Cutaneous Adverse Events and Cancer Survival Prognosis With Immune Checkpoint Inhibitor Treatment: A Systematic Review and Meta-Analysis

Management of immune-related myocarditis, myositis and myasthenia gravis (MMM) overlap syndrome: a single institution case series and literature review

Background

Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of various malignancies, particularly melanoma. However, immune-related adverse events (irAEs) pose significant challenges, particularly in cases of severe toxicity syndromes. One such life-threatening irAE is the myocarditis, myositis, and myasthenia gravis (MMM) overlap syndrome, which occurs in less than 1% of patients but has in-hospital mortality rates ranging from 40 to 60%. Due to its rarity and complexity, early recognition and a multidisciplinary approach are critical to improving outcomes.

Methods

We present a single-institution case series of four patients diagnosed with MMM overlap syndrome following ICI therapy. Clinical presentation, laboratory findings, imaging, and electrophysiological tests were analyzed to confirm the diagnosis. Therapeutic interventions-including corticosteroids, intravenous immunoglobulins (IVIG), plasma exchange (PLEX), tocilizumab, and rituximab- were evaluated in terms of efficacy and clinical outcomes.

Results

The onset of MMM syndrome varied from 2 to 4 weeks after initiating ICI therapy. Patients presented with rapidly progressive symptoms, including ptosis, bulbar dysfunction, respiratory distress, myopathy, and cardiac conduction abnormalities. Immunosuppressive therapy with high-dose corticosteroids was initiated in all cases. Additional immunomodulatory treatments (IVIG, tocilizumab, PLEX, and rituximab) were administered based on clinical deterioration and autoimmune profile. Two patients achieved complete recovery, one remains on maintenance immunosuppression, and one died due to respiratory failure despite aggressive treatment.

Conclusion

MMM overlap syndrome is a severe and often fatal irAE associated with ICI therapy. Early identification, aggressive immunosuppressive treatment, and individualized therapeutic strategies are essential to optimize patient outcomes. Further research is needed to refine diagnostic criteria, identify predictive biomarkers, and establish standardized treatment protocols.

Association Between Cutaneous Immune-Related Adverse Events and Efficacy of Immune Checkpoint Inhibitors in Advanced Non-Small Cell Lung Cancer

Background/Objectives: Immune checkpoint inhibitors (ICIs) have transformed the treatment of patients with non-small cell lung cancer (NSCLC). Numerous studies have suggested that immune-related adverse events (irAEs) are associated with ICI efficacy and can affect any organ system. This study aims to evaluate the prognostic significance of cutaneous IrAEs (cirAEs) and their impact on the effectiveness of PD-1/PD-L1 inhibitors in real-world NSCLC data. Methods: We retrospectively collected NSCLC patients treated with ICI as first- or second-line therapy between 2015 and 2022 at a single institution. We evaluated the association between cirAEs and treatment efficacy, measured by objective response rate (ORR), progression-free survival (PFS), and overall survival (OS). Kaplan-Meier survival curves were generated, and log-rank tests were used for significance testing. Multivariable analysis was performed using Cox proportional hazards regression models. Results: A total of 510 patients were included in the analysis, with a median age of 62 years (range 34-85), and 75% of patients were males. CirAEs of any grade were observed in 139 patients (27.3%). Among patients assessed for efficacy, the ORR was significantly higher in those with cirAEs compared to those without (54.3% vs. 29.9%, p = 0.0001). At a median follow-up of 48 months, PFS (14.6 vs. 4.7 months, p = 0.0001) and OS (29 vs. 9.2 months, p = 0.0001) were significantly improved in patients with cirAEs. Patients with grade 1-2 cirAEs showed even greater survival benefits (PFS: median 14.9 months, p = 0.003; OS: median 30 months, p = 0.001). Multivariable analysis confirmed that the development of any cirAE was independently associated with significantly improved OS (hazard ratio [HR] 0.60, 95% confidence interval [CI] 0.44-0.80, p = 0.0001). The presence of multisystem ≥ 2 SOC irAEs, including cirAE, was strongly correlated with the greatest benefit from ICIs HR:0.51 (95% CI 0.35-0.74), p = 0.001. Conclusions: This study supports that cirAEs could be used as a potential marker of ICI efficacy in NSCLC. The development of multisystem cirAEs may prognose the greatest benefit of treatment.

Incidence Rates of Cutaneous Immune-Related Adverse Events in Patients with Lung Cancer: A Systematic Review and Meta-Analysis

OBJECTIVE

Cutaneous immune-related adverse events (cirAEs) represent a prevalent manifestation of adverse reactions linked to immune checkpoint inhibitors (ICIs) therapy, substantially affecting patients' quality of life. This systematic review and meta-analysis aimed to quantify the pooled incidence of cirAEs in this population and strengthen clinical awareness for early recognition and management.

METHODS

A comprehensive search of PubMed, Embase, CINAHL, Cochrane Library, CBM, CNKI, and Wanfang databases was conducted from inception to December 2022. Literature that reported the incidence of cirAEs in patients with lung cancer receiving ICIs therapy was included. A meta-analysis was conducted using R software, version 4.4.1 to estimate the pooled incidence of cirAEs, and a random-effects model was used for data synthesis. Begg's rank correlation and funnel plots were used to assess publication bias.

RESULTS

A total of 99 articles involving 23,814 patients with lung cancer receiving ICIs therapy were included, with publication dates ranging from 2012 to 2022. The meta-analysis results reveal that the incidence of cirAEs in patients with lung cancer was 20.26% (95% confidence interval [CI (17.12-23.81)]. Significant differences were observed between all subgroups, including continent, study type, combination therapy, dual ICIs therapy, and diagnostic criteria for cirAEs for Grade 1-2 and Grade 3-4 incidences.

CONCLUSIONS

The incidence of cirAEs in patients with lung cancer is relatively high, particularly undergoing combined or dual ICIs therapy. To comprehensively characterize cirAEs in patients with lung cancer, large-scale multicenter studies integrating real-world pharmacovigilance data are warranted to establish precise incidence estimates and identify clinically significant risk factors.

IMPLICATIONS FOR CLINICAL PRACTICE

This review's insights aroused clinical staff's attention and concern about cirAEs, potentially enhancing the quality of life of patients with cancer.

Case Report and Literature Review on Skin Toxicity Induced by PD-1 Inhibitor in a Penile Cancer with Massive Ulceration of Chemoradiotherapy-Resistant and Successful Treatment by Immunotherapy

Penile cancer is a rare malignant tumor with a poor prognosis in advanced stages. Immune checkpoint inhibitors (ICIs) have demonstrated promising efficacy in patients with advanced penile cancer, but it can also induce immune-related adverse events (irAEs). This article reports a patient who achieved almost a complete response to the PD-1 inhibitor sintilimab as third-line treatment for advanced penile squamous cell cancer with massive ulceration of chemoradiotherapy-resistant, and successful treatment by immunotherapy. One year into maintenance therapy with sintilimab, skin toxicity in the form or grade-2 skin rashes and grade-3 pruritus occurred. Sintilimab was permanently discontinued. The skin toxicity was effectively controlled by oral prednisone at a daily dosage of 15 mg. At the last follow-up of 16 months after sintilimab discontinuation, the patient remained in partial response, with total progression-free survival exceeding 30 months. We also conducted a comprehensive literature search, and summarized skin toxicity of ICIs administration. These articles suggested that immune-related skin toxicity may be indicative of good treatment response.

Access to dermatologic care for cancer patients: employment of an oncodermatology referral system

PURPOSE

Oncodermatology addresses skin conditions caused by cancer or its treatment, which can affect treatment decisions and quality of life. However, electronic health record (EHR)-related communication gaps and appointment wait times hinder timely care. This study assesses the effectiveness of an oncodermatology referral system implemented on March 1, 2023, within a large tertiary healthcare system.

METHODS

A centralized email listserv was created to enable oncologists to refer patients with skin complaints for timely care. A retrospective analysis was conducted on 466 patients referred from oncology to dermatology between September 1, 2022, and September 1, 2023. Patients were divided into three groups: Batch 1 (EHR referrals pre-implementation), Batch 2 (EHR referrals only post-implementation), and Batch 3 (all email listserv referrals post-implementation). Key outcomes measured include referral-to-scheduling time, referral-to-appointment time, proportion of underserved patients referred, zip code distribution of referred patients, and success rate of scheduling appointments post-referral.

RESULTS

There was a statistically significant increase in scheduled dermatology appointments post-implementation (Batch 1, 71%; Batch 2, 73%; Batch 3, 88%; P = .0008), as well as significant reductions in referral-to-scheduling (P = 9.82 × 10-5) and referral-to-appointment times (P = 1.74 × 10-7). Across Batches 1, 2, and 3, the average referral-to-scheduling time decreased from 19 to 10 to 4 days, while referral-to-appointment time similarly decreased from 51 to 42 to 22 days. Post-implementation, significantly more appointments were created for non-white patients (P < .01) and patients living in peripheral regions within NYC (P < .01).

CONCLUSION

A centralized email-based oncodermatology referral system significantly improved scheduling efficiency and access for underserved populations, underscoring the importance of streamlined referral processes in improving dermatologic care for cancer patients.

Immune-related adverse events correlate with the clinical efficacy in advanced Non-Small-Cell Lung Cancer patients treated with PD-1 inhibitors combination therapy

OBJECTIVE

The potential of immune-related adverse events (irAEs) in predicting the efficacy of PD-1 inhibitors in advanced non-small-cell lung cancer (NSCLC) has rarely been assessed. This study investigated the associations between irAEs and the clinical efficacy of PD-1 inhibitors combination therapy in patients with advanced NSCLC.

METHODS

A retrospective analysis was conducted of 73 patients with advanced NSCLC receiving PD-1 inhibitors combination therapy from January 2022 and July 2023. Patients were divided into two cohorts: patients with irAEs and patients without irAEs. We conducted an analysis to investigate the impact of irAEs on these different clinical outcomes.

RESULTS

There were no significant differences observed in clinical characteristics between the two cohorts, except for smoking status (P = 0.011).The cohort with irAEs exhibited a higher objective response rate (ORR) and disease control rate (DCR) compared to the cohort without irAEs (ORR: 32.5% vs 12.1%, P = 0.040; DCR: 80.0% vs 48.5%, P = 0.010).Moreover, the median progression-free survival (PFS) and overall survival (OS) were significantly better in the cohort with irAEs compared to the cohort without irAEs (PFS: 12.4 months vs 6.8 months, P = 0.009; OS: not reached vs 18.3 months, P = 0.024). Additionally, the multivariate COX regression analysis revealed that mild irAEs (PFS: HR = 0.386, 95% CI: 0.199-0.748, P = 0.005; OS: HR = 0.300, 95% CI: 0.105-0.855, P = 0.024) and single-system irAEs (PFS: HR = 0.401, 95% CI: 0.208-0.772, P = 0.006; OS: HR = 0.264, 95% CI: 0.090-0.776, P = 0.015) were identified as independent prognostic factors for both PFS and OS.

CONCLUSIONS

IrAEs, especially thyroid irAEs, as well as mild or single-system irAEs, may serve as predictors of improved efficacy in advanced NSCLC patients receiving PD-1 inhibitors combination therapy.

Treatment of Pembrolizumab-Induced Mucocutaneous Lichen Planus With Metronidazole

This case report describes a man in his 50s with a diffuse pruritic rash after initiating treatment with pembrolizumab and enfortumab vedotin for metastatic urothelial carcinoma.

The correlation between immune-related adverse events and efficacy of immune checkpoint inhibitors

Immune checkpoint inhibitors have revolutionized cancer treatment by targeting the cytotoxic T lymphocyte antigen-4 and programmed death-1/ligand-1. Although immune checkpoint inhibitors show promising therapeutic efficacy, they often cause immune-related adverse events. Immune-related adverse events differ from the side effects of conventional chemotherapy and require vigilant monitoring. These events predominantly affect organs, such as the colon, liver, lungs, pituitary gland, thyroid and skin, with rare cases affecting the heart, nervous system and other tissues. As immune-related adverse events result from immune activation, indicating the reinvigoration of exhausted immune cells that attack both tumors and normal tissues, it is theoretically possible that immune-related adverse events may signal a better response to immune checkpoint inhibitor therapy. Recent retrospective studies have explored the link between immune-related adverse event development and clinical efficacy; however, the predictive value of immune-related adverse events in the immune checkpoint inhibitor response remains unclear. Additionally, studies have focused on immune-related adverse events, timing of onset and immunosuppressive treatments. This review focuses on pivotal studies of the association between immune-related adverse events and outcomes in patients treated with immune checkpoint inhibitors.

Does an Autoimmune Disorder Following Ovarian Cancer Diagnosis Affect Prognosis?

We investigated whether developing an autoimmune disorder (AID) following a high-grade epithelial ovarian cancer diagnosis improves overall survival. This retrospective study included data from women treated for high-grade serous, endometrioid, or transitional cell ovarian, fallopian tube, or peritoneal cancer FIGO stage III or IV at a Swiss cantonal gynecological cancer center (2008-2023). We used Kaplan-Meier estimates and the Cox proportional hazards model using time-varying covariates for the survival function estimation. In all, 9 of 128 patients developed an AID following a cancer diagnosis. The median time from cancer diagnosis to AID was 2 years (IQR 2-5). These women survived for a median of 3031 days (IQR 1765-3963) versus 972 days (IQR 568-1819) for those who did not develop an AID (p = 0.001). The median overall survival of nine women with a pre-existing AID was 1093 days (IQR 716-1705), similar to those who never had an AID. The multivariate analyses showed older age (p = 0.003, HR 1.04, 95% CI 1.013-1.064) was associated with a poorer prognosis, and developing an AID after a cancer diagnosis was associated with longer survival (p = 0.033, HR 0.113, 95% CI 0.015-0.837). Clinical manifestations of autoimmune disorders following ovarian cancer diagnoses were associated with better overall survival (8 versus 2.7 years), indicating an overactive immune response may improve cancer control.

Online Patient Attitudes Toward Cutaneous Immune-Related Adverse Events Attributed to Nivolumab and Pembrolizumab: Sentiment Analysis

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