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Hassel JC, Zimmer L. [Side effects of dermato-oncologic therapies]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024; 75:466-475. [PMID: 38802653 DOI: 10.1007/s00105-024-05354-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/12/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) such as PD(L)1 and CTLA4 antibodies as well as targeted therapies such as BRAF and MEK inhibitors have significantly improved the systemic treatment of skin cancer in adjuvant and advanced therapy settings. All these drugs differ in their spectrum of side effects. MATERIALS AND METHODS The aim of this article is to provide an overview of the spectrum of side effects of dermato-oncological therapies and their management, taking into account the current literature. RESULTS The most important side effects of ICIs, the CCR4 inhibitor mogamulizumab, the ImmTAC tebentafusp, the BRAF and MEK inhibitors and the multityrosine kinase inhibitor imatinib are considered. CONCLUSIONS Side effects can manifest themselves in all organ systems. Chronic side effects and long-term harm are possible, especially with ICIs, and require close therapy monitoring and patient education. Knowledge of the side effects and the temporal, sometimes delayed course of their occurrence are essential for diagnosis and prompt initiation of therapy.
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Affiliation(s)
- Jessica C Hassel
- Medizinische Fakultät, Hautklinik und Nationales Centrum für Tumorerkrankungen (NCT), NCT Heidelberg, eine Partnerschaft zwischen DKFZ und dem Universitätsklinikum Heidelberg, Universität Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Deutschland.
| | - Lisa Zimmer
- Klinik für Dermatologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
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Storwick JA, Tam H, Rosenbaum DG, Houghton K. Checkpoint inhibitor immunotherapy induced inflammatory arthritis secondary to Nivolumab and Ipilimumab: a pediatric first. Pediatr Rheumatol Online J 2024; 22:49. [PMID: 38685034 PMCID: PMC11059652 DOI: 10.1186/s12969-024-00983-3] [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: 12/27/2023] [Accepted: 04/09/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have expanded the arsenal of cancer therapeutics over the last decade but are associated with a spectrum of immune-related adverse events (irAEs), including inflammatory arthritis. While these complications are increasingly recognized in the adult population, no cases of inflammatory arthritis irAEs have been reported in the pediatric literature. CASE PRESENTATION A 14-year-old female with metastatic epithelioid mesothelioma was referred to the pediatric rheumatology clinic after developing progressive inflammatory joint pain in her bilateral shoulders, hips, and small joints of hands following the second cycle of Nivolumab and Ipilimumab. Initial examinations showed bilateral shoulder joint line tenderness, positive FABERs test bilaterally, tenderness over bilateral greater trochanters, and bilateral second PIP effusions. Her serological profile was notable for positive HLA-B27, positive anti-CCP, negative Rheumatoid Factor, and negative ANA. PET-CT scan performed for disease response following immunotherapy showed symmetric increased metabolic activity primarily involving the supraspinatus, gluteus medius and minimus, and semimembranosus tendon insertions. Her presentation was consistent with a grade 1 irAE that worsened to a grade 2 irAE despite NSAID therapy, prompting a short course of oral prednisolone. She achieved clinical remission of her mesothelioma following six cycles of Nivolumab and Ipilimumab and her inflammatory arthritis was controlled on Celebrex monotherapy. CONCLUSIONS To our knowledge, this is the first pediatric case of ICI-induced inflammatory arthritis and enthesitis. This case highlights the importance of increasing awareness of diagnosis and management of irAEs in children.
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Affiliation(s)
- John A Storwick
- Division of Pediatric Rheumatology, Department of Radiology, British Columbia Children's Hospital, The University of British Columbia, Vancouver, Canada.
| | - Herman Tam
- Division of Pediatric Rheumatology, Department of Radiology, British Columbia Children's Hospital, The University of British Columbia, Vancouver, Canada
| | - Daniel G Rosenbaum
- Division of Pediatric Rheumatology, Department of Radiology, British Columbia Children's Hospital, The University of British Columbia, Vancouver, Canada
| | - Kristin Houghton
- Division of Pediatric Rheumatology, Department of Radiology, British Columbia Children's Hospital, The University of British Columbia, Vancouver, Canada
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3
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Gideonse BM, Birkeland M, Vilstrup MH, Grupe P, Naghavi-Behzad M, Ruhlmann CH, Gerke O, Hildebrandt MG. Organ-specific accuracy of [ 18F]FDG-PET/CT in identifying immune-related adverse events in patients with high-risk melanoma treated with adjuvant immune checkpoint inhibitor. Jpn J Radiol 2024:10.1007/s11604-024-01554-y. [PMID: 38504000 DOI: 10.1007/s11604-024-01554-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 03/01/2024] [Indexed: 03/21/2024]
Abstract
PURPOSE This study aimed to determine the organ-specific accuracy of [18F]FDG-PET/CT in identifying immune-related adverse events (irAEs) in patients with high-risk (stage III/IV) surgically resected melanoma treated with an adjuvant immune checkpoint inhibitor (ICI) and determine the incidence of irAEs within the first year after starting treatment. MATERIALS AND METHODS This registry-based study included individuals who had undergone surgical removal of melanoma and were undergoing adjuvant ICI treatment (either nivolumab or pembrolizumab). The study specifically enrolled patients who had undergone both a baseline and at least one subsequent follow-up [18F]FDG-PET/CT scan. Follow-up scans were performed every third month in the first year after surgery to screen for disease recurrence. We retrospectively compared the follow-up scans with baseline scans to identify irAEs. Clinical information on irAEs was obtained from medical records and served as a reference standard for determining the accuracy of [18F]FDG-PET/CT. RESULTS A total of 123 patients with 363 [18F]FDG-PET/CT scans were included, and 65 patients (52.8%) developed irAEs. In decreasing order, the organ-specific incidences of irAEs were: skin 26/65 (40%), muscle and joints 21/65 (32.3%), intestines 13/65 (20%), thyroid gland 12/65 (18.5%), lungs 4/65 (6.2%), and heart 2/65 (3.1%). The sensitivities and specificities of [18F]FDG-PET/CT for diagnosing irAEs were: skin 19% (95% CI: 7-39%) and 95% (88-98%), muscles and joints 71% (48-89%) and 83% (75-90%), intestines 100% (75-100%) and 85% (77-91%); thyroid gland 92% (62-99%) and 95% (89-98%), lungs 75% (19-99%) and 90% (83-95%), and heart 50% (13-99%) and 97% (92-99%), respectively. CONCLUSION [18F]FDG-PET/CT generally had moderate to high sensitivities (except for skin and heart) and specificities in diagnosing irAEs in patients receiving adjuvant ICI; this could be suggested to be systematically assessed and reported in scan reports.
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Affiliation(s)
- Birte Molvik Gideonse
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Magnus Birkeland
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Mie Holm Vilstrup
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
- Department of Radiology and Nuclear Medicine, Esbjerg Hospital, Esbjerg, Denmark
| | - Peter Grupe
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Mohammad Naghavi-Behzad
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark.
- Centre for Personalized Response Monitoring in Oncology, Odense University Hospital, Odense, Denmark.
| | - Christina H Ruhlmann
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Oke Gerke
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Malene Grubbe Hildebrandt
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
- Centre for Personalized Response Monitoring in Oncology, Odense University Hospital, Odense, Denmark
- Centre for Innovative Medical Technology, Odense University Hospital, Odense, Denmark
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Yan T, Yu L, Zhang J, Chen Y, Fu Y, Tang J, Liao D. Achilles' Heel of currently approved immune checkpoint inhibitors: immune related adverse events. Front Immunol 2024; 15:1292122. [PMID: 38410506 PMCID: PMC10895024 DOI: 10.3389/fimmu.2024.1292122] [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: 09/11/2023] [Accepted: 01/04/2024] [Indexed: 02/28/2024] Open
Abstract
Immunotherapy has revolutionized the cancer treatment landscape by opening up novel avenues for intervention. As the use of immune checkpoint inhibitors (ICIs) has exponentially increased, so have immune-related adverse events (irAEs). The mechanism of irAEs may involve the direct damage caused by monoclonal antibodies and a sequence of immune responses triggered by T cell activation. Common side effects include dermatologic toxicity, endocrine toxicity, gastrointestinal toxicity, and hepatic toxicity. While relatively rare, neurotoxicity, cardiotoxicity, and pulmonary toxicity can be fatal. These toxicities pose a clinical dilemma regarding treatment discontinuation since they can result in severe complications and necessitate frequent hospitalization. Vigilant monitoring of irAEs is vital in clinical practice, and the principal therapeutic strategy entails the administration of oral or intravenous glucocorticoids (GSCs). It may be necessary to temporarily or permanently discontinue the use of ICIs in severe cases. Given that irAEs can impact multiple organs and require diverse treatment approaches, the involvement of a multidisciplinary team of experts is imperative. This review aims to comprehensively examine the pathogenesis, clinical manifestations, incidence, and treatment options for various irAEs.
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Affiliation(s)
- Ting Yan
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Lun Yu
- Department of Positron Emission Tomography–Computed Tomography (PET-CT) Center, Chenzhou No. 1 People’s Hospital, Chenzhou, China
| | - Jiwen Zhang
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
- School of Pharmacy, University of South China, Hengyang, China
| | - Yun Chen
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Yilan Fu
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Jingyi Tang
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Dehua Liao
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
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Bermas BL, Gerber DE. The Joint Problem of Rheumatoid Arthritis and Lung Cancer. J Thorac Oncol 2024; 19:196-198. [PMID: 38325979 DOI: 10.1016/j.jtho.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 11/13/2023] [Indexed: 02/09/2024]
Affiliation(s)
- Bonnie L Bermas
- Division of Rheumatology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David E Gerber
- Division of Hematology-Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas; Peter O'Donnell, Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas.
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Joseph GJ, Johnson DB, Johnson RW. Immune checkpoint inhibitors in bone metastasis: Clinical challenges, toxicities, and mechanisms. J Bone Oncol 2023; 43:100505. [PMID: 37842554 PMCID: PMC10568292 DOI: 10.1016/j.jbo.2023.100505] [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: 07/18/2023] [Revised: 09/19/2023] [Accepted: 09/19/2023] [Indexed: 10/17/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the field of anti-cancer therapy over the last decade; they provide durable clinical responses against tumors by inhibiting immune checkpoint proteins that canonically regulate the T cell-mediated immune response. Despite their success in many primary tumors and soft tissue metastases, ICIs function poorly in patients with bone metastases, and these patients do not have the same survival benefit as patients with the same primary tumor type (e.g., non-small cell lung cancer [NSCLC], urothelial, renal cell carcinoma [RCC], etc.) that has not metastasized to the bone. Additionally, immune-related adverse events including rheumatologic and musculoskeletal toxicities, bone loss, and increased fracture risk develop after treatment with ICIs. There are few preclinical studies that investigate the interplay of the immune system in bone metastases; however, the current literature suggests a role for CD8+ T cells and myeloid cell subsets in bone homeostasis. As such, this review focuses on findings from the clinical and pre-clinical studies that have investigated immune checkpoint blockade in the bone metastatic setting and highlights the need for more comprehensive investigations into the relationship between immune cell subsets, ICIs, and the bone-tumor microenvironment.
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Affiliation(s)
- Gwenyth J. Joseph
- Program in Cancer Biology, Vanderbilt University, Nashville, TN 37232, USA
- Vanderbilt Center for Bone Biology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Douglas B. Johnson
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Rachelle W. Johnson
- Program in Cancer Biology, Vanderbilt University, Nashville, TN 37232, USA
- Vanderbilt Center for Bone Biology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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Gente K, Diekmann L, Daniello L, Will J, Feisst M, Olsavszky V, Günther J, Lorenz HM, Souto-Carneiro MM, Hassel JC, Christopoulos P, Leipe J. Sex and anti-inflammatory treatment affect outcome of melanoma and non-small cell lung cancer patients with rheumatic immune-related adverse events. J Immunother Cancer 2023; 11:e007557. [PMID: 37730272 PMCID: PMC10510926 DOI: 10.1136/jitc-2023-007557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Rheumatic immune-related adverse events (R-irAEs) occur in 5-15% of patients receiving immune checkpoint inhibitors (ICI) and, unlike other irAEs, tend to be chronic. Herein, we investigate the factors influencing cancer and R-irAEs outcomes with particular focus on adverse effects of anti-inflammatory treatment. METHODS In this prospective, multicenter, long-term, observational study, R-irAEs were comprehensively analyzed in patients with malignant melanoma (MM, n=50) and non-small cell lung cancer (NSCLC, n=41) receiving ICI therapy who were enrolled in the study between August 1, 2018, and December 11, 2022. RESULTS After a median follow-up of 33 months, progressive disease or death occurred in 66.0% and 30.0% of MM and 63.4% and 39.0% of patients with NSCLC. Male sex (progression-free survival (PFS): p=0.013, and overall survival (OS): p=0.009), flare of a pre-existing condition (vs de novo R-irAE, PFS: p=0.010) and in trend maximum glucocorticoid (GC) doses >10 mg and particularly ≥1 mg/kg prednisolone equivalent (sex-adjusted PFS: p=0.056, OS: p=0.051) were associated with worse cancer outcomes. Patients receiving disease-modifying antirheumatic drugs (DMARDs) showed significantly longer PFS (n=14, p=0.011) and OS (n=20, p=0.018). Effects of these variables on PFS and/or OS persisted in adjusted Cox regression models. Additionally, GC treatment negatively correlated with the time from diagnosis of malignancy and the latency from ICI start until R-irAE onset (all p<0.05). R-irAE features and outcomes were independent of other baseline patient characteristics in both studied cancer entities. CONCLUSION Male sex, flare of pre-existing rheumatologic conditions and extensive GC treatment appeared to be linked with unfavorable cancer outcomes, while DMARD use had a favorable impact. These findings challenge the current dogma of restrictive DMARD use for R-irAE and thus may pave the way to better strategies and randomized controlled trials for the growing number of patients with R-irAE.
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Affiliation(s)
- Karolina Gente
- Department of Internal Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Leonore Diekmann
- Department of Internal Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Lea Daniello
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumor Diseases (NCT) at University Hospital Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC-H), Member of German Center for Lung Research, Heidelberg, Germany
| | - Julia Will
- Department of Internal Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Manuel Feisst
- Institute of Medical Biometry (IMBI), University Hospital Heidelberg, Heidelberg, Germany
| | - Victor Olsavszky
- Department of Dermatology, University Medical Centre Mannheim, Mannheim, Germany
| | - Janine Günther
- Department of Internal Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hanns-Martin Lorenz
- Department of Internal Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - M Margarida Souto-Carneiro
- Department of Internal Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica C Hassel
- Department of Dermatology and National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Petros Christopoulos
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumor Diseases (NCT) at University Hospital Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC-H), Member of German Center for Lung Research, Heidelberg, Germany
| | - Jan Leipe
- Department of Medicine V - Division of Rheumatology, University Medical Centre Mannheim, Mannheim, Germany
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Ceccarelli F, Natalucci F, Picciariello L, Olivieri G, Cirillo A, Gelibter A, Picone V, Botticelli A, Conti F. Rheumatic Diseases Development in Patients Treated by Anti-PD1 Immune Checkpoint Inhibitors: A Single-Centre Descriptive Study. Life (Basel) 2023; 13:life13040877. [PMID: 37109406 PMCID: PMC10141051 DOI: 10.3390/life13040877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
The introduction of the so-called immune checkpoint inhibitors (ICIs) substantially changed the history of cancer therapy. On the other hand, they can induce the development of rheumatic immune-related adverse events (Rh-irAEs). In the scenario of a joint oncology/rheumatology outpatient clinic, we conducted a single-centre descriptive study to define from a laboratory, clinical and therapeutic point of view, rheumatic conditions developed during anti-PD1 treatment. The study included 32 patients (M/F 16/16, median age 69, IQR 16.5). According to the international classification criteria, eight patients could be classified as affected by Rheumatoid Arthritis, one by Psoriatic Arthritis, six by Polymyalgia Rheumatica, five by systemic connective tissue diseases (two systemic lupus erythematosus, two Sjögren’s syndrome, one undifferentiated connective tissue disease). The remaining patients were diagnosed as having undifferentiated arthritis or inflammatory arthralgia. The median interval between ICIs starting and the onset of symptoms was 14 weeks (IQR 19.75). Moving to treatment, the longitudinal observation revealed that all RA, PsA and CTD patients required the introduction of treatment with DMARDs. In conclusion, the growing use of ICIs in a real-life setting confirmed the possible development of different rheumatological conditions, further emphasising the need for shared oncology/rheumatology management.
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Pacholczak-Madej R, Kosałka-Węgiel J, Kuszmiersz P, Mituś JW, Püsküllüoğlu M, Grela-Wojewoda A, Korkosz M, Bazan-Socha S. Immune Checkpoint Inhibitor Related Rheumatological Complications: Cooperation between Rheumatologists and Oncologists. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4926. [PMID: 36981837 PMCID: PMC10049070 DOI: 10.3390/ijerph20064926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 06/18/2023]
Abstract
In cancer, immune checkpoint inhibitors (ICIs) improve patient survival but may lead to severe immune-related adverse events (irAEs). Rheumatic irAEs are a distinct entity that are much more common in a real-life than in clinical trial reports due to their unspecific symptoms and them being a rare cause of hospitalization. This review focuses on an interdisciplinary approach to the management of rheumatic irAEs, including cooperation between oncologists, rheumatologists, and immunologists. We discuss the immunological background of rheumatic irAEs, as well as their unique clinical characteristics, differentiation from other irAEs, and treatment strategies. Importantly, steroids are not the basis of therapy, and nonsteroidal anti-inflammatory drugs should be administered in the front line with other antirheumatic agents. We also address whether patients with pre-existing rheumatic autoimmune diseases can receive ICIs and how antirheumatic agents can interfere with ICIs. Interestingly, there is a preclinical rationale for combining ICIs with immunosuppressants, particularly tumor necrosis factor α and interleukin 6 inhibitors. Regardless of the data, the mainstay in managing irAEs is interdisciplinary cooperation between oncologists and other medical specialties.
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Affiliation(s)
- Renata Pacholczak-Madej
- Department of Clinical Oncology, The Maria Skłodowska-Curie National Research Institute of Oncology, Kraków Branch, 31-115 Kraków, Poland
- Department of Anatomy, Jagiellonian University Medical College, 33-332 Kraków, Poland
| | - Joanna Kosałka-Węgiel
- Department of Rheumatology and Immunology, Jagiellonian University Medical Kraków, 30-688 Krakow, Poland
- Division of Rheumatology and Immunology Clinical, University Hospital, 30-688 Kraków, Poland
| | - Piotr Kuszmiersz
- Department of Rheumatology and Immunology, Jagiellonian University Medical Kraków, 30-688 Krakow, Poland
- Division of Rheumatology and Immunology Clinical, University Hospital, 30-688 Kraków, Poland
| | - Jerzy W. Mituś
- Department of Anatomy, Jagiellonian University Medical College, 33-332 Kraków, Poland
- Department of Surgical Oncology, National Research Institute of Oncology, Kraków Branch, 31-115 Kraków, Poland
| | - Mirosława Püsküllüoğlu
- Department of Clinical Oncology, The Maria Skłodowska-Curie National Research Institute of Oncology, Kraków Branch, 31-115 Kraków, Poland
| | - Aleksandra Grela-Wojewoda
- Department of Clinical Oncology, The Maria Skłodowska-Curie National Research Institute of Oncology, Kraków Branch, 31-115 Kraków, Poland
| | - Mariusz Korkosz
- Department of Rheumatology and Immunology, Jagiellonian University Medical Kraków, 30-688 Krakow, Poland
- Division of Rheumatology and Immunology Clinical, University Hospital, 30-688 Kraków, Poland
| | - Stanisława Bazan-Socha
- Department of Internal Medicine, Jagiellonian University Medical College, 30-688 Kraków, Poland
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Reid P, Cappelli LC. Treatment of rheumatic adverse events of cancer immunotherapy. Best Pract Res Clin Rheumatol 2022; 36:101805. [PMID: 36539321 PMCID: PMC10198805 DOI: 10.1016/j.berh.2022.101805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Immune checkpoint inhibitors (ICIs), used to treat many advanced cancers, activate the immune system to elicit an antitumor response. ICIs can also cause immune-related adverse events (irAEs) when nontumor tissues are affected by excess inflammation and autoimmunity. Rheumatic irAEs include inflammatory arthritis, myositis, sicca syndrome, polymyalgia rheumatica, and several other rare phenotypes. Treating rheumatic irAEs requires balancing the desire to decrease off-target inflammation while not negatively impacting the antitumor immune response. In this review, treatment recommendations for rheumatic irAEs have been discussed. Pathogenesis of rheumatic irAEs has been briefly reviewed. Knowledge about the effects of corticosteroids and steroid-sparing agents on tumor responses has been detailed to give context for treatment decisions. Recommendations ultimately depend not only on the clinical presentation and severity of the irAE but also on the goals of cancer treatment. Finally, how to safely use ICI therapy in patients with preexisting autoimmune diseases is considered.
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Affiliation(s)
- Pankti Reid
- University of Chicago, Department of Medicine, Section of Rheumatology, 5841 South Maryland Ave. MC 0930, Chicago, IL, 60637, USA.
| | - Laura C Cappelli
- Johns Hopkins University, Department of Medicine, Division of Rheumatology, 5501 Hopkins Bayview Circle, Suite 1B1, Baltimore, MD, 21224, USA.
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Gosangi B, McIntosh L, Keraliya A, Irugu DVK, Baheti A, Khandelwal A, Thomas R, Braschi-Amirfarzan M. Imaging features of toxicities associated with immune checkpoint inhibitors. Eur J Radiol Open 2022; 9:100434. [PMID: 35967881 PMCID: PMC9372737 DOI: 10.1016/j.ejro.2022.100434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/16/2022] [Accepted: 07/28/2022] [Indexed: 12/11/2022] Open
Abstract
The past decade has witnessed a change in landscape of cancer management with the advent of precision oncology. Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment and have played an important role in improving patient survival. While the patients are living longer, treatment with ICIs are sometimes associated with adverse effects, some of which could be fatal. Radiologists can play a crucial role by early identification of some of these adverse effects during restaging scans. Our paper focuses on the imaging features of commonly occurring ICI toxicities based on organ system.
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Key Words
- AIP, acute interstitial pneumonitis
- ARDS, acute respiratory distress syndrome
- CTCAE, Common Terminology Criteria for Adverse Events
- CTLA-4 inhibitor, Cytotoxic T-lymphocyte antigen- 4 inhibitor
- Colitis
- FDA, Food and Drug Administration
- Hepatitis
- ICI, Immune check point inhibitor
- Immune check point inhibitors toxicity
- LGE, late Gadolinium enhancement
- NSCLC, non-small cell lung cancer
- NSIP, non-specific interstitial pneumonia
- OP, organizing pneumonia
- PD-1 inhibitor, programmed cell death-1 inhibitor
- PD-L1 inhibitor, programmed cell death ligand-1 inhibitor
- PFS, progression free survival
- Pancreatitis
- Pneumonitis
- RRP, radiation recall pneumonitis
- irAE, immune-related adverse event
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Affiliation(s)
- Babina Gosangi
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Lacey McIntosh
- Department of Radiology, University of Massachusetts, Worcester, MA, USA
| | - Abhishek Keraliya
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Richard Thomas
- Department of Radiology, Lahey Health System, Burlington, MA, USA
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Benesova K, Kraus FV, Carvalho RA, Lorenz H, Hörth CH, Günther J, Klika KD, Graf J, Diekmann L, Schank T, Christopoulos P, Hassel JC, Lorenz HM, Souto-Carneiro M. Distinct immune-effector and metabolic profile of CD8 + T cells in patients with autoimmune polyarthritis induced by therapy with immune checkpoint inhibitors. Ann Rheum Dis 2022; 81:annrheumdis-2022-222451. [PMID: 35922125 PMCID: PMC9664113 DOI: 10.1136/ard-2022-222451] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/16/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Rheumatic immune-related adverse events (irAE) such as (poly)arthritis in patients undergoing immune checkpoint inhibitor (ICI) treatment pose a major clinical challenge. ICI therapy improves CD8+ T cell (CD8) function, but CD8 contributes to chronic inflammation in autoimmune arthritis (AA). Thus, we investigated whether immune functional and metabolic changes in CD8 explain the development of musculoskeletal irAE in ICI-treated patients. METHODS Peripheral CD8 obtained from ICI-treated patients with and without arthritis irAEs and from AA patients with and without a history of malignancy were stimulated in media containing 13C-labelled glucose with and without tofacitinib or infliximab. Changes in metabolism, immune-mediator release, expression of effector cell-surface molecules and inhibition of tumour cell growth were quantified. RESULTS CD8 from patients with irAE showed significantly lower frequency and expression of cell-surface molecule characteristic for activation, effector-functions, homing, exhaustion and apoptosis and reduced release of cytotoxic and proinflammatory immune mediators compared with CD8 from ICI patients who did not develop irAE. This was accompanied by a higher glycolytic rate and ATP production. Gene-expression analysis of pre-ICI-treated CD8 revealed several differentially expressed transcripts in patients who later developed arthritis irAEs. In vitro tofacitinib or infliximab treatment did not significantly change the immune-metabolic profile nor the capacity to release cytolytic mediators that inhibit the growth of the human lung cancer cell line H838. CONCLUSIONS Our study shows that CD8 from ICI-treated patients who develop a musculoskeletal irAE has a distinct immune-effector and metabolic profile from those that remain irAE free. This specific irAE profile overlaps with the one observed in CD8 from AA patients and may prove useful for novel therapeutic strategies to manage ICI-induced irAEs.
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Affiliation(s)
- Karolina Benesova
- Department of Internal Medicine V Hematology Oncology Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Franziska Viktoria Kraus
- Department of Internal Medicine V Hematology Oncology Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Rui A Carvalho
- Department of Life Sciences, University of Coimbra Faculty of Sciences and Technology, Coimbra, Portugal
| | - Holger Lorenz
- Imaging Facility, Center of Molecular Biology (ZMBH), Universität Heidelberg, Heidelberg, Germany
| | - Christian H Hörth
- Imaging Facility, Center of Molecular Biology (ZMBH), Universität Heidelberg, Heidelberg, Germany
| | - Janine Günther
- Department of Internal Medicine V Hematology Oncology Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Karel D Klika
- Molecular and Structural Biology, German Cancer Research Centre, Heidelberg, Germany
| | - Jürgen Graf
- Nuclear Magnetic Resonance Laboratory, Institute of Organic Chemistry, Universität Heidelberg, Heidelberg, Germany
| | - Leonore Diekmann
- Department of Internal Medicine V Hematology Oncology Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Timo Schank
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
- National Center of Tumor Diseases, Heidelberg, Germany
| | - Petros Christopoulos
- National Center of Tumor Diseases, Heidelberg, Germany
- Department of Thoracic Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica C Hassel
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
- National Center of Tumor Diseases, Heidelberg, Germany
| | - Hanns-Martin Lorenz
- Department of Internal Medicine V Hematology Oncology Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Margarida Souto-Carneiro
- Department of Internal Medicine V Hematology Oncology Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
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Gómez-Puerta JA, Lobo-Prat D, Perez-García C, Ponce A, Frade-sosa B, Millán Arciniegas AM, Ojeda F, Ruiz-Esquide V, Corominas H. Clinical Patterns and Follow-Up of Inflammatory Arthritis and Other Immune-Related Adverse Events Induced by Checkpoint Inhibitors. A Multicenter Study. Front Med (Lausanne) 2022; 9:888377. [PMID: 35783644 PMCID: PMC9240301 DOI: 10.3389/fmed.2022.888377] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/12/2022] [Indexed: 01/04/2023] Open
Abstract
Objectives To describe different clinical patterns of rheumatic immune-related adverse events (irAEs) induced by immune checkpoint inhibitors (ICI) and their rheumatic and oncologic outcomes. Methods We classified clinical syndromes according to five different categories: non-inflammatory arthralgias (NIA), rheumatoid arthritis (RA)-like, psoriatic arthritis (PsA)-like, polymyalgia rheumatica (PMR)-like, and a miscellaneous group of patients with other syndromes. We conducted a baseline visit and then follow-up in order to determine their clinical pattern, treatment response, and outcome. Results We included 73 patients (64% male) with a mean age of 66.1 ± 11.6 years. Main underlying diagnosis was lung carcinoma in 29 (39%) patients, melanoma in 20 (27%), and renal-urothelial cancer in 11 (15%). Main ICI included Pembrolizumab in 24 (32%), Nivolumab 17 (23%), and Atezolizumab 7 (9 %). Seventeen out of seventy-three patients had an underlying rheumatic disease before ICI treatment. Fourteen patients developed other irAEs before or simultaneously with rheumatic syndromes. Main rheumatic irAEs included: RA-like in 31 (42.4%), NIA in 19 (26.0%), PMR-like in 10 (13.7%), and PsA-like in 5 (6.8%), among others. Median time from ICI to irAEs was 5 months (IQR 3–9). Those patients who received combined therapy, had a trend for an earlier presentation than those who received monotherapy (4.3 months IQR 1.85–17 vs. 6 months IQR 3–9.25, p = NS). Mean follow-up time was 14.0 ± 10.8 (SD, months). At the last visit, 47 % were taking glucocorticoids and 11% DMARD therapy. At the last visit, 13 (17.8%) patients remained with persistent arthritis, 19 (26%) had intermittent flares, and 39 (53.4%) had a self-limited pattern. Only in 15.1% of patients ICI therapy was discontinued. Conclusions We described different patterns according to treatment and irAEs. Combined ICI therapy had an earlier onset of symptoms. Patients who presented as RA-like, had a higher risk of persistent arthritis. After a mean follow-up of more than 1 year, one-fifth of the patients remained with persistent arthritis and 11% required DMARD therapy.
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Affiliation(s)
- José A. Gómez-Puerta
- Rheumatology Department, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Medicine, Universitat de Barcelona, Barcelona, Spain
- *Correspondence: José A. Gómez-Puerta
| | - David Lobo-Prat
- Rheumatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Andrés Ponce
- Rheumatology Department, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Beatriz Frade-sosa
- Rheumatology Department, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Fabiola Ojeda
- Rheumatology Department, Hospital del Mar, Barcelona, Spain
| | - Virginia Ruiz-Esquide
- Rheumatology Department, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Hector Corominas
- Rheumatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Chan KK, Bass AR. Monitoring and Management of the Patient with Immune Checkpoint Inhibitor-Induced Inflammatory Arthritis: Current Perspectives. J Inflamm Res 2022; 15:3105-3118. [PMID: 35642215 PMCID: PMC9148583 DOI: 10.2147/jir.s282600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/18/2022] [Indexed: 11/23/2022] Open
Abstract
In this review, we draw from observational studies, treatment guidelines and our own clinical experience to describe approaches to monitoring and management of immune checkpoint inhibitor (ICI)-induced inflammatory arthritis, including polymyalgia rheumatica. This condition occurs in about 4% of ICI-treated cancer patients and can persist for a year or longer. Mild arthritis can generally be managed with non-steroidal anti-inflammatory drugs, intraarticular steroids injections and/or low dose corticosteroids. Higher grade arthritis should be brought under control with corticosteroids, but early introduction of a steroid-sparing agent is recommended to minimize steroid toxicity. In order to assess the effectiveness of any arthritis treatment, tender and swollen joint counts and patient reported measures of physical function, such as the health assessment questionnaire, should be obtained at each visit. Referral to a rheumatologist is recommended for patients with high grade arthritis to help guide the use of disease-modifying antirheumatic drugs.
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Affiliation(s)
- Karmela K Chan
- Department of Medicine, Hospital for Special Surgery/Weill Cornell Medicine, New York, NY, USA
| | - Anne R Bass
- Department of Medicine, Hospital for Special Surgery/Weill Cornell Medicine, New York, NY, USA
- Correspondence: Anne R Bass, Email
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15
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Sun G, Liu H, Shi X, Tan P, Tang W, Chen X, Sun G, Yang W, Kong X, Zheng Z, Cao H, Shao G. Treatment of patients with cancer using PD‑1/PD‑L1 antibodies: Adverse effects and management strategies (Review). Int J Oncol 2022; 60:74. [PMID: 35485291 PMCID: PMC9084612 DOI: 10.3892/ijo.2022.5364] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 03/14/2022] [Indexed: 12/12/2022] Open
Abstract
In 2020, there were an estimated 19.3 million new cancer cases and close to 10 million cancer deaths worldwide. Cancer remains one of the leading causes of death. In recent years, with the continuous improvement of our understanding of tumor immunotherapy, immunotherapeutics, such as immune checkpoint inhibitors, have gradually become a hot spot for tumor treatment. Amongst these, programmed cell death protein 1/programmed cell death protein ligand 1 (PD-1/PD-L1) related inhibitors, such as nivolumab and pembrolizumab, atezolizumab, avelumab and durvalumab have been shown to exhibit a high level of efficacy in several types of tumors. It has been confirmed that these inhibitors play an important role in the anti-tumor process, significantly improving the survival rate of patients and delaying the progress of the underlying cancer. However, its method of therapeutic interference and potential for damaging the immune system has caused concern regarding its suitability. As these adverse effects are caused by an immune response to endogenous tissues, they are designated as immune-related adverse events (irAEs). In this review, the typical irAEs reported in recent years and the management strategies adopted are highlighted, to serve as a reference in assessing the clinical response to these adverse reactions.
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Affiliation(s)
- Guangshun Sun
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Hanyuan Liu
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Xuesong Shi
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Pengyu Tan
- Department of Food Science and Engineering, Nanjing Xiaozhuang University, Nanjing, Jiangsu 211166, P.R. China
| | - Weiwei Tang
- Hepatobiliary/Liver Transplantation Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Living Donor Transplantation, Chinese Academy of Medical Sciences, Nanjing, Jiangsu 215005, P.R. China
| | - Xin Chen
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Guoqiang Sun
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Weijun Yang
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Xiangyi Kong
- Hepatobiliary/Liver Transplantation Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Living Donor Transplantation, Chinese Academy of Medical Sciences, Nanjing, Jiangsu 215005, P.R. China
| | - Zhiying Zheng
- Hepatobiliary/Liver Transplantation Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Living Donor Transplantation, Chinese Academy of Medical Sciences, Nanjing, Jiangsu 215005, P.R. China
| | - Hongyong Cao
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Guoqiang Shao
- Department of Nuclear Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
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Distinct molecular and immune hallmarks of inflammatory arthritis induced by immune checkpoint inhibitors for cancer therapy. Nat Commun 2022; 13:1970. [PMID: 35413951 PMCID: PMC9005525 DOI: 10.1038/s41467-022-29539-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 03/17/2022] [Indexed: 12/12/2022] Open
Abstract
Immune checkpoint inhibitors are associated with immune-related adverse events (irAEs), including arthritis (arthritis-irAE). Management of arthritis-irAE is challenging because immunomodulatory therapy for arthritis should not impede antitumor immunity. Understanding of the mechanisms of arthritis-irAE is critical to overcome this challenge, but the pathophysiology remains unknown. Here, we comprehensively analyze peripheral blood and/or synovial fluid samples from 20 patients with arthritis-irAE, and unmask a prominent Th1-CD8+ T cell axis in both blood and inflamed joints. CX3CR1hi CD8+ T cells in blood and CXCR3hi CD8+ T cells in synovial fluid, the most clonally expanded T cells, significantly share TCR repertoires. The migration of blood CX3CR1hi CD8+ T cells into joints is possibly mediated by CXCL9/10/11/16 expressed by myeloid cells. Furthermore, arthritis after combined CTLA-4 and PD-1 inhibitor therapy preferentially has enhanced Th17 and transient Th1/Th17 cell signatures. Our data provide insights into the mechanisms, predictive biomarkers, and therapeutic targets for arthritis-irAE. Arthritis is the most common rheumatic immune-related adverse event (irAE) occurring in cancer patients receiving immune checkpoint inhibitors. Here the authors study the immune landscape of blood and synovial fluid samples from patients with arthritis-irAE, reporting immunological differences and similarities with classic autoimmune arthritis.
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Jensen AK, Chatzidionysiou K, Torp CK, Sørensen AS, Tenstad HB, Schäfer VS, Kostine M, Jacobsen S, Leipe J, Kragstrup TW. Comparison of immune checkpoint inhibitor-induced arthritis and reactive arthritis to inform therapeutic strategy. Biomed Pharmacother 2022; 148:112687. [PMID: 35228067 DOI: 10.1016/j.biopha.2022.112687] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Immune checkpoint inhibitor-induced inflammatory arthritis (ICI-IA) is a relatively new disease entity caused by ICI agents during cancer therapy. Reactive arthritis (ReA) is a well-known disease entity caused by urogenital or gastrointestinal bacterial infection or pneumonia. In this sense, ICI-IA and ReA are both defined by a reaction to a well-specified causal event. As a result, comparing these diseases may help to determine therapeutic strategies. METHODS We compared ICI-IA and ReA with special focus on pharmacological management. Specifically regarding treatment, we conducted a literature search of studies published in the PubMed database. Inclusion criteria were studies on treatment with non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids (GC), or disease modifying antirheumatic drugs (DMARDs) in ICI-IA or ReA. During systematic selection, 21 studies evaluating ICI-IA and 14 studies evaluating ReA were included. RESULTS In ICI-IA, prospective and retrospective studies have shown effects of non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoid (GC), sulfasalazine (SSZ), methotrexate (MTX), hydroxychloroquine (HCQ) and TNFi. In ReA, retrospective studies evaluated NSAIDs and GC. A randomized controlled trial reported the effect of SSZ, and a retrospective study reported the effect of MTX and SSZ in combination with tumor necrosis factor alpha inhibition (TNFi). For both entities, small case reports show treatment effects of interleukin 6 receptor inhibition (IL-6Ri). DISCUSSION This literature review identified both similarities and differences regarding the pathogenesis and clinical features of ReA and ICI-IA. Studies on treatment reported effectiveness of NSAIDs, GC, MTX, SSZ and TNFi in both diseases. Further, small case reports showed effects of IL-6Ri.
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Affiliation(s)
- Anders Kirkegaard Jensen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Sygehus Lillebælt, Kolding, Denmark
| | - Katerina Chatzidionysiou
- Department of Medicine Solna, Karolinska Institutet, Rheumatology Unit, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Valentin S Schäfer
- Clinic of Internal Medicine III, Department of Oncology, Hematology, Rheumatology and Clinical Immunology, University Hospital Bonn, Bonn, Germany
| | - Marie Kostine
- Department of Rheumatology, Bordeaux, University, Hospital, France
| | - Søren Jacobsen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen, Denmark; Department of Rheumatology, Rigshospitalet, Copenhagen, Denmark
| | - Jan Leipe
- Division of Rheumatology, Department of Medicine V, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Germany.
| | - Tue Wenzel Kragstrup
- Department of Biomedicine, Aarhus University, Aarhus, Denmark; Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.
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18
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Ghosh N, Bass AR. Checkpoint Inhibitor-Associated Autoimmunity: What a Rheumatologist Needs to Know. J Clin Rheumatol 2022; 28:e659-e666. [PMID: 31743272 DOI: 10.1097/rhu.0000000000001209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Nilasha Ghosh
- From the Division of Rheumatology, Department of Medicine, Hospital for Special Surgery; and Weill Cornell Medicine, New York, NY
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Zhang Y, Zhang X, Li W, Du Y, Hu W, Zhao J. Biomarkers and risk factors for the early prediction of immune-related adverse events: a review. Hum Vaccin Immunother 2022; 18:2018894. [PMID: 35108160 PMCID: PMC8986173 DOI: 10.1080/21645515.2021.2018894] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In recent years, immunotherapy has been widely used to treat patients with malignant tumors. While immune checkpoint inhibitors (ICIs) significantly improve the prognosis of cancer patients, the incidence of immune-related adverse events (irAEs) is increasing. Not only can irAEs accumulate in multiple organ systems throughout the body, but rare adverse reactions may also occur continuously. In severe cases, irAEs can be life-threatening or even lead to death. Therefore, the early identification, diagnosis and treatment of irAEs are very important. Early identification of patients with high-risk irAEs as well as the reduction or avoidance of severe irAEs have important clinical significance. This article will review the research progress of early predictive biomarkers and risk factors for the occurrence of irAEs and propose potential future directions for follow-up research and clinical applications.
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Affiliation(s)
- Ying Zhang
- Department of Oncology, Changzhi People's Hospital, The Affiliated Hospital of Changzhi Medical College, Changzhi, Shanxi, China
| | - Xiaoling Zhang
- Department of Oncology, Changzhi People's Hospital, The Affiliated Hospital of Changzhi Medical College, Changzhi, Shanxi, China
| | - Weiling Li
- Department of Oncology, Changzhi People's Hospital, The Affiliated Hospital of Changzhi Medical College, Changzhi, Shanxi, China
| | - Yunyi Du
- Department of Oncology, Changzhi People's Hospital, The Affiliated Hospital of Changzhi Medical College, Changzhi, Shanxi, China
| | - Wenqing Hu
- Department of Gastrointestinal Surgery, Changzhi People's Hospital, The Affiliated Hospital of Changzhi Medical College, Changzhi, Shanxi, China
| | - Jun Zhao
- Department of Oncology, Changzhi People's Hospital, The Affiliated Hospital of Changzhi Medical College, Changzhi, Shanxi, China
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20
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Cano-Cruz LG, Barrera-Vargas A, Mateos-Soria A, Soto-Perez-de-Celis E, Merayo-Chalico J. Rheumatological Immune-related Adverse Events of Checkpoints Inhibitors: a Narrative Review for the Latin American Rheumatologist. Arch Med Res 2021; 53:113-121. [PMID: 34649738 DOI: 10.1016/j.arcmed.2021.09.004] [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: 02/11/2021] [Accepted: 09/23/2021] [Indexed: 11/02/2022]
Abstract
Latin America is experiencing a demographic and epidemiological transition, with an increase in non-communicable diseases such as cancer. One of the greatest advances in the therapeutic approach to cancer has been the discovery of immunotherapy, and specifically of checkpoint inhibitors (CPIs). Since inhibition of CTLA-4 and PD-1/PD-L1 enhances the immune response, cancer immunotherapies are associated with a new class of toxicities of autoimmune and/or autoinflammatory origin. These immune-related adverse events (irAEs) result in a broad spectrum of clinical events including rheumatic clinical syndromes, which may resemble classic rheumatic diseases. The most common rheumatic manifestations include inflammatory arthritis, myositis, vasculitis, and sicca syndrome. Recognizing rheumatologic irAEs is challenging due to the wide spectrum of clinical presentations that often do not fulfill traditional classification criteria of rheumatic diseases. A delayed diagnosis and treatment can lead to long-term disability, and disorders may become chronic and require ongoing immunosuppressive therapy. The management of irAEs includes the prompt detection and appropriate grading since their management is dictated by their severity. The growing use of CPIs, and the ensuing increase in irAEs, warrants an increasing collaboration between rheumatologists and oncologists. Understanding the pathophysiology, diagnosis, grading, and therapeutic implications of irAEs in patients with cancer is thus a requirement for Latin American oncologists and rheumatologists alike.
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Affiliation(s)
- Lilian Guadalupe Cano-Cruz
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Ana Barrera-Vargas
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Abigail Mateos-Soria
- Departamento de Hemato-Oncología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Enrique Soto-Perez-de-Celis
- Departamento de Geriatría, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Javier Merayo-Chalico
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México.
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21
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Reid P, Liew DF, Akruwala R, Bass AR, Chan KK. Activated osteoarthritis following immune checkpoint inhibitor treatment: an observational study. J Immunother Cancer 2021; 9:jitc-2021-003260. [PMID: 34526389 PMCID: PMC8444247 DOI: 10.1136/jitc-2021-003260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 02/04/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy but can result in toxicities, known as immune-related adverse events (irAEs), due to a hyperactivated immune system. ICI-related inflammatory arthritis has been described in literature, but herewith we introduce and characterize post-ICI-activated osteoarthritis (ICI-aOA). We conducted a multicenter, retrospective, observational study of patients with cancer treated with ICIs and diagnosed with ICI-aOA by a rheumatologist. ICI-aOA was defined by (1) an increase in non-inflammatory joint pain after ICI initiation, (2) in joints characteristically affected by osteoarthritis, and (3) lack of inflammation on exam. Cases were graded using the Common Terminology Criteria for Adverse Events (CTCAE) V.6.0 rubric for arthralgia. Response Evaluation Criteria in Solid Tumors V.1.1 (v.4.03) guidelines determined tumor response. Results were analyzed using χ2 tests of association and multivariate logistic regression. Thirty-six patients had ICI-aOA with a mean age at time of rheumatology presentation of 66 years (51–81 years). Most patients had metastatic melanoma (10/36, 28%) and had received a PD-1/PD-L1 inhibitor monotherapy (31/36, 86%) with 5/36 (14%) combination therapy. Large joint involvement (hip/knee) was noted in 53% (19/36), small joints of hand 25% (9/36), and spine 14% (5/36). Two-thirds (24/36) suffered multiple joint involvement. Three of 36 (8%) had CTCAE grade 3, 14 (39%) grade 2 and 19 (53%) grade 1 manifestations. Symptom onset ranged from 6 days to 33.8 months with a median of 5.2 months after ICI initiation; five patients suffered from ICI-aOA after ICI cessation (0.6, 3.5, 4.4, 7.3, and 15.4 months after ICI cessation). The most common form of therapy was intra-articular corticosteroid injections only (15/36, 42%) followed by non-steroidal anti-inflammatory drugs only (7/36, 20%). Twenty patients (56%) experienced other irAEs, with rheumatic and dermatological being the most common. All three patients with high-grade ICI-aOA also had another irAE diagnosis at some point after ICI initiation. ICI-aOA should be recognized as an adverse event of ICI immunotherapy. Early referral to a rheumatologist can facilitate the distinction between ICI induced inflammatory arthritis from post-ICI mechanical arthropathy, the latter of which can be managed with local therapy that will not compromise ICI efficacy.
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Affiliation(s)
- Pankti Reid
- Medicine, University of Chicago Biological Sciences Division, Chicago, Illinois, USA
| | - David Fl Liew
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Division of Rheumatology and Department of Clinical Pharmacology and Therapeutics, Austin Health, Heidelberg, Victoria, Australia
| | - Rajshi Akruwala
- Department of Medicine, SUNY Downstate Medical Center, New York City, New York, USA
| | - Anne R Bass
- Division of Rheumatology, Hospital for Special Surgery, New York, New York, USA
| | - Karmela K Chan
- Division of Rheumatology, Hospital for Special Surgery, New York, New York, USA
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Daniello L, Elshiaty M, Bozorgmehr F, Kuon J, Kazdal D, Schindler H, Shah R, Volckmar AL, Lusky F, Diekmann L, Liersch S, Faehling M, Muley T, Kriegsmann M, Benesova K, Stenzinger A, Thomas M, Christopoulos P. Therapeutic and Prognostic Implications of Immune-Related Adverse Events in Advanced Non-Small-Cell Lung Cancer. Front Oncol 2021; 11:703893. [PMID: 34268127 PMCID: PMC8277237 DOI: 10.3389/fonc.2021.703893] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/09/2021] [Indexed: 01/14/2023] Open
Abstract
Introduction PD-(L)1 inhibitors have improved prognosis of non-small-cell lung cancer (NSCLC), but can also cause immune-related adverse events (irAEs) that complicate management. Methods We analyzed NSCLC patients receiving PD-(L)1 inhibitors from 2012 to 2020 in a German academic center. Results IrAE showed comparable frequencies in stage IV (198/894 or 22%) vs. III (14/45 or 31%, p = 0.15), after anti-PD-(L)1 monotherapy vs. chemoimmunotherapy (139/483 vs. 58/213, p = 0.75), and across treatment lines. In stage IV, irAE occurred after 3.1 months in median, affected multiple organs (median 2) in 27/894 patients and were associated with PD-L1 positivity (25 vs. 14%, p = 0.003), lower neutrophil-to-lymphocyte ratios (29 vs. 17%, p < 0.001 for NLR dichotomized at 5), better ECOG status (26 vs. 18% for 0 vs. 1, p = 0.004), but not related to age, sex, smoking and palliative radiotherapy. Two hundred thirty two irAEs occurred mostly in endocrine glands (4.9%), lungs (4.4%), the musculoskeletal system (4.2%), colon (4.1%), liver (3.7%), and skin (2.6%), while pneumonitis was most frequent with durvalumab following definitive chemoradiation (16% or 7/45, p < 0.01). IrAE severity was grade 1 in 11%, 2 in 41%, 3 in 36%, and 4 in 11% events, while two were lethal (<1%, myocarditis and pneumonitis). Therapy was suspended in 72%, while steroids were initiated in 66% and complemented by other immunosuppressants in 6%, with longest treatment duration for rheumatic events (mean >3 months), and average cumulative prednisone doses >700 mg for all organs, except for skin. Patients developing irAE had longer progression-free (PFS) and overall survival (OS) in multivariable 12/14-week landmark analyses including ECOG status, treatment line, treatment type, PD-L1 TPS, and NLR (median PFS 17 vs. 10 months, HR = 0.68, p = 0.009; median OS 37 vs. 15 months, HR = 0.40, p < 0.001), regardless of grade. OS was longest with skin (95% at 2 years) and shortest with pneumonitis, hepatitis, neurologic, and cardiologic irAE (38, 37, 28, and 0% at 2 years, p < 0.001). Conclusions Approximately one-fourth of immunotherapy-treated NSCLC patients develop irAEs, most of which necessitate treatment suspension and steroids. Despite more frequent occurrence with PD-L1 positive tumors, lower NLR, and better ECOG PS, irAEs are independently associated with longer survival, especially when affecting the skin. Lethality is below 1%.
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Affiliation(s)
- Lea Daniello
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumor Diseases (NCT) at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center of Lung Research (DZL), Heidelberg, Germany
| | - Mariam Elshiaty
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumor Diseases (NCT) at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center of Lung Research (DZL), Heidelberg, Germany
| | - Farastuk Bozorgmehr
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumor Diseases (NCT) at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center of Lung Research (DZL), Heidelberg, Germany
| | - Jonas Kuon
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumor Diseases (NCT) at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center of Lung Research (DZL), Heidelberg, Germany
| | - Daniel Kazdal
- Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center of Lung Research (DZL), Heidelberg, Germany.,Institute of Pathology Heidelberg, Heidelberg, Germany
| | - Hannah Schindler
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumor Diseases (NCT) at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center of Lung Research (DZL), Heidelberg, Germany
| | - Rajiv Shah
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumor Diseases (NCT) at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center of Lung Research (DZL), Heidelberg, Germany
| | | | - Fabienne Lusky
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumor Diseases (NCT) at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center of Lung Research (DZL), Heidelberg, Germany
| | - Leonore Diekmann
- Department of Internal Medicine V, Hematology, Oncology und Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stephan Liersch
- Department of Pharmacy, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Faehling
- Department of Cardiology, Angiology and Pneumology, Esslingen Hospital, Esslingen, Germany
| | - Thomas Muley
- Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center of Lung Research (DZL), Heidelberg, Germany.,Translational Research Unit, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Mark Kriegsmann
- Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center of Lung Research (DZL), Heidelberg, Germany.,Institute of Pathology Heidelberg, Heidelberg, Germany
| | - Karolina Benesova
- Department of Internal Medicine V, Hematology, Oncology und Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Albrecht Stenzinger
- Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center of Lung Research (DZL), Heidelberg, Germany.,Institute of Pathology Heidelberg, Heidelberg, Germany
| | - Michael Thomas
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumor Diseases (NCT) at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center of Lung Research (DZL), Heidelberg, Germany
| | - Petros Christopoulos
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumor Diseases (NCT) at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center of Lung Research (DZL), Heidelberg, Germany
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23
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Brahmer JR, Abu-Sbeih H, Ascierto PA, Brufsky J, Cappelli LC, Cortazar FB, Gerber DE, Hamad L, Hansen E, Johnson DB, Lacouture ME, Masters GA, Naidoo J, Nanni M, Perales MA, Puzanov I, Santomasso BD, Shanbhag SP, Sharma R, Skondra D, Sosman JA, Turner M, Ernstoff MS. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immune checkpoint inhibitor-related adverse events. J Immunother Cancer 2021; 9:e002435. [PMID: 34172516 PMCID: PMC8237720 DOI: 10.1136/jitc-2021-002435] [Citation(s) in RCA: 283] [Impact Index Per Article: 94.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are the standard of care for the treatment of several cancers. While these immunotherapies have improved patient outcomes in many clinical settings, they bring accompanying risks of toxicity, specifically immune-related adverse events (irAEs). There is a need for clear, effective guidelines for the management of irAEs during ICI treatment, motivating the Society for Immunotherapy of Cancer (SITC) to convene an expert panel to develop a clinical practice guideline. The panel discussed the recognition and management of single and combination ICI irAEs and ultimately developed evidence- and consensus-based recommendations to assist medical professionals in clinical decision-making and to improve outcomes for patients.
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Affiliation(s)
- Julie R Brahmer
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
| | - Hamzah Abu-Sbeih
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Paolo Antonio Ascierto
- Unit of Melanoma Cancer Immunotherapy and Innovative Therapy, National Tumour Institute IRCCS Fondazione 'G. Pascale', Napoli, Italy
| | - Jill Brufsky
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Laura C Cappelli
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Frank B Cortazar
- Massachusetts General Hospital, Boston, Massachusetts, USA
- New York Nephrology Vasculitis and Glomerular Center, Albany, New York, USA
| | - David E Gerber
- Department of Hematology and Oncology, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lamya Hamad
- Department of Pharmacy, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Eric Hansen
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Mario E Lacouture
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gregory A Masters
- Department of Medicine, Helen F. Graham Cancer Center, Newark, Delaware, USA
| | - Jarushka Naidoo
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
- Department of Oncology, Beaumont Hospital Dublin, The Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Michele Nanni
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Miguel-Angel Perales
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Bianca D Santomasso
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Satish P Shanbhag
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Cancer Specialist of North Florida, Fleming Island, Florida, USA
| | - Rajeev Sharma
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Dimitra Skondra
- Department of Ophthalmology and Visual Science, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Jeffrey A Sosman
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University Medical Center, Chicago, Illinois, USA
| | - Michelle Turner
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
| | - Marc S Ernstoff
- Division of Cancer Treatment & Diagnosis, National Cancer Institute, Rockville, Maryland, USA
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24
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Tingry T, Massy E, Piperno M, Auroux M, Kostine M, Maillet D, Amini-Adle M, Fabien N, Estublier C, Goncalves D, Girard N, Confavreux CB. [Rheumatic immune adverse events related to immune checkpoint inhibitors-(IrAEs related to ICI)]. Bull Cancer 2021; 108:643-653. [PMID: 33902919 DOI: 10.1016/j.bulcan.2021.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 01/12/2021] [Accepted: 01/20/2021] [Indexed: 12/17/2022]
Abstract
New anti-cancer therapeutics have been developed in the recent years and dramatically change prognosis and patient management. Either used alone or in combination, immune checkpoint inhibitors (ICI), such as anti-CTLA-4 and anti-PD1/PD-(L)1, act by removing T-cell inhibition to enhance their antitumor response. This change in therapeutic targets leads to a break in immune-tolerance and a unique toxicity profile resulting in immune complications. These side effects, called Immune-Related Adverse Events (IrAEs), can affect all organs, with a wide range of clinical and biological presentations and severity. Various rheumatic and musculoskeletal manifestations have been reported in the literature, ranging from mild arthralgia, polymyalgia rheumatica, to genuine serodefined rheumatoid arthritis and myositis. Tolerance studies suggest some correlations between IrAEs occurrence and tumor response. Assessment of patient musculoskeletal status prior to the start of the ICI is warranted. Management of rheumatic IrAEs does not usually request ICI discontinuation, exception for myositis or very severe forms where it should be discussed. Treatment relies on non-steroidal anti-inflammatory drugs (NSAIDs) or low dose glucocortioids (<20mg per day). Dose should be adjusted according to severity. The use of disease modifying anti-rheumatic drugs (DMARDs), either conventional and/or biological should be very cautious and result from a shared decision between oncologist and rheumatologist to best manage dysimmunitary complications without hampering the antitumor efficacy of ICI.
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Affiliation(s)
- Thomas Tingry
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France; Université de Lyon, Inserm UMR 1033-LYOS, 69003 Lyon, France; Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France
| | - Emmanuel Massy
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France; Université de Lyon, Inserm UMR 1033-LYOS, 69003 Lyon, France; Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France
| | - Muriel Piperno
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France; Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France
| | - Maxime Auroux
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France
| | - Marie Kostine
- Centre hospitalier universitaire de Bordeaux, département de rhumatologie, 33000 Bordeaux, France
| | - Denis Maillet
- Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France; Centre Hospitalier Lyon Sud, Hospices civils de Lyon, service d'oncologie médicale, 69310 Pierre Bénite, France
| | - Mona Amini-Adle
- Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France; Centre de lutte contre le cancer Léon-Bérard, service de dermatologie, 69003 Lyon, France
| | - Nicole Fabien
- Centre Hospitalier Lyon Sud, hospices civils de Lyon, laboratoire d'auto-immunité, 69310 Pierre Bénite, France
| | - Charline Estublier
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France; Université de Lyon, Inserm UMR 1033-LYOS, 69003 Lyon, France; Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France
| | - David Goncalves
- Centre Hospitalier Lyon Sud, hospices civils de Lyon, laboratoire d'auto-immunité, 69310 Pierre Bénite, France
| | - Nicolas Girard
- Institut Curie, institut du Thorax Curie Montsouris, 75005 Paris, France
| | - Cyrille B Confavreux
- Centre hospitalier Lyon Sud-hospices civils de Lyon, service de rhumatologie, centre expert des métastases et d'oncologie osseuse secondaire (CEMOS), 69310 Pierre Bénite, France; Université de Lyon, Inserm UMR 1033-LYOS, 69003 Lyon, France; Institut de cancérologie des hospices Civils de Lyon, ImmuCare (Immunology cancer research), 69310 Pierre Bénite, France.
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25
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Verspohl SH, Holderried T, Behning C, Brossart P, Schäfer VS. Prevalence, therapy and tumour response in patients with rheumatic immune-related adverse events following immune checkpoint inhibitor therapy: a single-centre analysis. Ther Adv Musculoskelet Dis 2021; 13:1759720X211006963. [PMID: 33912248 PMCID: PMC8047846 DOI: 10.1177/1759720x211006963] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/10/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Immune checkpoint inhibitors (ICIs) improved cancer therapy by inducing a higher immune system activity. This effect can cause rheumatic immune-related adverse events (rh-irAEs), which have not yet been extensively studied. Methods: We analysed 437 patients between 2014 and 2019, treated with ipilimumab (anti-CTLA-4) and/or nivolumab (anti-PD-1) or pembrolizumab (anti-PD-1) at the Clinic for Internal Medicine III, Oncology, Haematology and Rheumatology at the University Hospital Bonn, Germany. Results: Of the 437 patients 60% were males. Patients were mainly treated for melanoma, lung cancer, head and neck tumour and urothelial carcinoma. At least one immune-related adverse event (irAE) was observed in 163 patients (37.3%), including rh-irAE. Most common side effects were rash, colitis and hepatitis. We identified 19 patients (4.3%) with a minimum of one rh-irAE due to ICI therapy; three of those had a pre-existing rheumatic disease. Arthralgia developed most frequently in eight patients (42.1%). Other rh-irAEs were: arthritis (n = 7; distinguished in rheumatoid arthritis, psoriatic arthritis, juvenile idiopathic arthritis and undifferentiated arthritis), myalgia (n = 2) and myositis (n = 3). Most rh-irAEs were classified as moderately severe (Common Terminology Criteria of Adverse Events grade 2: 68.4%). Median time between starting ICI therapy and the occurrence of rh-irAE was 109 days (interquartile range 40–420 days). Fifteen patients (78.9%) were treated with glucocorticosteroids. In four cases additional therapy with methotrexate or tocilizumab was required. Even though patients benefited from ICI treatment, therapy had to be discontinued in six of the participants due to rh-irAE. Interestingly, patients with rh-irAE had a significantly higher tumour response compared with patients without rh-irAE (94.4% versus 43.5%; p < 0.0001). Conclusion: Rh-irAEs occur under ICI therapy, especially in patients with higher tumour response. However, they are not the most frequent irAE after ICI exposure: 9.3% of all irAEs were rheumatic (20 rh-irAE cases in 19 patients of a total of 215 irAE cases in 163 patients).
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Affiliation(s)
- Sophia H Verspohl
- Clinic for Internal Medicine III, Department of Oncology, Haematology, Rheumatology and Clinical Immunology, University Hospital of Bonn, Bonn, Germany
| | - Tobias Holderried
- Clinic for Internal Medicine III, Department of Oncology, Haematology, Rheumatology and Clinical Immunology, University Hospital of Bonn, Bonn, Germany
| | - Charlotte Behning
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Peter Brossart
- Clinic for Internal Medicine III, Department of Oncology, Haematology, Rheumatology and Clinical Immunology, University Hospital of Bonn, Bonn, Germany
| | - Valentin S Schäfer
- Clinic for Internal Medicine III, Department of Oncology, Haematology, Rheumatology and Clinical Immunology, University Hospital of Bonn, Germany, Venusberg Campus 1, Bonn 53127, Germany
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26
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Ceccarelli F, Botticelli A, Natalucci F, Olivieri G, Cirillo A, Alessandri C, Marchetti P, Conti F. Immune checkpoint inhibitors and pre-existing antinuclear antibodies: the rheumatologist point of view. Clin Transl Oncol 2021; 23:1961-1962. [PMID: 33728870 DOI: 10.1007/s12094-021-02584-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 03/05/2021] [Indexed: 10/21/2022]
Affiliation(s)
- F Ceccarelli
- Reumatologia, Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Viale del Policlinico 155, 00161, Rome, Italy.
| | - A Botticelli
- Medical Oncology Unit B, Policlinico Umberto I, Rome, Italy
| | - F Natalucci
- Reumatologia, Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Viale del Policlinico 155, 00161, Rome, Italy
| | - G Olivieri
- Reumatologia, Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Viale del Policlinico 155, 00161, Rome, Italy
| | - A Cirillo
- Medical Oncology Unit B, Policlinico Umberto I, Rome, Italy
| | - C Alessandri
- Reumatologia, Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Viale del Policlinico 155, 00161, Rome, Italy
| | - P Marchetti
- Medical Oncology Unit B, Policlinico Umberto I, Rome, Italy
| | - F Conti
- Reumatologia, Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Viale del Policlinico 155, 00161, Rome, Italy
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27
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Kramer R, Zaremba A, Moreira A, Ugurel S, Johnson DB, Hassel JC, Salzmann M, Gesierich A, Weppler A, Spain L, Loquai C, Dudda M, Pföhler C, Hepner A, Long GV, Menzies AM, Carlino MS, Sachse MM, Lebbé C, Baroudjian B, Enokida T, Tahara M, Schlaak M, Hayani K, Bröckelmann PJ, Meier F, Reinhardt L, Friedlander P, Eigentler T, Kähler KC, Berking C, Zimmer L, Heinzerling L. Hematological immune related adverse events after treatment with immune checkpoint inhibitors. Eur J Cancer 2021; 147:170-181. [PMID: 33706206 DOI: 10.1016/j.ejca.2021.01.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/09/2020] [Accepted: 01/12/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION With the increasing use of checkpoint inhibitors, rare immune-related adverse events (irAE) are being identified. Haematological irAE (hem-irAE) are difficult to treat and have shown high mortality rates. In order to improve side-effect management for these potentially life-threatening events, we analysed frequency, severity and outcomes. PATIENTS AND METHODS Patients who developed hem-irAE while being treated with immune checkpoint inhibitors (ICI) therapy were retrospectively identified from 18 international cancer centres. RESULTS In total, more than 7626 patients treated with ICI were screened, and 50 patients with hem-irAE identified. The calculated incidence amounts to 0.6% and median onset was 6 weeks after the ICI initiation (range 1-128 weeks). Thrombocytopenia and leucopaenia were the most frequent hem-irAE with 34% (17/50) and 34% (17/50), respectively, followed by anaemia 28% (14/50), hemophagocytic lymphohistiocytosis (4% (2/50)), aplastic anaemia (2% (1/50)), acquired haemophilia A (2% (1/50)) and coagulation deficiency (2% (1/50)). Simultaneous thrombocytopenia and neutropenia occurred in two patients, concurrent anaemia and thrombocytopenia in one patient. Other than cessation of ICI (in 60%) and corticosteroids (in 78%), treatment included second-line immunosuppression in 24% of cases. Events resolved in 78% (39/50), while 18% (9/50) had persistent changes, and 2% (1/50) had fatal outcomes (agranulocytosis). CONCLUSION Hem-irAE can affect all haematopoietic blood cell lineages and may persist or even be fatal. Management may require immunosuppression beyond corticosteroids. Although these irAE are rare, treating physicians should be aware, monitor blood counts regularly and promptly act upon detection.
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Affiliation(s)
- Rafaela Kramer
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany; Deutsches Zentrum Immuntherapie (DZI), Erlangen, Germany; Comprehensive Cancer Center Erlangen-European Metropolitan Area of Nürnberg (CCC ER-EMN), Erlangen, Germany
| | - Anne Zaremba
- Department of Dermatology, Venerology und Allergology, University Hospital Essen, Essen, Germany
| | - Alvaro Moreira
- Tisch Cancer Institute at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Selma Ugurel
- Department of Dermatology, Venerology und Allergology, University Hospital Essen, Essen, Germany
| | - Douglas B Johnson
- Vanderbilt University Medical Center, Department of Medicine, Division of Hematology and Oncology, Nashville, USA
| | - Jessica C Hassel
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Salzmann
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Anja Gesierich
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Alison Weppler
- Medical Oncology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Lavinia Spain
- Medical Oncology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Carmen Loquai
- Department of Dermatology, University Medical Center, Mainz, Germany
| | - Milena Dudda
- Department of Dermatology, University Medical Center, Mainz, Germany
| | - Claudia Pföhler
- Department of Dermatology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Adriana Hepner
- Department of Medical Oncology, Melanoma Institute Australia, Sydney, Australia; Medical Oncology Service, Instituto do Cancer do Estado de Sao Paulo, Sao Paulo, Brazil
| | - Georgina V Long
- Melanoma Institute Australia, University of Sydney, Royal North Shore and Mater Hospitals, Sydney, NSW, Australia
| | - Alexander M Menzies
- Melanoma Institute Australia, University of Sydney, Royal North Shore and Mater Hospitals, Sydney, NSW, Australia
| | - Matteo S Carlino
- Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney, NSW, Australia
| | - Michael M Sachse
- Department of Dermatology, Allergology and Phlebology, Bremerhaven Reinkenheide Hospital, Bremerhaven, Germany
| | - Céleste Lebbé
- APHP, Department of Dermatology, Saint-Louis Hospital, Université de Paris, INSERM U976, Paris, France
| | - Barouyr Baroudjian
- APHP, Department of Dermatology, Saint-Louis Hospital, Université de Paris, INSERM U976, Paris, France
| | - Tomohiro Enokida
- Department of Head and Neck Medical Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Makoto Tahara
- Department of Head and Neck Medical Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Max Schlaak
- Department of Dermatology, Charité University Hospital, Berlin, Germany
| | - Kinan Hayani
- Department of Dermatology and Allergy, LMU, University Hospital, Munich, Germany
| | - Paul J Bröckelmann
- Department I of Internal Medicine, Centre of Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Friedegund Meier
- Skin Cancer Center at the University Cancer Centre Dresden and National Center for Tumor Diseases, Dresden, Germany; Department of Dermatology, University Hospital Carl Gustav Carus, TU Dresden, Germany
| | - Lydia Reinhardt
- Skin Cancer Center at the University Cancer Centre Dresden and National Center for Tumor Diseases, Dresden, Germany; Department of Dermatology, University Hospital Carl Gustav Carus, TU Dresden, Germany
| | - Philip Friedlander
- Tisch Cancer Institute at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas Eigentler
- Department of Dermatology, University Hospital Tübingen, Germany
| | | | - Carola Berking
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany; Deutsches Zentrum Immuntherapie (DZI), Erlangen, Germany; Comprehensive Cancer Center Erlangen-European Metropolitan Area of Nürnberg (CCC ER-EMN), Erlangen, Germany
| | - Lisa Zimmer
- Department of Dermatology, Venerology und Allergology, University Hospital Essen, Essen, Germany
| | - Lucie Heinzerling
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany; Deutsches Zentrum Immuntherapie (DZI), Erlangen, Germany; Comprehensive Cancer Center Erlangen-European Metropolitan Area of Nürnberg (CCC ER-EMN), Erlangen, Germany; Department of Dermatology and Allergy, LMU, University Hospital, Munich, Germany.
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Rheumatic and musculoskeletal disorders induced by immune checkpoint inhibitors: Consequences on overall survival. Joint Bone Spine 2021; 88:105168. [PMID: 33675979 DOI: 10.1016/j.jbspin.2021.105168] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/10/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Immune checkpoint inhibitors (ICIs) frequently induce immune related adverse events (irAEs) that may be associated with more favorable clinical outcomes. We aimed to evaluate the impact of all types of rheumatic adverse events (AEs) on overall survival (OS) and tumor response in patients treated with ICIs. METHODS We performed a single-center retrospective observational study to analyze the OS and tumor response in patients receiving ICIs who experienced a rheumatic AE compared to those who did not experience any AE. RESULTS From December 2010 to September 2018, 264 patients with any cancer type were included. Forty-three patients (16.3%) presented with at least one rheumatic AE. The median OS of patients with rheumatic AEs was significantly higher than that of patients without AEs, with 132 weeks (95% CI [69.3-not reached]) and 42.7 weeks (95% CI [25.6-not reached]), respectively (P<0.01). This result remained significant after multivariate analysis (HR 0.54, 95% CI [0.30-0.97], P<0.05). Also, tumor response was better in patients with rheumatic AEs. CONCLUSION The occurrence of rheumatic AEs in patients treated with ICIs is associated with better survival and tumor response. Therefore, it seems essential to detect rheumatic AEs as early as possible to allow rapid and optimal management, given the long-term response potential of these patients.
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Canavan M, Floudas A, Veale DJ, Fearon U. The PD-1:PD-L1 axis in Inflammatory Arthritis. BMC Rheumatol 2021; 5:1. [PMID: 33423684 PMCID: PMC7798255 DOI: 10.1186/s41927-020-00171-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 11/03/2020] [Indexed: 12/22/2022] Open
Abstract
The activation of antigen specific T cells during an immune response is a tightly regulated process at the level of both costimulatory and coinhibitory receptors. One such coinhibitory receptor or checkpoint inhibitor which has received much attention in the field of oncology is the programmed cell death protein 1 (PD-1). Blockade of PD-1 or its ligand PD-L1 has proven successful in the treatment of a wide variety of cancers, therefore highlighting an important role for this pathway in anti-tumour immune responses. However, a caveat of PD-1 therapy and boosting anti-tumour immune responses is the development of self-reactive T cells which can lead to the induction of various autoimmune or inflammatory diseases, referred to as immune- related adverse events (irAEs). The emergence of rheumatological irAEs such as Inflammatory Arthritis (IA) in recent years has highlighted the importance of PD-1 in maintaining self-tolerance. Furthermore, the emergence of rheumatology related irAEs raises an important question as to how defects in this pathway can contribute to spontaneous rheumatological disease. In this review, we describe the biological distribution, function and regulation of the PD-1 pathway, its potential role in IA and irAE related IA.
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Affiliation(s)
- Mary Canavan
- Department of Molecular Rheumatology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin 2, Ireland.
- EULAR Centre of Excellence, Centre for Arthritis & Rheumatic Diseases, St. Vincent's University Hospital, University College Dublin, Dublin, Ireland.
| | - Achilleas Floudas
- Department of Molecular Rheumatology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin 2, Ireland
- EULAR Centre of Excellence, Centre for Arthritis & Rheumatic Diseases, St. Vincent's University Hospital, University College Dublin, Dublin, Ireland
| | - Douglas J Veale
- EULAR Centre of Excellence, Centre for Arthritis & Rheumatic Diseases, St. Vincent's University Hospital, University College Dublin, Dublin, Ireland
| | - Ursula Fearon
- Department of Molecular Rheumatology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin 2, Ireland
- EULAR Centre of Excellence, Centre for Arthritis & Rheumatic Diseases, St. Vincent's University Hospital, University College Dublin, Dublin, Ireland
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Cappelli LC, Bingham CO. Expert Perspective: Immune Checkpoint Inhibitors and Rheumatologic Complications. Arthritis Rheumatol 2020; 73:553-565. [PMID: 33186490 DOI: 10.1002/art.41587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022]
Abstract
Rheumatologists increasingly receive consults for patients treated with immune checkpoint inhibitors (ICIs) for cancer. ICIs can cause inflammatory syndromes known as immune-related adverse events (IRAEs). Several rheumatic IRAEs have been reported, including inflammatory arthritis, polymyalgia rheumatica, and myositis. For patients who present with musculoskeletal symptoms while receiving ICI therapy, it is important to have an algorithm for evaluation. The differential diagnosis includes a range of musculoskeletal syndromes, such as crystalline arthritis, mechanical issues, and osteoarthritis, in addition to IRAEs. After diagnosing a rheumatic IRAE, rheumatologists must work with the patient and the oncologist to form a treatment plan. Treatment of IRAEs is guided by severity. Evidence for management is limited to observational studies. Inflammatory arthritis and polymyalgia rheumatica are treated with nonsteroidal antiinflammatory drugs in mild cases, glucocorticoids for moderate-to-severe cases, and sometimes require other disease-modifying antirheumatic drugs. Myositis due to ICIs can be accompanied by myocarditis or myasthenia gravis. Glucocorticoids and withholding the ICI are usually required to treat myositis; some patients with severe myositis require intravenous immunoglobulin or plasmapheresis. Further research is needed to optimize treatment of IRAEs that does not compromise the antitumor effect of ICIs.
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Dey A, Manolios N, Long GV, Carlino MS, Kefford R, Schrieber L. Musculoskeletal immune-related adverse events with the use of checkpoint inhibitors in malignancy. Intern Med J 2020; 52:818-827. [PMID: 33135853 DOI: 10.1111/imj.15123] [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: 10/26/2019] [Revised: 10/12/2020] [Accepted: 10/18/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Immunotherapy has revolutionised the treatment of many malignancies. Along with their success, there have been inflammatory and immune-related adverse events (irAE). There is a paucity of literature describing the Australian experience of rheumatic irAE. AIMS To describe and characterise the Royal North Shore Hospital and Westmead Hospital cohort with rheumatic irAE. METHODS This case series reports on 17 patients with advanced cancer treated at two sites in Sydney, Australia who were referred for rheumatological evaluation from 2013 to 2016. Data were collected retrospectively and inspected for clinical signs, duration of immunotherapy prior to onset of symptoms, management strategies and cancer outcomes. RESULTS Patients presented with arthralgias, myalgias, periarticular and systemic symptoms. Onset of rheumatological symptoms was variable, with a median of 4 months (range 0.2-24) for monotherapy and 5.05 months (range 0.2-6.9) for combination. The predominant findings were of tenosynovitis (23%) and large joint involvement (65%). All patients were seronegative for RF and anti-CCP. Most patients responded well to non-steroidal anti-inflammatory drugs or low-dose prednisone (59%) and remained on immunotherapy (77%). The majority (76%) of patients experienced concomitant irAE in other organ systems. Sixty-five percent of patients had complete response of their malignancy to immunotherapy. CONCLUSION Rheumatic irAE are heterogenous clinical entities, which require further evaluation into classification, patient susceptibility and response. From our study, there was no clear clinical pattern. The present case series supports that rheumatic irAE may be associated with tumour response. However, there is still limited experience in rheumatic irAE management and outcomes.
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Affiliation(s)
- Abhishikta Dey
- Department of Rheumatology, University of Sydney, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Nicholas Manolios
- Department of Rheumatology, Westmead Hospital and; Professor of Rheumatology, Faculty of Medicine and Health University of Sydney, The University of Sydney, Sydney, New South Wales, Australia
| | - Georgina V Long
- Department of Oncology, University of Sydney, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Melanoma Institute Australia, Sydney, New South Wales, Australia
| | - Matteo S Carlino
- Melanoma Institute Australia, Sydney, New South Wales, Australia.,Crown Princess Mary Cancer Centre, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Richard Kefford
- Melanoma Institute Australia, Sydney, New South Wales, Australia.,Crown Princess Mary Cancer Centre, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia.,Department of Clinical Medicine, Macquarie University, Sydney, New South Wales, Australia
| | - Leslie Schrieber
- Department of Rheumatology, University of Sydney, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Arthralgia Induced by BRAF Inhibitor Therapy in Melanoma Patients. Cancers (Basel) 2020; 12:cancers12103004. [PMID: 33081201 PMCID: PMC7602871 DOI: 10.3390/cancers12103004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/05/2020] [Accepted: 10/15/2020] [Indexed: 11/16/2022] Open
Abstract
Simple Summary BRAF inhibitors (BRAFi) are standard of care for BRAF-mutated metastatic melanoma (MM). One of the most common side effects is arthralgia, for which a high incidence has been described, but whose clinical presentation and management have not yet been characterized. The aim of this retrospective study was to assess the patterns and clinical course of this drug-induced joint pain and to discuss a potential pathogenesis based on our clinical findings. In our cohort of patients treated with BRAFi between 2010 and 2018, 48 of 154 (31%) patients suffered from new-onset joint pain, which primarily affected small joints with a symmetrical pattern, as can be observed in patients affected by rheumatoid arthritis, the most frequent rheumatic and musculoskeletal disease. Most cases were sufficiently treated by non-steroidal anti-inflammatory drugs; however, some patients required dose reduction or permanent discontinuation of the BRAFi. Interestingly, we found that the occurrence of arthralgia was associated with better tumor control. Abstract Introduction: BRAF inhibitors (BRAFi), commonly used in BRAF-mutated metastatic melanoma (MM) treatment, frequently cause arthralgia. Although this is one of the most common side effects, it has not been characterized yet. Methods: We retrospectively included all patients treated with BRAFi +/− MEK inhibitors (MEKi) for MM at the National Center for Tumor Diseases (Heidelberg) between 2010 and 2018 and reviewed patient charts for the occurrence and management of arthralgia. The evaluation was supplemented by an analysis of frozen sera. Results: We included 154 patients (63% males); 31% (48/154) of them reported arthralgia with a median onset of 21 days after the start of the therapy. Arthralgia mostly affected small joints (27/36, 75%) and less frequently large joints (19/36, 53%). The most commonly affected joints were in fingers (19/36, 53%), wrists (16/36, 44%), and knees (12/36, 33%). In 67% (24/36) of the patients, arthralgia occurred with a symmetrical polyarthritis, mainly of small joints, resembling the pattern typically observed in patients affected by rheumatoid arthritis (RA), for which a role of the MAPK signaling pathway was previously described. Patients were negative for antinuclear antibodies, anti-citrullinated protein antibodies, and rheumatoid factor; arthritis was visible in 10 of 13 available PET–CT scans. The development of arthralgia was linked to better progression-free survival and overall survival. Conclusion: Arthralgia is a common side effect in patients receiving BRAFi +/− MEKi therapy and often presents a clinical pattern similar to that observed in RA patients. Its occurrence was associated with longer-lasting tumor control.
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Benesova K, Leipe J. Nebenwirkungen immunonkologischer Therapien. AKTUEL RHEUMATOL 2020. [DOI: 10.1055/a-1209-0659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ZusammenfassungImmunonkologische Therapien und insbesondere die Immuncheckpoint-Inhibitoren (ICPi) als Hauptvertreter dieser neuen Substanzklasse kommen bei zunehmender Anzahl von soliden und teils auch hämatologischen Tumorentitäten und Indikationen zum Einsatz. Die relativ hohen (Langzeit-)Tumoransprechraten auch in fortgeschrittenen und therapierefraktären Stadien haben die therapeutischen Möglichkeiten der Onkologie geradezu revolutioniert. Gleichzeitig bringt der zunehmende Einsatz von ICPi auch neue Herausforderungen: Immunonkologische Therapien verursachen ein breites Spektrum an autoimmunen Nebenwirkungen, sogenannten „immune-related adverse events“ (irAEs), die teilweise klassischen Autoimmunopathien ähneln und jedes Organsystem betreffen können. Die große Mehrheit der ICPi-behandelten Patienten erlebt ein irAE an mindestens einem Organsystem und davon weisen ca. 5–20% ein rheumatisches irAEs auf. Diese sind interessanterweise mit einem besseren Tumoransprechraten bei ICPi-Therapie assoziiert und können entweder die Erstmanifestation einer klassischen entzündlich-rheumatischen Erkrankung oder auch nur eine transiente Nebenwirkung mit spezifischen Charakteristika sein. Zweifelsohne wird das interdisziplinäre Management immunvermittelter Nebenwirkungen auch den Rheumatologen in den nächsten Jahren zunehmend beschäftigen. Der vorliegende Artikel fasst die Erkenntnisse zum klinischen Management von irAEs für den praktizierenden Rheumatologen zusammen.
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Affiliation(s)
- Karolina Benesova
- Sektion Rheumatologie, Abteilung Innere Medizin V Hämatologie Onkologie Rheumatologie, Universitätsklinikum Heidelberg, Heidelberg
| | - Jan Leipe
- Sektion Rheumatologie, Medizinische Klinik V, Universitätsklinikum Mannheim, Mannheim
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München Medizinische Fakultät, München
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Verspohl SH, Schulze-Koops H, Heine A, Schäfer VS. [Prevalence and treatment of rheumatological adverse events due to immune checkpoint inhibitor therapy]. Z Rheumatol 2020; 79:797-808. [PMID: 32926217 DOI: 10.1007/s00393-020-00873-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) have essentially improved the treatment options for various malignant diseases. They lead to an activation of the immune system and subsequent attack of tumor cells by affecting the immune system and preventing tumor cells from avoiding detection. In addition to this desired effect, immune-related adverse events (irAE) can occur in nearly all organ systems and therefore also rheumatological irAE (rh-irAE). OBJECTIVE The occurrence of rh-irAE has been described in various publications and is specifically investigated in this review. The aim is to provide an overview on the prevalence, severity, treatment options and altered tumor response in patients with rh-irAE. MATERIAL AND METHODS We conducted a literature search for studies and case reports on rh-irAE under ICI therapy in PubMed up to January 2020 using the PICO model. RESULTS A total of 18 publications were included, most of which were clinical studies (n = 13) and the rest case reports (n = 5). Several rh-irAE can occur with a wide variety of manifestations of which arthralgia, arthritis and myositis were the most common. Other rheumatic diseases, such as vasculitis, connective tissue diseases and sarcoidosis were less frequently described. The published prevalence of rh-irAE varied with a prevalence between 2.3% and 6.6%. Treatment of rh-irAE depends on the severity and most patients receive nonsteroidal anti-inflammatory drugs and glucocorticosteroids. In some cases, conventional DMARDs, such as methotrexate and biological DMARDs, were administered. Patients with rh-irAE in general had a higher tumor response rate compared to patients without side effects. CONCLUSION A close observation of patients and early detection of rh-irAE are important in order to treat these side effects in time. Further prospective studies are necessary to systematically investigate rh-irAE.
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Affiliation(s)
- S H Verspohl
- Medizinische Klinik und Poliklinik III, Klinik für Hämatologie, Onkologie, Rheumatologie und klinische Immunologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
| | - H Schulze-Koops
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, München, Deutschland
| | - A Heine
- Medizinische Klinik und Poliklinik III, Klinik für Hämatologie, Onkologie, Rheumatologie und klinische Immunologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
| | - V S Schäfer
- Medizinische Klinik und Poliklinik III, Klinik für Hämatologie, Onkologie, Rheumatologie und klinische Immunologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland.
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Multinational Association of Supportive Care in Cancer (MASCC) 2020 clinical practice recommendations for the management of immune-mediated cardiovascular, rheumatic, and renal toxicities from checkpoint inhibitors. Support Care Cancer 2020; 28:6159-6173. [PMID: 32856212 DOI: 10.1007/s00520-020-05710-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have emerged as the newest pillar of cancer treatment. Immune-mediated toxicities, stemming from increased activity within the T cell lineage, range from asymptomatic or mild complications to those that are fulminant and potentially fatal. Although they are of variable occurrence, cardiovascular, rheumatic, and renal immune-mediated toxicities are among the most serious of these adverse events. We present MASCC recommendations with respect to the workup and management of cardiovascular, rheumatic, and renal immune-mediated toxicities with a focus on presentations that require treatment with immunomodulating agents.
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Williams SG, Mollaeian A, Katz JD, Gupta S. Immune checkpoint inhibitor-induced inflammatory arthritis: identification and management. Expert Rev Clin Immunol 2020; 16:771-785. [PMID: 32772596 DOI: 10.1080/1744666x.2020.1804362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) have proved to be groundbreaking in the field of oncology. However, immune system overactivation from ICIs has introduced a novel medical entity known as immune-related adverse events (irAEs), that can affect any organ or tissue. ICI-induced inflammatory arthritis (ICI-IIA) is the most common musculoskeletal irAE and can lead to significant morbidity and limitation in anti-cancer therapy. AREAS COVERED In this review, the authors focus on ICI-IIA. Relevant articles were identified through PubMed searches, spanning 2010 to the present. The authors detail the current understanding of its pathogenesis, diagnostic evaluation, and management strategies. EXPERT OPINION ICI-IIA is a complex irAE that we are just beginning to understand mechanistically and pathologically. It often presents later in the disease course than other irAEs and, due to various reasons, is under-recognized. In some patients, ICI-IIA may become a chronic disease, which distinguishes it from most irAEs that resolve after ICI discontinuation. Multiple important questions still demand further research including which patients may develop ICI-IIA? What are possible diagnostic and prognostic markers? Do anti-arthritis therapies interfere with the anti-tumor response? and when should steroid-sparing agents be initiated? Close collaboration and shared decision-making between oncologists, rheumatologists, and the patient are essential when managing this particular irAE.
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Affiliation(s)
- Sandra G Williams
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH) , Bethesda, MD, USA
| | - Arash Mollaeian
- Department of Medicine, MedStar Health Internal Medicine Residency Program , Baltimore, MD, USA
| | - James D Katz
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH) , Bethesda, MD, USA
| | - Sarthak Gupta
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH) , Bethesda, MD, USA
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Immune checkpoint inhibitor-induced musculoskeletal manifestations. Rheumatol Int 2020; 41:33-42. [PMID: 32743706 DOI: 10.1007/s00296-020-04665-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/27/2020] [Indexed: 12/17/2022]
Abstract
Immune checkpoint inhibitors (ICI) associate with a wide range of immune-related adverse events (Ir-AE), including musculoskeletal manifestations. We aimed at identifying all studies reporting musculoskeletal Ir-AE. An electronic (Medline, Scopus and Web of Science) search was performed using two sets of key words. The first set consisted of: arthritis, musculoskeletal, polymyalgia rheumatica and myositis. The second set consisted of: anti-PD-1, anti-PD-L1, anti-CTLA-4, ipilimumab, tremelimumab, pembrolizumab, nivolumab, atezolizumab, avelumab and durvalumab. We identified 3 prospective studies, 17 retrospective studies and 4 case series reporting 363 patients in total. Combined data from all three prospective studies provide a prevalence rate of 6.13%. Most patients were males (59.68%) and the vast majority (73%) were on programmed death-1 (PD-1)/programmed death ligand-1 (PD-L1) inhibitors. Most studies report a median time of ≤ 12 weeks from first ICI administration to symptom onset. The main clinical phenotypes reported were: (a) inflammatory arthritis (57.57%), (b) myositis (14.04%) and (c) polymyalgia rheumatica (PMR) (12.12%). A total of 256 patients required steroids (70.52%) and 67 patients (18.45%) were treated with DMARDs. Positive auto-antibodies and family history of any autoimmune disease were present in 18.48% and 19.04% of cases, respectively. Only a few patients (19%) had to discontinue treatment due to musculoskeletal Ir-AE. Two prospective studies show that significantly more patients with musculoskeletal Ir-AE exhibit a favorable oncologic response compared to patients not exhibiting such manifestations whereas retrospective studies show that 77.22% of patients with musculoskeletal Ir-AE have a good tumor response. One out of 15 patients treated with ICI will develop musculoskeletal Ir-AE; in most cases the severity of these manifestations is mild/moderate and usually ICI may be continued. Rheumatologists should familiarize with this new clinical entity and develop relevant therapeutic algorithms.
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Roberts J, Ennis D, Hudson M, Ye C, Saltman A, Himmel M, Rottapel R, Pope J, Hoa S, Tisseverasinghe A, Fifi-Mah A, Maltez N, Jamal S. Rheumatic immune-related adverse events associated with cancer immunotherapy: A nationwide multi-center cohort. Autoimmun Rev 2020; 19:102595. [DOI: 10.1016/j.autrev.2020.102595] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 02/23/2020] [Indexed: 12/16/2022]
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Kim ST, Murphy WA, Aparicio A, Subudhi SK. RS3PE Following Treatment With Combination of Hormonal Therapies Plus Ipilimumab in a Patient With Metastatic Prostate Cancer. JOURNAL OF IMMUNOTHERAPY AND PRECISION ONCOLOGY 2020; 3:128-132. [PMID: 35663254 DOI: 10.36401/jipo-20-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 03/16/2020] [Indexed: 11/09/2022]
Abstract
Introduction Immune checkpoint inhibitors (ICIs) are often associated with inflammatory toxicities known as immune-related adverse events (irAEs). Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) is an atypical inflammatory arthritis. Herein, we report a case of RS3PE in a patient with metastatic prostate cancer who was receiving a combination of second-generation hormonal therapies plus ipilimumab. Case Presentation A 59-year-old man with metastatic prostate cancer developed sudden onset of pain and swelling of the right hand after 15 weeks of treatment with second-generation hormonal therapies plus three cycles of ipilimumab. Symptoms alternated to the left hand. Physical examination showed tender, pitting edema of the left hand with tenderness on the right second through fifth metacarpal phalangeal joints, leading to the diagnosis of RS3PE. Ipilimumab was withheld, and the RS3PE self-resolved; however, 1 month later, the patient had another flare of RS3PE. A bone scan showed active inflammation on bilateral wrists and hands. Methotrexate was initiated, and his symptoms resolved over a few days. Methotrexate was discontinued 2 months later, and RS3PE has been in complete remission. His prostate cancer progressed, and radium-223 treatment was initiated. Conclusion To the best of our knowledge, this is the first reported case of RS3PE after the combined second-generation hormonal therapy plus ipilimumab. Both rheumatologists and oncologists should be aware that RS3PE can develop as an irAE. Understanding the mechanism of ICI therapy-associated RS3PE is critical to identify predictive biomarkers and develop optimal therapeutic strategies that do not sacrifice antitumor immunity.
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Affiliation(s)
- Sang T Kim
- Department of General Internal Medicine, Section of Rheumatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William A Murphy
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ana Aparicio
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sumit K Subudhi
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Immune checkpoint inhibitor-induced inflammatory arthritis: a qualitative study identifying unmet patient needs and care gaps. BMC Rheumatol 2020; 4:32. [PMID: 32766511 PMCID: PMC7395372 DOI: 10.1186/s41927-020-00133-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/14/2020] [Indexed: 12/12/2022] Open
Abstract
Background Patients treated for cancer with immune checkpoint inhibitors (ICI) may develop autoimmune adverse events, including ICI-induced inflammatory arthritis (IA). ICI-induced IA treatment requires balancing immune activation to fight cancer and immune modulation to control autoimmunity. Our objective was to learn how patients experience ICI-induced IA and potentially conflicting treatment decisions. Methods Semi-structured interviews were conducted with participants with rheumatologist-diagnosed ICI-induced IA recruited from a longitudinal cohort. The interview guide probed the experience of diagnosis and treatment, symptoms and impact of ICI-induced IA, coping mechanisms, and treatment decision-making. Two researchers used an iterative coding process to identify themes through inductive thematic analysis and consensus. An overarching conceptual framework was derived from the qualitative analysis to identify care gaps perceived by patients, and inform future research. Results Fourteen patients with ICI-induced IA participated in semi-structured interviews. Five overarching themes were identified: an awareness gap leading to delay in diagnosis of IA, descriptors of ICI-induced IA and relationship to other adverse events, emotional and quality-of-life impact of IA, fear and decision-making, and contextual factors including social support. Conclusions As reported by patients, ICI-induced IA had a significant functional and emotional impact, even as compared to cancer and other ICI-induced side effects. Increasing awareness and integrated care of ICI-induced IA, and increasing social support are key targets for improving patient care. Additionally, more data on cancer outcomes in patients requiring immunomodulation for ICI-induced IA would help address fear and uncertainty for patients, and better support them through therapeutic decisions.
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Immune Checkpoint Inhibition-Does It Cause Rheumatic Diseases? Mechanisms of Cancer-Associated Loss of Tolerance and Pathogenesis of Autoimmunity. Rheum Dis Clin North Am 2020; 46:587-603. [PMID: 32631606 DOI: 10.1016/j.rdc.2020.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mechanisms of immune checkpoints and their role in autoimmunity are discussed in the context of immune checkpoint inhibitor (ICI) therapy for cancer. The updated clinical spectrum of immune-related adverse events (irAEs), with an in-depth discussion of rheumatic irAEs, is presented. The relationship between ICI-induced loss of self-tolerance in cancer and the implications for understanding of irAEs, rheumatic irAEs in particular, is overviewed.
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42
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[Clinical management of rheumatic immune-related adverse events : Recognize and treat rheumatological side effects of checkpoint inhibition]. Z Rheumatol 2020; 79:545-553. [PMID: 32613268 DOI: 10.1007/s00393-020-00825-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Immune checkpoint inhibitors (ICPi) represent a major breakthrough in the treatment and prognosis of many cancers, particularly of malignant melanoma and non-small cell lung cancer; however, the high tumor response rates with ICPi are also frequently associated with autoimmune side effects, so-called immune-related adverse events (irAEs), which can involve virtually any organ system and mirror classical autoimmune diseases. Recent studies revealed that around 5-20% of patients treated with ICPi experience rheumatic irAEs covering the full spectrum of inflammatory rheumatic diseases. This article summarizes the state of the art of knowledge with respect to diagnostics and management of this newly recognized disease entity in rheumatology.
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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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Kostine M, Finckh A, Bingham CO, Visser K, Leipe J, Schulze-Koops H, Choy EH, Benesova K, Radstake TRDJ, Cope AP, Lambotte O, Gottenberg JE, Allenbach Y, Visser M, Rusthoven C, Thomasen L, Jamal S, Marabelle A, Larkin J, Haanen JBAG, Calabrese LH, Mariette X, Schaeverbeke T. EULAR points to consider for the diagnosis and management of rheumatic immune-related adverse events due to cancer immunotherapy with checkpoint inhibitors. Ann Rheum Dis 2020; 80:36-48. [PMID: 32327425 PMCID: PMC7788064 DOI: 10.1136/annrheumdis-2020-217139] [Citation(s) in RCA: 122] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/03/2020] [Accepted: 04/07/2020] [Indexed: 12/13/2022]
Abstract
Background Rheumatic and musculoskeletal immune-related adverse events (irAEs) are observed in about 10% of patients with cancer receiving checkpoint inhibitors (CPIs). Given the recent emergence of these events and the lack of guidance for rheumatologists addressing them, a European League Against Rheumatism task force was convened to harmonise expert opinion regarding their identification and management. Methods First, the group formulated research questions for a systematic literature review. Then, based on literature and using a consensus procedure, 4 overarching principles and 10 points to consider were developed. Results The overarching principles defined the role of rheumatologists in the management of irAEs, highlighting the shared decision-making process between patients, oncologists and rheumatologists. The points to consider inform rheumatologists on the wide spectrum of musculoskeletal irAEs, not fulfilling usual classification criteria of rheumatic diseases, and their differential diagnoses. Early referral and facilitated access to rheumatologist are recommended, to document the target organ inflammation. Regarding therapeutic, three treatment escalations were defined: (1) local/systemic glucocorticoids if symptoms are not controlled by symptomatic treatment, then tapered to the lowest efficient dose, (2) conventional synthetic disease-modifying antirheumatic drugs, in case of inadequate response to glucocorticoids or for steroid sparing and (3) biological disease-modifying antirheumatic drugs, for severe or refractory irAEs. A warning has been made on severe myositis, a life-threatening situation, requiring high dose of glucocorticoids and close monitoring. For patients with pre-existing rheumatic disease, baseline immunosuppressive regimen should be kept at the lowest efficient dose before starting immunotherapies. Conclusion These statements provide guidance on diagnosis and management of rheumatic irAEs and aim to support future international collaborations.
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Affiliation(s)
- Marie Kostine
- Rheumatology, University Hospital of Bordeaux, Bordeaux, France
| | - Axel Finckh
- Division of Rheumatology, University Hospital of Geneva, Geneva, Switzerland
| | | | - Karen Visser
- Rheumatology, Haga Hospital, Den Haag, The Netherlands
| | - Jan Leipe
- Department of Medicine V, Division of Rheumatology, University Hospital Centre, Mannheim, Germany.,Department of Internal Medicine IV, Division of Rheumatology and Clinical Immunology, University of Munich, Munich, Germany
| | - Hendrik Schulze-Koops
- Department of Internal Medicine IV, Division of Rheumatology and Clinical Immunology, University of Munich, Munich, Germany
| | - Ernest H Choy
- Institute of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK
| | | | | | - Andrew P Cope
- Academic Department of Rheumatology, King's College London, London, UK
| | - Olivier Lambotte
- Internal Medicine and Clinical Immunology, Hopital Bicetre, Le Kremlin-Bicetre, France
| | | | - Yves Allenbach
- Internal Medicine and Clinical Immunology, Sorbonne Université, Pitié-Salpêtrière University Hospital, Paris, France
| | - Marianne Visser
- EULAR PARE Patient Research Partners, Amsterdam, The Netherlands
| | - Cindy Rusthoven
- EULAR PARE Patient Research Partners, Amsterdam, The Netherlands
| | | | - Shahin Jamal
- Rheumatology, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - James Larkin
- Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - John B A G Haanen
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, The Netherlands
| | | | - Xavier Mariette
- Rheumatology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux universitaires Paris-Sud - Hôpital Bicêtre, Le Kremlin Bicêtre, France.,3Université Paris-Sud, Center for Immunology of Viral Infections and Auto-immune Diseases (IMVA), Institut pour la Santé et la Recherche Médicale (INSERM) UMR 1184, Université Paris-Saclay, Le Kremlin Bicêtre, France
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45
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Steven NM, Fisher BA. Management of rheumatic complications of immune checkpoint inhibitor therapy - an oncological perspective. Rheumatology (Oxford) 2020; 58:vii29-vii39. [PMID: 31816079 PMCID: PMC6900910 DOI: 10.1093/rheumatology/kez536] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 09/30/2019] [Indexed: 02/06/2023] Open
Abstract
Immune checkpoint inhibitors (CPIs) are an effective treatment for many cancers but cause diverse immune-related adverse events (IrAEs). Rheumatological IrAEs include arthralgia, arthritis, tenosynovitis, myositis, polymyalgia rheumatica and sicca syndrome. CPI use can unmask RA as well as causing flares of prior autoimmune or connective tissue disease. Oncologists categorize and grade IrAEs using the Common Terminology Criteria for Adverse Events and manage them according to international guidelines. However, rheumatological events are unfamiliar territory: oncologists need to work with rheumatologists to elicit and assess symptoms, signs, results of imaging and autoantibody testing and to determine the use of steroids and DMARDs. Myositis may overlap with myasthenic crisis and myocarditis and can be life-threatening. Treatment should be offered on balance of risk and benefit, including whether to continue CPI treatment and recognizing the uncertainty over whether glucocorticoids and DMARDs might compromise cancer control.
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Affiliation(s)
- Neil M Steven
- Institute of Immunology and Immunotherapy, Birmingham, UK.,Cancer Centre, University Hospital Birmingham, Birmingham, UK
| | - Benjamin A Fisher
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,National Institute of Health Research Birmingham Biomedical Research Centre and Department of Rheumatology, University Hospital Birmingham, Birmingham, UK
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46
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Kostine M, Truchetet ME, Schaeverbeke T. Clinical characteristics of rheumatic syndromes associated with checkpoint inhibitors therapy. Rheumatology (Oxford) 2020; 58:vii68-vii74. [PMID: 31816082 PMCID: PMC6900916 DOI: 10.1093/rheumatology/kez295] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/31/2019] [Indexed: 12/21/2022] Open
Abstract
Compared with conventional cancer therapies, the spectrum of toxicities observed with checkpoint inhibitors is unique and can affect any organ system. Arthralgia and myalgia were by far the most commonly reported rheumatic immune-related adverse events in clinical trials, and there is now a growing number of case series and reports describing clinical features of de novo rheumatic immune-related adverse events, which will be the focus of this review. Some patients develop genuine classic rheumatic and musculoskeletal diseases, but a number of rheumatic immune-related adverse events mimic rheumatic and musculoskeletal diseases with atypical features, mainly polymyalgia rheumatica, rheumatoid arthritis and myositis, as well as several systemic conditions, including sicca syndrome, vasculitis, sarcoidosis, systemic sclerosis and lupus.
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Affiliation(s)
- Marie Kostine
- Department of Rheumatology, Bordeaux University Hospital, Bordeaux, France
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47
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Leipe J, Mariette X. Management of rheumatic complications of ICI therapy: a rheumatology viewpoint. Rheumatology (Oxford) 2020; 58:vii49-vii58. [PMID: 31816078 PMCID: PMC6900914 DOI: 10.1093/rheumatology/kez360] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/05/2019] [Indexed: 12/13/2022] Open
Abstract
Since immune checkpoint inhibitors became the standard of care for an increasing number of indications, more patients have been exposed to these drugs and physicians are more challenged with the management of a unique spectrum of immune-related adverse events (irAEs) associated with immune checkpoint inhibitors. Those irAEs of autoimmune or autoinflammatory origin, or both, can involve any organ or tissue, but most commonly affect the dermatological, gastrointestinal and endocrine systems. Rheumatic/systemic irAEs seem to be less frequent (although underreporting in clinical trials is probable), but information on their management is highly relevant given that they can persist longer than other irAEs. Their management consists of anti-inflammatory treatment including glucocorticoids, synthetic and biologic immunomodulatory/immunosuppressive drugs, symptomatic therapies as well as holding or, rarely, discontinuation of immune checkpoint inhibitors. Here, we summarize the management of rheumatic/systemic irAEs based on data from clinical trials but mainly from published case reports and series, contextualize them and propose perspectives for their treatment.
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Affiliation(s)
- Jan Leipe
- Department of Medicine V, Division of Rheumatology, University Medical Centre, Mannheim, Munich, Germany.,Department of Internal Medicine IV, Division of Rheumatology and Clinical Immunology, University of Munich, Munich, Germany
| | - Xavier Mariette
- Department of Rheumatology, Université Paris-Sud, AP-HP, Hôpitaux Universitaires Paris-Sud, Centre for Immunology of Viral Infections and Autoimmune Diseases, INSERM UMR1184, Le Kremlin Bicêtre, France
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48
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Cappelli LC, Thomas MA, Bingham CO, Shah AA, Darrah E. Immune checkpoint inhibitor-induced inflammatory arthritis as a model of autoimmune arthritis. Immunol Rev 2020; 294:106-123. [PMID: 31930524 PMCID: PMC7047521 DOI: 10.1111/imr.12832] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/04/2019] [Indexed: 02/06/2023]
Abstract
The development of inflammatory arthritis in patients receiving immune checkpoint inhibitor therapy is increasingly recognized due to the growing use of these drugs for the treatment of cancer. This represents an important opportunity not only to define the mechanisms responsible for the development of this immune-related adverse event and to ultimately predict or prevent its development, but also to provide a unique window into early events in the development of inflammatory arthritis. Knowledge gained through the study of this patient population, for which the inciting event is known, could shed light into the pathogenesis of autoimmune arthritis. This review will highlight the clinical and immunologic features of these entities to define common elements for future study.
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Affiliation(s)
- Laura C. Cappelli
- Johns Hopkins School of Medicine, Division of Rheumatology, Baltimore, MD, USA
| | - Mekha A. Thomas
- Johns Hopkins School of Medicine, Division of Rheumatology, Baltimore, MD, USA
| | - Clifton O. Bingham
- Johns Hopkins School of Medicine, Division of Rheumatology, Baltimore, MD, USA
| | - Ami A. Shah
- Johns Hopkins School of Medicine, Division of Rheumatology, Baltimore, MD, USA
| | - Erika Darrah
- Johns Hopkins School of Medicine, Division of Rheumatology, Baltimore, MD, USA
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49
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Calabrese L, Mariette X. Chronic inflammatory arthritis following checkpoint inhibitor therapy for cancer: game changing implications. Ann Rheum Dis 2020; 79:309-311. [DOI: 10.1136/annrheumdis-2019-216510] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/14/2019] [Accepted: 12/16/2019] [Indexed: 12/16/2022]
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50
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Abdel-Wahab N, Suarez-Almazor ME. Frequency and distribution of various rheumatic disorders associated with checkpoint inhibitor therapy. Rheumatology (Oxford) 2019; 58:vii40-vii48. [PMID: 31816084 PMCID: PMC6900912 DOI: 10.1093/rheumatology/kez297] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/17/2019] [Indexed: 12/20/2022] Open
Abstract
Immune checkpoint inhibitors have advanced the treatment paradigm of various cancers, achieving remarkable survival benefits. However, a myriad of immune-related adverse events (irAE) has been recognized in almost every organ system, presumably because of persistent immune system activation. Rheumatic symptoms such as arthralgia or myalgia are very common. More specific irAE are increasingly being reported. The most frequent ones are inflammatory arthritis, polymyalgia-like syndromes, myositis and sicca manifestations. These rheumatic irAE can develop in ∼5-10% of patients treated with immune checkpoint inhibitors, although true incidence rates cannot be estimated given the lack of prospective cohort studies, and likely underreporting of rheumatic irAE in oncology trials. In this review, we will provide a summary of the epidemiologic data reported for these rheumatic irAE, until more robust prospective longitudinal studies become available to further define the true incidence rate of rheumatic irAE in patients receiving these novel cancer therapies.
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Affiliation(s)
- Noha Abdel-Wahab
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Rheumatology and Rehabilitation, Faculty of Medicine, Assiut University Hospitals, Assiut, Egypt
| | - Maria E Suarez-Almazor
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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