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Luo J, Zhou L, Sun A, Yang H, Zhang P, Liu K, Yu X, Lin Y, Huang Y, Han L. Herbal medicine for Hashimoto's thyroiditis: A systematic review and network meta-analysis. J Ethnopharmacol 2024; 323:117663. [PMID: 38181936 DOI: 10.1016/j.jep.2023.117663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 08/31/2023] [Accepted: 12/24/2023] [Indexed: 01/07/2024]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Conventional treatments for Hashimoto's thyroiditis (HT) are limited. Herbal medicines (HM) are considered a potential intervention for the treatment of HT. AIM OF THE STUDY This study aimed to investigate the efficacy and safety of HM for HT. MATERIALS AND METHODS A Bayesian network meta-analysis was conducted for patients with HT in randomized controlled trials identified in PubMed, Cochrane Library, Web of Science, EMBASE, Chinese Clinical Trial Registry (Chi CTR), China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (the VIP), China Chinese Biomedical Database (CBM), and Wanfang Database were searched from their inception to Oct 1, 2022. Outcomes included the primary outcome (TPOAb), secondary outcomes (TSH, TGAb, FT3, FT4, and traditional Chinese medicine symptom scores), and adverse events. This study was registered in PROSPERO (CRD42022363640). RESULTS Sixteen trials were reviewed and 16 HM formulae were compared. Compared with non-drug therapy (NDT), all therapies, except for Tiaoqi-Qingjie Therapy, reduced the primary outcome of TPOAb with different levels of effectiveness, ranging from 0.01 (95%CI 0.00, 0.02) to 0.92 (95%CI 0.56, 1.53). Ranking probability analysis indicated that Yiqi Huayu Recipe, Liqi Xiaoying decoction, and Shugan Sanjie therapy reduced thyroid antibody levels the most, including TPOAb (100.0%, 90.9%, and 90.3%, respectively) and TGAb (98.3%, 94.4%, and 87.3%, respectively). All HMs displayed a significant effect on the TCM Symptom score and possibly benefitted the treatment of HT, ranging from 6.62 (95% CI 2.06, 21.24) to 94.50 (95% CI 15.97, 559.14). No serious adverse events were reported. CONCLUSIONS Herbal medicines may be effective in the treatment of HT, especially in reducing thyroid antibody levels and improving clinical symptoms without affecting thyroid function. However, these results should be considered preliminary and further verified using high-quality evidence.
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Affiliation(s)
- Jinli Luo
- Institute of Metabolic Diseases, Guang' Anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China; Graduate College, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Ling Zhou
- Institute of Metabolic Diseases, Guang' Anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China; Graduate College, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Aru Sun
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, 130117, China
| | - Haoyu Yang
- Institute of Metabolic Diseases, Guang' Anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Pei Zhang
- Institute of Metabolic Diseases, Guang' Anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Ke Liu
- Institute of Metabolic Diseases, Guang' Anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Xiaotong Yu
- Institute of Metabolic Diseases, Guang' Anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Yiqun Lin
- Department of Endocrinology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences (South Campus), Beijing, 100105, China.
| | - Yishan Huang
- Institute of Metabolic Diseases, Guang' Anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
| | - Lin Han
- Institute of Metabolic Diseases, Guang' Anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
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2
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Chaker L, Cooper DS, Walsh JP, Peeters RP. Hyperthyroidism. Lancet 2024; 403:768-780. [PMID: 38278171 DOI: 10.1016/s0140-6736(23)02016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/07/2023] [Accepted: 09/16/2023] [Indexed: 01/28/2024]
Abstract
Thyrotoxicosis causes a variety of symptoms and adverse health outcomes. Hyperthyroidism refers to increased thyroid hormone synthesis and secretion, most commonly from Graves' disease or toxic nodular goitre, whereas thyroiditis (typically autoimmune, viral, or drug induced) causes thyrotoxicosis without hyperthyroidism. The diagnosis is based on suppressed serum concentrations of thyroid-stimulating hormone (TSH), accompanied by free thyroxine and total or free tri-iodothyronine concentrations, which are raised (overt hyperthyroidism) or within range (subclinical hyperthyroidism). The underlying cause is determined by clinical assessment, detection of TSH-receptor antibodies and, if necessary, radionuclide thyroid scintigraphy. Treatment options for hyperthyroidism include antithyroid drugs, radioactive iodine, and thyroidectomy, whereas thyroiditis is managed symptomatically or with glucocorticoid therapy. In Graves' disease, first-line treatment is a 12-18-month course of antithyroid drugs, whereas for goitre, radioactive iodine or surgery are preferred for toxic nodules or goitres. Evidence also supports long-term treatment with antithyroid drugs as an option for patients with Graves' disease and toxic nodular goitre.
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Affiliation(s)
- Layal Chaker
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Epidemiology, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - David S Cooper
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John P Walsh
- Department of Endocrinology & Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia; Medical School, University of Western Australia, Crawley, WA, Australia
| | - Robin P Peeters
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands.
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3
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Sachin J, Shukla R, Anil A, Saravanan A, Santhyavu S, Varthya SB, Ambwani S, Singh S. COVISHIELD vaccine-induced thyroiditis: a case report. J Med Case Rep 2023; 17:542. [PMID: 38098118 PMCID: PMC10722757 DOI: 10.1186/s13256-023-04279-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 11/17/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND The rapid development of coronavirus disease 2019 vaccines during the pandemic has left their long-term effects largely unknown. Instances of autoimmune and subacute thyroiditis showing features of autoimmune/inflammatory syndrome induced by adjuvants have been reported post-vaccination. This case report aims to highlight the autoimmune/inflammatory syndrome induced by adjuvants syndrome after coronavirus disease 2019 vaccination, drawing attention to a possible connection with thyroid dysfunction and urging for further thorough research. CASE PRESENTATION We present a case of thyroiditis induced by the COVISHIELD vaccine in a 37-year-old Indian woman. An apparently normal and healthy adult woman developed neck pain and easy fatigability 2 weeks after the second dose of COVISHIELD, which gradually increased and was associated with irritability, decreased sleep, excessive sweating, tremor, palpitation, and weight loss. She presented to the outpatient department after 1 week of symptoms and was evaluated with laboratory tests and imaging. She was diagnosed with thyroiditis due to the coronavirus disease 2019 vaccine and was treated with propranolol. CONCLUSION This case report adds to the growing evidence of coronavirus disease 2019 vaccine-related thyroid issues. The development of thyroiditis is rare and underreported post-coronavirus disease 2019 vaccination; hence, research to evaluate the association of coronavirus disease 2019 vaccines with thyroid dysfunction needs to be done in the future.
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Affiliation(s)
- J Sachin
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Ravindra Shukla
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Abhishek Anil
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Aswini Saravanan
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Sanjay Santhyavu
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Shoban Babu Varthya
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Sneha Ambwani
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Surjit Singh
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India.
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4
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Markus E, Bel-Ange A, Benbassat C, Steinschneider M, Koren R. Short- and long-term outcomes of patients with hyper or hypothyroidism following COVID vaccine. J Investig Med 2023; 71:700-706. [PMID: 37199279 DOI: 10.1177/10815589231173876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
Since the beginning of the wide-scale anti-Coronavirus disease 2019 (COVID-19) vaccination program, sporadic cases of thyroid disease following vaccination have been reported. We describe 19 consecutive cases of COVID vaccine-related thyroid disease. Medical records were reviewed for 9 patients with Graves' disease (GD) and 10 with Thyroiditis, all of whom were diagnosed following COVID-19 vaccination. In the GD group, the median age was 45.5 years, female/male(F/M) ratio 5:4, thyroid-stimulating immunoglobulins were elevated in seven patients. The median time from vaccination to diagnosis was 3 months. Methimazole treatment was given to all but one patient. At a median follow-up of 8.5 months from vaccination, three patients were still on methimazole, five went into remission (data were missing for one). In the Thyroiditis group, the median age was 47 years, the F/M ratio 7:3. Thyroiditis was diagnosed after the first, second, and third doses in one, two, and seven patients, respectively. The median time from vaccination to diagnosis was 2 months. TPO antibodies were positive in three patients. All patients were euthyroid off medication at the last visit. Six patients were diagnosed in the hypothyroid phase at 2.5 months from vaccination. Four resolved spontaneously at 3, 6, 4, and 8 months; the other two were treated with thyroxine at 1.5 and 2 months from vaccination and remained on treatment at their last visit, at 11.5 and 8.5 months, respectively. Thyroid disease should be included among possible complications of COVID-19 vaccine and either a late onset or delayed diagnosis should be considered.
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Affiliation(s)
- Efrat Markus
- Endocrine Institute, Shamir medical center, Zerifin, Israel
| | - Anat Bel-Ange
- Endocrine Institute, Shamir medical center, Zerifin, Israel
| | - Carlos Benbassat
- Endocrine Institute, Shamir medical center, Zerifin, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Miriam Steinschneider
- Endocrine Institute, Shamir medical center, Zerifin, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Koren
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Internal Medicine A, Shamir Medical Center, Zerifin, Israel
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Abstract
At the end of 2019, the world began to fight the coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus-2. Many vaccines have quickly been developed to control the epidemic, and with the widespread use of vaccines globally, several vaccine-related adverse events have been reported. This review mainly focused on COVID-19 vaccination-associated thyroiditis and summarized the current evidence regarding vaccine-induced subacute thyroiditis, silent thyroiditis, Graves' disease, and Graves' orbitopathy. The main clinical characteristics of each specific disease were outlined, and possible pathophysiological mechanisms were discussed. Finally, areas lacking evidence were specified, and a research agenda was proposed.
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Affiliation(s)
- Süleyman Nahit Şendur
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Seda Hanife Oğuz
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Uğur Ünlütürk
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey.
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6
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Lechner MG, Zhou Z, Hoang AT, Huang N, Ortega J, Scott LN, Chen HC, Patel AY, Yakhshi-Tafti R, Kim K, Hugo W, Famini P, Drakaki A, Ribas A, Angell TE, Su MA. Clonally expanded, thyrotoxic effector CD8 + T cells driven by IL-21 contribute to checkpoint inhibitor thyroiditis. Sci Transl Med 2023; 15:eadg0675. [PMID: 37196065 PMCID: PMC10227862 DOI: 10.1126/scitranslmed.adg0675] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/19/2023] [Indexed: 05/19/2023]
Abstract
Autoimmune toxicity occurs in up to 60% of patients treated with immune checkpoint inhibitor (ICI) therapy for cancer and represents an increasing clinical challenge for expanding the use of these treatments. To date, human immunopathogenic studies of immune-related adverse events (IRAEs) have relied on sampling of circulating peripheral blood cells rather than affected tissues. Here, we directly obtained thyroid specimens from individuals with ICI-thyroiditis, one of the most common IRAEs, and compared immune infiltrates with those from individuals with spontaneous autoimmune Hashimoto's thyroiditis (HT) or no thyroid disease. Single-cell RNA sequencing revealed a dominant, clonally expanded population of thyroid-infiltrating cytotoxic CXCR6+ CD8+ T cells (effector CD8+ T cells) present in ICI-thyroiditis but not HT or healthy controls. Furthermore, we identified a crucial role for interleukin-21 (IL-21), a cytokine secreted by intrathyroidal T follicular (TFH) and T peripheral helper (TPH) cells, as a driver of these thyrotoxic effector CD8+ T cells. In the presence of IL-21, human CD8+ T cells acquired the activated effector phenotype with up-regulation of the cytotoxic molecules interferon-γ (IFN-γ) and granzyme B, increased expression of the chemokine receptor CXCR6, and thyrotoxic capacity. We validated these findings in vivo using a mouse model of IRAEs and further demonstrated that genetic deletion of IL-21 signaling protected ICI-treated mice from thyroid immune infiltration. Together, these studies reveal mechanisms and candidate therapeutic targets for individuals who develop IRAEs.
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Affiliation(s)
- Melissa G. Lechner
- Division of Endocrinology, Diabetes, and Metabolism, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Zikang Zhou
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Aline T. Hoang
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
- Drexel Medical School; Philadelphia, PA 19129
| | - Nicole Huang
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Jessica Ortega
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Lauren N. Scott
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Ho-Chung Chen
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Anushi Y. Patel
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Rana Yakhshi-Tafti
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
- Rosalind Franklin Medical School; Chicago, IL 60064
| | - Kristy Kim
- UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Willy Hugo
- Division of Dermatology, Department of Medicine, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Pouyan Famini
- Division of Endocrinology, Diabetes, and Metabolism, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Alexandra Drakaki
- Division of Hematology and Oncology, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Antoni Ribas
- Division of Hematology and Oncology, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Trevor E. Angell
- Division of Endocrinology and Diabetes, USC Keck School of Medicine; Los Angeles, CA 90033
| | - Maureen A. Su
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
- Division of Pediatric Endocrinology, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
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7
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Patrizio A, Fallahi P, Antonelli A, Ferrari SM. Immune Checkpoint Inhibitor-induced Thyroid Disorders: A Single Center Experience. Curr Pharm Des 2023; 29:295-299. [PMID: 35593347 DOI: 10.2174/1381612828666220518151509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/16/2022] [Accepted: 03/28/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) foster T lymphocytes to fight cancer, but they can also trigger immune-related adverse events (irAE) in various organs, including thyroid dysfunction that can manifest itself in terms of both hyperthyroidism and hypothyroidism or subclinical disease. OBJECTIVE Based on previous observations, this study evaluated the impact of oncological immunotherapy on the development of thyroid dysfunction in a cohort of patients treated with ICI at our institution. METHODS We collected 10 cases of thyroid irAE that emerged from 24 cancer patients treated with immunotherapy, belonging to a cohort of 120 patients who were sent to our clinic by the Oncology Department of our institution, between December 2016 and March 2020. RESULTS From the analysis of the data, thyroid irAEs emerged after a median time of 9 weeks, and they occurred mainly in females. Regardless of the initial presentation (thyroiditis with thyrotoxicosis, hypothyroidism, or worsening of the previous subclinical hypothyroidism), later all patients developed persistent hypothyroidism which required hormone replacement therapy with levothyroxine. This finding was confirmed by a statistically significant increase in the median value of TSH (thyroid-stimulating hormone) between the pre-ICI treatment and subsequent phases and, for the first time, by a reduction in the median value of the thyroid volume estimated by neck ultrasound, a sign of destructive thyroiditis. CONCLUSION Our results confirm that patients undergoing immunotherapy should be monitored for potential thyroid dysfunction with biochemical assessments and changes in thyroid volume estimated by ultrasound could be helpful in the diagnostic work-up.
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Affiliation(s)
- Armando Patrizio
- Department of Emergency Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Poupak Fallahi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
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de Filette JMK, André S, De Mey L, Aspeslagh S, Karmali R, Van der Auwera BJ, Bravenboer B. Durvalumab-induced thyroiditis in a patient with non-small cell lung carcinoma: a case report and review of pathogenic mechanisms. BMC Endocr Disord 2022; 22:291. [PMID: 36419114 PMCID: PMC9682778 DOI: 10.1186/s12902-022-01190-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 10/26/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) targeting cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), programmed cell death protein 1 and its ligand (PD-1/PD-L1) have become the current standard-of-care for advanced cancers. This novel therapeutic approach comes with its costs in the form of immune-related adverse events (irAE), including endocrinopathy. CASE PRESENTATION A 63-year-old woman was diagnosed with a non-small cell lung carcinoma of the right superior lobe, cT3N2M0. She developed thyrotoxicosis followed by hypothyroidism induced by consolidation immunotherapy with durvalumab (anti-PD-L1). Analysis of the human leukocyte antigen (HLA) region showed HLA-DR4 (susceptible) and DR13 (protective). The possible mechanisms are subsequently discussed in detail. CONCLUSIONS The case of a patient with thyroiditis associated with the PD-L1 inhibitor durvalumab is described, highlighting the need for proactive monitoring of thyroid hormone levels. Identifying biomarkers associated with an increased risk of ICI-induced side effects (such as HLA) is of interest for better patient selection, optimal management and improved understanding of the mechanisms involved.
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Affiliation(s)
- Jeroen M K de Filette
- Department of Endocrinology, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
- Department of Endocrinology, UZ Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Stéphanie André
- Department of Pulmonary Medicine, Saint-Pierre University Hospital, Rue Haute 322, 1000, Brussels, Belgium
- Université Libre de Bruxelles, Brussels, Belgium
- Department of Pulmonary Medicine, Brugmann University Hospital, Brussels, Belgium
| | - Lynn De Mey
- Department of Nuclear Medicine, UZ Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Sandrine Aspeslagh
- Department of Medical Oncology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Rafik Karmali
- Department of Endocrinology, UZ Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | | | - Bert Bravenboer
- Department of Endocrinology, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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9
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Kobayashi T, Iwama S, Yamagami A, Yasuda Y, Okuji T, Ito M, Zhou X, Ando M, Onoue T, Miyata T, Sugiyama M, Hagiwara D, Suga H, Banno R, Hase T, Morise M, Ito T, Kikumori T, Inoue M, Ando Y, Masuda N, Kawashima H, Hashimoto N, Arima H. Elevated TSH Level, TgAb, and Prior Use of Ramucirumab or TKIs as Risk Factors for Thyroid Dysfunction in PD-L1 Blockade. J Clin Endocrinol Metab 2022; 107:e4115-e4123. [PMID: 35918067 DOI: 10.1210/clinem/dgac467] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Thyroid dysfunction is frequently caused by treatment with antiprogrammed cell death-1 ligand 1 antibodies (PD-L1-Abs) and anticancer drugs, including ramucirumab (RAM) and multitargeted tyrosine kinase inhibitors (multi-TKIs), which are often used prior to PD-L1-Ab treatment in cancer patients. METHODS A total of 148 patients treated with PD-L1-Abs were evaluated for antithyroid antibodies at baseline and for thyroid function every 6 weeks for 24 weeks after treatment initiation and then were observed until the visits stopped. RESULTS Of the 148 patients, 15 (10.1%) developed thyroid dysfunction after PD-L1-Ab treatment (destructive thyroiditis in 8 and hypothyroidism without preceding thyrotoxicosis in 7). The prevalence of an elevated thyroid-stimulating hormone (TSH) level at baseline (3/15 [20.0%] vs 4/133 [3.0%], P < .05), positive antithyroglobulin antibodies (TgAbs) at baseline (4/15 [26.7%] vs 5/133 [3.8%], P < .05) and prior treatment with RAM or multi-TKIs (3/15 [20.0%] vs 5/133 [3.8%], P < .05) were significantly higher in patients with vs without thyroid dysfunction. In a multivariate analysis, elevated TSH level at baseline, TgAb positivity at baseline, and prior treatment with RAM or multi-TKIs were significantly associated with the development of thyroid dysfunction, with ORs of 7.098 (95% CI 1.154-43.638), 11.927 (95% CI 2.526-56.316), and 8.476 (95% CI 1.592-45.115), respectively. CONCLUSION The results of this real-world study suggest that the risk of thyroid dysfunction induced by PD-L1-Abs can be predicted by the TSH level at baseline, TgAb positivity at baseline, and prior treatment with RAM or multi-TKIs.
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Affiliation(s)
- Tomoko Kobayashi
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shintaro Iwama
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ayana Yamagami
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshinori Yasuda
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takayuki Okuji
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaaki Ito
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Xin Zhou
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiko Ando
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Takeshi Onoue
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Miyata
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mariko Sugiyama
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daisuke Hagiwara
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidetaka Suga
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryoichi Banno
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Research Center of Health, Physical Fitness and Sports, Nagoya University, Nagoya, Japan
| | - Tetsunari Hase
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiro Morise
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takanori Ito
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyone Kikumori
- Department of Breast and Endocrine Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Megumi Inoue
- Department of Clinical Oncology and Chemotherapy, Nagoya University Hospital, Nagoya, Japan
| | - Yuichi Ando
- Department of Clinical Oncology and Chemotherapy, Nagoya University Hospital, Nagoya, Japan
| | - Norikazu Masuda
- Department of Breast and Endocrine Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naozumi Hashimoto
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
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10
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Koyama H, Hattori R, Sagawa H, Tanaka T. Progressive loss of the thyroid tissue integrity visualised by serial CT scans. BMJ Case Rep 2022; 15:e251857. [PMID: 36109095 PMCID: PMC9478785 DOI: 10.1136/bcr-2022-251857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A man in his 70s developed thyrotoxicosis due to painless thyroiditis after starting nivolumab, which was subsequently followed by severe hypothyroidism. We diagnosed him as chronic thyroiditis, initiated levothyroxine supplementation and treated appropriately. Retrospective CT images of the thyroid gland during the clinical course revealed that the CT attenuation value was high at first but gradually decreased. The high-density signal of the normal thyroid tissues reflects its function of concentrating inorganic iodine, and the progressive decrease of the CT density in the present case can be viewed as a reflection of the thyroid destruction and progressive loss of iodine during the clinical course of the development of chronic thyroiditis. Considering the high incidence rate of functional thyroid disease in patients treated with immune checkpoint inhibitors, CT density of the thyroid gland needs to be paid attention to as the first sign of thyroiditis in this patient population.
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Affiliation(s)
- Hiroyuki Koyama
- Gastroenterology and Metabolism, Graduate School of Medical Sciences and Medical School, Nagoya City University, Nagoya, Japan
| | - Rei Hattori
- Gastroenterology and Metabolism, Graduate School of Medical Sciences and Medical School, Nagoya City University, Nagoya, Japan
| | - Hiroyuki Sagawa
- Gastroenterological Surgery, Graduate School of Medical Sciences and Medical School, Nagoya City University, Nagoya, Japan
| | - Tomohiro Tanaka
- Gastroenterology and Metabolism, Graduate School of Medical Sciences and Medical School, Nagoya City University, Nagoya, Japan
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11
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Affiliation(s)
- Nobuhiko Nakaizumi
- Department of Internal Medicine, Kuma Hospital, Kuma Byoin, Kobe, Hyogo, Japan.
| | - Shuji Fukata
- Department of Internal Medicine, Kuma Hospital, Kuma Byoin, Kobe, Hyogo, Japan
| | - Takashi Akamizu
- Department of Internal Medicine, Kuma Hospital, Kuma Byoin, Kobe, Hyogo, Japan
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12
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Marsukjai A, Theerasuwipakorn N, Tumkosit M, Chattranukulchai P, Srichomkwun P, Prechawat S. Concomitant myocarditis and painless thyroiditis after AstraZeneca coronavirus disease 2019 vaccination: a case report. J Med Case Rep 2022; 16:212. [PMID: 35581666 PMCID: PMC9112634 DOI: 10.1186/s13256-022-03438-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/30/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Incidence of myocarditis following messenger RNA coronavirus disease 2019 vaccination has been widely described, but this clinical scenario after adenoviral vector coronavirus disease 2019 vaccination has only been rarely reported. In addition, a few case reports of thyroiditis after adenoviral vector coronavirus disease 2019 vaccination have been published. CASE PRESENTATION A 55-year-old Thai woman presented with palpitation without neck pain 14 days after receiving AstraZeneca coronavirus disease 2019 vaccination. Electrocardiography revealed sinus tachycardia. Her blood tests showed elevation of cardiac troponin and free triiodothyronine with suppressed serum thyroid stimulating hormone, reflecting a hyperthyroid status. Evidence of myocardial inflammation and necrosis from cardiac magnetic resonance imaging supported the diagnosis of recent myocarditis. Laboratory results and imaging findings were consistent with thyroiditis. After 3 weeks of symptomatic treatment, her symptom and blood tests had returned to normal. CONCLUSIONS This case demonstrates that the adenoviral vector coronavirus disease 2019 vaccine could possibly cause myocarditis and painless thyroiditis. Clinicians should have a high index of suspicion and promptly evaluate these conditions, despite minimal symptoms.
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Affiliation(s)
- Apichai Marsukjai
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Nonthikorn Theerasuwipakorn
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand.
| | - Monravee Tumkosit
- Department of Radiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Pairoj Chattranukulchai
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Panudda Srichomkwun
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Excellent Center in Diabetes, Hormones and Metabolism, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Somchai Prechawat
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
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13
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Abstract
Immune-related adverse events (irAEs) are caused by immune checkpoint inhibitors in several organs including the endocrine glands. Thyroid dysfunction (thyroid irAEs) is often observed among endocrine irAEs and is induced by blockade of programmed cell death 1 (PD-1), programmed death ligand 1, or PD-1 plus cytotoxic T-lymphocyte antigen 4. Endocrinologically, destructive thyroiditis or hypothyroidism is observed in most cases, whereas hyperthyroidism (Graves' disease) is rare. Most patients who develop destructive thyroiditis or hypothyroidism subsequently require thyroid hormone replacement therapy. Thyroid irAE development is associated with prolonged survival in patients with non-small cell lung carcinoma. The incidence of thyroid irAEs is higher in patients who are positive versus negative for anti-thyroid antibodies at baseline, suggesting that these antibodies can predict thyroid irAE development. Cytotoxic T cells, especially CD4 T cells, are reportedly involved in the development of destructive thyroiditis. In this review, we describe the clinical features, potential biomarkers, and mechanism of thyroid irAEs.
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Affiliation(s)
- Shintaro Iwama
- Department of Endocrinology and Diabetes, Nagoya University Hospital, Japan.
| | - Tomoko Kobayashi
- Department of Endocrinology and Diabetes, Nagoya University Hospital, Japan
| | - Yoshinori Yasuda
- Department of Endocrinology and Diabetes, Nagoya University Hospital, Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
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14
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Strohbehn IA, Street S, Chute D, Seethapathy H, Lee M, Seethapathy R, Drobni ZD, Rahma O, Neilan TG, Zubiri L, Reynolds K, Sise ME. Immune checkpoint inhibitor-induced thyroiditis is a risk factor for acute and chronic kidney dysfunction. Nephrol Dial Transplant 2021; 37:187-189. [PMID: 34383953 PMCID: PMC8719582 DOI: 10.1093/ndt/gfab240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ian A Strohbehn
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sarah Street
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Donald Chute
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Harish Seethapathy
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Meghan Lee
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Zsofia D Drobni
- Cardiovascular Imaging Research Center, Division of Cardiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Osama Rahma
- Division of Hematology and Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Tomas G Neilan
- Cardiovascular Imaging Research Center, Division of Cardiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Leyre Zubiri
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Kerry Reynolds
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Meghan E Sise
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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15
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Affiliation(s)
- Melissa G Lechner
- Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Mabel Ryder
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA.
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA.
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16
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Katakura Y, Kimura T, Kusano T, Tatsumi F, Iwamoto Y, Sanada J, Fushimi Y, Shimoda M, Kohara K, Nakanishi S, Kaku K, Mune T, Kaneto H. Case Report: A Variety of Immune-Related Adverse Events Triggered by Immune Checkpoint Inhibitors in a Subject With Malignant Melanoma: Destructive Thyroiditis, Aseptic Meningitis and Isolated ACTH Deficiency. Front Endocrinol (Lausanne) 2021; 12:722586. [PMID: 34712202 PMCID: PMC8547604 DOI: 10.3389/fendo.2021.722586] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/20/2021] [Indexed: 11/16/2022] Open
Abstract
Recently, immune checkpoint inhibitors have been drawing much attention as cancer immunotherapy, but it has been shown that various immune-related adverse events (irAEs) are induced by immune checkpoint inhibitors in various organs, which has become one of the serious issues at present. A 58-year-old Japanese male with malignant melanoma was treated with nivolumab and/or ipilimumab. During the period of treatment, he suffered from various irAEs. Firstly, about 1 month after starting nivolumab monotherapy, destructive thyroiditis was induced, and so we started replacement therapy with levothyroxine. Secondly, about 1 month after starting nivolumab and ipilimumab combination therapy, aseptic meningitis was induced. We stopped both drugs and started steroid therapy with prednisolone. Finally, about 9 months after restarting nivolumab, isolated adrenocorticotropic hormone (ACTH) deficiency was induced, and so we started replacement therapy with hydrocortisone. Taken together, we should bear in mind the possibility of a variety of irAEs when we use immune checkpoint inhibitors.
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Affiliation(s)
| | - Tomohiko Kimura
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
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17
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Affiliation(s)
- Jonathan Schimmel
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eva L Alba
- Division of Endocrinology, Diabetes and Bone Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Angela Chen
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Matthew Russell
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Reshmi Srinath
- Division of Endocrinology, Diabetes and Bone Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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18
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Abstract
Objective Painless thyroiditis (PT) is characterized by transient hyperthyroidism with a low 99mTc uptake. We herein describe 11 cases of PT that occurred during treatment with potassium iodide (KI) for Graves' disease (GD). Methods From August 2016 to December 2018, 11 women with GD who developed PT during treatment with KI were enrolled. Of these patients, 10 discontinued antithyroid drug (ATD) because of side effects and began KI, and 1 patient switched from thiamazole to KI because she was planning a pregnancy. The mean patient age was 40.1 years old. Thyroid function tests, thyroid autoantibodies including anti thyroglobulin antibody (TgAb), anti-thyroperoxidase antibody (TPOAb), and M22-TRAb, and the 99mTc uptake were evaluated at the time of PT. Results All 11 women patients presented with transient thyrotoxicosis in which 99mTc scans revealed a low uptake of 0.34±0.15% (normal 0.70-1.02%). M22-TRAb was absent in all cases except for one (2.4 IU/L), whereas TgAb and TPOAb were present in 10 and 6 cases, respectively. Ten patients returned to a euthyroid status without passing through the post-hypothyroid phase, and one patient underwent total thyroidectomy during the euthyroid phase of PT. Only four patients require beta-blocker therapy. All patients with KI-induced PT except 1 displayed GD remission during a mean observation period of 23.3 months, and 1 patient had recurrence of GD after PT. Conclusion We encountered 11 GD patients who developed PT during treatment with KI, which was initiated after ATD had been discontinued due to side effects.
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Affiliation(s)
- Keiichi Kamijo
- Department of Internal Medicine, Kamijo Thyroid Clinic, Japan
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19
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Gile JJ, Liu AJ, McGarrah PW, Eiring RA, Hobday TJ, Starr JS, Sonbol MB, Halfdanarson TR. Efficacy of Checkpoint Inhibitors in Neuroendocrine Neoplasms: Mayo Clinic Experience. Pancreas 2021; 50:500-505. [PMID: 33939660 DOI: 10.1097/mpa.0000000000001794] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Checkpoint inhibitors (CPIs) for low- and intermediate-grade neuroendocrine tumors (NETs) have been associated with limited efficacy; recent studies suggest CPIs may represent promising treatment for high-grade neuroendocrine neoplasms (NENs). METHODS We examined 57 patients with NENs who were treated with CPIs to determine if NETs and neuroendocrine carcinomas (NECs) respond to immunotherapy. RESULTS Patients with poorly differentiated NECs on CPI monotherapy had an objective response rate (ORR) of 0% and median progression-free survival (PFS) of 2.1 months (95% confidence interval [CI], 0.5-4.6). Patients with poorly differentiated NECs on dual CPI therapy had an ORR of 13% and PFS of 3.5 months (95% CI, 1.4-not reached [NR]). Patients with poorly differentiated NECs on CPI and cytotoxic therapy had an ORR of 36% with PFS of 4.2 months (95% CI, 1.6-NR). Well-differentiated grade 1 and 2 NETs on CPI monotherapy had an ORR of 25% with PFS NR. Well-differentiated grade 3 NETs had 0% ORR with a PFS of 2.9 months (95% CI, 1.4-4.2) on CPI monotherapy. CONCLUSIONS Checkpoint inhibitor therapy shows limited activity in patients with NENs. Future studies should identify biomarkers that can help identify patients who are likely responders to immunotherapy.
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Affiliation(s)
- Jennifer J Gile
- From the Division of Oncology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Alex J Liu
- Division of Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ
| | - Patrick W McGarrah
- From the Division of Oncology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Rachel A Eiring
- From the Division of Oncology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Timothy J Hobday
- From the Division of Oncology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Jason S Starr
- Division of Oncology, Department of Medicine, Mayo Clinic, Jacksonville, FL
| | - Mohamad B Sonbol
- Division of Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ
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20
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Newman C, Kgosidalwa O, Hakami OA, Kennedy C, Grogan L, Agha A. Multiple endocrinopathies, hypercalcaemia and pancreatitis following combined immune checkpoint inhibitor use- case report and review of literature. BMC Endocr Disord 2021; 21:33. [PMID: 33639911 PMCID: PMC7912868 DOI: 10.1186/s12902-021-00693-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 02/09/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are a novel class of oncological agents which are used to treat a number of malignancies. To date seven agents have been approved by the Food and Drug Administration (FDA) to treat both solid and haematological malignancies. Despite their efficacy they have been associated with a number of endocrinopathies. We report a unique case of hypophysitis, thyroiditis, severe hypercalcaemia and pancreatitis following combined ICI therapy. CASE PRESENTATION A 46-year old Caucasian female with a background history of malignant melanoma and lung metastases presented to the emergency department with lethargy, nausea, palpitations and tremors. She had been started on a combination of nivolumab and ipilimumab 24 weeks earlier. Initial investigations revealed thyrotoxicosis with a thyroid stimulating hormone (TSH) of < 0.01 (0.38-5.33) mIU/L, free T4 of 66.9 (7-16) pmol/.L. TSH receptor and thyroperoxidase antibodies were negative. She was diagnosed with thyroiditis and treated with a beta blocker. Six weeks later she represented with polyuria and polydipsia. A corrected calcium of 3.54 (2.2-2.5) mmol/l and parathyroid hormone (PTH) of 9 (10-65) pg/ml confirmed a diagnosis of non-PTH mediated hypercalcaemia. PTH-related peptide and 1, 25-dihydroxycholecalciferol levels were within the normal range. Cross-sectional imaging and a bone scan out ruled bone metastases but did reveal an incidental finding of acute pancreatitis - both glucose and amylase levels were normal. The patient was treated with intravenous hydration and zoledronic acid. Assessment of the hypothalamic-pituitary-adrenal (HPA) axis uncovered adrenocorticotrophic hormone (ACTH) deficiency with a morning cortisol of 17 nmol/L. A pituitary Magnetic Resonance Image (MRI) was unremarkable. Given her excellent response to ICI therapy she remained on ipilimumab and nivolumab. On follow-up this patient's thyrotoxicosis had resolved without anti-thyroid mediations - consistent with a diagnosis of thyroiditis secondary to nivolumab use. Calcium levels normalised rapidly and remained normal. ACTH deficiency persisted, and she is maintained on oral prednisolone. CONCLUSION This is a remarkable case in which ACTH deficiency due to hypophysitis; thyroiditis; hypercalcaemia and pancreatitis developed in the same patient on ipilimumab and nivolumab combination therapy. We postulate that hypercalcaemia in this case was secondary to a combination of hyperthyroidism and secondary adrenal insufficiency.
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Affiliation(s)
- Christine Newman
- Department of Diabetes and Endocrinology, Beaumont Hospital, Dublin 9, Republic of Ireland.
| | - Oratile Kgosidalwa
- Department of Diabetes and Endocrinology, Beaumont Hospital, Dublin 9, Republic of Ireland
| | - Osamah A Hakami
- Department of Diabetes and Endocrinology, Beaumont Hospital, Dublin 9, Republic of Ireland
| | - Carmel Kennedy
- Department of Diabetes and Endocrinology, Beaumont Hospital, Dublin 9, Republic of Ireland
| | - Liam Grogan
- Department of Medical Oncology, Beaumont Hospital, Dublin 9, Republic of Ireland
| | - Amar Agha
- Department of Diabetes and Endocrinology, Beaumont Hospital, Dublin 9, Republic of Ireland
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21
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Abstract
ABSTRACT A 58-year-old man with previous melanoma of the left leg underwent whole-body 18F-FDG PET/CT to stage metastatic disease prior to commencing pembrolizumab. Follow-up FDG PET/CT after 3 months of treatment showed partial metabolic response of soft tissue and nodal metastases and diffuse increased thyroid and colonic uptake, suggestive of thyroiditis and colitis. Pembrolizumab was ceased, and a repeat FDG PET/CT scan showed regression of uptake in the thyroid gland and colon, in keeping with resolution of inflammatory change. Immune-related adverse events induced by Immune checkpoint inhibitors, such as pembrolizumab, should be recognized-cessation of treatment often leads to resolution.
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22
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Abstract
Background: Thyroid immune-related adverse events (IRAEs) have been reported more frequently with programmed cell death protein-1 (PD-1) inhibitors than cytotoxic T lymphocyte antigen 4 (CTLA-4) inhibitors, but there is limited data describing endocrinopathies from programmed cell death protein-ligand 1 (PD-L1) inhibitors. This study characterizes thyroid IRAEs in cancer patients treated with PD-L1 inhibitors and examines the impact on overall survival. Methods: This is a retrospective cohort study of cancer patients treated with atezolizumab and avelumab at the Mayo Clinic, Rochester, Minnesota, from June 1, 2016 to January 30, 2018, and followed for a median of 10.1 months. Thyroid IRAEs were characterized as new onset hypothyroidism, thyrotoxicosis, and worsening of pre-existing hypothyroidism. Results: Of 91 patients treated with a PD-L1 inhibitor, 19 (21%) developed new onset thyroid dysfunction, of whom 14 presented with hypothyroidism and 5 with thyrotoxicosis (3 progressed to hypothyroidism and 2 returned to euthyroidism), and 4 (4%) had worsening of pre-existing hypothyroidism. Thyroid IRAEs occurred after a median of two doses (6 weeks), 48% required thyroid hormone replacement, and none required steroids or discontinuation of immunotherapy. Two out of four patients with thyroid peroxidase (TPO) antibody >9 IU/mL at baseline developed thyroid IRAEs. Median TPO antibody titer was not different between those with and without thyroid IRAEs but was higher in those with overt than those with subclinical hypothyroidism (5 vs. 0.3 IU/mL, p = 0.003) and those prescribed thyroid hormone replacement as compared with observation (5.5 vs. 0.3, p = 0.008). Diffusely increased thyroid 18-fluorodeoxyglucose (18FDG) uptake on positron emission tomography (PET) scan occurred in 71% with thyroid IRAE as compared with 6% without thyroid IRAEs (p = 0.001). Patients who developed thyroid IRAEs had longer overall survival (p = 0.027) and lower mortality (hazard ratio 0.49 [95% CI 0.25-0.99], p = 0.034) after adjusting for potential confounders. Conclusions: PD-L1 inhibitors lead to immune-mediated thyroiditis, the most frequent endocrine IRAE. In most cases, management is supportive without requiring steroids or discontinuation of immunotherapy. Diffusely increased thyroid 18FDG uptake on PET scan may predict the occurrence of thyroiditis, whereas TPO antibodies may help identify its severity. Thyroiditis may be a biomarker for antitumor immune response, highlighting the need to further characterize its underlying mechanism.
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Affiliation(s)
- Anupam Kotwal
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Lisa Kottschade
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Mabel Ryder
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
- Address correspondence to: Mabel Ryder, MD, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
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23
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Zaborowski M, Sywak M, Nylén C, Gill AJ, Chou A. Unique and distinctive histological features of immunotherapy-related thyroiditis. Pathology 2020; 52:271-273. [PMID: 31902621 DOI: 10.1016/j.pathol.2019.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/24/2019] [Accepted: 10/02/2019] [Indexed: 11/21/2022]
Affiliation(s)
- Matthew Zaborowski
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, Australia; NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Mark Sywak
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Endocrine Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Carolina Nylén
- Department of Endocrine Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Anthony J Gill
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, Australia; NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
| | - Angela Chou
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, Australia; NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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24
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Koizumi Y, Hirooka M, Hiraoka A, Ochi H, Tanaka T, Yukimoto A, Imai Y, Watanabe T, Yoshida O, Miyake T, Matsuura B, Michitaka K, Joko K, Abe M, Hiasa Y. Lenvatinib-induced thyroid abnormalities in unresectable hepatocellular carcinoma. Endocr J 2019; 66:787-792. [PMID: 31142692 DOI: 10.1507/endocrj.ej19-0140] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Lenvatinib has anti-tumor activity against advanced hepatocellular carcinoma (HCC). Hypothyroidism is also a frequent complication in patients treated with lenvatinib. However, studies on lenvatinib-induced thyroid toxicity and destructive thyroiditis are limited. Therefore, this study aimed to clarify the frequency and timing of thyroid abnormalities in lenvatinib for unresectable HCC. This retrospective study enrolled 50 patients with advanced HCC treated with lenvatinib. Patients were classified to have euthyroid, subclinical hypothyroidism, overt hypothyroidism, and thyrotoxicosis. The timing of thyroid dysfunction was assessed, and risk factors for incident hypothyroidism or thyrotoxicosis were evaluated using multivariate models. Subclinical hypothyroidism, overt hypothyroidism, and thyrotoxicosis occurred in 7 (14.0%), 26 (52.0%), and 5 (10.0%) patients, respectively. In the 33 patients with hypothyroidism, 27 (84.4%) developed the condition within 2 weeks of starting lenvatinib treatment. Of the 5 patients with thyrotoxicosis, 3 developed the condition within 8 weeks of starting lenvatinib administration. One patient developed thyrotoxicosis in only 1 week of the initiation of treatment. No correlation between the presence of antibodies and the incidence and severity of thyroid dysfunction due to the autoimmune mechanism was observed. The progression-free survival was significantly better in the hypothyroidism group. Lenvatinib treatment for unresectable HCC not only causes hypothyroidism, but also thyrotoxicosis. Moreover, these thyroid conditions develop within the early period of treatment at a higher prevalence. Patients with thyroid dysfunction had better prognosis. Based on these results, in patients administered with lenvatinib, there is need for careful assessment for the possibility of thyroid dysfunction from the onset of treatment.
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Affiliation(s)
- Yohei Koizumi
- Departments of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Masashi Hirooka
- Departments of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Atsushi Hiraoka
- Gastroenterology Center, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Hironori Ochi
- Center for Liver-Biliary-Pancreatic Disease, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Takaaki Tanaka
- Departments of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Atsushi Yukimoto
- Departments of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Yuusuke Imai
- Departments of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Takao Watanabe
- Departments of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Osamu Yoshida
- Departments of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Teruki Miyake
- Departments of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Bunzo Matsuura
- Departments of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Kojiro Michitaka
- Gastroenterology Center, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Kouji Joko
- Center for Liver-Biliary-Pancreatic Disease, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Masanori Abe
- Departments of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Yoichi Hiasa
- Departments of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
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25
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Abstract
Immune checkpoint inhibitors act to restore T cell-mediated antitumor immunity. By this nature, these cancer immunotherapy drugs are associated with various immune-related adverse events such as thyroid dysfunction. We describe a case of thyrotoxicosis secondary to a programmed cell death 1 (PD-1) immune checkpoint inhibitor, pembrolizumab. A 30-year-old female was started on pembrolizumab immunotherapy for stage III small cell carcinoma of the ovary, hypercalcemic type. Thirteen days after her second cycle of therapy, she presented with symptoms consistent with thyrotoxicosis. A thyroiditis was diagnosed by thyroid function tests and ultrasonography. She was originally treated with prednisone and metoprolol for possible Grave's disease. Pertechnetate thyroid scan was more consistent with thyroiditis secondary to pembrolizumab. She underwent a total thyroidectomy 10 days after initial presentation for refractory thyrotoxicosis despite maximal medical therapy. Her symptoms resolved and thyroid function tests significantly improved. Pathology was consistent with severe thyroiditis. Immune microenvironment may play a role in the expression of programmed cell death protein 1 ligand 1 (PD-L1). Chronic inflammation surrounding tumor upregulates PD-L1 expression on tumor cells by the release of cytokines, which acts to inhibit tumor destruction. We suggest that our patient had an undetected chronic inflammation of the thyroid, specifically Hashimoto's thyroidits, which predisposed her to thyroid destruction when taking pembrolizumab. Understanding that an inflammatory environment impacts thyroid toxicity to PD-1 inhibitor therapy is novel and should be further studied.
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Affiliation(s)
- Brittney A Imblum
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, Six Founders Pavilion, Philadelphia, PA, 19104-4283, USA.
| | - Zubair W Baloch
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, Six Founders Pavilion, Philadelphia, PA, 19104-4283, USA
| | - Douglas Fraker
- Department of Surgery and Division of Endocrine & Oncologic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Four Silverstein, Philadelphia, PA, 19104-4283, USA
| | - Virginia A LiVolsi
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, Six Founders Pavilion, Philadelphia, PA, 19104-4283, USA
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Yamauchi I, Yasoda A, Matsumoto S, Sakamori Y, Kim YH, Nomura M, Otsuka A, Yamasaki T, Saito R, Kitamura M, Kitawaki T, Hishizawa M, Kawaguchi-Sakita N, Fujii T, Taura D, Sone M, Inagaki N. Incidence, features, and prognosis of immune-related adverse events involving the thyroid gland induced by nivolumab. PLoS One 2019; 14:e0216954. [PMID: 31086392 PMCID: PMC6516638 DOI: 10.1371/journal.pone.0216954] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 05/01/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Blocking the PD-1 pathway induces immune-related adverse events (irAEs) which often involve the thyroid gland (thyroid irAEs). Clinical features of a thyroid irAE including its predictability and relationship to prognosis remain to be elucidated. METHODS Two hundred consecutive patients treated with nivolumab at Kyoto University Hospital between September 1, 2014 and August 31, 2017 were included in a retrospective cohort study. We systematically determined and classified subclinical and overt thyroid irAEs based on data collected of serum free T4 and TSH levels. Baseline characteristics and detailed clinical data were analyzed, and analyses of overall survival (OS) excluded patients censored within 1 month from the first administration of nivolumab. RESULTS Sixty-seven patients (33.5%) developed thyroid irAEs and these were divided into a subclinical thyroid irAE group (n = 40, 20.0%) and an overt thyroid irAE group (n = 27, 13.5%). Patients with thyroid uptake of FDG-PET before treatment showed high incidences of overt thyroid irAE (adjusted odds ratio 14.48; 95% confidence interval [CI] 3.12-67.19), while the same relationship was not seen with subclinical thyroid irAE. Regarding the total cohort, the thyroid irAE (+) group had a significantly longer median OS than the thyroid irAE (-) group (16.1 versus 13.6 months, hazard ratio [HR] 0.61; 95% CI 0.39-0.93). In 112 non-excluded patients with lung cancer, the thyroid irAE (+) group similarly had a longer median OS than the thyroid irAE (-) group (not reached versus 14.2 months, HR 0.51; 95% CI 0.27-0.92). However, this observation was not seen in 41 non-excluded patients with malignant melanoma (12.0 versus 18.3 months, HR 1.54; 95% CI 0.67-3.43). CONCLUSIONS By thyroid uptake of FDG-PET, overt thyroid irAEs could be predicted before nivolumab therapy. Thyroid irAEs related to good prognosis in lung cancer but might be inconclusive in malignant melanoma.
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Affiliation(s)
- Ichiro Yamauchi
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akihiro Yasoda
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shigemi Matsumoto
- Department of Medical Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuichi Sakamori
- Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Young Hak Kim
- Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Motoo Nomura
- Department of Medical Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Atsushi Otsuka
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Toshinari Yamasaki
- Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryoichi Saito
- Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Morimasa Kitamura
- Department of Otolaryngology, Head and Neck Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Toshio Kitawaki
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masakatsu Hishizawa
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Toshihito Fujii
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Daisuke Taura
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masakatsu Sone
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
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27
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Abstract
Hypothyroidism is a frequently occurring complication in patients on lenvatinib treatment. However, little is known about lenvatinib-induced thyrotoxicosis and destructive thyroiditis. We herein report the cases of three patients who developed hyperthyroidism during the course of lenvatinib treatment. All patients had multiple hepatocellular carcinoma of Child-Pugh class A. Two patients required beta blockers for the management of palpitations. One patient developed hyperthyroidism only one week after the initiation of lenvatinib treatment. Thus, the possibility of hyperthyroidism developing within one week after the first administration should be kept in mind, and periodic surveillance of the thyroid function should be performed during the early period of lenvatinib therapy (within the first two weeks or so after the initial administration).
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Affiliation(s)
- Masashi Hirooka
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Japan
| | - Hironori Ochi
- Center for Liver-Biliary-Pancreatic Diseases, Matsuyama Red Cross Hospital, Japan
| | - Atsushi Hiraoka
- Gastroenterology Center, Ehime Prefectural Central Hospital, Japan
| | - Yohei Koizumi
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Japan
| | - Bunzo Matsuura
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Japan
| | - Kouji Joko
- Center for Liver-Biliary-Pancreatic Diseases, Matsuyama Red Cross Hospital, Japan
| | - Kojiro Michitaka
- Gastroenterology Center, Ehime Prefectural Central Hospital, Japan
| | - Masanori Abe
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Japan
| | - Yoichi Hiasa
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Japan
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28
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Abstract
Nivolumab-induced multiple organ immune-related adverse events (irAEs) have been described in some case reports. The symptoms of endocrinological irAEs are especially nonspecific. A 63-year-old man with a postoperative recurrence of pulmonary adenocarcinoma who was treated with nivolumab presented fever, anorexia and fatigue after the 7th cycle. He underwent a rapid adrenocorticotrophic hormone test, four-hormone tolerance test and thyroid gland scintigraphy. The results were consistent with destructive thyroiditis, hypophysitis and secondary adrenal insufficiency. Nivolumab was restarted following glucocorticoid and thyroid hormone replacement treatment. When a patient presents nonspecific symptoms, the possibility of endocrinological irAEs should be considered as it may enable their early detection.
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Affiliation(s)
- Yuka Mishima
- Respiratory Medicine, Ome Municipal General Hospital, Japan
| | | | - Naohiko Inase
- Respiratory Medicine, Tokyo Medical and Dental University, Japan
| | - Susumu Isogai
- Respiratory Medicine, Ome Municipal General Hospital, Japan
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29
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Lei M, Michael A, Patel S, Wang D. Evaluation of the impact of thyroiditis development in patients receiving immunotherapy with programmed cell death-1 inhibitors. J Oncol Pharm Pract 2019; 25:1402-1411. [PMID: 30782080 DOI: 10.1177/1078155219829813] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE We evaluated if the development of thyroiditis in patients who received treatment with immune checkpoint inhibitors across various tumor types was associated with tumor response. METHODS In this retrospective, single-center, cross-sectional study, patients with various tumor types who received treatment with nivolumab or pembrolizumab as standard of care were evaluated. The primary endpoint was to evaluate the objective response rate in patients who developed thyroiditis compared with patients who did not develop thyroiditis. Secondary endpoints included disease control rate, progression-free survival, and overall survival. RESULTS One hundred and three patients were included for analysis with a median follow-up duration of 12.8 months (range, 4.0-21.6). The data cutoff was 31 December 2016. The objective response rate was 38.2% among the 34 patients in the thyroiditis group and 17.4% in the 69 patients in the non-thyroiditis group (p = 0.028). Progression-free survival was longer in the thyroiditis group than in the non-thyroiditis group. The median progression-free survival was 10.1 months (95% CI, 1.6-18.5) in the thyroiditis group and 3.7 months (95% CI, 2.5-4.9) in the non-thyroiditis group (hazard ratio, 0.45; 95% CI, 0.27-0.76; p = 0.002). CONCLUSION Patients with various tumor types who received treatment with immune checkpoint inhibitors and developed thyroiditis had a higher objective response rate than those who did not develop thyroiditis. The development of thyroiditis should be investigated further in the context of prospective randomized trials as a surrogate marker for tumor response to treatment with immune checkpoint inhibitor therapies.
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Affiliation(s)
- Matthew Lei
- 1 Department of Pharmacy, Henry Ford Hospital, Detroit, MI, USA
| | - Angela Michael
- 1 Department of Pharmacy, Henry Ford Hospital, Detroit, MI, USA
| | - Seema Patel
- 1 Department of Pharmacy, Henry Ford Hospital, Detroit, MI, USA
| | - Ding Wang
- 2 Department of Medicine, Division of Hematology/Oncology, Henry Ford Hospital, Detroit, MI, USA
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30
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Affiliation(s)
- Christina Neppl
- Department of Clinical Pathology, Institute of Pathology; Inselspital, Bern University Hospital; University of Bern, Bern, Switzerland
| | - Reto M Kaderli
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital; University of Bern, Bern, Switzerland
| | - Roman Trepp
- Department of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism, and Inselspital, Bern University Hospital; University of Bern, Bern, Switzerland
| | - Anja M Schmitt
- Department of Clinical Pathology, Institute of Pathology; Inselspital, Bern University Hospital; University of Bern, Bern, Switzerland
- Department of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism, and Inselspital, Bern University Hospital; University of Bern, Bern, Switzerland
| | - Martin D Berger
- Department of Medical Oncology, Inselspital, Bern University Hospital; University of Bern, Bern, Switzerland
| | - Marc Wehrli
- Department of Medical Oncology, Inselspital, Bern University Hospital; University of Bern, Bern, Switzerland
| | - Christian A Seiler
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital; University of Bern, Bern, Switzerland
| | - Rupert Langer
- Department of Clinical Pathology, Institute of Pathology; Inselspital, Bern University Hospital; University of Bern, Bern, Switzerland
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Pariani N, Willis M, Muller I, Healy S, Nasser T, McGowan A, Lyons G, Jones J, Chatterjee K, Dayan C, Robertson N, Coles A, Moran C. Alemtuzumab-Induced Thyroid Dysfunction Exhibits Distinctive Clinical and Immunological Features. J Clin Endocrinol Metab 2018; 103:3010-3018. [PMID: 29878256 PMCID: PMC6097600 DOI: 10.1210/jc.2018-00359] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 06/01/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT Alemtuzumab, a highly effective treatment for multiple sclerosis (MS), predisposes to Graves disease (GD), with a reportedly indolent course. OBJECTIVE To determine the type, frequency, and course of thyroid dysfunction (TD) in a cohort of alemtuzumab-treated patients with MS in the United Kingdom. DESIGN Case records of alemtuzumab-treated patients who developed TD were reviewed. RESULTS A total of 41.1% (102 out of 248; 80 female and 22 male) of patients developed TD, principally GD (71.6%). Median onset was 17 months (range 2 to 107) following the last dose, with the majority (89%) within 3 years. Follow-up data (range 6 to 251 months) were available in 71 case subjects, of whom 52 (73.2%) developed GD: 10 of these (19.2%) had fluctuating TD. All 52 patients with GD commenced antithyroid drugs (ATDs): 3 required radioiodine (RAI) due to ATD side effects, and drug therapy is ongoing in 2; of those who completed a course, 16 are in remission, 1 developed spontaneous hypothyroidism, and 30 (64%) required definitive or long-term treatment (RAI, n = 17; thyroidectomy, n = 5; and long-term ATDs, n = 8). Three cases of thyroiditis and 16 cases of hypothyroidism were documented: 5 with antithyroid peroxidase antibody positivity only, 10 with positive TSH receptor antibody (TRAb), and 1 of uncertain etiology. Bioassay confirmed both stimulating and blocking TRAb in a subset of fluctuating GD cases. CONCLUSIONS Contrary to published literature, we recorded frequent occurrence of GD that required definitive or prolonged ATD treatment. Furthermore, fluctuating thyroid status in GD and unexpectedly high frequency of TRAb-positive hypothyroidism suggested changing activity of TRAb in this clinical context; we have documented the existence of both blocking and stimulating TRAb in these patients.
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Affiliation(s)
- Nadia Pariani
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Mark Willis
- Division of Psychological Medicine and Clinical Neuroscience, Department of Neurology, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Ilaria Muller
- Thyroid Research Group, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Sarah Healy
- Division of Psychological Medicine and Clinical Neuroscience, Department of Neurology, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Taha Nasser
- Division of Psychological Medicine and Clinical Neuroscience, Department of Neurology, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Anne McGowan
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Greta Lyons
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Joanne Jones
- Department of Clinical Neurosciences, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Krishna Chatterjee
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Colin Dayan
- Thyroid Research Group, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Neil Robertson
- Division of Psychological Medicine and Clinical Neuroscience, Department of Neurology, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Alasdair Coles
- Department of Clinical Neurosciences, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Carla Moran
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, United Kingdom
- Correspondence and Reprint Requests: Carla Moran, MB, PhD, University of Cambridge, Metabolic Research Laboratories, Institute of Metabolic Science, Level 4, Box 289, Addenbrooke’s Hospital, Cambridge, CB2 0QQ, United Kingdom. E-mail:
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32
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O'Malley G, Lee HJ, Parekh S, Galsky MD, Smith CB, Friedlander P, Yanagisawa RT, Gallagher EJ. RAPID EVOLUTION OF THYROID DYSFUNCTION IN PATIENTS TREATED WITH NIVOLUMAB. Endocr Pract 2017; 23:1223-1231. [PMID: 29045188 DOI: 10.4158/ep171832.or] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the evolution of thyroid dysfunction in a series of patients with cancer treated with the immune checkpoint inhibitor anti-programmed cell death protein-1 (PD-1) monoclonal antibody, nivolumab. METHODS Cases of thyroid dysfunction after initiation of checkpoint inhibitor treatment were identified from the Division of Endocrinology clinical practice at Mount Sinai Hospital, New York from April 2016 to February 2017. Charts were reviewed to identify patients treated with nivolumab with new onset of thyroid dysfunction. RESULTS Nine cases of thyroid function in patients who were treated with nivolumab were identified. There were 4 male and 5 female patients, with a mean age of 66 years (range 50-76 years). Seven patients ultimately developed hypothyroidism. Five of the 7 patients developed abnormal thyroid function tests within the first 90 days of starting therapy (range 21-84 days), 3 of whom had transient hyperthyroidism. Transient hyperthyroidism evolved rapidly to hypothyroidism; elevated thyroid-stimulating hormone (TSH) levels were detected within 16 to 32 days of the last documented low TSH. In the 2 patients without a hyperthyroid phase, TSH levels >50 were found 18 to 28 days after the last normal TSH value. CONCLUSION As the use of immune checkpoint inhibitor therapy increases, the need for prompt diagnosis and treatment of drug-induced thyroid disease will become more important. As illustrated in this case series, in contrast to other causes of auto-immune thyroiditis, hypothyroidism can develop rapidly within 3 months of treatment. Close monitoring is necessary to detect the development of thyroid dysfunction and avoid preventable morbidity. ABBREVIATIONS Anti-TPO Abs = anti-thyroglobulin antibodies; CT = computed tomography; CTLA-4 = cytotoxic T-lymphocyte-associated protein 4; FDA = U.S. Food & Drug Administration; FDG-PET = fluorodeoxyglucose-positron emission tomography; PD-1 = programmed cell death protein-1; PD-L1 = programmed death-ligand 1; T3 = triiodothyronine; T4 = thyroxine; TG = thyroglobulin; TPO = thyroperoxidase; TSH = thyroid-stimulating hormone.
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Delivanis DA, Gustafson MP, Bornschlegl S, Merten MM, Kottschade L, Withers S, Dietz AB, Ryder M. Pembrolizumab-Induced Thyroiditis: Comprehensive Clinical Review and Insights Into Underlying Involved Mechanisms. J Clin Endocrinol Metab 2017; 102:2770-2780. [PMID: 28609832 PMCID: PMC5546861 DOI: 10.1210/jc.2017-00448] [Citation(s) in RCA: 171] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 05/02/2017] [Indexed: 12/21/2022]
Abstract
CONTEXT Thyroid immune-related adverse events (irAEs) in patients treated with programmed death receptor-1 (PD-1) blockade are increasingly recognized as one of the most common adverse effects. Our aim was to determine the incidence and examine the potential mechanisms of anti-PD-1-induced thyroid irAEs. DESIGN Single-center, retrospective cohort study. PATIENTS AND MEASUREMENTS We studied 93 patients with advanced cancer (ages 24 to 82 years; 60% males) who received at least one infusion of pembrolizumab. Thyroid test results and thyroid imaging modalities were reviewed. Comprehensive 10-color flow cytometry of peripheral blood was performed. RESULTS Thirteen (14%) thyroid irAEs were observed. Thyroiditis occurred in seven patients (54%), from which four recovered. New onset of hypothyroidism overt/subclinical developed in three patients. Levothyroxine dosing required doubling in three patients with a known history of hypothyroidism. Thyroperoxidase antibodies were positive in the minority of the patients [4/13 (31%)] and diffuse increased 18fludeoxyglucose uptake of the thyroid gland was observed in the majority [7/11 (64%)] of patients. We observed more circulating CD56+CD16+ natural killer (NK) cells and an elevated HLA-DR surface expression in the inflammatory intermediate CD14+CD16+ monocytes in anti-PD-1-treated patients. CONCLUSIONS Thyroid dysfunction is common in cancer patients treated with pembrolizumab. Reversible destructive thyroiditis and overt hypothyroidism are the most common clinical presentations. The mechanism of thyroid destruction appears independent of thyroid autoantibodies and may include T cell, NK cell, and/or monocyte-mediated pathways. Because the thyroid is a frequent target of anti-PD-1 therapies, patients with therapeutically refractory thyroid cancer may be ideal candidates for this treatment.
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Affiliation(s)
- Danae A. Delivanis
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota 55905
| | - Michael P. Gustafson
- Human Cell Therapy Laboratory, Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota 55905
| | - Svetlana Bornschlegl
- Department of Laboratory Medicine & Pathology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota 55905
| | - Michele M. Merten
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota 55905
| | - Lisa Kottschade
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota 55905
| | - Sarah Withers
- Department of Laboratory Medicine & Pathology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota 55905
| | - Allan B. Dietz
- Human Cell Therapy Laboratory, Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota 55905
| | - Mabel Ryder
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota 55905
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota 55905
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Yamauchi I, Sakane Y, Fukuda Y, Fujii T, Taura D, Hirata M, Hirota K, Ueda Y, Kanai Y, Yamashita Y, Kondo E, Sone M, Yasoda A, Inagaki N. Clinical Features of Nivolumab-Induced Thyroiditis: A Case Series Study. Thyroid 2017; 27:894-901. [PMID: 28537531 DOI: 10.1089/thy.2016.0562] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The programmed cell death-1 (PD-1) pathway is a novel therapeutic target in immune checkpoint therapy for cancer. It consists of the PD-1 receptor and its two ligands, programmed death-ligand 1 (PD-L1) and programmed death-ligand 2 (PD-L2). Nivolumab is an anti-PD-1 monoclonal antibody approved for malignant melanoma, advanced non-small cell lung cancer, and advanced renal cell carcinoma in Japan. Thyrotoxicosis and hypothyroidism have both been reported in international Phase 3 studies and national post-marketing surveillance of nivolumab in Japan. METHODS This study analyzed five consecutive cases with thyroid dysfunction associated with nivolumab therapy. Second, it examined the mRNA and protein expressions of PD-L1 and PD-L2 by reverse transcription polymerase chain reaction and Western blotting. RESULTS All patients were diagnosed with painless thyroiditis. Thyrotoxicosis developed within four weeks from the first administration of nivolumab and normalized within four weeks of onset in three of the five patients. Hypothyroidism after transient thyrotoxicosis developed in two patients, and preexisting hypothyroidism persisted in one patient. The other two patients were treated with glucocorticoids and discontinued nivolumab therapy for comorbid adverse events. One did not develop hypothyroidism, and the other developed mild, transient hypothyroidism. In addition, it was verified that normal thyroid tissue expresses PD-L1 and PD-L2 mRNA and those proteins. CONCLUSIONS In the present cases, nivolumab-induced thyrotoxicosis seemed to be associated with painless thyroiditis, while no patient with Graves' disease was observed. A transient and rapid course with subsequent hypothyroidism was observed in nivolumab-induced thyroiditis. In addition, it was verified that PD-L1 and PD-L2 are expressed in normal thyroid tissue. This suggests that nivolumab therapy reduces immune tolerance, even in normal thyroid tissue, and leads to the development of thyroiditis. Treating thyrotoxicosis with only supportive care and considering levothyroxine replacement therapy once subsequent hypothyroidism occurs is proposed. Further investigations are required to confirm whether glucocorticoid therapy and discontinuation of nivolumab therapy prevent subsequent hypothyroidism.
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Affiliation(s)
- Ichiro Yamauchi
- 1 Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine , Kyoto, Japan
| | - Yoriko Sakane
- 1 Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine , Kyoto, Japan
- 2 Preemptive Medicine and Lifestyle Disease Research Center, Kyoto University Hospital , Kyoto, Japan
| | - Yorihide Fukuda
- 1 Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine , Kyoto, Japan
| | - Toshihito Fujii
- 1 Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine , Kyoto, Japan
| | - Daisuke Taura
- 1 Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine , Kyoto, Japan
| | - Masakazu Hirata
- 1 Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine , Kyoto, Japan
| | - Keisho Hirota
- 1 Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine , Kyoto, Japan
| | - Yohei Ueda
- 1 Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine , Kyoto, Japan
| | - Yugo Kanai
- 1 Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine , Kyoto, Japan
| | - Yui Yamashita
- 1 Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine , Kyoto, Japan
| | - Eri Kondo
- 1 Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine , Kyoto, Japan
| | - Masakatsu Sone
- 1 Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine , Kyoto, Japan
| | - Akihiro Yasoda
- 1 Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine , Kyoto, Japan
| | - Nobuya Inagaki
- 1 Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine , Kyoto, Japan
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35
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de Filette J, Jansen Y, Schreuer M, Everaert H, Velkeniers B, Neyns B, Bravenboer B. Incidence of Thyroid-Related Adverse Events in Melanoma Patients Treated With Pembrolizumab. J Clin Endocrinol Metab 2016; 101:4431-4439. [PMID: 27571185 PMCID: PMC5095250 DOI: 10.1210/jc.2016-2300] [Citation(s) in RCA: 152] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 08/19/2016] [Indexed: 12/26/2022]
Abstract
CONTEXT Immune checkpoint blockade is associated with endocrine-related adverse events. Thyroid dysfunction during pembrolizumab therapy, an anti-programmed cell death 1 (PD-1) receptor monoclonal antibody, remains to be fully characterized. OBJECTIVE To assess the incidence and characteristics of pembrolizumab-associated thyroid dysfunction. DESIGN AND SETTING Thyroid function was monitored prospectively in melanoma patients who initiated pembrolizumab within an expanded access program at a referral oncology center. 18Fluorodeoxyglucose uptake on positron emission tomography/computed tomography (18FDG-PET/CT) was reviewed in cases compatible with inflammatory thyroiditis. PATIENTS Ninety-nine patients with advanced melanoma (age, 26.3-93.6 years; 63.6% females) who received at least one administration of pembrolizumab. MAIN OUTCOME MEASURES Patient characteristics, thyroid function (TSH, free T4), thyroid autoantibodies, and 18FDG-PET/CT. RESULTS Eighteen adverse events of thyroid dysfunction were observed in 17 patients. Thyrotoxicosis occurred in 12 patients, of which nine evolved to hypothyroidism. Isolated hypothyroidism was present in six patients. Levothyroxine therapy was required in 10 of 15 hypothyroid patients. Thyroid autoantibodies were elevated during thyroid dysfunction in four of 10 cases. Diffuse increased 18FDG uptake by the thyroid gland was observed in all seven thyrotoxic patients who progressed to hypothyroidism. CONCLUSIONS Thyroid dysfunction is common in melanoma patients treated with pembrolizumab. Hypothyroidism and thyrotoxicosis related to inflammatory thyroiditis are the most frequent presentations. Serial measurements of thyroid function tests are indicated during anti-PD-1 monoclonal antibody therapy. Thyrotoxicosis compatible with inflammatory thyroiditis was associated with diffuse increased 18FDG uptake by the thyroid gland. The prospective role of thyroid autoantibodies should be further investigated, together with the histopathological correlates.
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Affiliation(s)
- Jeroen de Filette
- Departments of Endocrinology (J.d.F., B.V., B.B.), Medical Oncology (Y.J., M.S., B.N.), and Nuclear Medicine (H.E.), Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Yanina Jansen
- Departments of Endocrinology (J.d.F., B.V., B.B.), Medical Oncology (Y.J., M.S., B.N.), and Nuclear Medicine (H.E.), Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Max Schreuer
- Departments of Endocrinology (J.d.F., B.V., B.B.), Medical Oncology (Y.J., M.S., B.N.), and Nuclear Medicine (H.E.), Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Hendrik Everaert
- Departments of Endocrinology (J.d.F., B.V., B.B.), Medical Oncology (Y.J., M.S., B.N.), and Nuclear Medicine (H.E.), Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Brigitte Velkeniers
- Departments of Endocrinology (J.d.F., B.V., B.B.), Medical Oncology (Y.J., M.S., B.N.), and Nuclear Medicine (H.E.), Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Bart Neyns
- Departments of Endocrinology (J.d.F., B.V., B.B.), Medical Oncology (Y.J., M.S., B.N.), and Nuclear Medicine (H.E.), Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Bert Bravenboer
- Departments of Endocrinology (J.d.F., B.V., B.B.), Medical Oncology (Y.J., M.S., B.N.), and Nuclear Medicine (H.E.), Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
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Orlov S, Salari F, Kashat L, Walfish PG. Induction of painless thyroiditis in patients receiving programmed death 1 receptor immunotherapy for metastatic malignancies. J Clin Endocrinol Metab 2015; 100:1738-41. [PMID: 25751110 DOI: 10.1210/jc.2014-4560] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
CONTEXT Immunotherapies against immune checkpoints that inhibit T cell activation [cytotoxic T lymphocyte antigen 4 (CTLA-4) and programmed cell death 1 (PD-1)] are emerging and promising treatments for several metastatic malignancies. However, the precise adverse effects of these therapies on thyroid gland function have not been well described. CASE DESCRIPTION We report on 10 cases of painless thyroiditis syndrome (PTS) from a novel etiology, following immunotherapy with anti-PD-1 monoclonal antibodies (mAb) during treatment for metastatic malignancies. Six patients presented with transient thyrotoxicosis in which thyrotropin binding inhibitory immunoglobulins (TBII) were absent for all, whereas four patients had evidence of positive antithyroid antibodies. All thyrotoxic patients required temporary beta-blocker therapy and had spontaneous resolution of thyrotoxicosis with subsequent hypothyroidism. Four patients presented with hypothyroidism without a detected preceding thyrotoxic phase, occurring 6-8 weeks after initial drug exposure. All of these patients had positive antithyroid antibodies and required thyroid hormone replacement therapy for a minimum of 6 months. CONCLUSIONS Patients receiving anti-PD-1 mAb therapy should be monitored for signs and symptoms of PTS which may require supportive treatment with beta-blockers or thyroid hormone replacement. The anti-PD-1 mAb is a novel exogenous cause of PTS and provides new insight into the possible perturbations of the immune network that may modulate the development of endogenous PTS, including cases of sporadic and postpartum thyroiditis.
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Affiliation(s)
- Steven Orlov
- Department of Medicine (S.O., F.S., L.K., P.G.W.), Endocrine Division, and Otolaryngology-Head and Neck Surgery Program (P.G.W.), Mt. Sinai Hospital, Toronto, ON M5G 1X5, Canada and University of Toronto School of Medicine, Toronto, ON M5S 1A8, Canada
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Abstract
CONTEXT Amiodarone (AMIO) is one of the most effective antiarrhythmic drugs available; however, its use is limited by a serious side effect profile, including thyroiditis. The mechanisms underlying AMIO thyroid toxicity have been elusive; thus, identification of novel approaches in order to prevent thyroiditis is essential in patients treated with AMIO. OBJECTIVE Our aim was to evaluate whether AMIO treatment could induce endoplasmic reticulum (ER) stress in human thyroid cells and the possible implications of this effect in AMIO-induced destructive thyroiditis. RESULTS Here we report that AMIO, but not iodine, significantly induced the expression of ER stress markers including Ig heavy chain-binding protein (BiP), phosphoeukaryotic translation initiation factor 2α (eIF2α), CCAAT/enhancer-binding protein homologous protein (CHOP) and spliced X-box binding protein-1 (XBP-1) in human thyroid ML-1 cells and human primary thyrocytes. In both experimental systems AMIO down-regulated thyroglobulin (Tg) protein but had little effect on Tg mRNA levels, suggesting a mechanism involving Tg protein degradation. Indeed, pretreatment with the specific proteasome inhibitor MG132 reversed AMIO-induced down-regulation of Tg protein levels, confirming a proteasome-dependent degradation of Tg protein. Corroborating our findings, pretreatment of ML-1 cells and human primary thyrocytes with the chemical chaperone 4-phenylbutyric acid completely prevented the effect of AMIO on both ER stress induction and Tg down-regulation. CONCLUSIONS We identified ER stress as a novel mechanism contributing to AMIO-induced destructive thyroiditis. Our data establish that AMIO-induced ER stress impairs Tg expression via proteasome activation, providing a valuable therapeutic avenue for the treatment of AMIO-induced destructive thyroiditis.
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Affiliation(s)
- Angela Lombardi
- Division of Endocrinology (A.L., K.E.F., Y.T.) and Department of Surgery (W.B.I., R.O.), Icahn School of Medicine at Mt Sinai, New York, New York 10029; and James J. Peters Veterans Affairs Medical Center (Y.T.), Bronx, New York 10468
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Mammen JS, Ghazarian SR, Rosen A, Ladenson PW. Patterns of interferon-alpha-induced thyroid dysfunction vary with ethnicity, sex, smoking status, and pretreatment thyrotropin in an international cohort of patients treated for hepatitis C. Thyroid 2013; 23:1151-8. [PMID: 23517287 PMCID: PMC3770239 DOI: 10.1089/thy.2012.0565] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Interferon-alpha (IFNα)-induced thyroid dysfunction occurs in up to 20% of patients undergoing therapy for hepatitis C. The diversity of thyroid disease presentations suggests that several different pathological mechanisms are involved, such as autoimmunity and direct toxicity. Elucidating the relationships between risk factors and disease phenotype provides insight into the mechanisms of disease pathophysiology. METHODS We studied 869 euthyroid patients from the ACHIEVE 2/3 trial, a randomized international clinical trial comparing pegylated-IFNα2a weekly or albumin-IFNα2b every 2 weeks for up to 24 weeks in patients with hepatitis C, genotype 2 or 3, from 136 centers. The study population was 60% male and 55% white. Serum thyrotropin (TSH) and free thyroxine were measured before therapy, monthly during treatment from week 8, and at 4- and 12-week follow-up visits. RESULTS Overall, 181 (20.8%) participants had at least one abnormal TSH during the study. Low TSH occurred in 71 (8.2%), of whom 30 (3.5%) had a suppressed TSH below 0.1 mU/L. Hypothyroidism occurred in 53 patients (6.1%), with peak TSH above 10 mU/L in 12 patients (1.4%). Fifty-seven patients had a biphasic thyroiditis (6.6%), with extreme values for the nadir and/or peak TSH in all but one. Medical therapy was given to one thyrotoxic patient, four hypothyroid patients, and 26 biphasic thyroiditis patients. Multivariate logistic regression analysis demonstrated that biphasic thyroiditis is associated with being female and higher pretreatment serum TSH, whereas being Asian or a current smoker decreased the risk of thyroiditis. Hypo- and hyperthyroidism are most strongly predicted by the pretreatment TSH. CONCLUSIONS Biphasic thyroiditis accounted for the majority (58%) of clinically relevant IFNα-induced thyroid dysfunction. We confirmed our recent findings in a related cohort that female sex is a risk factor for thyroiditis but not hypothyroidism. Further, in this large multiethnic study, the risk of thyroiditis is dramatically increased, specifically for white women. Smoking was found to be protective of thyroiditis. These results support closer monitoring of women and those with a serum TSH at the extremes of the normal range during therapy so that prompt intervention can mitigate the consequences of thyroid dysfunction associated with IFNα treatment.
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Affiliation(s)
- Jennifer S. Mammen
- Division of Endocrinology and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sharon R. Ghazarian
- Division of Biostatistics, Epidemiology and Data Management Core, Center for Child and Community Health Research; Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Antony Rosen
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Paul W. Ladenson
- Division of Endocrinology and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Soldevila B, Alonso N, Martínez-Arconada MJ, Granada ML, Boada A, Vallejos V, Fraile M, Fernández-Sanmartín MA, Pujol-Borrell R, Puig-Domingo M, Sanmartí A, Martínez-Cáceres EM. Regulatory T cells and other lymphocyte subpopulations in patients with melanoma developing interferon-induced thyroiditis during high-dose interferon-α2b treatment. Clin Endocrinol (Oxf) 2013; 78:621-8. [PMID: 22957689 DOI: 10.1111/cen.12036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 06/03/2012] [Accepted: 09/01/2012] [Indexed: 11/26/2022]
Abstract
CONTEXT One of the side effects of interferon-alpha therapy is interferon-induced thyroiditis (IIT). The role of lymphocyte subpopulations in IIT melanoma patients remains to be defined. OBJECTIVE Our objective was to assess different peripheral blood lymphocyte subpopulations, mainly regulatory T cells (Tregs), in melanoma patients who developed IIT. DESIGN, PATIENTS AND METHODS From 30 melanoma patients receiving high-dose interferon (HDI)-alpha 2b (IFN-α2b) treatment, those who developed IIT (IIT patients) were selected and compared with patients who did not develop IIT (Co-MM) and healthy controls (Co-H). Peripheral blood mononuclear cells were obtained before treatment (BT), mid-treatment (MT), end of treatment (ET), 24 weeks post-treatment and at appearance of IIT (TT). RESULTS Nine patients developed IIT (30%): four Hashimoto's thyroiditis and five destructive thyroiditis. An increase in Tregs was observed in both melanoma groups during HDI treatment. A decrease in CD3(+) , NKT lymphocyte subpopulations and Bcl2 expression on B cells was also observed in both groups. However, no changes were observed in the percentage of CD4(+) , CD8(+) , CD3(+) γδ(+) , CD19(+) , transitional B cells (CD24(high) CD38(high) CD19(+) CD27(-) ), natural killer (NK), invariant NKT (iNKT) lymphocytes and Th1/Th2 balance when BT was compared with ET. At TT, IIT patients had a higher Tregs percentage than Co-MM (P = 0·012) and Co-H (P = 0·004), a higher iNKT percentage than Co-MM (P = 0·011), a higher transitional B cells percentage than Co-H (P = 0·015), a lower CD3(+) percentage than Co-H (P = 0·001) and a lower Bcl2 expression on B cells than Co-H (P < 0·001). CONCLUSIONS Our results point to the immunomodulatory effects of IFN-α on different lymphocyte subpopulations and a possible role of Tregs in melanoma patients who developed IIT.
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Affiliation(s)
- Berta Soldevila
- Department of Endocrinology and Nutrition, Hospital Universitari Germans Trias i Pujol, Universitat Autonoma de Barcelona, spain.
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Ohba K, Takayama T, Matsunaga H, Matsushita A, Sasaki S, Oki Y, Ozono S, Nakamura H. Inappropriate elevation of serum thyrotropin levels in patients treated with axitinib. Thyroid 2013; 23:443-8. [PMID: 23157669 DOI: 10.1089/thy.2012.0378] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Although anticancer treatment with the tyrosine kinase inhibitor (TKI) axitinib frequently causes thyroid dysfunction, the associated mechanism and clinical features have not been elucidated. METHODS Six patients were treated with axitinib for metastatic renal cell carcinoma at the Hamamatsu University School of Medicine between 2008 and 2010. We reviewed their thyroid function results and compared them to those of patients treated with two other TKIs, sunitinib or sorafenib, and to those of subjects with normal hypothalamic-pituitary-thyroid (HPT) function. RESULTS Axitinib-induced thyroid dysfunction was observed in all patients, and two patterns were observed: increased serum thyrotropin (TSH) levels within one month after administration occurred in five patients and transient thyrotoxicosis due to destructive thyroiditis occurred in five patients within 7 months of treatment. Four patients exhibited both. When the relationship between the serum TSH and thyroid hormones was evaluated using plots of TSH versus both free thyroxine and free triiodothyronine, four patients showed an inappropriate elevation of serum TSH during administration of axitinib. Their values apparently shifted against the regression line compared to data from patients with a normal HPT function. A similar tendency, though weaker, was observed in some patients treated with sunitinib or sorafenib. CONCLUSION This is the first study to report an inappropriate elevation of serum TSH levels in patients treated with axitinib.
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Affiliation(s)
- Kenji Ohba
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan.
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Tran HA, Jones TL, Ianna EA, Foy A, Reeves GEM. Thyroid disease in chronic hepatitis C infection treated with combination interferon-α and ribavirin: management strategies and future perspective. Endocr Pract 2013; 19:292-300. [PMID: 23186968 PMCID: PMC4134094 DOI: 10.4158/ep12195.ra] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Hepatitis C virus (HCV) infection is one of the major epidemics afflicting young people in both developed and developing countries. The most common endocrine disorder associated with this infection, especially in conjunction with interferon-α (IFN-α)-based therapy, is thyroid disease (TD). This review examines the development of TD before, during, and after the completion of treatment with combination IFN-α and ribavirin (RBV) for chronic HCV infection. We also summarize the current understanding of the natural history of the condition and propose management and follow-up guidelines. METHODS PubMed was searched up to June 30, 2011 for English-language publications that contained the search terms "hepatitis C virus," "chronic hepatitis C," "HCV," "thyroid disease," "thyroiditis," "autoimmunity," "interferon-alpha," and "ribavirin." Additional publications were identified from the reference lists of identified papers. The included studies were original research publications and included combination IFN-α and RBV use in patients that developed TD. RESULTS The prevalence of TD before combination IFN-α and RBV therapy ranges from 4.6 to 21.3%; during therapy, 1.1 to 21.3%; and after therapy, 6.7 to 21.3%. The most common TD is thyroiditis. Thyroid function testing (TFT) frequency and diagnostic criteria for various thyroid conditions are not standardized, and many of the existing studies are retrospective. CONCLUSION Patients undergoing this therapy should be assessed with a standardized protocol to appropriately detect and manage developed TD. Based on the currently available literature, we recommend that patients receiving combination interferon-α and RBV therapy undergo monthly thyrotropin (TSH) level testing.
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Affiliation(s)
- Huy A Tran
- Department of Clinical Chemistry, Hunter Area Pathology Service, Newcastle, New South Wales, Australia.
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Shi YN, Liu FH, Yu XJ, Liu ZB, Li QX, Yuan JH, Zang XY, Li LY. Polyinosine-polycytidylic acid promotes excessive iodine intake induced thyroiditis in non-obese diabetic mice via Toll-like receptor 3 mediated inflammation. Chin Med J (Engl) 2013; 126:703-710. [PMID: 23422193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Excessive iodine intake and viral infection are recognized as both critical factors associated with autoimmune thyroid diseases. Toll-like receptors (TLRs) have been reported to play an important role in autoimmune and inflammatory disorders. In this study, we aimed to clarify the possible mechanism of TLR3 involved in polyinosine-polycytidylic acid (poly(I:C)) promoting excessive iodine intake induced thyroiditis in non-obese diabetic (NOD) mice. METHODS Both NOD and BALB/c mice were randomly assigned to four groups: control group (n = 5), high iodine intake (HI) group (n = 7), poly(I:C) group (n = 7) and combination of excessive iodine and poly(I:C) injection (HIP) group (n = 7). After 8 weeks, mice were weighed and blood samples were collected. All the mice were sacrificed before dissection of spleen and thyroid gland. Then, thyroid histology, thyroid secreted hormone, expression of CD3(+) cells and TLR3 as well as inflammatory mRNA level were evaluated. RESULTS Both NOD and BALB/c mice from HI and HIP group represented goiter and increasing thyroid relative weight. Thyroid histology evidence indicated that only HIP group of NOD mice showed severe thyroiditis with lymphocytes infiltration in majority of thyroid tissue, severe damage of follicles and general fibrosis. Immunofluorescence staining results displayed a large number of CD3(+) cells in HIP NOD mice. Real-time polymerase chain reaction (PCR) results suggested interferon (IFN)-α increased over 30 folds and IFN-γ expression was doubled compared with control group, but interleukin (IL)-4 remained unchanged in HIP group of NOD mice thyroid. Meanwhile, over one third decrease of blood total thyroxine (TT4) and increased thyroid-stimulating hormone (TSH) was observed in HIP group of NOD mice. Only HIP group of NOD mice represented significantly elevation of TLR3 expression. CONCLUSION Poly(I:C) enhanced excessive dietary iodine induced thyroiditis in NOD mice through increasing TLR3 mediated inflammation.
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Affiliation(s)
- Ya-nan Shi
- 2011 Collaborative Innovation Center of Tianjin for Medical Epigenetics, Key Laboratory of Hormones and Development (Ministry of Health), Metabolic Diseases Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin 300070, China
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Mammen JS, Ghazarian SR, Pulkstenis E, Subramanian GM, Rosen A, Ladenson PW. Phenotypes of interferon-α-induced thyroid dysfunction among patients treated for hepatitis C are associated with pretreatment serum TSH and female sex. J Clin Endocrinol Metab 2012; 97:3270-6. [PMID: 22689690 DOI: 10.1210/jc.2012-1026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
CONTEXT Thyroid dysfunction is a common complication of interferon-α (IFNα) therapy, with many phenotypic patterns and the potential for significant morbidity. OBJECTIVE Our objective was to gain mechanistic insight and predict clinical presentations by determining the risk factors for distinct subtypes of IFNα-induced thyroid dysfunction. DESIGN ACHIEVE-1, a randomized trial conducted from 2005-2009, compared long-acting preparations of IFNα in 1323 patients with hepatitis C, genotype 1. SETTING A total of 149 outpatient clinics in North America, Europe, and Australia participated. PATIENTS We studied 1233 patients who were euthyroid at baseline. This population is 60% male and 82% Caucasian. INTERVENTIONS Patients were treated with pegylated IFNα2a weekly or albumin-IFNα2b every 2 wk for 48 wk. Serum TSH and free T(4) were measured before therapy and 12 or more times over 60 weeks. MAIN OUTCOME MEASURES Thyroid dysfunction was defined as a TSH outside the normal range during the course of therapy. Low serum TSH indicated thyrotoxicosis, elevated TSH indicated hypothyroidism, and both abnormalities occurred in biphasic thyroiditis. RESULTS Of previously euthyroid patients, 16.7% developed abnormal TSH values during therapy, including 24 with TSH below 0.1 mU/liter, 69 with TSH over 5.5 mU/liter, and 76 with biphasic thyroiditis. Biphasic thyroiditis was over 8-fold more common among women than men using multivariate logistic regression analysis [odds ratio (OR) = 8.4; 95% confidence interval (CI) = 4.5-15.8]. Thyrotoxicosis was most strongly associated with a lower pretreatment TSH (OR = 4.1 per -1 mU/liter decline; 95% CI = 1.9-9), whereas hypothyroidism was strongly associated with higher pretreatment TSH (OR = 3.9 per 1 mU/liter increase; 95% CI = 3-5.2). CONCLUSIONS Biphasic thyroiditis is common among women treated for hepatitis C with IFNα. Lower and higher pretreatment serum TSH are associated with greater likelihood of thyrotoxicosis and hypothyroidism, respectively. Antithyroid antibody levels were not available for the cohort, and thus we cannot clarify the role of pretreatment thyroid autoimmunity as a risk factor. Our results do show that readily identifiable patient characteristics are risk factors for specific patterns of IFN-induced thyroid dysfunction. These findings suggest that distinct mechanisms may underlie subtypes of thyroid dysfunction associated with immune-modulatory therapy for hepatitis C.
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Affiliation(s)
- Jennifer S Mammen
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21224, USA.
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Affiliation(s)
- Ozgur Mete
- Department of Pathology, University Health Network, Toronto, ON, Canada.
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Kozielewicz D, Halota W. Interferon-induced thyroiditis during treatment of chronic hepatitis C. Endokrynol Pol 2012; 63:66-70. [PMID: 22378101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Thyroid function disorders affect between 5% and 15% of patients treated with IFNα and RBV for chronic hepatitis C. Women and patients with thyroid peroxidase antibodies (TPOAb) found before the treatment are at risk of developing the disorders (46.1% vs. 5.4%). The spectrum of IFNα-induced thyroiditis (IIT) includes two groups. Disorders with an autoimmune background are: presence of thyroid autoantibodies without clinical disease, Hashimoto's disease and Graves' disease. The second group comprises diseases caused by the direct toxic effect of IFNα on the thyroid gland, i.e. destructive thyroiditis and non-autoimmune hypothyroidism. Thyroid diseases are not an absolute contraindication for IFNα and RBV therapy. In patients diagnosed with thyroid dysfunction, before the antiviral therapy it is necessary to achieve euthyreosis. Thyroid function disorders may occur at any moment of the therapy. The earliest have been observed in the 4th week of treatment, and the latest 12 months after its termination. During the therapy, in order to diagnose IIT early, it is recommended to determine TSH level every 2-3 months depending on the presence of TPOAb before the treatment. The diagnosis and treatment of thyroid function disorders should be conducted in co-operation with an endocrinologist.
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Affiliation(s)
- Dorota Kozielewicz
- Department of Infectious Diseases and Hepatology, L. Rydygier Collegium Medicum in Bydgoszcz, ul. Św. Floriana 12, Bydgoszcz, Poland.
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Kim BK, Choi YS, Park YH, Lee SU. Interferon-alpha-induced destructive thyroiditis followed by Graves' disease in a patient with chronic hepatitis C: a case report. J Korean Med Sci 2011; 26:1638-41. [PMID: 22148004 PMCID: PMC3230027 DOI: 10.3346/jkms.2011.26.12.1638] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 09/25/2011] [Indexed: 11/20/2022] Open
Abstract
Interferon-induced thyroiditis (IIT) is a major clinical problem for patients receiving interferon-alpha (IFN-α) therapy. But, destructive thyroiditis followed by Graves' disease associated with IFN-α therapy is very rarely reported. Herein, we report a rare case of pegylated IFN-α (pegIFN-α) induced destructive thyroiditis followed by Graves' disease in a patient with HCV infection. A 31-yr-old woman suffered from chronic active hepatitis C and was treated with pegIFN-α and ribavirin for 12 months. Results of a thyroid function test and autoantibody levels were normal before IFN-α therapy was initiated. Destructive thyrotoxicosis appeared seven months after the initiation of IFN-α therapy, followed by Graves' thyrotoxicosis two months after the cessation of therapy. The diagnoses of destructive thyroiditis and Graves' disease were confirmed by the presence of TSH receptor antibodies in addition to Tc-99m scintigraphy findings. The patient's antithyroglobulin antibody titer increased gradually during IFN-α therapy and remained weakly positive after IFN-α therapy was discontinued.
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Affiliation(s)
- Bu Kyung Kim
- Department of Internal Medicine, Kosin University, College of Medicine, Busan, Korea
| | - Young Sik Choi
- Department of Internal Medicine, Kosin University, College of Medicine, Busan, Korea
| | - Yo Han Park
- Department of Internal Medicine, Kosin University, College of Medicine, Busan, Korea
| | - Sang Uk Lee
- Department of Internal Medicine, Kosin University, College of Medicine, Busan, Korea
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Soldevila B, Alonso N, Martínez-Arconada MJ, Granada ML, Baía D, Vallejos V, Fraile M, Morillas RM, Planas R, Pujol-Borrell R, Martínez-Cáceres EM, Sanmartí AM. A prospective study of lymphocyte subpopulations and regulatory T cells in patients with chronic hepatitis C virus infection developing interferon-induced thyroiditis. Clin Endocrinol (Oxf) 2011; 75:535-43. [PMID: 21592168 DOI: 10.1111/j.1365-2265.2011.04112.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE One of the side effects of interferon-alpha (IFN-α) therapy is interferon-induced thyroiditis (IIT). The role of lymphocyte subpopulations in IIT remains to be defined. The aim of this study was to assess different peripheral blood lymphocyte subpopulations, mainly CD4(+) CD25(+) CD127low/-FoxP3(+) regulatory T cells (Tregs), in patients with chronic hepatitis C virus (HCV) infection who developed IIT. DESIGN, PATIENTS AND METHODS From 120 patients with chronic HCV who started antiviral treatment, those who developed IIT (IIT patients) were selected and compared with patients who did not develop IIT (Co-HCV). Peripheral blood mononuclear cells were obtained before treatment (BT), mid-treatment (MT), end of treatment (ET), 24 weeks post-treatment (PT) and at appearance of IIT (TT). RESULTS Eleven patients developed IIT: three Hashimoto's thyroiditis, one Graves'disease, one positive antithyroidal antibodies, one nonautoimmune hypothyroidism and five destructive thyroiditis. During antiviral treatment, an increase in CD8(+) and in Tregs was observed in both groups. A decrease in CD3(+) , CD19(+) and NKT lymphocyte subpopulations was also observed (all P < 0·05). However, no changes were observed in the percentage of CD4(+) , CD3(+) γδ(+) and iNKT lymphocytes, Th1/Th2 balance and Bcl2 expression on B cells when BT was compared with ET. At the appearance of IIT (TT), IIT patients had a higher Th1 response (CCR5(+) CCR7(-) ) (P < 0·01) and a higher Tregs percentage (P < 0·05) than Co-HCV. CONCLUSIONS Our results point to the immunomodulatory effects of IFN-α on different lymphocyte subpopulations and a possible role of Th1 response and Tregs in patients with HCV who developed IIT.
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Affiliation(s)
- Berta Soldevila
- Department of Medicine, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain.
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Abstract
BACKGROUND Thyrotoxicosis caused by destructive thyroiditis is self-limited and results from the subacute release of preformed thyroid hormone. Common etiologies include painful subacute thyroiditis and silent (painless) subacute thyroiditis (including postpartum thyroiditis, amiodarone-associated destructive thyroiditis, and lithium-associated thyroiditis). Thyrotoxicosis commonly evolves slowly over a matter of weeks. PATIENT FINDINGS We report a unique case of severe thyrotoxicosis caused by acute- onset painful destructive thyroiditis in a patient who received large amounts of nonionic contrast dye Hexabrix® for cardiac catheterization. The results of thyroid function and physical examination were normal before the catheterization. SUMMARY The acute onset of severe thyroid pain, rapid increase in serum Free Thyroxine Index, and thyroglobulin concentrations with a triiodothyronine to free thyroxine index ratio of < 20 to 1 were compatible with an acute onset destructive thyroiditis, likely related to direct toxicity from the iodinated contrast material. CONCLUSIONS In light of the large number of patients who receive these contrast agents during cardiac catheterization, clinicians should be advised of this potentially serious complication, particularly in the setting of unstable cardiac disease.
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Affiliation(s)
- Laura Calvi
- Endocrine Division, Department Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Abstract
BACKGROUND Sorafenib is a multi-targeted tyrosine kinase inhibitor licensed for the treatment of hepatocellular carcinoma and renal cell carcinoma. Thyroid function test abnormalities have been reported for different tyrosine kinase inhibitors, but only limited data on thyroid function test abnormalities related to sorafenib are available, demonstrating the occurrence of hypothyroidism in patients treated with sorafenib. SUMMARY We describe two patients who developed temporary hyperthyroidism during the course of sorafenib treatment, which was followed by overt and subclinical hypothyroidism, respectively. Thyroid ultrasonography showed an atrophic thyroid gland in patient 1 , and signs of thyroiditis in patient 2 . Detailed reassessment of thyroid volumes on routinely performed computerized tomography scans showed a gradual decrease in thyroid volume during sorafenib treatment in one patient, suggesting progressive thyroid destruction. CONCLUSION This case report describes in detail and for the first time two cases of sorafenib-induced thyroiditis. We assume that this sorafenib-induced destructive thyroiditis is an important cause of sorafenib-induced hypothyroidism.
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Affiliation(s)
- Leni van Doorn
- Department of Medical Oncology, Erasmus University Medical Center, Rotterdam, The Netherlands
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