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Kotwal A, Kennedy R, Kikani N, Thosani S, Goldner W, Shariff A. Endocrinopathies Associated With Immune Checkpoint Inhibitor Use. Endocr Pract 2024; 30:584-591. [PMID: 38554775 DOI: 10.1016/j.eprac.2024.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/12/2024] [Accepted: 03/20/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE To provide a clinical approach towards immune checkpoint inhibitor (ICI)-associated endocrinopathies, their link with cancer outcomes, factors which differentiate them from other immune related adverse events, and health systems innovation to improve care for these patients. METHODS A literature search for articles pertaining to ICIs and endocrinopathies was performed and supplemented by expert opinions of the authors. RESULTS While immune related adverse events can affect almost any organ, they frequently target the endocrine glands, most commonly thyroid. Different classes of ICIs have varying frequencies of endocrinopathies related to hypophysitis, thyroiditis, diabetes mellitus, and rarely hypoadrenalism and hypoparathyroidism. ICI-associated endocrinopathies share some features with classic endocrine autoimmunity but appear to be a distinct entity. They can be challenging to diagnose and manage due to nonspecific clinical features, use of exogenous glucocorticoids, and at times rapid and severe hormone deficiency. The role of anti-inflammatory high-dose glucocorticoids is minimal, and the ICI does not usually require permanent discontinuation. ICI-associated endocrinopathies usually cause permanent hormone deficiency necessitating long-term management and patient engagement. ICI-thyroiditis has been associated with improved survival, while other endocrinopathies have not shown a significant association with outcomes in cancer patients receiving ICIs. Oncoendocrinology teams can improve the care of patients with ICI-associated endocrinopathies. CONCLUSION This narrative review provides guidance to clinicians prescribing ICIs and those managing ICI-associated endocrinopathies, and complements the frameworks provided by major scientific societies in this field.
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Affiliation(s)
- Anupam Kotwal
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, Nebraska.
| | - Randol Kennedy
- Division of Endocrinology, Metabolism, and Nutrition, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Nupur Kikani
- Department of Endocrine Neoplasia & Hormonal Disorders, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Sonali Thosani
- Department of Endocrine Neoplasia & Hormonal Disorders, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Whitney Goldner
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, Nebraska
| | - Afreen Shariff
- Division of Endocrinology, Metabolism, and Nutrition, Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Cancer Institute, Duke Health, Durham, North Carolina
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Liguori L, Luciano A, Polcaro G, Ottaiano A, Cascella M, Perri F, Pepe S, Sabbatino F. Prior Anti-Angiogenic TKI-Based Treatment as Potential Predisposing Factor to Nivolumab-Mediated Recurrent Thyroid Disorder Adverse Events in mRCC Patients: A Case Series. Biomedicines 2023; 11:2974. [PMID: 38001973 PMCID: PMC10669217 DOI: 10.3390/biomedicines11112974] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/26/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) targeting programmed cell death 1 (PD-1) or its ligand 1 (PD-L1) have revolutionized the management of many types of solid tumors, including metastatic renal cell carcinoma (mRCC). Both sequential and combinatorial therapeutic strategies utilizing anti-PD-1 monoclonal antibodies (mAbs) and anti-angiogenic tyrosine kinase inhibitors (TKIs) have demonstrated to improve the survival of patients with mRCC as compared to standard therapies. On the other hand, both ICIs and TKIs are well known to potentially cause thyroid disorder adverse events (TDAEs). However, in the context of sequential therapeutic strategy, it is not clear whether prior anti-angiogenic TKI may increase the risk and/or the severity of ICI-related TDAEs. In this work, by describing and analyzing a case series of mRCC patients treated sequentially with prior TKIs and then with ICIs, we investigated the role of prior anti-angiogenic TKI-based treatment as a potential predisposing factor to anti-PD-1-mediated recurrent TDAEs, as well as its potential impact on the clinical characteristics of nivolumab-mediated recurrent TDAEs. Fifty mRCC patients were included in the analysis. TKI-mediated TDAEs were reported in ten out of fifty patients. TKI-mediated TDAEs were characterized by hypothyroidism in all ten patients. Specifically, 40%, 40% and 20% of patients presented grade 1, 2 and 3 hypothyroidisms, respectively. Following tumor progression and during anti-PD-1 nivolumab treatment, five out of ten patients developed anti-PD-1 nivolumab-mediated recurrent TDAEs. Anti-PD-1 nivolumab-mediated recurrent TDAEs were characterized by an early transient phase of thyrotoxicosis and a late phase of hypothyroidism in all five patients. The TDAEs were grade 1 and 2 in four and one patients, respectively. Prior anti-angiogenic TKI did not modify the clinical characteristics of nivolumab-mediated recurrent TDAEs. However, all five patients required an increased dosage of levothyroxine replacement therapy. In conclusion, our work suggests that prior anti-angiogenic TKI-based treatment significantly increases the risk of ICI-mediated recurrent TDAEs in patients with mRCC without modifying their clinical characteristics. The most relevant effect for these patients is the need to increase the dosage of lifelong levothyroxine replacement therapy.
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Affiliation(s)
- Luigi Liguori
- Oncology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (L.L.); (A.L.)
- Oncology Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (G.P.); (S.P.)
| | - Angelo Luciano
- Oncology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (L.L.); (A.L.)
- Oncology Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (G.P.); (S.P.)
| | - Giovanna Polcaro
- Oncology Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (G.P.); (S.P.)
| | - Alessandro Ottaiano
- SSD Innovative Therapies for Abdominal Metastases, Abdominal Oncology, INT IRCCS Foundation “G. Pascale”, 80131 Naples, Italy;
| | - Marco Cascella
- Unit of Anesthesiology, Intensive Care Medicine, and Pain, Department of Medicine, Surgery and Dentistry Medicine, University of Salerno, 84081 Baronissi, Italy;
| | - Francesco Perri
- Medical and Experimental Head and Neck Oncology Unit, INT IRCCS Foundation “G. Pascale”, 80131 Naples, Italy;
| | - Stefano Pepe
- Oncology Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (G.P.); (S.P.)
| | - Francesco Sabbatino
- Oncology Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy; (G.P.); (S.P.)
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Ruggeri RM, Spagnolo CC, Alibrandi A, Silvestris N, Cannavò S, Santarpia M. Predictors of thyroid adverse events during cancer immunotherapy: a real-life experience at a single center. J Endocrinol Invest 2023; 46:2399-2409. [PMID: 37076759 DOI: 10.1007/s40618-023-02096-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/07/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Thyroid dysfunction is among the most common immune-related adverse events (irAEs) of immune checkpoint inhibitors (ICIs) therapy. Data regarding potential predictors of the development of thyroid irAEs are still limited and sometimes conflicting. PATIENTS AND METHODS We assessed potential risk factors and clinical outcomes associated with the onset of thyroid irAEs in a cohort of patients with different types of cancer treated with ICIs at a single center. Clinical and biochemical data, including thyroid function tests and autoantibodies at baseline and during treatment, were collected, and the onset of thyroid irAEs was recorded. Patients with thyroid dysfunction and/or under levothyroxine therapy before starting ICI were excluded. RESULTS 110 patients (80 M, 30 F, aged 32-85 years; 56.4% non-small-cell lung cancer, 87% treated with anti-PD-1) with complete information were included in the study. Among them, 32 (29%) developed thyroid irAEs during ICIs therapy. Primary hypothyroidism was the most common irAEs, occurring in 31 patients (28.18% of the whole cohort), including 14 patients who experienced a transient thyrotoxicosis. About 60% of irAEs occurred within the first 8 weeks of therapy. At multivariate analysis, anti-thyroid autoantibodies positivity at baseline (OR 18.471, p = 0.022), a pre-existing (autoimmune and non-autoimmune) thyroid disorder (OR 16.307, p < 0.001), and a family history of thyroid diseases (OR = 9.287, p = 0.002) were independent predictors of the development of thyroid irAEs. CONCLUSION Our data confirm the high frequency of thyroid dysfunctions (mostly hypothyroidism) during ICIs, and provide data on valuable predictors of thyroid toxicities that may help clinicians in identifying patients at risk for developing irAEs.
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Affiliation(s)
- R M Ruggeri
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy.
- Medical Oncology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy.
- Unit of Statistical and Mathematical Sciences, Department of Economics, University of Messina, Messina, Italy.
- Endocrine Unit, Department of Clinical and Experimental Medicine, "Gaetano Martino" University Hospital, 98125, Messina, Italy.
| | - C C Spagnolo
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Medical Oncology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Unit of Statistical and Mathematical Sciences, Department of Economics, University of Messina, Messina, Italy
| | - A Alibrandi
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Medical Oncology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Unit of Statistical and Mathematical Sciences, Department of Economics, University of Messina, Messina, Italy
| | - N Silvestris
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Medical Oncology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Unit of Statistical and Mathematical Sciences, Department of Economics, University of Messina, Messina, Italy
| | - S Cannavò
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Medical Oncology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Unit of Statistical and Mathematical Sciences, Department of Economics, University of Messina, Messina, Italy
| | - M Santarpia
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Medical Oncology Unit, Department of Human Pathology of Adulthood and Childhood DETEV "G. Barresi", University of Messina, Messina, Italy
- Unit of Statistical and Mathematical Sciences, Department of Economics, University of Messina, Messina, Italy
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Zhang Q, Jiao X, Lai X. Clinical Characters and Influence Factors of Immune Checkpoint Inhibitor-related Thyroid Dysfunction. J Clin Endocrinol Metab 2023; 108:2916-2923. [PMID: 37183427 PMCID: PMC10583978 DOI: 10.1210/clinem/dgad260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/14/2023] [Accepted: 05/11/2023] [Indexed: 05/16/2023]
Abstract
CONTEXT Explore the clinical characteristics and influencing factors of immune thyroid dysfunction (ITD) caused by immune checkpoint inhibitors (ICIs) in the treatment of malignant tumors. METHODS This was a retrospective study of cancer patients treated with ICIs between January 2019 and December 2021 at the Second Affiliated Hospital of Nanchang University. According to the occurrence of thyroid dysfunction, patients were divided into an ITD group and non-ITD group. We describe the clinical characteristics, autoantibody levels, and their impact on prognosis of patients with ICI-related ITD. RESULT A total of 560 cases meeting the criteria were included, with a median follow-up time of 11.0 months. The incidence of ITD was 50.7%. Baseline TSH levels (OR, 1.935/mcIU/L; 95% CI, 1.613-2.321; P < .001) and combination targeted therapy (OR, 2.101; 95% CI, 1.433-3.079; P < .001) were most strongly associated with the occurrence of ITD. The median time to ITD in patients receiving medication with ICIs was 73 (34.5-149) days. Of the 87 patients initially diagnosed with hyperthyroid ITD, 46 (52.9%) progressed to hypothyroidism over the course of the disease. Baseline anti-thyroglobulin antibody abnormalities were strongly associated with the occurrence of ITD (OR, 67.393; 95% CI, 5.637-805.656; P = .001). Overall survival was significantly lower in patients who did not develop ITD than in those who did (hazard ratio, 0.523; 95% CI, 0.599-0.97; P < .001). CONCLUSION The incidence of ICI-related ITD is high, and the course of the disease is rapidly changing, and thyroid function in patients treated with immunotherapy should be monitored to detect ITD and permit early intervention.
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Affiliation(s)
- Qin Zhang
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Jiangxi 330006, Nanchang, China
| | - Xiaojuan Jiao
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Jiangxi 330006, Nanchang, China
| | - Xiaoyang Lai
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Jiangxi 330006, Nanchang, China
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Iwamoto Y, Kimura T, Dan K, Ohnishi M, Takenouchi H, Iwamoto H, Sanada J, Fushimi Y, Katakura Y, Shimoda M, Nakanishi S, Mune T, Kaku K, Kaneto H. Immune checkpoint inhibitor-induced hypothyroidism predicts treatment response in Japanese subjects. Front Endocrinol (Lausanne) 2023; 14:1221723. [PMID: 37583431 PMCID: PMC10424728 DOI: 10.3389/fendo.2023.1221723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/14/2023] [Indexed: 08/17/2023] Open
Abstract
Background Immune checkpoint inhibitors (ICIs) cause a variety of immune-related adverse events (irAEs). Among them, thyroid dysfunction is most frequently observed. Patients with irAEs have higher survival rates than those without irAEs, but there is no certainty as to whether the degree of thyroid dysfunction is associated with treatment response or survival with ICIs. Method This is a single-center, retrospective, observational study. The study included 466 patients who received ICI at Kawasaki Medical School Hospital from September 1, 2014, to May 31, 2022 and evaluated the degree of abnormal thyroid function and survival and remission rates after treatment with ICIs. Primary hypothyroidism of less than 10 μIU/mL TSH was classified as grade 1, and primary hypothyroidism requiring more than 10 μIU/mL TSH or levothyroxine as grade 2-4. Result The mean age of the study participants was 68.2 ± 10.3 years, and the percentage of male participants was 72.6%. The frequency of ICI-induced thyroid dysfunction in the study participants was 28.2%. TSH levels were significantly higher in Grade 1 and Grades 2-4 when treated with ICI compared to NTF (p<0.0001). The survival rate at 1 year after ICI administration was significantly higher with 64.9% for grade 1 and 88.9% for grades 2-4 compared to 52.1% for NTF (p<0.0001). Cancer stage at the time of ICI administration did not differ among the groups (p=0.68). Nevertheless, the remission rate assessed by RECIST criteria was significantly higher in grades 2-4 compared to NTF (p<0.0001). Conclusion ICI-induced thyroid dysfunction was significantly correlated with survival, mean observation time, and treatment remission rate. It is important to monitor thyroid hormone levels regularly in patients receiving ICIs.
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Affiliation(s)
- Yuichiro Iwamoto
- Division of Diabetes, Metabolism and Endocrinology, Kawasaki Medical School, Kurashiki, Japan
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6
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Cardona Z, Sosman JA, Chandra S, Huang W. Endocrine side effects of immune checkpoint inhibitors. Front Endocrinol (Lausanne) 2023; 14:1157805. [PMID: 37251665 PMCID: PMC10210589 DOI: 10.3389/fendo.2023.1157805] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/05/2023] [Indexed: 05/31/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have increasingly been the mainstay of treatment for numerous malignancies. However, due to their association with autoimmunity, ICIs have resulted in a variety of side effects that involve multiple organs including the endocrine system. In this review article, we describe our current understanding of the autoimmune endocrinopathies as a result of the use of ICIs. We will review the epidemiology, pathophysiology, clinical presentation, diagnosis, and management of the most commonly encountered endocrinopathies, including thyroiditis, hypophysitis, Type 1 diabetes, adrenalitis, and central diabetes insipidus.
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Affiliation(s)
- Zulma Cardona
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jeffrey A. Sosman
- Division of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Sunandana Chandra
- Division of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Wenyu Huang
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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7
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Percik R, Criseno S, Adam S, Young K, Morganstein DL. Diagnostic criteria and proposed management of immune-related endocrinopathies following immune checkpoint inhibitor therapy for cancer. Endocr Connect 2023; 12:e220513. [PMID: 36884258 PMCID: PMC10160541 DOI: 10.1530/ec-22-0513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/07/2023] [Indexed: 03/09/2023]
Abstract
Checkpoint inhibitors are now widely used in the management of many cancers. Endocrine toxicity is amongst the most common side effects. These endocrinopathies differ from most other immune-related toxicities in frequently being irreversible and rarely requiring cessation of checkpoint inhibitor therapy. This review considers an approach to the presentation and diagnosis of endocrinopathies, compared to classical endocrine diagnosis, suggesting improvements to classification and treatment based on fundamental endocrine principles. These will help to align management with other similar endocrine conditions and standardise the diagnosis and reporting of endocrine toxicity of checkpoint inhibitors to improve both endocrine and oncological care. In particular, the importance of considering any inflammatory phase (such as painful thyroiditis or hypophysitis resulting in the pituitary enlargement), from the endocrine consequences (transient hyperthyroidism followed by hypothyroidism, pan-hypopituitarism or isolated adrenocorticotrophic hormone deficiency), is highlighted. It is also important to consider the potential confounder of exogenous corticosteroids in adrenal suppression.
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Affiliation(s)
- Ruth Percik
- Institute of Endocrinology, Diabetes and Metabolism, Sheba Medical Centre, Ramat Gan, Israel
| | - Sherwin Criseno
- Department of Endocrinology, University Hospital Birmingham, Birmingham, UK
| | - Safwaan Adam
- Department of Endocrinology, The Christie NHS Foundation Trust, Manchester, UK
| | | | - Daniel L Morganstein
- Department of Endocrinology, Chelsea and Westminster Hospital, London, UK
- Royal Marsden Hospital, London, UK
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Kotwal A, Perlman JE, Goldner WS, Marr A, Mammen JS. Endocrine Dysfunction From Immune Checkpoint Inhibitors: Pearls and Pitfalls in Evaluation and Management. JCO Oncol Pract 2023:OP2300023. [PMID: 37023383 DOI: 10.1200/op.23.00023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
Immune checkpoint inhibitors (ICPis) have proven extremely efficacious in cancer therapy but also lead to a plethora of immune-related adverse events (irAEs). The endocrine irAEs are not only quite common but also may pose a challenge to the clinician while managing a patient with cancer treated with ICPis. The clinical features of endocrine dysfunction are usually nonspecific and may overlap with concurrent illnesses, underlying the importance of accurate hormone testing and efforts toward case-finding. The management of endocrine irAEs is unique in the focus being on hormone replacement rather than curtailing the autoimmune process. Although the management of thyroid irAEs appears straightforward, adrenal insufficiency and insulin-dependent diabetes can be life-threatening if not promptly recognized and treated. This clinical review synthesizes the studies to provide pearls and pitfalls in the evaluation and management of endocrine irAEs with specific reference to guidelines from oncologic societies.
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Affiliation(s)
- Anupam Kotwal
- Division of Diabetes, Endocrinology, and Metabolism, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Jordan E Perlman
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University Medical Center, Baltimore, MD
| | - Whitney S Goldner
- Division of Diabetes, Endocrinology, and Metabolism, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Alissa Marr
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Jennifer S Mammen
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University Medical Center, Baltimore, MD
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Alqaisi S, Rahman A. A Rare Case of Pembrolizumab-Associated Graves' Disease. Cureus 2023; 15:e34696. [PMID: 36909047 PMCID: PMC9998112 DOI: 10.7759/cureus.34696] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 02/09/2023] Open
Abstract
Immune checkpoint inhibitors (ICPis), such as pembrolizumab (Keytruda®), are associated with the development of several immune-related adverse events (irAEs). Thyroid dysfunction is a common endocrine irAE associated with pembrolizumab; however, Graves' disease induced by pembrolizumab is extremely rare. Few cases of this condition have been reported in the literature. Here, we report the case of a 50-year-old patient who presented with thyrotoxicosis that was attributed to Graves' disease secondary to pembrolizumab therapy.
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Affiliation(s)
- Sura Alqaisi
- Internal Medicine, Memorial Healthcare, Pembroke Pines, USA
| | - Ali Rahman
- Internal Medicine, Northwell Health at Mather Hospital, Port Jefferson, USA
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10
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Dwivedi SN, Kalaria T, Buch H. Thyroid autoantibodies. J Clin Pathol 2023; 76:19-28. [PMID: 36270794 DOI: 10.1136/jcp-2022-208290] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 09/24/2022] [Indexed: 12/26/2022]
Abstract
Thyroid-stimulating hormone (TSH) receptor antibody (TSH-R-Ab or TRAb) testing plays a pivotal role in arriving at the aetiological diagnosis in patients with thyrotoxicosis. A positive test establishes the diagnosis of Graves' disease (GD) while a negative result in conjunction with imaging studies supports other possible aetiologies. In patients with GD, TRAb levels at diagnosis and at the time of withdrawal of antithyroid drugs can identify patients who are unlikely to achieve remission and guide clinical management decisions. We provide an algorithm that incorporates TRAb in the decision-making process for the management of thyrotoxicosis. The utility of TRAb in predicting the risk of fetal and neonatal thyroid dysfunction is established and widely accepted in guidelines. TRAb may also help in the diagnosis of Graves' orbitopathy, especially in euthyroid or hypothyroid patients and its role in guiding its management is evolving as a useful adjunct to the clinical parameters used in making therapeutic decisions.Anti-thyroid peroxidase antibodies (TPOAb) and anti-thyroglobulin antibodies (TgAb) indicate thyroid autoimmunity. The most common use of TPOAb is to identify patients at a higher risk of progression to treatment-requiring hypothyroidism. They also aid the diagnosis of immune thyroiditis and Hashimoto's encephalopathy. Thyroglobulin measurement is used to help guide differentiated thyroid cancer treatment. TgAb is used as an accompanying test with thyroglobulin measurement as its presence can interfere with the thyroglobulin assay. A negative TgAb result reduces the likelihood of, but does not exclude, interference with thyroglobulin assay.
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Affiliation(s)
| | - Tejas Kalaria
- Clinical Biochemistry, New Cross Hospital, Black Country Pathology Services, Wolverhampton, UK
| | - Harit Buch
- Endocrinology and Diabetes, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
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11
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Sharma R. Hypothyroidism After Use of Immune Checkpoint Inhibitor Therapy in Patient With Graves' Disease: Cure? JCEM CASE REPORTS 2023; 1:luac024. [PMID: 37908246 PMCID: PMC10578381 DOI: 10.1210/jcemcr/luac024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Indexed: 11/02/2023]
Abstract
Immune checkpoint inhibitors (ICIs) are frequently used as treatment for many malignancies. Immune-related adverse events (irAEs) due to use of ICIs are common. Thyroid involvement is the most common endocrine irAE. Here, we present an unusual case of Graves' disease potentially cured due to destructive thyroiditis caused by inflammation due to ICIs. Thyroid irAEs are more common with programmed cell death protein-1 (PD-1) inhibitor or programmed cell death-ligand 1 (PD-L1) inhibitors than cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitors. Baseline and serial monitoring of thyroid function tests is recommended.
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Affiliation(s)
- Rajeev Sharma
- Division of Endocrinology, Roswell Park Comprehensive Cancer Center & Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York, NY 14203, USA
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12
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Hirao N, Iijima T, Tanuma D, Ohira E, Kurai H, Shinzawa T, Kase M, Sakurai S, Tomaru T, Jojima T, Usui I, Aso Y. Effects of treatment with methimazole on circulating CD4 + and CD8 + T cells positive for programed cell death protein-1 and on subsets of CD4 + T cells in untreated hyperthyroid patients with Graves' disease. Clin Endocrinol (Oxf) 2022; 97:841-848. [PMID: 35692119 DOI: 10.1111/cen.14788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/31/2022] [Accepted: 06/08/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We investigated longitudinal changes in circulating CD4+ and CD8+ T cells positive for programed cell death protein-1 (PD-1) and in other subsets of CD4+ T cells in untreated hyperthyroid patients with Graves' disease after treatment with methimazole (MMI). DESIGN AND PATIENTS The study included 18 untreated hyperthyroid patients with Graves' disease and 18 age-matched controls. Before and after 12-week treatment with MMI, we used flow cytometry to measure circulating PD-1+ D4+ and PD-1+ CD8+ T cells and subsets of CD4+ T cells in peripheral blood, as well as serum levels of chemokines related to T-helper type 1 (Th-1) and Th-2 cells. RESULTS At baseline, the percentage of CD4+ and CD8+ T cells expressing PD-1 was significantly higher in patients than in age-matched controls. Serum levels of chemokines related to Th-1 and Th-2 also were higher in patients. Twelve weeks after initiation of MMI, the percentage of CD4+ T cells expressing PD-1 was significantly lower than at baseline, but no such change was seen in CD8+ T cells. Furthermore, the percentage of Th-1 cells among CD4+ T cells and the serum levels of soluble CD26/dipeptidyl peptidase-4, a surface marker of Th-1 cells, also were significantly lower than at baseline. CONCLUSIONS The expression of PD-1 on circulating CD4+ and CD8+ T cells is increased in hyperthyroid patients with active Graves' disease. MMI significantly decreases levels of circulating PD-1+ CD4+ T cells, suggesting that PD-1+ T lymphocytes may be associated with the pathogenesis of Graves' disease.
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Affiliation(s)
- Nanako Hirao
- Department of Endocrinology and Metabolism, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Toshie Iijima
- Department of Endocrinology and Metabolism, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Dai Tanuma
- Department of Endocrinology and Metabolism, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Eriko Ohira
- Department of Endocrinology and Metabolism, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Hidetaka Kurai
- Department of Endocrinology and Metabolism, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Toshimitsu Shinzawa
- Department of Endocrinology and Metabolism, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Masato Kase
- Department of Endocrinology and Metabolism, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Shintaro Sakurai
- Department of Endocrinology and Metabolism, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Takuya Tomaru
- Department of Endocrinology and Metabolism, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Teruo Jojima
- Department of Endocrinology and Metabolism, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Isao Usui
- Department of Endocrinology and Metabolism, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Yoshimasa Aso
- Department of Endocrinology and Metabolism, Dokkyo Medical University, Mibu, Tochigi, Japan
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13
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Ferreira MN, Rao M, Kamal AH, Shariff A. Top Ten Tips Palliative Care Clinicians Should Know About Managing Immune-Mediated Endocrine Toxicities in Cancer. J Palliat Med 2022; 25:1715-1720. [PMID: 35696238 DOI: 10.1089/jpm.2022.0204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Immune checkpoint inhibitors (ICI), such as PD-1/PDL-1 and CTLA-4, have become widely used in the treatment of solid and hematological malignancies; their use and side effects are increasingly seen in the palliative care (PC) population. These drugs can result in immune-mediated endocrinopathies; the thyroid is the most common endocrine gland affected, but the pituitary, adrenals, and pancreas may be affected as well. Symptoms may be insidious and nonspecific. A high index of suspicion and routine laboratory monitoring allows for prompt diagnosis and treatment, which can significantly improve symptoms and increase quality of life. In this study, we present an approach to monitoring and initial management of ICI-induced endocrinopathies in the PC patient population.
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Affiliation(s)
- Michelle N Ferreira
- Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Meghana Rao
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Arif H Kamal
- Division of Medical Oncology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Afreen Shariff
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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14
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Liu Z, Yang H, Chen Z, Jing C. A novel chromatin regulator-related immune checkpoint related gene prognostic signature and potential candidate drugs for endometrial cancer patients. Hereditas 2022; 159:40. [PMID: 36253800 PMCID: PMC9578220 DOI: 10.1186/s41065-022-00253-w] [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: 07/28/2022] [Accepted: 09/22/2022] [Indexed: 11/14/2022] Open
Abstract
Background Endometrial cancer (EC) is the most common gynecologic malignancy in developed countries and its prevalence is increasing. As an emerging therapy with a promising efficacy, immunotherapy has been extensively applied in the treatment of solid tumors. In addition, chromatin regulators (CRs), as essential upstream regulators of epigenetics, play a significant role in tumorigenesis and cancer development. Methods CRs and immune checkpoint-related genes (ICRGs) were obtained from the previous top research. The Genome Cancer Atlas (TCGA) was utilized to acquire the mRNA expression and clinical information of patients with EC. Correlation analysis was utilized for screen CRs-related ICRGs (CRRICRGs). By Cox regression and least absolute shrinkage and selection operator (LASSO) analysis, prognosis related CRRICRGs were screened out and risk model was constructed. The Kaplan–Meier curve was used to estimate the prognosis between high- and low-risk group. By comparing the IC50 value, the drugs sensitivity difference was explored. We obtained small molecule drugs for the treatment of UCEC patients based on CAMP dataset. Results We successfully constructed a 9 CRRICRs-based prognostic signature for patients with UCEC and found the riskscore was an independent prognostic factor. The results of functional analysis suggested that CRRICRGs may be involved in immune processes associated with cancer. Immune characteristics analysis provided further evidence that the CRRICRGs-based model was correlated with immune cells infiltration and immune checkpoint. Eight small molecule drugs that may be effective for the treatment of UCEC patients were screened. Effective drugs identified by drug sensitivity profiling in high- and low-risk groups. Conclusion In summary, our study provided novel insights into the function of CRRICRGs in UCEC. We also developed a reliable prognostic panel for the survival of patients with UCEC. Supplementary Information The online version contains supplementary material available at 10.1186/s41065-022-00253-w.
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Affiliation(s)
- Zesi Liu
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning Province, China
| | - Hongxia Yang
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning Province, China
| | - Ziyu Chen
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning Province, China
| | - Chunli Jing
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning Province, China.
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15
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Chilelli MG, Signorelli C, Giron Berrios JR, Onorato A, Nelli F, Fabbri MA, Primi F, Marrucci E, Virtuoso A, Schirripa M, Mazzotta M, Ruggeri EM. Immune-related Thyroid Dysfunction (irTD) in Non-small Cell Lung Cancer (NSCLC) Correlates With Response and Survival. CANCER DIAGNOSIS & PROGNOSIS 2022; 2:55-63. [PMID: 35400002 PMCID: PMC8962849 DOI: 10.21873/cdp.10076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/15/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND There is no clear information on the proportion of patients who need therapy for immune-related thyroid dysfunction (irTD) or who need to delay, omit, or discontinue immunotherapy. Furthermore, it is not well known whether irTD correlates with better outcomes or not. PATIENTS AND METHODS We conducted a retrospective study in patients with metastatic non-small cell lung cancer (NSCLC) treated with anti-PD1 or anti-PD-L1. RESULTS Our study enrolled 75 patients, 25.3% of them developed immune-related thyroid dysfunction. Three patients delayed a course of immunotherapy due to irTD, 2 patients omitted a course and 1 patient permanently discontinued. In patients with irTD compared with those without irTD the ORR was 42.1% vs. 7.1% (p<0.001), DCR was 78.9% vs. 32.1% (p<0.001); mPFS was 15.7 vs. 3.6 months (p<0.001) and mOS was 18.6 months vs. 5.1 months (p<0.001). CONCLUSION Immune-related thyroid dysfunction has a mild impact on the immunotherapy treatment program. The occurrence of irTD correlates with more favorable response and survival.
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Affiliation(s)
| | - Carlo Signorelli
- Medical Oncology Unit, Belcolle Hospital, ASL Viterbo, Viterbo, Italy
| | | | - Angelo Onorato
- Medical Oncology Unit, Belcolle Hospital, ASL Viterbo, Viterbo, Italy
| | - Fabrizio Nelli
- Medical Oncology Unit, Belcolle Hospital, ASL Viterbo, Viterbo, Italy
| | | | - Francesca Primi
- Medical Oncology Unit, Belcolle Hospital, ASL Viterbo, Viterbo, Italy
| | - Eleonora Marrucci
- Medical Oncology Unit, Belcolle Hospital, ASL Viterbo, Viterbo, Italy
| | | | - Marta Schirripa
- Medical Oncology Unit, Belcolle Hospital, ASL Viterbo, Viterbo, Italy
| | - Marco Mazzotta
- Medical Oncology Unit, Belcolle Hospital, ASL Viterbo, Viterbo, Italy
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16
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Chera A, Stancu AL, Bucur O. Thyroid-related adverse events induced by immune checkpoint inhibitors. Front Endocrinol (Lausanne) 2022; 13:1010279. [PMID: 36204105 PMCID: PMC9530140 DOI: 10.3389/fendo.2022.1010279] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/29/2022] [Indexed: 11/24/2022] Open
Abstract
Immune checkpoint inhibitors, namely anti-CTLA-4, anti-PD-1 and anti-PD-L1 monoclonal antibodies, have emerged in the last decade as a novel form of cancer treatment, promoting increased survival in patients. As they tamper with the immune response in order to destroy malignant cells, a new type of adverse reactions has emerged, known as immune-related adverse events (irAEs), which frequently target the endocrine system, especially the thyroid and hypophysis. Thyroid irAEs include hyperthyroidism, thyrotoxicosis, hypothyroidism and a possibly life-threatening condition known as the "thyroid storm". Early prediction of occurrence and detection of the thyroid irAEs should be a priority for the clinician, in order to avoid critical situations. Moreover, they are recently considered both a prognostic marker and a means of overseeing treatment response, since they indicate an efficient activation of the immune system. Therefore, a multidisciplinary approach including both oncologists and endocrinologists is recommended when immune checkpoint inhibitors are used in the clinic.
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Affiliation(s)
- Alexandra Chera
- Victor Babes National Institute of Pathology, Bucharest, Romania
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Andreea Lucia Stancu
- Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Octavian Bucur
- Victor Babes National Institute of Pathology, Bucharest, Romania
- Viron Molecular Medicine Institute, Boston, MA, United States
- *Correspondence: Octavian Bucur, ;;
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17
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Oyibo SO, Mahgoub MO. Atezolizumab-Induced Hypothyroidism in a Patient With Pre-existing Triiodothyronine (T3) Thyrotoxicosis Due to Graves' Disease: A Case Report and Literature Review. Cureus 2021; 13:e19736. [PMID: 34812334 PMCID: PMC8603092 DOI: 10.7759/cureus.19736] [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] [Accepted: 11/18/2021] [Indexed: 11/05/2022] Open
Abstract
The use of immune checkpoint inhibitors has improved the management and prognosis of many solid tumors. Because of their mechanism of action, and as checks on the immune systems are reduced, immune-related adverse events are common, including the exacerbation of the pre-existing autoimmune disease. The literature is scanty regarding reports of the use of immune checkpoint inhibitors in patients with pre-existing Graves' disease. We report a case of a woman with pre-existing triiodothyronine (T3) thyrotoxicosis (hyperthyroidism) secondary to Graves' disease, who developed thyroiditis followed by severe hypothyroidism after receiving an immune checkpoint inhibitor (atezolizumab) for the treatment of small-cell lung cancer. She had been on an anti-thyroid drug for Graves' disease for two and a half years and was on the waiting list for a total thyroidectomy. However, the discovery of the severe hypothyroidism following atezolizumab-induced thyroiditis resulted in the need for long-term thyroid replacement therapy, and the planned surgery was no longer required. This case is one of the very few published reports of the use of atezolizumab in a patient with pre-existing Graves' disease, resulting in the conversion from pre-existing T3-thyrotoxicosis to overt hypothyroidism. A multidisciplinary team approach is required when using immune checkpoint inhibitors in patients with pre-existing Graves' disease or any other autoimmune disease.
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Affiliation(s)
- Samson O Oyibo
- Diabetes and Endocrinology, Peterborough City Hospital, Peterborough, GBR
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18
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Zhou N, Velez MA, Bachrach B, Gukasyan J, Fares CM, Cummings AL, Lind-Lebuffe JP, Akingbemi WO, Li DY, Brodrick PM, Yessuf NM, Rettinger S, Grogan T, Rochigneux P, Goldman JW, Garon EB, Lisberg A. Immune checkpoint inhibitor induced thyroid dysfunction is a frequent event post-treatment in NSCLC. Lung Cancer 2021; 161:34-41. [PMID: 34507111 DOI: 10.1016/j.lungcan.2021.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/27/2021] [Accepted: 08/20/2021] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Thyroid dysfunction is the most frequent endocrine immune related adverse event (irAE) in non-small cell lung cancer (NSCLC), typically arising 3-6 months into immune checkpoint inhibitor (ICI) therapy, but arising after ICI cessation, in some cases. Due to limited post-treatment adverse event reporting requirements on ICI trials, the incidence of ICI-induced thyroid dysfunction arising after therapy is unclear. We investigated ICI-induced thyroid dysfunction in a cohort of 294 NSCLC patients, with a specific focus on the post-treatment setting. METHODS Retrospective analysis of ICI-induced thyroid dysfunction (clinically acted upon or laboratory only) was performed in 294 UCLA NSCLC patients treated 2012-2018. Clinically acted upon thyroid dysfunction was defined as thyroid diagnosis documentation and/or thyroid medication administration. Laboratory only dysfunction was defined as abnormal thyroid labs in the absence of clinical action. Timing of thyroid dysfunction relative to ICI treatment and thyroid monitoring patterns were also assessed. RESULTS 82% (241/294) of ICI treated NSCLC patients had thyroid labs during treatment. Of these 241 patients, 13% (31/241) had clinically acted upon thyroid dysfunction prior to, 8% (18/241) during, and 4% (9/241) after ICI. Most patients, 66% (159/241), did not have thyroid labs after ICI, but in the 53 patients with labs and no prior clinical dysfunction, 17% (9/53) developed clinical dysfunction after ICI. In these 9 patients, median time from ICI initiation to dysfunction was 253 days. Two patients with post-treatment laboratory only dysfunction were observed. CONCLUSIONS ICI-induced thyroid dysfunction arising post-treatment appears more common than previously appreciated, warranting additional evaluation.
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Affiliation(s)
- Nanruoyi Zhou
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Maria A Velez
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Benjamin Bachrach
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Jaklin Gukasyan
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Charlene M Fares
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Amy L Cummings
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Jackson P Lind-Lebuffe
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Wisdom O Akingbemi
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Debory Y Li
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Paige M Brodrick
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Nawal M Yessuf
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Sarah Rettinger
- Department of Endocrinology, Providence Health & Services, Santa Monica, CA, USA
| | - Tristan Grogan
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Philippe Rochigneux
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA; Department of Medical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Jonathan W Goldman
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Edward B Garon
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Aaron Lisberg
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA.
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