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Gill J, Walker J, Ye C. Elevated CK from immune checkpoint inhibitor- related hypophysitis: a case report. J Chemother 2024:1-4. [PMID: 38818974 DOI: 10.1080/1120009x.2024.2359838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/21/2024] [Indexed: 06/01/2024]
Abstract
Immune checkpoint inhibitors (ICIs), have emerged to the forefront of management for various advanced cancers, such as melanoma, lung cancer and renal cell carcinoma. Immune checkpoints such as CTLA-4 and PD-1 serve to inhibit T cell activation and signaling; therefore through blockade of these pathways, ICIs promote anti-tumour immune activation. However, as a result of T cell disinhibition, ICIs have been reported to cause immune related adverse events (irAEs) affecting numerous organ systems. One of the most serious and potentially life-threatening irAE is inflammatory myositis. Myositis, which generally presents with progressive proximal muscle weakness and elevated serum creatine kinase (CK), has been reported in <1% of patients who have received ICI therapy. A rare cause of elevated CK is adrenal insufficiency, which has been reported in up to 6% of ICI users. Here we report a case of ICI-related hypophysitis related myopathy that was initially misdiagnosed as ICI-associated inflammatory myositis. This case illustrates the importance of considering a wide differential when assessing hyperCKemia in the setting of ICI use.
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Affiliation(s)
- Jasmine Gill
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Carrie Ye
- Department of Medicine, Division of Rheumatology, University of Alberta, Edmonton, Alberta
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Lei C, Kong X, Li Y, Yang H, Zhang K, Wang Z, Chang H, Xuan L. PD-1/PD-L1 Inhibitor - Related Adverse Events and Their Management in Breast Cancer. J Cancer 2024; 15:2770-2787. [PMID: 38577606 PMCID: PMC10988294 DOI: 10.7150/jca.85433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 03/03/2024] [Indexed: 04/06/2024] Open
Abstract
As the positive results of multiple clinical trials were released, the Programmed cell death 1 (PD-1) and Programmed cell death ligand 1 (PD-L1) inhibitors emerge as the focus of integrative breast cancer treatment. PD-1/PD-L1 inhibitors are often used as a sequential agent to be combined with other agents such as chemotherapeutic agents, targeted agents, and radiation therapy. As multiple therapies are administered simultaneously or in sequence, they are prone to a variety of adverse effects on patients while achieving efficacy. It is a challenge for clinicians to maintaining the balance between immune-related adverse effects(irAEs) and treatment efficacy. Previous literatures have paid lots of attention on the adverse effects caused by immunosuppressive agents themselves, while there is a dearth of the research on the management of adverse immune effects during the combination of immunotherapy with other treatments. In this review, we discuss the overall incidence of irAEs caused by PD-1/PD-L1 inhibitors in combination with various types of treatments in breast cancer, including chemotherapy, CTLA-4 inhibitors, targeted therapy, and radiotherapy, and systematically summarizes the clinical management to each organ-related adverse immune reaction. It is important to emphasize that in the event of irAEs such as neurological, hematologic, and cardiac toxicity, there is no alternative treatment but to terminate immunotherapy. Thus, seeking more effective strategy of irAEs' management is imminent and clinicians are urged to raise the awareness of the management of adverse immune reactions.
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Affiliation(s)
- Chuqi Lei
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiangyi Kong
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Li
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huaiyu Yang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke Zhang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhongzhao Wang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hu Chang
- Administration Office, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Lixue Xuan
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Vardarli I, Tan S, Brandenburg T, Weidemann F, Görges R, Herrmann K, Führer D. Risk and Incidence of Endocrine Immune-Related Adverse Effects Under Checkpoint Inhibitor Mono- or Combination Therapy in Solid Tumors: A Meta-Analysis of Randomized Controlled Trials. J Clin Endocrinol Metab 2024; 109:1132-1144. [PMID: 37967245 DOI: 10.1210/clinem/dgad670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 11/17/2023]
Abstract
CONTEXT Few meta-analyses on incidence of endocrine immune-related adverse effects (eirAEs) have been published and many trials have been published since. OBJECTIVE We performed a comprehensive meta-analysis with updated literature to assess risk and incidence of eirAEs of any grade and grade 3 to 5 by immune checkpoint inhibitor (ICI) monotherapy or combination therapy in solid tumors. METHODS An electronic search using PubMed/Medline, Embase, and the Cochrane Library was performed. Randomized controlled studies (RCTs) assessing eirAEs under ICI monotherapy or ICI combination therapy were selected. Stata software (v17) was used for statistical analyses and risk of bias was evaluated using Review Manager version 5.3. RESULTS A total of 69 RCTs with 80 independent reports, involving 42 886 patients, were included in the study. Meta-analysis revealed the following pooled estimates for risk ratio and incidence, respectively: for any grade hypothyroidism 7.81 (95% CI, 5.68-10.74, P < .0001) and 7.64% (95% CI, 6.23-9.17, P < .0001); significantly increased also for hyperthyroidism, hypophysitis/hypopituitarism, and adrenal insufficiency; and for insulin-dependent diabetes mellitus 1.52 (95% CI, 1.07-2.18, P = .02), and 0.087% (95% CI, 0.019-0.189, P = .0006), respectively. Meta-regression showed that combination of ICIs (nivolumab plus ipilimumab; durvalumab plus tremelimumab) is an independent risk factor for any grade hypophysitis/hypopituitarism, and that ICI agent is an independent factor of risk for adrenal insufficiency, but that cancer type is not an independent risk factor for eirAEs. CONCLUSION We showed that risk, independent from cancer type, and incidence of eirAEs are substantially increased with ICI therapy. Combination of ICIs increases risk for eirAEs, especially for hypophysitis/hypopituitarism.
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Affiliation(s)
- Irfan Vardarli
- 5th Medical Department, Division of Endocrinology and Diabetes, Medical Faculty Mannheim, Heidelberg University, Mannheim 68167, Germany
- Department of Medicine I, Klinikum Vest, Knappschaftskrankenhaus Recklinghausen, Academic Teaching Hospital, Ruhr-University Bochum, Recklinghausen 45657, Germany
| | - Susanne Tan
- Department of Endocrinology, Diabetes and Metabolism, Clinical Chemistry-Division of Laboratory Research; Endocrine Tumor Center at WTZ/Comprehensive Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen 45147, Germany
| | - Tim Brandenburg
- Department of Endocrinology, Diabetes and Metabolism, Clinical Chemistry-Division of Laboratory Research; Endocrine Tumor Center at WTZ/Comprehensive Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen 45147, Germany
| | - Frank Weidemann
- Department of Medicine I, Klinikum Vest, Knappschaftskrankenhaus Recklinghausen, Academic Teaching Hospital, Ruhr-University Bochum, Recklinghausen 45657, Germany
| | - Rainer Görges
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Essen 45147, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Essen 45147, Germany
| | - Dagmar Führer
- Department of Endocrinology, Diabetes and Metabolism, Clinical Chemistry-Division of Laboratory Research; Endocrine Tumor Center at WTZ/Comprehensive Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen 45147, Germany
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Zhang S, Wu J, Zhao Y, Zhang J, Zhang X, Wu C, Zhang Z, Guo Z. Immune-Related Adverse Event-Related Adrenal Insufficiency Mediates Immune Checkpoint Inhibitors Efficacy in Cancer Treatment. Cancer Manag Res 2024; 16:151-161. [PMID: 38501053 PMCID: PMC10946443 DOI: 10.2147/cmar.s444916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 03/05/2024] [Indexed: 03/20/2024] Open
Abstract
Purpose Immune checkpoint inhibitors (ICIs) have significantly improved the outcomes of patients with cancer; however, these agents may initiate immune-related adverse events (irAEs). Previous studies have demonstrated a robust correlation between disease prognosis and the occurrence of irAEs, specifically skin or endocrine irAEs. Herein, we aimed to evaluate the correlation between irAE-related adrenal insufficiency (AI) and ICI treatment efficacy. Patients and methods Patients diagnosed with gastrointestinal, respiratory, head and neck, urological, skin and gynecologic cancers treated with anti-programmed cell death 1 (PD-1)/anti-programmed cell death ligand 1 (PD-L1) antibody as monotherapy or combined therapy (combined with chemotherapy or targeted therapy) were divided into irAE-A (patients with irAE-related AI), irAE-B (patients with other irAEs) and non-irAE groups. Immunotherapy efficacy was assessed based on the disease control rate (DCR), progression-free survival (PFS), and overall survival (OS). Survival probabilities were estimated using the Kaplan-Meier method with the log-rank test. Results Of the 192 patients enrolled in our study, 17 developed irAE-related AI and 83 developed other irAEs. The DCR of the irAE-A and irAE-B groups were higher than that of the non-irAE group (P<0.05). Multiple extended Cox regression analyses showed that irAE status (irAE-A vs non-irAE, P=0.008; irAE-B vs non-irAE, P=0.020), Eastern Cooperative Oncology Group (ECOG) status (P=0.045), tumor-node-metastasis (TNM) stage (P=0.000), and treatment line (P=0.002) were independent predictors of PFS. Contrarily, irAE status (irAE-A vs non-irAE, P=0.009; irAE-B vs non-irAE, P=0.013), ECOG status (P=0.007), TNM stage (P=0.035), treatment line (P=0.001) and treatment modality (P=0.008) were independent predictors for OS. Conclusion IrAE-related AI was significantly associated with ICI treatment efficacy in patients with cancer, which could be a potentially predictable marker. Due to the destruction of adrenal tissue by T cells with enhanced activity, AI reflects enhanced T cell activity to some extent.
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Affiliation(s)
- Shasha Zhang
- Department of Immunology and Rheumatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, People’s Republic of China
| | - Jianhua Wu
- Animal Center, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, People’s Republic of China
| | - Yue Zhao
- Department of Gastroenterology and Hepatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, People’s Republic of China
| | - Jingjing Zhang
- Department of Immunology and Rheumatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, People’s Republic of China
| | - Xiaoyun Zhang
- Department of Immunology and Rheumatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, People’s Republic of China
| | - Chensi Wu
- Department of Gastroenterology and Hepatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, People’s Republic of China
| | - Zhidong Zhang
- Department of Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, People’s Republic of China
| | - Zhanjun Guo
- Department of Immunology and Rheumatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, People’s Republic of China
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Liblik K, Caterini J, Touma NJ. Immune Checkpoint Inhibitors for Kidney and Bladder Cancer: Adrenotoxic Consequences. Urology 2024:S0090-4295(24)00129-8. [PMID: 38431157 DOI: 10.1016/j.urology.2024.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/25/2024] [Accepted: 02/21/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Kiera Liblik
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Jessica Caterini
- Department of Urology, Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada
| | - Naji J Touma
- Department of Urology, Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada.
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Fujimiya T, Azuma K, Togashi Y, Kuwata K, Unezaki S, Takeuchi H. Pembrolizumab-induced secondary adrenal insufficiency due to adrenocorticotrophic hormone deficiency in a patient with non-small-cell lung carcinoma: a case report. J Pharm Health Care Sci 2024; 10:10. [PMID: 38365819 PMCID: PMC10873928 DOI: 10.1186/s40780-024-00332-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/31/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Pembrolizumab can cause immune-related adverse events such as adrenal insufficiency (AI). However, there is no consensus regarding appropriate monitoring of adrenal function during subsequent chemotherapy in patients who have received immune checkpoint inhibitors (ICIs) such as pembrolizumab. CASE PRESENTATION In this report, we discuss the case of a 60s-year-old male patient with non-small cell lung cancer receiving chemotherapy who developed secondary AI due to adrenocorticotrophic hormone (ACTH) deficiency 8 months after the discontinuation of pembrolizumab, which was 17 months after the initiation of pembrolizumab immunotherapy. After 5 months of chemotherapy, he developed fever and diarrhoea, after which chemotherapy was discontinued. Thereafter, he was hospitalised owing to the development of general fatigue and anorexia. Although cortisol and ACTH levels were not measured during chemotherapy, they were measured before hospitalisation, and secondary AI was suspected. After admission, a detailed endocrine workup was performed, and the patient was diagnosed with secondary AI due to ACTH deficiency. Treatment with hydrocortisone was initiated, which markedly improved his general fatigue and anorexia. The patient showed no evidence of progressive disease 9 months after the discontinuation of pembrolizumab. CONCLUSIONS Although rare, the possibility of AI should be considered in patients who have received ICIs when nonspecific symptoms develop during or after subsequent chemotherapy, and measurements of endocrine function (including cortisol and ACTH levels) should be performed.
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Affiliation(s)
- Tatsuhiro Fujimiya
- Department of Practical Pharmacy, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1, Horinouchi, 192-0392, Hachioji-city, Tokyo, Japan.
| | - Kanako Azuma
- Department of Pharmacy, Tokyo Medical University Hospital, 6-7-1, Nishi-shinjuku, Shinjuku-ku, 160-0023, Tokyo, Japan
| | - Yuki Togashi
- Department of Respiratory Medicine, Tokyo Medical University Hospital, 6-7-1, Nishi-shinjuku, Shinjuku-ku, 160-0023, Tokyo, Japan
| | - Koji Kuwata
- Department of Diabetes, Metabolism and Endocrinology, Tokyo Medical University Hospital, 6-7-1, Nishi-shinjuku, Shinjuku-ku, 160-0023, Tokyo, Japan
| | - Sakae Unezaki
- Department of Practical Pharmacy, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1, Horinouchi, 192-0392, Hachioji-city, Tokyo, Japan
| | - Hironori Takeuchi
- Department of Practical Pharmacy, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1, Horinouchi, 192-0392, Hachioji-city, Tokyo, Japan
- Department of Pharmacy, Tokyo Medical University Hospital, 6-7-1, Nishi-shinjuku, Shinjuku-ku, 160-0023, Tokyo, Japan
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Wang Y, Zhao P, Zhao Z, Yang H, Zhang F. Primary multiple endocrine insufficiency during immune checkpoint inhibitor treatment: A case report. Medicine (Baltimore) 2024; 103:e36998. [PMID: 38241587 PMCID: PMC10798724 DOI: 10.1097/md.0000000000036998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/27/2023] [Indexed: 01/21/2024] Open
Abstract
RATIONALE Immunotherapy with immune checkpoint inhibitors (ICI) has shown promising activity against many tumor types. However, they can also induce a wide array of immune-related adverse events, ranging from mild to fatal. Primary 3 endocrine gland insufficiency during treatment with ICI has rarely been reported. PATIENT CONCERNS We report the case of a 33-year-old man with Ewing sarcoma who was treated with toripalimab as a second-line treatment. Approximately 11 months after initiating treatment, the patient developed subclinical hypothyroidism, which was followed by adrenal insufficiency and hypogonadism 6 months later. Consequently, the decision was made to discontinue ICI therapy and initiate hormone replacement therapy to manage endocrine deficiencies. DIAGNOSES Serum adrenocorticotropic hormone, thyroid stimulating hormone, and prolactin levels increased significantly, while cortisol, estradiol, and testosterone levels decreased (Table 1). The patient had negative findings on the pituitary MRI. INTERVENTION As part of the management strategy, ICI therapy was ceased and hormone replacement therapy was commenced to address endocrine deficiencies. OUTCOMES After hormone replacement therapy, his symptoms improved and follow-up examinations showed normalization of hormone levels. LESSONS Clinicians should be aware of the potential of immune checkpoint inhibitor therapy to cause endocrine dysfunction. Prompt recognition and management of these adverse events are crucial for patient health and quality of life.
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Affiliation(s)
- Yaning Wang
- School of Clinical Medicine, Weifang Medical University, Weifang, Shandong, China
- Department of Endocrinology, Qingdao Central Hospital, Qingdao, Shandong, China
| | - Peng Zhao
- Department of Laboratory, Qingdao Central Hospital, Qingdao, Shandong, China
| | - Ziyun Zhao
- Department of Laboratory, Qingdao Central Hospital, Qingdao, Shandong, China
| | - Hai Yang
- Department of Pharmacy, Qingdao Central Hospital, Qingdao, Shandong, China
| | - Fanghua Zhang
- Department of Endocrinology, Qingdao Central Hospital, Qingdao, Shandong, China
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Wei H, Zuo A, Chen J, Zheng C, Li T, Yu H, Guo Y. Adrenal crisis mainly manifested as recurrent syncope secondary to tislelizumab: a case report and literature review. Front Immunol 2024; 14:1295310. [PMID: 38292481 PMCID: PMC10825015 DOI: 10.3389/fimmu.2023.1295310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 12/28/2023] [Indexed: 02/01/2024] Open
Abstract
As an immune checkpoint inhibitor (ICI), tislelizumab is an anti-programmed cell death protein 1 (PD-1) drug. With the extensive application of ICIs, there is an ever-increasing proportion of immune-related adverse events (irAEs) in clinical settings, some of which may even be life-threatening. Herein, we present a patient with tislelizumab-induced adrenal crisis. The main clinical manifestation was recurrent syncope accompanied by high-grade fever. Timely identification and hormone replacement therapy helped the patient overcome the crisis well. Finally, the patient discontinued tislelizumab and switched to antibody-drug conjugate (ADC) therapy. We report this case to improve our understanding of this situation, identify this kind of disease, and prevent adrenal crisis in time. Eventually, limiting toxicities reduces the interruption of immunotherapy. Since irAEs are multisystem damage with more non-specific symptoms, except for oncologists, general practitioners who endorse the need for taking a holistic approach to the patient should play a vital role in the management of cancer treatment.
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Affiliation(s)
| | | | | | | | | | | | - Yuan Guo
- Department of General Practice, Qilu Hospital of Shandong University, Jinan, China
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Iesaka H, Kameda H, Miya A, Nomoto H, Cho KY, Nakamura A, Abe T, Shinohara N, Atsumi T. Fulminant ACTH decrease following diabetic ketoacidosis induced by immune checkpoint inhibitor combination therapy with nivolumab and ipilimumab: A case report. Medicine (Baltimore) 2023; 102:e36664. [PMID: 38134115 PMCID: PMC10735057 DOI: 10.1097/md.0000000000036664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023] Open
Abstract
RATIONALE The increasing use of immune checkpoint inhibitors (ICIs) for treating malignant tumors result in the concomitant rise of immune-related adverse events (irAEs). This case report may provide useful insight to understanding the etiology of ICI-induced hypophysitis, a severe irAE leading to potentially fatal secondary adrenal insufficiency. PATIENT CONCERNS An 81-year-old Japanese man was hospitalized for diabetic ketoacidosis following 4 courses of ICI combination therapy with nivolumab and ipilimumab for metastatic renal cell carcinoma. DIAGNOSIS Insulin secretion was depleted, leading to diagnosis of fulminant type 1 diabetes. Adrenocorticotropic hormone (ACTH) and cortisol levels were very high (60.8 pmol/L and 1575 nmol/L, respectively) upon admission. ACTH and cortisol returned to normal ranges on the 2nd day. On the 8th day, an ACTH loading test showed intact cortisol response (peak value 519 nmol/L). However, on the 14th day, there was a sharp decrease in ACTH and cortisol levels (10.5 pmol/L and 47 nmol/L, respectively) accompanied by fatigue and a drop in blood pressure to 97/63 mm Hg. As secondary adrenal insufficiency was suspected, hydrocortisone replacement was initiated. An ACTH loading test on the 17th day revealed low cortisol peak (peak value 232 nmol/L), indicating sudden disruption of adrenal function. Magnetic resonance imaging showed no abnormal findings and there was no other pituitary hormone deficiency. These findings, along with the patient clinical course, suggest that secondary adrenal insufficiency was caused by acute ACTH producing cell destruction as an irAE associated with ICI therapy. INTERVENTIONS The patient hyperglycemia and ketoacidosis were treated using extracellular fluid and insulin therapy. After development of adrenal insufficiency, hydrocortisone 20 mg was started, and the patient symptoms improved. OUTCOMES He was continued on insulin therapy, hydrocortisone, and reinitiated nivolumab. LESSONS This case provides a detailed course of the fulminant onset of ACTH deficiency during ICI administration, emphasizing the importance of close monitoring.
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Affiliation(s)
- Hiroshi Iesaka
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiraku Kameda
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Aika Miya
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroshi Nomoto
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kyu Yong Cho
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Akinobu Nakamura
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takashige Abe
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Nobuo Shinohara
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Xiang J, Liu X, Hao Y, Zhu Y, Wu M, Lou J, Wang Y, Xu C, Xie Y, Huang J. Clinical characteristics and treatment efficacy of immune checkpoint inhibitors (ICIs) in patients with ICIs-induced Adrenal insufficiency. Transl Oncol 2023; 38:101787. [PMID: 37729740 PMCID: PMC10518362 DOI: 10.1016/j.tranon.2023.101787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/04/2023] [Accepted: 09/08/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Adrenal insufficiency (AI) caused by immune checkpoint inhibitors (ICIs) is an extremely rare immune-related adverse event (irAE). The detailed clinical characteristics and outcomes of patients with ICI-induced AI are unavailable. This study aimed to explore the clinical characteristics and efficacy of treatment in patients with ICI-induced AI. METHODS We retrospectively collected information on patients diagnosed with AI caused by ICIs at LiShui Municipal Central Hospital and Zhejiang Cancer Hospital, including baseline characteristics, laboratory results, symptoms, treatment outcomes of AI, and hormone use. Survival outcomes were calculated using the Kaplan-Meier method and stratified according to the different situations. RESULTS From December 2020 to February 2023, among 1014 patients treated with ICI therapy, a total of twenty patients were diagnosed with ICI-induced AI. Most of the patients were men (80%, n = 16), with a performance status (PS) of 0 - 1 (95%, n = 19). The median (range) age was 65.9 (49-80) years and 14 patients (70%) were treated with ICIs as first-line therapy. The majority of the patients (70%, n = 14) experienced grade 3 - 4 AI. All patients received corticosteroid replacement therapy, and only 7 patients recovered. The median time to the diagnosis of AI after starting ICI therapy was 5.2 (3.0 - 7.5) months. The objective response rate was 70% and median progression-free survival in these patients was 16.0 months (95% confidence interval: 11.7 - 20.3 months). CONCLUSIONS ICI-induced AI is a rare irAE, and close monitoring of cortisol levels is important. Patients diagnosed with AI after receiving immunotherapy seem to have a favorable outcome.
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Affiliation(s)
- Jing Xiang
- Department of Clinical Trial, Zhejiang Cancer Hospital, Hangzhou, Zhejiang 310022, China; The Second Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053, China
| | - Xueni Liu
- Department of Medical Oncology, Lishui Municipal Central Hospital, Lishui, Zhejiang 323000, China
| | - Yue Hao
- Department of Clinical Trial, Zhejiang Cancer Hospital, Hangzhou, Zhejiang 310022, China; The Second Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053, China
| | - Yanyan Zhu
- Department of Pharmacy, Lishui Municipal Central Hospital, Lishui, Zhejiang 323000, China
| | - Minhua Wu
- Department of Medical Oncology, Lishui Municipal Central Hospital, Lishui, Zhejiang 323000, China
| | - Jian Lou
- Department of Medical Oncology, Lishui Municipal Central Hospital, Lishui, Zhejiang 323000, China
| | - Yonghui Wang
- Department of Medical Oncology, Lishui Municipal Central Hospital, Lishui, Zhejiang 323000, China
| | - Chunwei Xu
- Department of Respiratory Medicine, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China; Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences, Hangzhou, Zhejiang 310018, China
| | - Yanru Xie
- Department of Medical Oncology, Lishui Municipal Central Hospital, Lishui, Zhejiang 323000, China; The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, Zhejiang 323000, China.
| | - Jianhui Huang
- Department of Medical Oncology, Lishui Municipal Central Hospital, Lishui, Zhejiang 323000, China; The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, Zhejiang 323000, China.
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Yoo WS, Ku EJ, Lee EK, Ahn HY. Incidence of Endocrine-Related Dysfunction in Patients Treated with New Immune Checkpoint Inhibitors: A Meta-Analysis and Comprehensive Review. Endocrinol Metab (Seoul) 2023; 38:750-759. [PMID: 37956967 PMCID: PMC10764989 DOI: 10.3803/enm.2023.1785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 09/10/2023] [Accepted: 09/25/2023] [Indexed: 11/21/2023] Open
Abstract
BACKGRUOUND This study investigated the incidence of endocrine immune-related adverse events (irAEs) for recently developed immune checkpoint inhibitor (ICI) drugs. METHODS We collected studies on newly developed ICI drugs using PubMed/Medline, Embase, and Cochrane Library from inception through January 31, 2023. Among ICI drugs, nivolumab, pembrolizumab, and ipilimumab were excluded from the new ICI drugs because many papers on endocrine-related side effects have already been published. RESULTS A total of 44,595 patients from 177 studies were included in this analysis. The incidence of hypothyroidism was 10.1% (95% confidence interval [CI], 8.9% to 11.4%), thyrotoxicosis was 4.6% (95% CI, 3.8% to 5.7%), hypophysitis was 0.8% (95% CI, 0.5% to 1.1%), adrenal insufficiency was 0.9% (95% CI, 0.7% to 1.1%), and hyperglycemia was 2.3% (95% CI, 1.6% to 3.4%). Hypothyroidism and thyrotoxicosis occurred most frequently with programmed cell death protein-1 (PD-1) inhibitors (13.7% and 7.5%, respectively). The rate of endocrine side effects for the combination of a programmed death-ligand 1 inhibitor (durvalumab) and cytotoxic T lymphocyte-associated antigen 4 inhibitor (tremelimumab) was higher than that of monotherapy. In a meta-analysis, the combination of tremelimumab and durvalumab had a 9- to 10-fold higher risk of pituitary and adrenal-related side effects than durvalumab alone. CONCLUSION Newly developed PD-1 inhibitors had a high incidence of thyroid-related irAEs, and combined treatment with durvalumab and tremelimumab increased the risk of pituitary- and adrenal-related irAEs. Based on these facts, it is necessary to predict the endocrine side effects corresponding to each ICI drug, diagnose and treat them appropriately, and try to reduce the morbidity and mortality of patients.
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Affiliation(s)
- Won Sang Yoo
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Eu Jeong Ku
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Eun Kyung Lee
- Department of Internal Medicine, Center for Thyroid Cancer, National Cancer Center, Goyang, Korea
| | - Hwa Young Ahn
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
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12
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Ikeda Y, Sato S, Omu R, Nishimura A, Arii S, Uchida R, Nomura K, Sato S, Murata A, Shimada Y, Genda T. Isolated Adrenocorticotropic Hormone Deficiency Associated with Atezolizumab and Bevacizumab Administration for Treating Hepatocellular Carcinoma: A Case Series. Intern Med 2023; 62:3341-3346. [PMID: 37032085 PMCID: PMC10713368 DOI: 10.2169/internalmedicine.1446-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/21/2023] [Indexed: 04/11/2023] Open
Abstract
Atezolizumab and bevacizumab are currently available as first-line treatments for unresectable hepatocellular carcinoma, but immune-related adverse events are a major concern. We herein report two cases of isolated adrenocorticotropic hormone (ACTH) deficiency. Both patients presented with general fatigue, appetite loss, eosinophilia, and hyponatremia after nine cycles in case 1 and three months after stopping treatment for inflammatory arthritis in case 2. Endocrinological investigations revealed unsatisfactory ACTH and cortisol responses despite the preservation of other anterior pituitary hormones, suggesting isolated ACTH deficiency. As it is rapidly improved by steroid replacement therapy, an early diagnosis and treatment make it possible to resume immunotherapy.
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Affiliation(s)
- Yuji Ikeda
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Shunsuke Sato
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Rifa Omu
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Arisa Nishimura
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Shin Arii
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Ryota Uchida
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Kei Nomura
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Sho Sato
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Ayato Murata
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Yuji Shimada
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Takuya Genda
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
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13
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Chen P, Li J, Tan H. Progress and Challenges of Immune Checkpoint Inhibitor-Induced Hypophysitis. J Clin Med 2023; 12:jcm12103468. [PMID: 37240574 DOI: 10.3390/jcm12103468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 04/13/2023] [Accepted: 04/29/2023] [Indexed: 05/28/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are a new type of antitumor drug which can achieve antitumor goals by blocking the binding of immune checkpoints to their ligands, thereby enhancing the activity of T cells. Meanwhile, ICIs block the binding of immune checkpoints to their ligands, disrupting the immune tolerance of T cells to self-antigens, which may lead to a series of immune-related adverse events (irAEs). Immune checkpoint inhibitor-induced hypophysitis (IH) is a relatively rare irAE. Due to the lack of specificity in clinical manifestations, it is difficult to accurately diagnose IH in a timely manner in clinical practice. However, the risk of adverse events, especially IH, for patients receiving ICIs has not been adequately investigated. Missed or delayed diagnosis may lead to poor prognosis or even adverse clinical outcomes. In this article, we summarize the epidemiology, pathogenesis, clinical manifestations, diagnosis and treatment of IH.
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Affiliation(s)
- Piaohong Chen
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jianwei Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
- Institute of Pituitary Adenomas and Related Diseases, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Huiwen Tan
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
- Institute of Pituitary Adenomas and Related Diseases, West China Hospital, Sichuan University, Chengdu 610041, China
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14
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Berz AM, Boughdad S, Vietti-Violi N, Digklia A, Dromain C, Dunet V, Duran R. Imaging assessment of toxicity related to immune checkpoint inhibitors. Front Immunol 2023; 14:1133207. [PMID: 36911692 PMCID: PMC9995973 DOI: 10.3389/fimmu.2023.1133207] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/10/2023] [Indexed: 02/25/2023] Open
Abstract
In recent years, a wide range of cancer immunotherapies have been developed and have become increasingly important in cancer treatment across multiple oncologic diseases. In particular, immune checkpoint inhibitors (ICIs) offer promising options to improve patient outcomes. However, a major limitation of these treatments consists in the development of immune-related adverse events (irAEs) occurring in potentially any organ system and affecting up to 76% of the patients. The most frequent toxicities involve the skin, gastrointestinal tract, and endocrine system. Although mostly manageable, potentially life-threatening events, particularly due to neuro-, cardiac, and pulmonary toxicity, occur in up to 30% and 55% of the patients treated with ICI-monotherapy or -combination therapy, respectively. Imaging, in particular computed tomography (CT), magnetic resonance imaging (MRI), and 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/computed tomography (18F-FDG-PET/CT), plays an important role in the detection and characterization of these irAEs. In some patients, irAEs can even be detected on imaging before the onset of clinical symptoms. In this context, it is particularly important to distinguish irAEs from true disease progression and specific immunotherapy related response patterns, such as pseudoprogression. In addition, there are irAEs which might be easily confused with other pathologies such as infection or metastasis. However, many imaging findings, such as in immune-related pneumonitis, are nonspecific. Thus, accurate diagnosis may be delayed underling the importance for adequate imaging features characterization in the appropriate clinical setting in order to provide timely and efficient patient management. 18F-FDG-PET/CT and radiomics have demonstrated to reliably detect these toxicities and potentially have predictive value for identifying patients at risk of developing irAEs. The purpose of this article is to provide a review of the main immunotherapy-related toxicities and discuss their characteristics on imaging.
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Affiliation(s)
- Antonia M Berz
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Department of Radiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Berlin, Germany
| | - Sarah Boughdad
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Naïk Vietti-Violi
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Antonia Digklia
- Department of Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Clarisse Dromain
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Vincent Dunet
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Rafael Duran
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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15
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Jacques JP, Valadares LP, Moura AC, Oliveira MRF, Naves LA. Frequency and clinical characteristics of hypophysitis and hypopituitarism in patients undergoing immunotherapy - A systematic review. Front Endocrinol (Lausanne) 2023; 14:1091185. [PMID: 36875457 PMCID: PMC9974646 DOI: 10.3389/fendo.2023.1091185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 01/16/2023] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVE To describe the frequency of hypophysitis and hypopituitarism in cancer patients who are undergoing antineoplastic treatment with immunotherapy, as well as to describe the clinical, epidemiological, and demographic characteristics of these patients. METHODS A systematic search of the literature in PubMed, Embase, Web of Science, ClinicalTrials.gov and Cochrane Controlled Register of Trials took place on May 8 and 9, 2020. Randomized and nonrandomized clinical trials, cohort studies, case-control studies, case series and case reports were included. RESULTS A total of 239 articles were obtained, in which 963 cases of hypophysitis and 128 cases of hypopituitarism were found in a treated population of 30,014 individuals (3.20% and 0.42% of the evaluated population, respectively). In the cohort studies, the incidence of hypophysitis and hypopituitarism ranged from 0% to 27.59% and from 0% to 17.86%, respectively. In the non-randomized clinical trials, the incidence of hypophysitis and hypopituitarism ranged from 0% to 25% and from 0% to 14.67%, and in randomized clinical trials from 0% to 16.2% and from 0% to 33.33%. The most common hormonal changes were in the corticotrophic, thyrotrophic and gonadotrophic axes. The main magnetic resonance imaging (MRI) findings were enlargement of the pituitary gland and enhanced contrast uptake. The main symptoms presented by patients with hypophysitis were fatigue and headache. CONCLUSION The present review reported a frequency of hypophysitis and hypopituitarism of 3.20% and 0.42%, respectively, in the evaluated population. The clinical-epidemiological characteristics of patients affected by hypophysitis were also described. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/, identifier CRD42020175864.
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Affiliation(s)
- Juliana Prudêncio Jacques
- Faculty of Health Science, University of Brasilia, Brasilia, Brazil
- *Correspondence: Juliana Prudêncio Jacques,
| | - Luciana Pinto Valadares
- Department of Internal Medicine and Endocrinology, Sarah Network of Rehabilitation Hospitals, Brasília, Brazil
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16
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Hayashi H, Sawada K, Hasebe T, Nakajima S, Sawada J, Takiyama Y, Takiyama Y, Okumura T, Fujiya M. A Successful Case of Hepatocellular Carcinoma Treated with Atezolizumab Plus Bevacizumab with Multisystem Immune-related Adverse Events. Intern Med 2022; 61:3497-3502. [PMID: 35491133 PMCID: PMC9790772 DOI: 10.2169/internalmedicine.9393-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
A 63-year-old man with hepatitis C was treated with atezolizumab plus bevacizumab for unresectable diffuse hepatocellular carcinoma (HCC). After four cycles of atezolizumab plus bevacizumab, the diffuse HCC markedly shrank; however, he complained of general fatigue, loss of appetite, and slight loss of muscle strength in the lower legs. He was diagnosed with isolated adrenocorticotropic hormone deficiency (IAD), hypothyroidism, and myopathy, suggesting multisystem immune-related adverse events (irAEs). After administration of hydrocortisone, the clinical symptoms rapidly disappeared. Patients with multisystem irAEs can have favorable outcomes; thus, to continue immune-checkpoint inhibitors therapy, a correct diagnosis and management of multisystem irAEs are important.
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Affiliation(s)
- Hidemi Hayashi
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| | - Koji Sawada
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| | - Takumu Hasebe
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| | - Shunsuke Nakajima
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| | - Jun Sawada
- Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Medicine, Asahikawa Medical University, Japan
| | - Yuri Takiyama
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| | - Yumi Takiyama
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| | - Toshikatsu Okumura
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
| | - Mikihiro Fujiya
- Gastroenterology and Endoscopy, Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Japan
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17
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Lu D, Yao J, Yuan G, Gao Y, Zhang J, Guo X. Immune checkpoint inhibitor-associated new-onset primary adrenal insufficiency: a retrospective analysis using the FAERS. J Endocrinol Invest 2022; 45:2131-2137. [PMID: 35870109 PMCID: PMC9525402 DOI: 10.1007/s40618-022-01845-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 06/18/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Our study aimed to investigate the prevalence and demographic characteristics of immune checkpoint inhibitor-associated primary adrenal insufficiency (ICI-PAI) and to explore the risk factors of its clinical outcome using data from the US FDA Adverse Event Reporting System (FAERS). METHODS This was a retrospective study. All cases of new-onset or newly diagnosed primary adrenal insufficiency associated with FDA-approved ICIs from 1 January 2007 to 31 December 2020 were identified and collected using FAERS. Data on age, sex category, body weight of the participating individuals, the reporting year and the prognosis of cases, and other accompanying endocrinopathies related to ICIs, were analysed. RESULTS The incidence of ICI-PAI was 1.03% (1180/114121). Of the 1180 cases of PAI, 46 were "confirmed PAI", and 1134 were "suspected PAI". Combination therapy with anti-CTLA-4 and anti-PD-1 was related to a higher risk of PAI compared with the anti-PD-1-only group (χ2 = 92.88, p < 0.001). Male and elderly individuals showed a higher risk of ICI-PAI (male vs. female, 1.17% vs. 0.94%, χ2 = 12.55, p < 0.001; age < 65 vs. ≥ 65, 1.20 vs. 1.41%, χ2 = 6.89, p = 0.009). The co-occurrence rate of endocrinopathies other than PAI was 24.3%, which showed a higher trend in patients on nivolumab-ipilimumab treatment than in those on PD-1 inhibitors (χ2 = 3.227, p = 0.072). Body weight was negatively associated with the risk of death in the study population [p = 0.033 for the regression model; B = - 0.017, OR 0.984, 95% CI (0.969-0.998), p = 0.029]. CONCLUSION ICI-associated PAI is a rare but important irAE. Male and elderly patients have a higher risk of ICI-PAI. Awareness among clinicians is critical when patients with a lower body weight develop PAI, which indicates a higher risk of a poor clinical outcome.
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Affiliation(s)
- D. Lu
- Department of Endocrinology, Peking University First Hospital, Beijing, 100034 People’s Republic of China
| | - J. Yao
- Department of Endocrinology, Peking University First Hospital, Beijing, 100034 People’s Republic of China
| | - G. Yuan
- Department of Endocrinology, Peking University First Hospital, Beijing, 100034 People’s Republic of China
| | - Y. Gao
- Department of Endocrinology, Peking University First Hospital, Beijing, 100034 People’s Republic of China
| | - J. Zhang
- Department of Endocrinology, Peking University First Hospital, Beijing, 100034 People’s Republic of China
| | - X. Guo
- Department of Endocrinology, Peking University First Hospital, Beijing, 100034 People’s Republic of China
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18
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Shah S, Manzoor S, Rothman Y, Hagen M, Pater L, Golnik K, Mahammedi A, Lin AL, Bhabhra R, Forbes JA, Sengupta S. Complete Response of a Patient With a Mismatch Repair Deficient Aggressive Pituitary Adenoma to Immune Checkpoint Inhibitor Therapy: A Case Report. Neurosurgery 2022; 91:e51-e56. [PMID: 35544035 PMCID: PMC9514746 DOI: 10.1227/neu.0000000000002024] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 03/10/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Aggressive pituitary adenomas (APAs) are pituitary tumors that are refractory to standard treatments and carry a poor prognosis. Current treatment guidelines are not standardized but combine surgical resection, radiation therapy, and chemotherapy. Temozolomide is the only chemotherapeutic agent with documented effectiveness and is recommended for APA in European Society of Endocrinology clinical guidelines. CLINICAL PRESENTATION A 57-year-old man presented with visual deterioration and bitemporal hemianopsia. MRI of the brain demonstrated a sellar mass suspected to be pituitary macroadenoma with displacement of the stalk and optic nerve impingement. The patient underwent stereotactic endoscopic transsphenoidal resection of the mass. Postoperative MRI demonstrated gross total resection. Pathology revealed a sparsely granulated corticotroph adenoma with malignant transformation. Immunohistochemistry showed loss of expression of MLH1 and PMS2 in the tumor cells. Proton therapy was recommended given an elevated Ki67 index and p53 positivity. Before radiotherapy, there was no radiographic evidence of residual tumor. Temozolomide therapy was initiated after surveillance MRI showed recurrence at 16 months postoperatively. However, MRI demonstrated marked progression after 3 cycles. Next-generation sequencing using the MSK-IMPACT platform identified somatic mutations in MLH1 Y548lfs*9 and TP53 R337C . Immunotherapy with ipilimumab/nivolumab was initiated, and MRI demonstrated no residual tumor burden 34 months postoperatively. CONCLUSION APA is a tumor with frequent recurrence and a short median expected length of survival. Here, we demonstrate the utility of immunotherapy in a single case report of APA, with complete resolution of recurrent APA and improved survival compared with life expectancy.
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Affiliation(s)
- Sanjit Shah
- Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Saima Manzoor
- Department of Endocrinology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
- Current affiliation: Houston Methodist Hospital, Houston, Texas, USA
| | - Yehudit Rothman
- Department of Oncology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Matthew Hagen
- Department of Pathology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Luke Pater
- Department of Radiation Oncology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Karl Golnik
- Department of Ophthalmology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Abdelkader Mahammedi
- Department of Radiology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Andrew L. Lin
- Departments of Neurology and Neurosurgery, Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ruchi Bhabhra
- Department of Endocrinology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
- Current affiliation: University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Jonathan A. Forbes
- Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Soma Sengupta
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
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19
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Kanji S, Morin S, Agtarap K, Purkayastha D, Thabet P, Bosse D, Wang X, Lunny C, Hutton B. Adverse Events Associated with Immune Checkpoint Inhibitors: Overview of Systematic Reviews. Drugs 2022; 82:793-809. [PMID: 35416592 DOI: 10.1007/s40265-022-01707-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recognition and management of adverse events (AEs) associated with immune checkpoint inhibitor (ICI) use by cancer patients requires expertise from multiple disciplines. Greater awareness of potential AEs may result in earlier recognition, appropriate management, and better patient outcomes. OBJECTIVE The primary objective of this overview of systematic reviews was to synthesize and consolidate systematic review evidence describing the incidence proportion and severity of AEs associated with various ICI therapies across different cancers. METHODS A systematic literature search of four databases was conducted to identify systematic reviews that describe the incidence proportion and severity of AEs related to ICI therapy in cancer patients. A systematic review was eligible if it included adults with cancer; on ICI alone or in combination with another ICI, chemotherapy, or targeted therapy; severity (graded according to the Common Terminology Criteria for Adverse Events) and incidence proportion of AEs and whether it reported its eligibility criteria. AEs of interest were identified through an iterative ranking exercise by key stakeholders and knowledge users. Extraction of PICOTTS elements and quality indicators (AMSTAR-2) were used to manage overlap of primary studies across systematic reviews at the outcome level. Cancer subtypes were mapped to drug class and AE severity. RESULTS Overall, 129 systematic reviews met the inclusion criteria for data mapping. Systematic reviews reported incidence proportions for more than 76 AEs, of which 34 were identified as AEs of interest. After overlap assessment, 65 systematic reviews were chosen for data extraction. The three AEs with the highest median incidence were fatigue (18.3%, interquartile range [IQR] 15.0-28.0%), diarrhea (15.3%, IQR 9.7-29.2%) and rash (14.4%, IQR 10.3-19.2%). The three AEs (high-grade) with the highest median incidence were diarrhea (1.5%, IQR 1.2-6.0%), colitis (1.3%, IQR 0.6-6.1%) and neutropenia (1.2%, IQR 0.4-3.3%). Incidence proportions of high-grade AEs were often considerably lower than all-grade AEs and combination therapy (ICI combinations or combinations of ICI with chemotherapy or targeted therapy) was responsible for some of the highest incidence proportions regardless of AE. Rare AEs and certain cancer subtypes were not well reported. CONCLUSIONS Early recognition of AEs associated with ICIs requires expertise from diverse specialists, not just oncologists. Greater awareness of potential AEs may result in earlier recognition, appropriate management, and better patient outcomes. PROSPERO REGISTRATION CRD42021231593.
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Affiliation(s)
- Salmaan Kanji
- The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada. .,Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | | | | | | | | | - Dominick Bosse
- The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada
| | - Xiang Wang
- The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada
| | - Carole Lunny
- St. Michaels Hospital, Unity Health Toronto, Toronto, ON, Canada.,University of British Columbia, Vancouver, BC, Canada
| | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
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20
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Chiloiro S, Bianchi A, Giampietro A, Milardi D, De Marinis L, Pontecorvi A. The changing clinical spectrum of endocrine adverse events in cancer immunotherapy. Trends Endocrinol Metab 2022; 33:87-104. [PMID: 34895977 DOI: 10.1016/j.tem.2021.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/18/2021] [Accepted: 10/29/2021] [Indexed: 12/15/2022]
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of several malignancies, improving patient survival and quality of life. Endocrinopathies have emerged as a clinically significant group of immune-related adverse events (IRAEs). Although the mechanism of ICI toxicities has not been clarified, inhibition of immune checkpoints reduces immune tolerance to autoantigens, resulting in the development of autoimmunity disorders. We report current evidence regarding endocrine IRAEs that may have diagnostic and therapeutic implications. Management should be focused on a multidisciplinary approach to reach a prompt diagnosis and an appropriate and safe treatment.
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Affiliation(s)
- Sabrina Chiloiro
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy.
| | - Antonio Bianchi
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
| | - Antonella Giampietro
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
| | - Domenico Milardi
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
| | - Laura De Marinis
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
| | - Alfredo Pontecorvi
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
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21
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Hayes AG, Rushworth RL, Torpy DJ. Risk assessment, diagnosis, and treatment of cancer treatment-related adrenal insufficiency. Expert Rev Endocrinol Metab 2022; 17:21-33. [PMID: 34979842 DOI: 10.1080/17446651.2022.2023009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/22/2021] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Adrenal insufficiency (AI) is an easily treatable, potentially life-threatening condition, which is increasingly recognized in malignancy. The recent introduction of immune checkpoint inhibitors, in particular, and increasing use of tyrosine kinase inhibitors have increased the frequency of AI in patients with malignancy. A review is therefore warranted to summarize current knowledge on the topic and guide safe clinical practices. AREAS COVERED Malignancy may directly impact the hypothalamic-pituitary-adrenal axis and cause AI, or their treatment including surgery, radiotherapy and medication. In this narrative review, we discuss new causes of AI, recognition of suggestive clinical features, diagnosis and subsequent treatment, aiming to avoid potentially fatal adrenal crisis (AC). Standard literature searching and authors assessment of clinical applicability were used. EXPERT OPINION Adrenal insufficiency can be easily treated once identified but life threatening if unrecognized. While use of new agents such as immune checkpoint inhibitors (ICIs) is increasing, greater understanding of the mechanism of AI is needed to target prediction tools and enhance risk stratification.
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Affiliation(s)
- Annabelle G Hayes
- Royal Adelaide Hospital, Endocrine and Metabolic Unit Adelaide, Adelaide, Australia
| | - R Louise Rushworth
- The University of Notre Dame Australia, School of Medicine, Sydney Campus Darlinghurst, Darlinghurst, Australia
| | - David J Torpy
- Royal Adelaide Hospital, Endocrine and Metabolic Unit Adelaide, Adelaide, Australia
- University of Adelaide, Discipline of Medicine, Adelaide, Australia
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22
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de Vries F, van Furth WR, Biermasz NR, Pereira AM. Hypophysitis: A comprehensive overview. Presse Med 2021; 50:104076. [PMID: 34687912 DOI: 10.1016/j.lpm.2021.104076] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/27/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022] Open
Abstract
Hypophysitis is defined as inflammation of the pituitary gland. It is a heterogeneous condition as it can originate from different parts of the pituitary gland, can be caused by different pathophysiological processes, and can be isolated or the manifestation of a underlying systemic disease. Hypophysitis usually presents with endocrine deficiencies, including diabetes insipidus, with varying patterns. A subset of patients presents with mass effects. The last decades major progress has been made in the understanding of this disease. New forms are now recognized, new diagnostics are being developed, and specific treatments are proposed. This review provides an overview of the current knowledge on hypophysitis using an aetiology-based approach and provides the clinician with a stepwise approach to the patient with (suspected) hypophysitis.
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Affiliation(s)
- F de Vries
- Department of Neurosurgery and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands; Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - W R van Furth
- Department of Neurosurgery and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - N R Biermasz
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - A M Pereira
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
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23
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Iglesias P, Sánchez JC, Díez JJ. Isolated ACTH deficiency induced by cancer immunotherapy: a systematic review. Pituitary 2021; 24:630-643. [PMID: 33761049 DOI: 10.1007/s11102-021-01141-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 12/19/2022]
Abstract
Immunotherapy with immune checkpoint inhibitor (ICI) monoclonal antibodies has shown to be an effective therapeutic alternative in several malignant tumors. However, adverse effects related to an activation of the immune system may accompany ICI therapy. Among the immune-related adverse events (irAEs) are autoimmune endocrine adverse effects, such as thyroiditis, and hypophysitis. Secondary adrenal insufficiency due to isolated ACTH deficiency (IAD) has also been recently reported to be associated with ICI antibodies. We carried out a systematic review of IAD cases induced by cancer immunotherapy published to date using PubMed's database. We selected 35 articles that reported 60 cancer patients diagnosed with IAD induced by ICI therapy. The prevalence was higher in men (ratio 1.6/1). Mean age at diagnosis was 63.2 ± 11.6 (range,30-87). Melanoma was the tumor most commonly reported (35%) followed by lung (28.3%) and kidney cancer (18.3%). The ICI monoclonal antibody most frequently associated was nivolumab in monotherapy (60%), followed by pembrolizumab (18.3%). Median (IQR) time to develop IAD after starting ICI therapy was 6 (4-8) months. The main symptoms at IAD diagnosis were fatigue (82.8%) and anorexia (67.2%). Hyponatremia (68%) and eosinophilia (31.8%) were the laboratory abnormalities most frequently associated with IAD. Pituitary magnetic resonance imaging (MRI) was normal in most patients (93%). Thyroiditis was the most prevalent (35%) endocrine irAE associated with IAD. In conclusion, ICI-induced IAD is a rare and potentially life-threatening condition that must be taken into account whenever treatment with immunotherapy in cancer patients is started due to their potential serious prognostic implications.
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Affiliation(s)
- Pedro Iglesias
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Calle Manuel de Falla 1, 28222, Madrid, Spain.
- Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana (IDIPHISA), Madrid, Spain.
| | - Juan Cristóbal Sánchez
- Medical Oncology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana (IDIPHISA), Madrid, Spain
| | - Juan José Díez
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Calle Manuel de Falla 1, 28222, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana (IDIPHISA), Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
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24
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Kichloo A, Albosta M, Dahiya D, Guidi JC, Aljadah M, Singh J, Shaka H, Wani F, Kumar A, Lekkala M. Systemic adverse effects and toxicities associated with immunotherapy: A review. World J Clin Oncol 2021; 12:150-163. [PMID: 33767971 PMCID: PMC7968107 DOI: 10.5306/wjco.v12.i3.150] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/21/2021] [Accepted: 02/20/2021] [Indexed: 02/06/2023] Open
Abstract
Immunotherapy is rapidly evolving secondary to the advent of newer immunotherapeutic agents and increasing approval of the current agents by the United States Food and Drug Administration to treat a wide spectrum of cancers. Immunotherapeutic agents have gained immense popularity due to their tumor-specific action. Immunotherapy is slowly transforming into a separate therapeutic entity, and the fifth pillar of management for cancers alongside surgery, radiotherapy, chemotherapy, and targeted therapy. However, like any therapeutic entity it has its own adverse effects. With the increasing use of immuno-therapeutic agents, it is vital for physicians to acquaint themselves with these adverse effects. The aim of this review is to investigate the common systemic adverse effects and toxicities associated with the use of different classes of immunotherapeutic agents. We provide an overview of potential adverse effects and toxicities associated with different classes of immunotherapeutic agents organized by organ systems, as well as an extensive discussion of the current recommendations for treatment and clinical trial data. As we continue to see increasing usage of these agents in clinical practice, it is vital for physicians to familiarize themselves with these effects.
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Affiliation(s)
- Asim Kichloo
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
- Department of Internal Medicine, Samaritan Medical Center, Watertown, NY 13601, United States
| | - Michael Albosta
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
| | - Dushyant Dahiya
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
| | - Jean Claude Guidi
- Department of Internal Medicine, Samaritan Medical Center, Watertown, NY 13601, United States
| | - Michael Aljadah
- Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI 53201, United States
| | - Jagmeet Singh
- Department of Nephrology, Guthrie Robert Packer Hospital, Sayre, PA 18840, United States
| | - Hafeez Shaka
- Department of Internal Medicine, John H Stroger Jr. Hospital of Cook County, Chicago, IL 60612, United States
| | - Farah Wani
- Department of Family Medicine, Samaritan Medical Center, Watertown, NY 13601, United States
| | - Akshay Kumar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Manidhar Lekkala
- Department of Hematology and Oncology, University of Rochester Medical Center, Rochester, NY 14642, United States
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25
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Miner M, Elbaum M, Jawiarczyk-Przybyłowska A, Kubicka E. Endocrine complications of new anticancer therapies. POSTEP HIG MED DOSW 2021. [DOI: 10.5604/01.3001.0014.8121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Studying and analyzing of complex molecular mechanisms and immunological processes of
cancer enables oncology to introduce new cancer therapies. In the treatment of cancer, we
successively increase the use of targeted therapies with tyrosine kinase inhibitors and mTOR
inhibitors and immunotherapy using checkpoint inhibitors CTLA-4 (cytotoxic T-cell antigen-4)
and PD-1/PD-L1 (programmed death receptor 1/programmed death ligand 1). New anticancer
drugs gradually replace conventional chemotherapy and have already found application in the
treatment of many cancers, including thyroid cancer, hepatocellular carcinoma, non-small
cell lung cancer, kidney cancer, bladder cancer, melanoma, breast cancer, acute and chronic
myelogenous leukemia. The use of these drugs is less toxic than classical chemotherapy, but
it can cause gastrointestinal, cardiovascular, respiratory, skin and endocrine complications.
Most of the side effects of new cancer therapies are mild and moderate disorders, however
some might be severe and life-threatening. Endocrinopathies are one of the more common
side effects of these treatments. They can affect many endocrine glands (pituitary, thyroid,
parathyroid, adrenal, pancreas) and cause both transient and permanent disorders.
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Affiliation(s)
- Michał Miner
- Katedra i Klinika Endokrynologii, Diabetologii i Leczenia Izotopami, Uniwersytet Medyczny im. Piastów Śląskich we Wrocławiu
| | - Michał Elbaum
- Katedra i Klinika Endokrynologii, Diabetologii i Leczenia Izotopami, Uniwersytet Medyczny im. Piastów Śląskich we Wrocławiu
| | | | - Eliza Kubicka
- Katedra i Klinika Endokrynologii, Diabetologii i Leczenia Izotopami, Uniwersytet Medyczny im. Piastów Śląskich we Wrocławiu
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26
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Chen C, Wu B, Zhang C, Xu T. Immune-related adverse events associated with immune checkpoint inhibitors: An updated comprehensive disproportionality analysis of the FDA adverse event reporting system. Int Immunopharmacol 2021; 95:107498. [PMID: 33725634 DOI: 10.1016/j.intimp.2021.107498] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/06/2021] [Accepted: 02/08/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUNDS Immune-related adverse events were reported in patients treated with immune checkpoint inhibitors (ICIs). However, with the increasing number of immune-related adverse events (irAEs), the differences of each immune checkpoint inhibitor regimen had not been fully assessed. METHODS Disproportionality analysis was used in data mining of the suspected adverse events after ICIs administration based on the Food and Drug Administration Adverse Event Reporting System (FAERS) from January 2004 to December 2019. The onset time and fatality proportion of ICI-associated irAEs were further evaluated. RESULTS A total of 32,441 reports of ICI-associated irAEs were gathered. This study showed that all ICI regimens generated lung toxicity and endocrine toxicity signals. Colitis, pneumonitis and interstitial lung disease were the most common ICI-associated irAEs. Five regimens including durvalumab monotherapy, ipilimumab monotherapy, ipilimumab plus nivolumab, ipilimumab plus pembrolizumab, durvalumab plus tremelimumab were associated with irAEs. Anti-PD-1 agents generated more signals of ocular toxicities than anti-PD-L1 agents, while anti-PD-L1 agents reported more signals of hematologic toxicities. Anti-CTLA-4 agents showed more signals of gastrointestinal toxicities compared with anti-PD-1 or anti-PD-L1 agents. The highest fatality proportion of lung toxicities with durvalumab monotherapy, hematological toxicities with avelumab monotherapy, renal and skin toxicities with cemiplimab monotherapy were found. CONCLUSION Our results demonstrated that each ICI regimen had different characteristics of irAEs. Pembrolizumab had the highest fatality proportion. Ipilimumab plus pembrolizumab had the shortest median time to onset irAEs. Further studies were expected to assess whether there were clinically relevant differences exist among ICIs.
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Affiliation(s)
- Chen Chen
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China; West China School of Pharmacy, Sichuan University, Chengdu, Sichuan 610041, China
| | - Bin Wu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China.
| | - ChenYu Zhang
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China; West China School of Pharmacy, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ting Xu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China; West China School of Pharmacy, Sichuan University, Chengdu, Sichuan 610041, China.
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27
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Hahner S, Ross RJ, Arlt W, Bancos I, Burger-Stritt S, Torpy DJ, Husebye ES, Quinkler M. Adrenal insufficiency. Nat Rev Dis Primers 2021; 7:19. [PMID: 33707469 DOI: 10.1038/s41572-021-00252-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 12/25/2022]
Abstract
Adrenal insufficiency (AI) is a condition characterized by an absolute or relative deficiency of adrenal cortisol production. Primary AI (PAI) is rare and is caused by direct adrenal failure. Secondary AI (SAI) is more frequent and is caused by diseases affecting the pituitary, whereas in tertiary AI (TAI), the hypothalamus is affected. The most prevalent form is TAI owing to exogenous glucocorticoid use. Symptoms of AI are non-specific, often overlooked or misdiagnosed, and are related to the lack of cortisol, adrenal androgen precursors and aldosterone (especially in PAI). Diagnosis is based on measurement of the adrenal corticosteroid hormones, their regulatory peptide hormones and stimulation tests. The goal of therapy is to establish a hormone replacement regimen that closely mimics the physiological diurnal cortisol secretion pattern, tailored to the patient's daily needs. This Primer provides insights into the epidemiology, mechanisms and management of AI during pregnancy as well as challenges of long-term management. In addition, the importance of identifying life-threatening adrenal emergencies (acute AI and adrenal crisis) is highlighted and strategies for prevention, which include patient education, glucocorticoid emergency cards and injection kits, are described.
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Affiliation(s)
- Stefanie Hahner
- Department of Medicine I, Division of Endocrinology and Diabetology, University Hospital Wuerzburg, Wuerzburg, Germany.
| | - Richard J Ross
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Wiebke Arlt
- Institute for Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes, and Metabolism, Birmingham Health Partners, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephanie Burger-Stritt
- Department of Medicine I, Division of Endocrinology and Diabetology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Diseases, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
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28
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Yang Y, Liu J, Yang K, Ma Y, Fu S, Tang X, Wang Y, Zhou L. Endocrine Adverse Events Caused by Different Types and Different Doses of Immune Checkpoint Inhibitors in the Treatment of Solid Tumors: A Meta-Analysis and Systematic Review. J Clin Pharmacol 2021; 61:282-297. [PMID: 33345342 DOI: 10.1002/jcph.1804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/16/2020] [Indexed: 12/19/2022]
Abstract
The aim of this meta-analysis was to assess the risks of endocrine adverse events in patients with malignancies treated with different types and different doses of immune checkpoint inhibitors (ICIs). PubMed and Embase were searched for randomized controlled trials on ICIs and endocrine adverse events since 2000, and meta-analysis was carried out. Twenty-six randomized controlled trials comprising 13 824 patients with malignancies were included. Compared with the other tumor therapies (used as a control group), patients treated with programmed death-1 inhibitors appeared to be at higher risks of hypothyroidism, hyperthyroidism, thyroiditis, hypophysitis or hypopituitarism, and type 1 diabetes mellitus, while there was no difference in the risk of primary adrenal insufficiency. It was also found that patients treated with cytotoxic T-lymphocyte-associated protein-4 inhibitors were at higher risk of hypophysitis or hypopituitarism, primary adrenal insufficiency, and hypothyroidism. In comparison, patients treated with programmed death-ligand 1 inhibitors were at higher risk of hyperthyroidism and hypothyroidism. Compared with the control group, both low-dose and high-dose ICI groups were at higher risk of hypothyroidism and hyperthyroidism, and the low-dose group had increased risk of thyroiditis and primary adrenal insufficiency. There was no significant difference in the risk of type 1 diabetes between the low-dose group and the high-dose group. The risk of hypophysitis or hypopituitarism in the high-dose group (relative risk, 20.12; 95% confidence interval, 8.02-50.46) was significantly higher than that in the low-dose group (relative risk, 4.92; 95% confidence interval, 2.11-11.47). The risk of endocrine adverse events was increased in patients treated with ICIs. Different types and doses of ICIs have varying characteristics of endocrine adverse events.
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Affiliation(s)
- Yaxian Yang
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Jingfang Liu
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China.,Department of Endocrinology, the First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Kaili Yang
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Yanqi Ma
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Songbo Fu
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China.,Department of Endocrinology, the First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Xulei Tang
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China.,Department of Endocrinology, the First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Yan Wang
- Department of Endocrinology, the First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Liyuan Zhou
- Department of Endocrinology, the First Hospital of Lanzhou University, Lanzhou, Gansu, China
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29
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Stelmachowska-Banaś M, Czajka-Oraniec I. Management of endocrine immune-related adverse events of immune checkpoint inhibitors: an updated review. Endocr Connect 2020; 9:R207-R228. [PMID: 33064663 PMCID: PMC7576644 DOI: 10.1530/ec-20-0342] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/16/2020] [Indexed: 12/18/2022]
Abstract
Immune checkpoint inhibitors (ICIs) belong to a new group of anticancer drugs targeting T-cell proteins involved in the activation of immune response toward malignancies. Their introduction into clinical practice was a milestone in modern cancer treatment. However, the significant advantage of ICIs over conventional chemotherapy in terms of therapeutic efficacy is accompanied by new challenges related to specific side effects. ICI-induced immune system activation could lead to the loss of self-tolerance, presenting as autoimmune inflammation and dysfunction of various tissues and organs. Thus, the typical side effects of ICIs include immune-related adverse events (irAEs), among which endocrine irAEs, affecting numerous endocrine glands, have been commonly recognized. This review aimed to outline the current knowledge regarding ICI-induced endocrine disorders from a clinical perspective. We present updated information on the incidence and clinical development of ICI-induced endocrinopathies, including the most frequent thyroiditis and hypophysitis, the rarely observed insulin-dependent diabetes mellitus and primary adrenal insufficiency, and the recently described cases of hypoparathyroidism and lipodystrophy. Practical guidelines for monitoring, diagnosis, and treatment of ICI-related endocrine toxicities are also offered. Rising awareness of endocrine irAEs among oncologists, endocrinologists, and other health professionals caring for patients receiving ICIs could contribute to better safety and efficacy. As immunotherapy becomes widespread and approved for new types of malignancies, increased incidences of endocrine irAEs are expected in the future.
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Affiliation(s)
- Maria Stelmachowska-Banaś
- Department of Endocrinology, The Centre of Postgraduate Medical Education, Warsaw, Polska, Poland
- Correspondence should be addressed to M Stelmachowska-Banaś:
| | - Izabella Czajka-Oraniec
- Department of Endocrinology, The Centre of Postgraduate Medical Education, Warsaw, Polska, Poland
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30
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Rushworth RL, Torpy DJ, Falhammar H. Adrenal crises in older patients. Lancet Diabetes Endocrinol 2020; 8:628-639. [PMID: 32559478 DOI: 10.1016/s2213-8587(20)30122-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/29/2020] [Accepted: 04/01/2020] [Indexed: 12/21/2022]
Abstract
Adrenal crises are severe manifestations of adrenal insufficiency that result in hospital admission and incur a risk of cardiovascular events, acute renal injury, and death. Evidence from population-based studies indicate that adults older than 60 years have the highest adrenal insufficiency incidence, contribute to the highest number of adrenal crises, and have the highest age-specific incidence of adrenal crisis, which doubles between the age groups of 60-69 years and 80 years or older. Older patients might be more susceptible to adrenal crises because of a higher prevalence of comorbidities and a consequently higher risk of acute illness. This susceptibility might be compounded by shortfalls in the implementation of prevention strategies for adrenal crisis, because of individual and social factors that increase with age. Although little research has focused on adrenal crisis prevention in older patients, it seems logical that a timely diagnosis of adrenal insufficiency and the use of consensus driven adrenal crisis prevention and attenuation strategies might reduce adrenal crises in patients older than 60 years old.
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Affiliation(s)
- Ruth L Rushworth
- School of Medicine, Sydney, The University of Notre Dame Australia, Darlinghurst, NSW, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; University of Adelaide, Adelaide, SA, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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31
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Ramos-Casals M, Brahmer JR, Callahan MK, Flores-Chávez A, Keegan N, Khamashta MA, Lambotte O, Mariette X, Prat A, Suárez-Almazor ME. Immune-related adverse events of checkpoint inhibitors. Nat Rev Dis Primers 2020; 6:38. [PMID: 32382051 PMCID: PMC9728094 DOI: 10.1038/s41572-020-0160-6] [Citation(s) in RCA: 639] [Impact Index Per Article: 159.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2020] [Indexed: 02/06/2023]
Abstract
Cancer immunotherapies have changed the landscape of cancer treatment during the past few decades. Among them, immune checkpoint inhibitors, which target PD-1, PD-L1 and CTLA-4, are increasingly used for certain cancers; however, this increased use has resulted in increased reports of immune-related adverse events (irAEs). These irAEs are unique and are different to those of traditional cancer therapies, and typically have a delayed onset and prolonged duration. IrAEs can involve any organ or system. These effects are frequently low grade and are treatable and reversible; however, some adverse effects can be severe and lead to permanent disorders. Management is primarily based on corticosteroids and other immunomodulatory agents, which should be prescribed carefully to reduce the potential of short-term and long-term complications. Thoughtful management of irAEs is important in optimizing quality of life and long-term outcomes.
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Affiliation(s)
- Manuel Ramos-Casals
- Department of Autoimmune Diseases, ICMiD, Barcelona, Spain. .,Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Barcelona, Spain. .,Department of Medicine, University of Barcelona, Hospital Clínic, Barcelona, Spain.
| | - Julie R. Brahmer
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Margaret K. Callahan
- Melanoma and Immunotherapeutics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA,Parker Institute for Cancer Immunotherapy, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Niamh Keegan
- Melanoma and Immunotherapeutics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Munther A. Khamashta
- Lupus Clinic, Rheumatology Department, Dubai Hospital, Dubai, United Arab Emirates
| | - Olivier Lambotte
- APHP Médecine Interne/Immunologie Clinique, Hôpital Bicêtre, Paris, France,Université Paris-Saclay – INSERM U1184 - CEA, Immunology of Viral Infections and Autoimmune Diseases, IDMIT Department, IBFJ, Fontenay-aux-Roses and Le Kremlin-Bicêtre, France
| | - Xavier Mariette
- Université Paris-Saclay, INSERM, CEA, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ; AP-HP.Université Paris-Saclay, Hôpital Bicêtre, Rheumatology Department, Le Kremlin Bicêtre, France
| | - Aleix Prat
- Translational Genomic and Targeted Therapeutics in Solid Tumors, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain,Department of Medical Oncology, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Maria E. Suárez-Almazor
- Section of Rheumatology/Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Lu J, Li L, Lan Y, Liang Y, Meng H. Immune checkpoint inhibitor-associated pituitary-adrenal dysfunction: A systematic review and meta-analysis. Cancer Med 2019; 8:7503-7515. [PMID: 31679184 PMCID: PMC6912062 DOI: 10.1002/cam4.2661] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/25/2019] [Accepted: 10/14/2019] [Indexed: 12/15/2022] Open
Abstract
With the growing use of immune checkpoint inhibitors (ICIs), case reports of rare yet life-threatening pituitary-adrenal dysfunctions, particularly for hypopituitarism, are increasingly being published. In this analysis, we focus on these events by including the most recent publications and reports from early phase I/II and phase III clinical trials and comparing the incidence and risks across different ICI regimens. PubMed, Embase, and the Cochrane Library were systematically searched from inception to April 2019 for clinical trials that reported on pituitary-adrenal dysfunction. The rates of events, odds ratios (ORs), and 95% confidence intervals (CIs) were obtained using random effects meta-analysis. The analyses included data from 160 trials involving 40 432 participants. The rate was 2.43% (95% CI, 1.73%-3.22%) for all-grade adrenal insufficiency and 3.25% (95% CI, 2.15%-4.51%) for hypophysitis. Compared with the placebo or other therapeutic regimens, ICI agents were associated with a higher incidence of serious-grade adrenal insufficiency (OR 3.19, 95% CI, 1.84 to 5.54) and hypophysitis (OR 4.77, 95% CI, 2.60 to 8.78). Among 71 serious-grade hypopituitarism instances in 12 336 patients, there was a significant association between ICIs and hypopituitarism (OR 3.62, 95% CI, 1.86 to 7.03). Substantial heterogeneity was noted across the studies for the rates of these events, which in part was attributable to the different types of ICIs and varied phases of the clinical trials. Although the rates of these events were low, the risk was increased following ICI-based treatment, particularly for CTLA-4 inhibitors, which were associated with a higher incidence of pituitary-adrenal dysfunction than PD-1/PD-L1 inhibitors.
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Affiliation(s)
- Jingli Lu
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, Henan, China
| | - Lulu Li
- Department of Pharmacy, Wuhan No.1 Hospital, Wuhan, Hubei, China
| | - Yan Lan
- Department of Pharmacy, Huangshi Center Hospital, Huangshi, Hubei, China
| | - Yan Liang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, Henan, China
| | - Haiyang Meng
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, Henan, China
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