Nivolumab-induced fatal myocarditis: A case report

Key Clinical Message

Baseline assessment and interval monitoring with a careful history, clinical examination, laboratory work-up, and noninvasive imaging modalities may be beneficial for early detection of immune checkpoint inhibitor-associated side effects.

Abstract

Previous reports of immune checkpoint inhibitors' cardiotoxic effects include pericarditis, myocarditis, myocardial infarction, ventricular dysfunction, vasculitis, and electrical abnormalities. The authors report a case of acute heart failure caused by nivolumab-induced cardiotoxicity in a middle-aged man with advanced esophageal carcinoma with no previous cardiac history or significant cardiovascular risk factors.

Cardiotoxicity in patients on anthracyclines and traztuzumab: Identifying risk factors and echocardiographic parameters

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Background: Anthracyclines and human epidermal growth factor receptor 2(HER-2) directed therapy are widely used as chemotherapy in various cancers. Up to 10% of patients treated with anthracyclines will develop reduction in left ventricle ejection fraction (LVEF), and cardiotoxicity by HER-2 directed therapy can be as high as 35%. The drop in EF is often late and changes may not be reversed at that point. Strain imaging using global longitudinal strain (GLS) has potential for detecting cardiotoxicity earlier however guidelines remain to be standardized. The objective of this study is to study variations in GLS over time as well as evaluate the relation of patient characteristics with various echocardiographic parameters. Methods: Linear mixed effects models with random intercepts were used to evaluate trends in EF and GLS over time and model the association of cancer therapy and patient characteristics with repeated measures of GLS and EF. Patients were enrolled in the study from 2018-2021 who received anthracycline, or HER-2 targeted treatment for any cancer and had serial echocardiography. Results: In the overall cohort there were more females (61%) than males (20%) in the study. Most patients had breast cancer (67%), followed by leukemia (14%) and lymphoma (13%).35% patients were in the younger age group (< 65 years) and 46% patients were in the older age (≥65 years). There was a significant change in GLS in older patients at 7-9 months (-15 SE 0.6) and 10-12 months (-14 SE 1) (P 0.006; P 0.001). Only 13 patients out of 81 patients developed cardiotoxicity as defined by the current consensus guidelines based on LVEF. Further analysis was then performed between these two groups at various time intervals. LV end diastolic volume (LVEDV) at baseline was significantly higher in the cardiotoxic group (P 0.016). GLS at baseline in both groups had no statistical difference. However, GLS began to show significant differences in the initial 1-3 months in the cardiotoxic group (-14; SE 0.9) as compared to the non-cardiotoxic group (-17.03; SE 0.3) (P 0.003). This difference persisted over various time points from 4 months till 1 year (P < 0.0001 at all points). Conclusions: Our data suggests that GLS may be used as a measure to identify patients who will develop cardiotoxicity by obtaining it at baseline and early during treatment. Higher baseline LVEDV was associated with development of cardiotoxicity. Older patients tend to have more drop in GLS and frequent measures will help to detect cardiotoxicity in this group.

Extrapulmonary sarcoidosis in an atypical patient demographic

Although it typically presents with cough and dyspnea due to pulmonary involvement, sarcoidosis is a multisystem granulomatous disease and therefore may present with extrapulmonary manifestations. Cutaneous manifestations are common, while hepatic sarcoidosis is uncommon and osseous manifestations are exceedingly rare. This article describes osseous, hepatic, and cutaneous manifestations due to sarcoidosis. The patient was diagnosed with sarcoidosis, treated with a dynamic hip screw implant with a derotational screw, and discharged on a new medication regimen: vitamin D, calcium supplements, alendronate, methotrexate, and hydroxychloroquine.

Hazards of the Cytokine Storm and Cytokine-Targeted Therapy in Patients With COVID-19: Review

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has challenged medicine and health care on a global scale. Its impact and frightening mortality rate are in large part attributable to the fact that there is a lack of available treatments. It has been shown that in patients who are severely ill, SARS-CoV-2 can lead to an inflammatory response known as cytokine storm, which involves activation and release of inflammatory cytokines in a positive feedback loop of pathogen-triggered inflammation. Currently, cytokine storm is one of the leading causes of morbidity and mortality in SARS-CoV-2, but there is no proven treatment to combat this systemic response.

Objective

The aim of this paper is to study the cytokine storm response in SARS-CoV-2 and to explore the early treatment options for patients who are critically ill with the coronavirus disease (COVID-19) in the early stages of the pandemic by reviewing the literature.

Methods

A literature review was performed from December 1, 2000, to April 4, 2020, to explore and compare therapies that target cytokine storm among SARS-CoV-2 and prior coronavirus cases.

Results

A total of 38 eligible studies including 24 systematic reviews, 5 meta-analyses, 5 experimental model studies, 7 cohort studies, and 4 case reports matched the criteria.

Conclusions

The severity of the cytokine storm, measured by elevated levels of interleukin-1B, interferon-γ, interferon-inducible protein 10, and monocyte chemoattractant protein 1, was associated with COVID-19 disease severity. Many treatment options with different targets have been proposed during the early stages of the COVID-19 pandemic, ranging from targeting the virus itself to managing the systemic inflammation caused by the virus and the excessive cytokine response. Among the different agents to manage cytokine storm in patients with COVID-19, there is developing support for convalescent plasma therapy particularly for patients who are critically ill or mechanically ventilated and resistant to antivirals and supportive care. Treatment options that were proposed in the beginning phases of the pandemic were multidimensional, and further research is needed to develop a more established treatment guideline.

Docetaxel-induced acute myositis: a case report with review of literature

Docetaxel is an anti-microtubule agent and a highly effective treatment of locally advanced and metastatic breast cancer. There are several adverse effects associated with docetaxel, such as myelosuppression, peripheral neuropathy, fluid retention, and asthenia. One of the most well-known side-effects of this medication is mild to moderate myalgia. Here, we report a case of a 49-year-old female with stage 3 breast cancers who developed severe acute myositis following docetaxel use. The mechanism of docetaxel-induced myositis remains unclear; however, physicians still need to be aware of the possibility of this complication in patients with cancer and a history of exposure to this medication.

Relative risk of hematological toxicities in patients with advanced renal cell carcinoma treated with upfront immune checkpoint inhibitors

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Background: Sunitinib was the standard first-line treatment of advanced renal cell carcinoma (aRCC) for the past decade, but it has been associated with significant hematological toxicities. Immune checkpoint inhibitors (ICI) based regimens have become the new preferred treatment for aRCC in the first-line setting. We conducted a meta-analysis of phase 3 randomized controlled trials (RCTs) to determine the relative risk of hematological toxicities associated with upfront use of ICI-based regimens for aRCC. Methods: We conducted a systematic search at PUBMED, MEDLINE, EMBASE, and meeting abstracts as per PRISMA guidelines from inception until May 2019. Phase 3 RCTs using ICIs in the intervention arm for the first-line treatment of aRCC were included. We used the Mantel-Haenszel (MH) method utilizing random effects model to calculate pooled risk ratio (RR) with 95% confidence interval (CI). Heterogeneity was tested with I2 value. Results: Four phase 3 RCTs, CheckMate 214, IMmotion151, JAVELIN Renal 101 and KEYNOTE-426, randomizing 3706 patients were included in the analysis of anemia and thrombocytopenia. CheckMate 214 did not report the number of neutropenia. Hence, other 3 RCTs that included 2624 patients were analyzed for neutropenia. Following regimens were used in the study arms — CheckMate 214: nivolumab+ipilimumab, IMmotion151: atezolizumab+bevacizumab, JAVELIN Renal 101: axitinib+avelumab; and KEYNOTE-426: axitinib+ pembrolizumab. Sunitinib was used in the control arms for all the studies. The pooled RR of any-grade hematological toxicities are as follows — anemia: 0.31 (95% CI:0.24-0.41, P< 0.00001, I2=39%); thrombocytopenia: 0.11 (95% CI: 0.06-0.19, P<0.00001, I2=63%); neutropenia: 0.08 (95% CI: 0.05-0.13, P<0.00001, I2=0%). The pooled RR of grade 3 and higher hematological toxicities are as follows — anemia: 0.14 (95% CI:0.08-0.25, P< 0.00001, I2=0); thrombocytopenia: 0.06 (95% CI:0.02-0.16, P<0.00001, I2=4%); neutropenia: 0.06 (95% CI: 0.02-0.16, P<0.00001, I2=0%). Conclusions: ICI-based regimens have significantly reduced risk of any-grade as well as high-grade hematological toxicities compared to sunitinib in patients with aRCC.

CLO19-059: A Systematic Review and Meta- Analysis of Randomized Controlled Trials to Evaluate the Risk of Health-Related Quality of Life Events in Patients With Hormone Receptor-Positive HER2-Negative Metastatic Breast Cancer Treated With CDK 4/6 Inhibitors

Background: Pain, fatigue, hot flushes, and rash significantly contribute to quality of life in breast cancer patients undergoing chemotherapy. Hormone receptor-positive breast cancer is a common entity among women worldwide. In cancer cells, CDK4/6 activity is over expressed, which can lead to amplification or overexpression of the genes encoding for CDK 4/6 or the cyclin D, ultimately leading to endocrine therapy resistance. We undertook a systematic review and meta-analysis of randomized controlled trials (RCT) to determine the risk of health-related quality of life (HRQOL) events associated with CDK 4/6 inhibitors. Methods: We conducted a comprehensive literature search using MEDLINE, EMBASE databases, and meeting abstracts from inception through September 2018. RTCs that mention HRQOL events as adverse effects were incorporated in the analysis. Mantel-Haenszel (MH) method was used to calculate the estimated pooled risk ratio (RR) with 95%CI. Random effects model was applied. Results: 8 RCTs (7 phase III and 1 phase II) with a total of 4,557 patients were eligible. The study arms used palbociclib/ribociclib/abemaciclib with letrozole or anastrozole or fulvestrant or other hormonal agent while the control arms utilized placebo in combination with letrozole or anastrozole or fulvestrant or other hormonal agent. The RR of all-grade side effects were as follows: fatigue, 1.226 (95% CI: 1.079–1.393; P=.002); back pain, 0.971 (95% CI: 0.844–1.117; P=.681); arthralgia, 0.978 (95% CI: 0.830–1.152; P=.790); headache, 1.046 (95% CI: 0.928–1.179; P=.459); alopecia, 2.635 (95% CI: 1.966–3.533; P<.001); hot flushes, 0.901 (95% CI: 0.766–1.060; P=.210); and rash, 2.068 (95% CI: 1.604–2.666; P<.001). The RR of high-grade side effects were as follows: fatigue, 3.487 (95% CI: 1.765–6.889; P<.001); back pain, 1.364 (95% CI: 0.695–2.679; P=.367); arthralgia, 1.148 (95% CI: 0.509–2.593; P=.740); headache, 0.807 (95% CI: 0.303–2.147; P=.667); and rash, 3.018(95% CI: 0.954–9.554; P=.060). Conclusions: Our study showed that the risk of developing all grades of fatigue and any-grade alopecia and rash was significantly with CDK 4/6 inhibitors. Prompt intervention with good supportive care is required.

EPR19-071: Risk of Hematologic Toxicities and Health-Related Quality of Life Events in Patients With Hematologic Malignancies Treated With Ibrutinib: A Combined Analysis of 6 Phase III Trials

Background: Bruton’s tyrosine kinase (BTK) is essential for signaling of B-cell and chemokine receptors. Ibrutinib targets BTK and has become frontier in many hematologic malignancies. We undertook systematic review and pooled analysis of randomized controlled trials (RCTs) to determine the risk of hematologic toxicities and health-related quality of life (HRQOL) events associated with ibrutinib. Methods: We performed a comprehensive literature search using MEDLINE, EMBASE databases, and meeting abstracts through September 2018. Phase III RCTs that mention hematologic toxicities and HRQOL events as adverse effects were incorporated in the analysis. Mantel-Haenszel method was used to calculate the estimated pooled risk ratio with 95% CI. Random effects model was applied. Results: 6 phase III RCTs with a total of 1,811 patients with chronic lymphocytic leukemia/small lymphocytic lymphoma, mantle-cell lymphoma, and Waldenstrom’s macroglobulinemia were eligible. Studies compared Ibrutinib (I) vs ofatumumab, I vs chlorambucil, I+ bendamustine (B) + rituximab (R) vs placebo + B+ R, I vs temsirolimus and I vs R were included in the analysis. The relative risks (RR) of all-grade side effects were as follows: anemia, 0.812 (95% CI: 0.565–1.168; P=.261); neutropenia, 0.956 (95% CI: 0.720–1.268; P=.754); thrombocytopenia, 1.054 (95% CI: 0.450–2.470; P=.904); fatigue, 0.896 (95% CI: 0.761–1.056; P=.192); pyrexia, 1.123 (95% CI: 0.893–1.413; P=.322); and arthralgia, 1.863 (95% CI: 1.101–3.152; P=.020). The RR of high-grade adverse effects were as follows: anemia, 0.522 (95% CI: 0.371–0.733; P<.0001); neutropenia, 0.969 (95% CI: 0.751–1.249; P=.807); thrombocytopenia, 0.608 (95% CI: 0.252–1.470; P=.270); fatigue, 0.618 (95% CI: 0.396–0.964; P=.034); pyrexia, 1.165 (95% CI: 0.534–2.542; P=.701); and arthralgia, 3.623 (95% CI: 0.743–17.663; P=.111). Conclusion: Ibrutinib increased the risk of all-grade arthralgia whereas the risks of high-grade anemia and fatigue were significantly lower in the study arm, favoring ibrutinib.

EPR19-73: Risk of Gastrointestinal and Hepatic Toxicities in Patients With Hormone Receptor-Positive HER2-Negative Metastatic Breast Cancer Treated With CDK4/6 Inhibitors

Background: CDK4 and CDK6 are cyclin-dependent kinases that control transition between G1 and S phases of the cell cycle, hence controlling cell cycle progression by reversible combination with cyclin D1. In cancer cell, CDK4/6 activity is overexpressed, which can lead to amplification or overexpression of the genes encoding for CDK 4/6 or the cyclin D. Additionally, loss of endogenous INK4 inhibitors can also lead to over activity of CDK4 and CDK6. We undertook a meta-analysis of randomized controlled trials (RCT) to determine the risk of gastrointestinal (GI) and hepatic toxicities associated with CDK 4/6 inhibitors. Methods: We conducted a comprehensive literature search using MEDLINE, EMBASE databases, and meeting abstracts from inception through September 2018. In our analysis, we incorporated RCTs that mention GI toxicities and elevation of aspartate aminotransferase (AST) or alanine aminotransferase (ALT) as adverse effects. Mantel-Haenszel (MH) method was used to calculate the estimated pooled risk ratio (RR) with 95% CI. Random effects model was applied. Results: A total of 4,557 patients with advanced breast cancer from 7 phase III and 1 phase II RCTs were eligible. The study arms used were palbociclib/ribociclib/abemaciclib or placebo in combination with letrozole or anastrozole or fulvestrant or other hormonal agents. The RR of all-grade side effects were as follows: diarrhea, 1.691 (95% CI: 1.220–2.345; P=.002); nausea, 1.632 (95% CI: 1.447–1.840; P<.001); vomiting, 1.684 (95% CI: 1.256–2.259, P=.001); stomatitis, 2.160 (95% CI: 1.332–3.503; P=.002); elevated AST, 1.832 (95% CI: 1.312–2.558; P<.001); and elevated ALT, 2.150 (95% CI: 1.649–2.803; P<.001). The RR of high-grade side effects were as follows: diarrhea, 2.592 (95% CI: 0.853–7.877; P=.093); nausea, 1.326 (95% CI: 0.589–2.988; P=.496); vomiting, 1.089 (95% CI: 0.479–2.476; P=.839); stomatitis, 2.097 (95% CI: 0.502–0.753; P=.310); elevated AST, 2.274 (95% CI: 1.173–4.410; P=.015); and elevated ALT, 3.988 (95% CI: 2.387–6.663; P<.001). Conclusions: Our study demonstrated that the risk of developing all grade GI toxicities and all grades of hepatic side effects including grade 3 and 4, was high in CDK 4/6 inhibitors group, compared to control arm, and prompt intervention with good supportive care is required.

Abstract P1-16-04: Risk of venous thromboembolism with abemaciclib based regimen versus other CDK 4/6 inhibitor containing regimens in patients with hormone receptor-positive HER2-negative metastatic breast cancer

Background: Approximately 70% of patients with metastatic breast cancer (MBC) are hormone receptor (HR) - positive and the cyclin dependent kinases (CDK) along with their D-type cyclin catalysts, have been shown to play a role in mediating the resistance to endocrine therapy. Several CDK-targeted agents have been recently approved by FDA. Nevertheless, the risk of venous thromboembolism (VTE) with the use of different CDK 4/6 inhibitors has never been reported. We undertook a systematic review and meta-analysis of randomized controlled trials (RCT) to determine the risk of VTE with abemaciclib based regimens versus other CDK 4/6 inhibitor containing regimens in patients with HR-positive HER2-negative MBC.

Methods: We systematically conducted a comprehensive literature search using MEDLINE, EMBASE databases and meeting abstracts through February 2018. The randomized controlled trials that mention deep vein thrombosis and pulmonary embolism as adverse effects of CDK 4/6 inhibitor therapy were incorporated in the analysis. The primary meta- analytic approach was a fixed effects model using the Mantel-Haenszel (MH) method. It was used to calculate the estimated pooled risk ratio (RR) and risk difference (RD) with 95% confidence interval (CI).

Results: Five phase 3 studies and one phase 2 study with a total of 3,159 patients with HR-positive HER2-negative MBC were eligible for analysis. The study arms used palbociclib-letrozole, palbociclib-fulvestrant, ribociclib-letrozole, abemaciclib-fulvestrant, and abemaciclib-nonsteroidal aromatase inhibitors (either letrozole or anastrozole) while the control arms utilized placebo in combination with letrozole or anastrozole or fulvestrant. The randomization ratio was 2 to 1 in PALOMA-2, PALOMA-3, MONARCH-2 and MONARCH-3 studies and 1 to 1 in PALOMA-1 and MONALEESA-2 trials. CDK 4/6 inhibitors were utilized as first line treatment in PALOMA-1, PALOMA-2, MONALEESA-2 and MONARCH-3. The I2 statistic for heterogeneity was 0, and the heterogeneity X2 (Cochran's Q) was 1 (P= 0.707), suggesting homogeneity among RCTs. The VTE incidence was 25 (3.255%) in the abemaciclib group vs 2 (0.520%) in the control group. The pooled relative risk for VTE was 6.222 (95% CI: 1.481 – 26.145, P = 0.013) and the absolute RD was 0.027 (95% CI: 0.013 – 0.042, P &lt; 0.0001). In other CDK 4/6 inhibitor containing regimens, the VTE incidence was reported at 15 (1.243%) vs 2 (0.374%) in the control arm. The pooled RR for VTE was 2.312 (95% CI: 0.852 –6.272, P = 0.100) and the absolute RD was 0.008 (95% CI: - 0.000 – 0.017, P = 0.259).

Conclusion: VTE is a major cause of morbidity and mortality and is particularly common in patients with breast cancer. Our meta-analysis demonstrated that the addition of abemaciclib to endocrine therapy notably contributed to a higher incidence of VTE with a relative risk of 6.22. However, no significant increase in the risk of VTE was noted in other CDK 4/6 inhibitor-based regimen. More randomized trials are required to determine the actual relation and definitive incidence of VTE among different CDK-targeted agents when added to endocrine therapy.

Citation Format: Thein KZ, Ball S, Zaw MH, Quirch M, Hardwicke F, Awasthi S, Oo TH, Jones C. Risk of venous thromboembolism with abemaciclib based regimen versus other CDK 4/6 inhibitor containing regimens in patients with hormone receptor-positive HER2-negative metastatic breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-16-04.

A systematic review and combined analysis of phase III trials to evaluate the safety of adjuvant sunitinib in patients with high risk renal cell carcinoma after nephrectomy

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Background: Sunitinib, an oral vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitor, has been approved in adjuvant treatment of high risk renal cell carcinoma (RCC) after nephrectomy despite distinct results among studies, along with notable safety concerns. We undertook a systematic review and meta-analysis of randomized controlled trials (RCT) to determine the risk of grade 3 and 4 adverse events in patients treated with adjuvant sunitinib. Methods: MEDLINE, EMBASE databases and meeting abstracts from inception through June 2018 were queried. Phase 3 RCTs which utilized adjuvant sunitinib in high risk RCC after nephrectomy were included. Mantel-Haenszel (MH) method was used to calculate the estimated pooled risk ratio (RR) with 95% confidence interval (CI). Random effects model was applied. Results: Two phase III RCTs with a total of 1866 patients were eligible. Studies utilized sunitinib versus placebo. The randomization ratio was 1:1 in both ASSURE and S-TRAC studies. The RR of high-grade adverse effects were as follows: hypertension, 4.26 (95% CI: 2.89 – 6.26, p < 0.001); fatigue, 5.40 (95% CI: 3.49 – 8.34; p < 0.001); rash/desquamation, 5.00 (95% CI: 1.59 – 15.68; p = 0.006); hand foot syndrome, 18.68 (95% CI: 5.98 – 58.28, p < 0.001); asthenia, 6.57 (95% CI: 1.005 – 43.04; p = 0.049); diarrhea, 18.08 (95% CI: 6.63 – 49.32; p < 0.001); dyspepsia, 12.68 (95% CI: 2.40 – 66.80, p = 0.003); stomatitis, 29.15 (95% CI: 5.73 – 148.18; p < 0.001); nausea, 19.63 (95% CI: 3.81 – 100.97; p < 0.001); and vomiting, 8.21 (95% CI: 2.21 – 30.51; p = 0.002). Conclusions: The rate of high-grade hypertension, fatigue, asthenia, dermatological toxicities, including hand foot syndrome, and gastrointestinal toxicities were extremely high in patients treated with adjuvant sunitinib, compared to placebo arm. Fatigue, hand foot syndrome and gastrointestinal toxicities significantly contribute to patients’ quality of life and providing good supportive care is warranted.

Discontinuation of adjuvant sunitinib due to adverse events in patients with high-risk renal cell carcinoma after nephrectomy: A combined analysis of phase III trials

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Background: Dysregulation in the vascular endothelial growth factor (VEGF) pathway has been implicated in the pathogenesis of renal cell carcinoma (RCC). Sunitinib is an oral VEGF receptor tyrosine kinase inhibitor and has been approved in the adjuvant treatment of high-risk RCC. However, there are significant adverse events, impacting patients’ quality of life, and leading to treatment discontinuation. We performed a systematic review and meta-analysis of randomized controlled trials (RCT) to determine the risk of high-grade toxicities and the rate of treatment discontinuation due to adverse events. Methods: We conducted a comprehensive literature search using MEDLINE, EMBASE databases and meeting abstracts from inception through June 2018. Phase III RCTs which utilized adjuvant sunitinib in high risk RCC after nephrectomy and mentioned treatment interruption or discontinuation or dose reduction due to adverse events were included. Mantel-Haenszel (MH) method was used to calculate the estimated pooled risk ratio (RR) with 95% confidence interval (CI). Fixed effects model was applied. Results: Two phase III RCTs with a total of 1866 patients were eligible. Studies utilized sunitinib versus placebo. The randomization ratio was 1:1 in both ASSURE and S-TRAC studies. The incidence of high-grade adverse events was 568 (60.5%) in sunitinib group versus 183 (19.6%) in placebo arm, with the relative risk of 3.10 (95% CI: 2.69 – 15.93, P < 0.001). The reduction in dose was reported in 541 (57.9%) in study arm versus 86 (9.2%) in placebo group. The pooled RR for dose reduction was statistically significant at 6.28 (95% CI: 5.10 – 7.74, P < 0.001). The treatment discontinuation rate was 27.9% higher with sunitinib than with placebo (RR - 4.14; 95% CI: 3.31 – 5.16, P < 0.001). Conclusions: Our meta-analysis demonstrated that the rate of dose reduction, treatment discontinuation and the risk of grade 3 and 4 adverse events were notably high in sunitinib group. Timely recognition and proper supportive care are entailed in minimizing those adverse events which may ultimately improve patients’ quality of life and overall compliance.