLC and brain metastases. Lastly, we highlight the unmet need of specific scoring systems for advanced NSCLC patients with brain metastases carrying oncogene alterations including BRAFV600E mutations.
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Affiliation(s)
- Angelo Luciano
- Oncology Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (A.L.); (L.L.); (G.P.); (S.P.)
- Oncology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
| | - Luigi Liguori
- Oncology Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (A.L.); (L.L.); (G.P.); (S.P.)
- Oncology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
| | - Giovanna Polcaro
- Oncology Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (A.L.); (L.L.); (G.P.); (S.P.)
| | - Francesco Sabbatino
- Oncology Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (A.L.); (L.L.); (G.P.); (S.P.)
| | - Stefano Pepe
- Oncology Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (A.L.); (L.L.); (G.P.); (S.P.)
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17
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Rumler S. Non-cellular immunotherapies in pediatric central nervous system tumors. Front Immunol 2023; 14:1242911. [PMID: 37885882 PMCID: PMC10598668 DOI: 10.3389/fimmu.2023.1242911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/21/2023] [Indexed: 10/28/2023] Open
Abstract
Central nervous system (CNS) tumors are the second most common type of cancer and the most common cause of cancer death in pediatric patients. New therapies are desperately needed for some of the most malignant of all cancers. Immunotherapy has emerged in the past two decades as an additional avenue to augment/replace traditional therapies (such as chemotherapy, surgery, and radiation therapy). This article first discusses the unique nature of the pediatric CNS immune system and how it interacts with the systemic immune system. It then goes on to review three important and widely studied types of immune therapies: checkpoint inhibitors, vaccines, and radiation therapy, and touches on early studies of antibody-mediated immunogenic therapies, Finally, the article discusses the importance of combination immunotherapy for pediatric CNS tumors, and addresses the neurologic toxicities associated with immunotherapies.
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Affiliation(s)
- Sarah Rumler
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
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18
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Villa A, Kuten-Shorrer M. Pathogenesis of Oral Toxicities Associated with Targeted Therapy and Immunotherapy. Int J Mol Sci 2023; 24:ijms24098188. [PMID: 37175898 PMCID: PMC10179284 DOI: 10.3390/ijms24098188] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/04/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
Targeted therapy and immunotherapy have redefined cancer treatment. While they have enhanced tumor response and improved survival rates in many cancer types, toxicities continue to occur, and these often involve the oral cavity. Broadly reported as "mucositis" or "stomatitis," oral toxicities induced by targeted therapies differ clinically and mechanistically from those associated with conventional chemotherapy. Manifesting primarily as mucosal lesions, salivary gland hypofunction, or orofacial neuropathies, these oral toxicities may nonetheless lead to significant morbidity and impact patients' quality of life, thereby compromising clinical outcomes. We conclude that familiarity with the spectrum of associated toxicities and understanding of their pathogenesis represent important areas of clinical research and may lead to better characterization, prevention, and management of these adverse events.
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Affiliation(s)
- Alessandro Villa
- Oral Medicine, Oral Oncology and Dentistry, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
- The Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33176, USA
- Department of Orofacial Sciences, University of California San Francisco, San Francisco, CA 94143, USA
| | - Michal Kuten-Shorrer
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, New York, NY 14642, USA
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19
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Evaluation and management of acute high-grade immunotherapy-related neurotoxicity. Heliyon 2023; 9:e13725. [PMID: 36851967 PMCID: PMC9958505 DOI: 10.1016/j.heliyon.2023.e13725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
Immune checkpoint inhibitor monoclonal antibodies allow the host's immune system to attack tumors, which has revolutionized cancer care over the last decade. As the use of immune checkpoint inhibitors has expanded, so have autoimmune-like complications known as immune-related adverse events. These include the infrequent but increasingly more common, potentially deadly neurological immune related adverse events. When feeling acutely ill, patients will often seek care not from their oncologist but from their family physician, clinics, emergency, and urgent care sites, or other available providers. Thus, while assessing acutely ill cancer patients who are experiencing neurological symptoms, non-oncologists should be prepared to recognize, diagnose, and treat neurological immune related adverse events in addition to more familiar conditions. This narrative review is designed to update acute care clinicians on current knowledge and to present a symptom-based framework for evaluating and treating neurological immune related adverse events based on the leading immunotoxicity organizations' latest recommendations.
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Berz AM, Boughdad S, Vietti-Violi N, Digklia A, Dromain C, Dunet V, Duran R. Imaging assessment of toxicity related to immune checkpoint inhibitors. Front Immunol 2023; 14:1133207. [PMID: 36911692 PMCID: PMC9995973 DOI: 10.3389/fimmu.2023.1133207] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/10/2023] [Indexed: 02/25/2023] Open
Abstract
In recent years, a wide range of cancer immunotherapies have been developed and have become increasingly important in cancer treatment across multiple oncologic diseases. In particular, immune checkpoint inhibitors (ICIs) offer promising options to improve patient outcomes. However, a major limitation of these treatments consists in the development of immune-related adverse events (irAEs) occurring in potentially any organ system and affecting up to 76% of the patients. The most frequent toxicities involve the skin, gastrointestinal tract, and endocrine system. Although mostly manageable, potentially life-threatening events, particularly due to neuro-, cardiac, and pulmonary toxicity, occur in up to 30% and 55% of the patients treated with ICI-monotherapy or -combination therapy, respectively. Imaging, in particular computed tomography (CT), magnetic resonance imaging (MRI), and 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/computed tomography (18F-FDG-PET/CT), plays an important role in the detection and characterization of these irAEs. In some patients, irAEs can even be detected on imaging before the onset of clinical symptoms. In this context, it is particularly important to distinguish irAEs from true disease progression and specific immunotherapy related response patterns, such as pseudoprogression. In addition, there are irAEs which might be easily confused with other pathologies such as infection or metastasis. However, many imaging findings, such as in immune-related pneumonitis, are nonspecific. Thus, accurate diagnosis may be delayed underling the importance for adequate imaging features characterization in the appropriate clinical setting in order to provide timely and efficient patient management. 18F-FDG-PET/CT and radiomics have demonstrated to reliably detect these toxicities and potentially have predictive value for identifying patients at risk of developing irAEs. The purpose of this article is to provide a review of the main immunotherapy-related toxicities and discuss their characteristics on imaging.
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Affiliation(s)
- Antonia M Berz
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Department of Radiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Berlin, Germany
| | - Sarah Boughdad
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Naïk Vietti-Violi
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Antonia Digklia
- Department of Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Clarisse Dromain
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Vincent Dunet
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Rafael Duran
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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