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Dinoto A, Trentinaglia M, Carta S, Mantovani E, Ferrari S, Tamburin S, Tinazzi M, Mariotto S. Autoimmune Movement Disorders Complicating Treatment with Immune Checkpoint Inhibitors. Mov Disord Clin Pract 2024; 11:543-549. [PMID: 38400610 PMCID: PMC11078485 DOI: 10.1002/mdc3.14003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/05/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) may trigger autoimmune neurological conditions, including movement disorders (MD). OBJECTIVES The aim of this study was to characterize MDs occurring as immune-related adverse events (irAEs) of ICIs. METHODS A systematic literature review of case reports/series of MDs as irAEs of ICIs was performed. RESULTS Of 5682 eligible papers, 26 articles with 28 patients were included. MDs occur as a rare complication of cancer immunotherapy with heterogeneous clinical presentations and in most cases in association with other irAEs. Inflammatory basal ganglia T2/fluid attenuated inversion recovery abnormalities are rarely observed, but brain imaging is frequently unrevealing. Cerebrospinal fluid findings are frequently suggestive of inflammation. Half of cases are associated with a wide range of autoantibodies. Steroids and ICI withdrawal usually lead to improvement, even though some patients experienced relapses or a severe clinical course. CONCLUSION MDs are a rare complication of ICIs that should be promptly recognized to offer patients a correct diagnosis and treatment.
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Affiliation(s)
- Alessandro Dinoto
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
| | - Milena Trentinaglia
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
| | - Sara Carta
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
| | - Elisa Mantovani
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
| | - Sergio Ferrari
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
| | - Stefano Tamburin
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
| | - Michele Tinazzi
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
| | - Sara Mariotto
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
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2
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Zammit F, Seront E. Neurological Adverse Events Related to Immune Checkpoint Inhibitors: A Practical Review. Pharmaceuticals (Basel) 2024; 17:501. [PMID: 38675461 PMCID: PMC11053462 DOI: 10.3390/ph17040501] [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: 03/05/2024] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
The increasing use of immune checkpoint inhibitors (ICI) in cancer therapy has brought attention to their associated neurotoxicities, termed neurological immune-related adverse events (n-irAEs). Despite their relatively rare incidence, n-irAEs pose a significant risk, potentially leading to severe, long-lasting disabilities or even fatal outcomes. This narrative review aims to provide a comprehensive overview of n-irAEs, focusing on their recognition and management. The review addresses a spectrum of n-irAEs, encompassing myositis, myasthenia gravis, various neuropathies, and central nervous system complications, such as encephalitis, meningitis, and demyelinating diseases. The key features of n-irAEs are emphasized in this review, including their early onset after initiation of ICIs, potential association with non-neurological irAEs and/or concurrent oncological response, the significance of ruling out other etiologies, and the expected improvement upon discontinuation of ICIs and/or immunosuppression. Furthermore, this review delves into considerations for ICI re-challenge and the intricate nature of n-irAEs within the context of pre-existing autoimmune and paraneoplastic syndromes. It underscores the importance of a multidisciplinary approach to diagnosis and treatment, highlighting the pivotal role of severity grading in guiding treatment decisions.
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Affiliation(s)
| | - Emmanuel Seront
- Institut Roi Albert II, Department of Medical Oncology, Cliniques Universitaires Saint Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium;
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3
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Alsalem AN, Scarffe LA, Briemberg HR, Aaroe AE, Harrison RA. Neurologic Complications of Cancer Immunotherapy. Curr Oncol 2023; 30:5876-5897. [PMID: 37366923 DOI: 10.3390/curroncol30060440] [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: 05/05/2023] [Revised: 06/07/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023] Open
Abstract
Immunotherapy has revolutionized cancer treatment over the past decade. As it is increasingly introduced into routine clinical practice, immune-related complications have become more frequent. Accurate diagnosis and treatment are essential, with the goal of reduced patient morbidity. This review aims to discuss the various clinical manifestations, diagnosis, treatments, and prognosis of neurologic complications associated with the use of immune checkpoint inhibitors, adoptive T-cell therapies, and T-cell redirecting therapies. We also outline a suggested clinical approach related to the clinical use of these agents.
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Affiliation(s)
- Aseel N Alsalem
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
| | - Leslie A Scarffe
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
| | - Hannah R Briemberg
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
| | - Ashley E Aaroe
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Rebecca A Harrison
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
- Division of Medical Oncology, BC Cancer, University of British Columbia, Vancouver, BC V5Z 4E6, Canada
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4
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Pinal-Fernandez I, Quintana A, Milisenda JC, Casal-Dominguez M, Muñoz-Braceras S, Derfoul A, Torres-Ruiz J, Pak K, Dell'Orso S, Naz F, Gutierrez-Cruz G, Milone M, Shelly S, Duque-Jaimez Y, Tobias-Baraja E, Matas-Garcia A, Garrabou G, Padrosa J, Ros J, Trallero-Araguás E, Walitt B, Christopher-Stine L, Lloyd TE, Zhao C, Swift S, Rajan A, Grau-Junyent JM, Selva-O'Callaghan A, Liewluck T, Mammen AL. Transcriptomic profiling reveals distinct subsets of immune checkpoint inhibitor induced myositis. Ann Rheum Dis 2023; 82:829-836. [PMID: 36801811 PMCID: PMC10545139 DOI: 10.1136/ard-2022-223792] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/08/2023] [Indexed: 02/19/2023]
Abstract
OBJECTIVES Inflammatory myopathy or myositis is a heterogeneous family of immune-mediated diseases including dermatomyositis (DM), antisynthetase syndrome (AS), immune-mediated necrotising myopathy (IMNM) and inclusion body myositis (IBM). Immune checkpoint inhibitors (ICIs) can also cause myositis (ICI-myositis). This study was designed to define gene expression patterns in muscle biopsies from patients with ICI-myositis. METHODS Bulk RNA sequencing was performed on 200 muscle biopsies (35 ICI-myositis, 44 DM, 18 AS, 54 IMNM, 16 IBM and 33 normal muscle biopsies) and single nuclei RNA sequencing was performed on 22 muscle biopsies (seven ICI-myositis, four DM, three AS, six IMNM and two IBM). RESULTS Unsupervised clustering defined three distinct transcriptomic subsets of ICI-myositis: ICI-DM, ICI-MYO1 and ICI-MYO2. ICI-DM included patients with DM and anti-TIF1γ autoantibodies who, like DM patients, overexpressed type 1 interferon-inducible genes. ICI-MYO1 patients had highly inflammatory muscle biopsies and included all patients that developed coexisting myocarditis. ICI-MYO2 was composed of patients with predominant necrotising pathology and low levels of muscle inflammation. The type 2 interferon pathway was activated both in ICI-DM and ICI-MYO1. Unlike the other types of myositis, all three subsets of ICI-myositis patients overexpressed genes involved in the IL6 pathway. CONCLUSIONS We identified three distinct types of ICI-myositis based on transcriptomic analyses. The IL6 pathway was overexpressed in all groups, the type I interferon pathway activation was specific for ICI-DM, the type 2 IFN pathway was overexpressed in both ICI-DM and ICI-MYO1 and only ICI-MYO1 patients developed myocarditis.
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Affiliation(s)
- Iago Pinal-Fernandez
- Muscle Disease Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Angela Quintana
- Muscle Disease Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
- Systemic Autoimmune Disease Unit, Vall d'Hebron Research Institute, Barcelona, Catalunya, Spain
| | - Jose Cesar Milisenda
- Muscle Disease Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
- Muscle Research Unit, Internal Medicine Service, Hospital Clinic, Barcelona, Catalunya, Spain
- CIBERER, IDIBAPS and University of Barcelona, Barcelona, Catalunya, Spain
| | - Maria Casal-Dominguez
- Muscle Disease Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sandra Muñoz-Braceras
- Muscle Disease Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
| | - Assia Derfoul
- Muscle Disease Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
| | - Jiram Torres-Ruiz
- Muscle Disease Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico city, Mexico
| | - Katherine Pak
- Muscle Disease Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
| | - Stefania Dell'Orso
- Muscle Disease Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
| | - Faiza Naz
- Muscle Disease Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
| | - Gustavo Gutierrez-Cruz
- Muscle Disease Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
| | - Margherita Milone
- Division of Neuromuscular Medicine, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shahar Shelly
- Department of Neurology, Rambam Health Care Campus, Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel, Haifa, Israel
| | - Yaiza Duque-Jaimez
- Muscle Research Unit, Internal Medicine Service, Hospital Clinic, Barcelona, Catalunya, Spain
| | - Ester Tobias-Baraja
- Muscle Research Unit, Internal Medicine Service, Hospital Clinic, Barcelona, Catalunya, Spain
| | - Ana Matas-Garcia
- Muscle Research Unit, Internal Medicine Service, Hospital Clinic, Barcelona, Catalunya, Spain
- CIBERER, IDIBAPS and University of Barcelona, Barcelona, Catalunya, Spain
| | - Gloria Garrabou
- Muscle Research Unit, Internal Medicine Service, Hospital Clinic, Barcelona, Catalunya, Spain
- CIBERER, IDIBAPS and University of Barcelona, Barcelona, Catalunya, Spain
| | - Joan Padrosa
- CIBERER, IDIBAPS and University of Barcelona, Barcelona, Catalunya, Spain
| | - Javier Ros
- Medical Oncology, Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
| | | | - Brian Walitt
- National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Lisa Christopher-Stine
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas E Lloyd
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Chen Zhao
- Thoracic and Gastrointestinal Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Shannon Swift
- Thoracic and Gastrointestinal Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Arun Rajan
- Thoracic and Gastrointestinal Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Josep Maria Grau-Junyent
- Muscle Research Unit, Internal Medicine Service, Hospital Clinic, Barcelona, Catalunya, Spain
- CIBERER, IDIBAPS and University of Barcelona, Barcelona, Catalunya, Spain
| | - Albert Selva-O'Callaghan
- Systemic Autoimmune Disease Unit, Vall d'Hebron Research Institute, Barcelona, Catalunya, Spain
- Universitat Autonoma de Barcelona, Barcelona, Catalunya, Spain
| | - Teerin Liewluck
- Division of Neuromuscular Medicine, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew Lee Mammen
- Muscle Disease Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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5
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Bompaire F, Birzu C, Bihan K, Desestret V, Fargeot G, Farina A, Joubert B, Leclercq D, Nichelli L, Picca A, Tafani C, Weiss N, Psimaras D, Ricard D. Advances in treatments of patients with classical and emergent neurological toxicities of anticancer agents. Rev Neurol (Paris) 2023; 179:405-416. [PMID: 37059646 DOI: 10.1016/j.neurol.2023.03.015] [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: 03/09/2023] [Revised: 03/18/2023] [Accepted: 03/21/2023] [Indexed: 04/16/2023]
Abstract
The neurotoxicity associated to the anticancer treatments has received a growing body of interest in the recent years. The development of innovating therapies over the last 20years has led to the emergence of new toxicities. Their diagnosis and management can be challenging in the clinical practice and further research is warranted to improve the understanding of their pathogenic mechanisms. Conventional treatments as radiation therapy and chemotherapy are associated to well-known and under exploration emerging central nervous system (CNS) and peripheral nervous system (PNS) toxicities. The identification of the risk factors and a better understanding of their pathogeny through a "bench to bedside and back again" approach, are the first steps towards the development of toxicity mitigation strategies. New imaging techniques and biological explorations are invaluable for their diagnosis. Immunotherapies have changed the cancer treatment paradigm from tumor cell centered to immune modulation towards an efficient anticancer immune response. The use of the immune checkpoints inhibitors (ICI) and chimeric antigen receptor (CAR-T cells) lead to an increase in the incidence of immune-mediated toxicities and new challenges in the neurological patient's management. The neurological ICI-related adverse events (n-irAE) are rare but potentially severe and may present with both CNS and PNS involvement. The most frequent and well characterized, from a clinical and biological standpoint, are the PNS phenotypes: myositis and polyradiculoneuropathy, but the knowledge on CNS phenotypes and their treatments is expanding. The n-irAE management requires a good balance between dampening the autoimmune toxicity without impairing the anticancer immunity. The adoptive cell therapies as CAR-T cells, a promising anticancer strategy, trigger cellular activation and massive production of proinflammatory cytokines inducing frequent and sometime severe toxicity known as cytokine release syndrome and immune effector cell-associated neurologic syndrome. Their management requires a close partnership between oncologist-hematologists, neurologists, and intensivists. The oncological patient's management requires a multidisciplinary clinical team (oncologist, neurologist and paramedical) as well as a research team leading towards a better understanding and a better management of the neurological toxicities.
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Affiliation(s)
- Flavie Bompaire
- Service de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France; UMR 9010 Centre Borelli, Université Paris-Saclay, École Normale Supérieure Paris-Saclay, CNRS, Service de Santé des Armées, Université Paris Cité, Inserm, Saclay, France; OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France
| | - Cristina Birzu
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Service de Neurologie 2-Mazarin, Sorbonne Université, Paris, France
| | - Kevin Bihan
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; AP-HP, Service de Pharmacologie, Centre Régional de Pharmacovigilance, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Inserm, CIC-1901, Sorbonne Universités, Paris, France
| | - Virginie Desestret
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Service de Neurocognition et Neuro-ophtalmologie, Hospices Civils de Lyon, Hôpital Neurologique Pierre-Wertheimer, Lyon, France; Centre de Référence Maladies Rares pour les Syndromes Neurologiques Paranéoplasiques et les Encéphalites Auto-Immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL-CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France
| | - Guillaume Fargeot
- AP-HP, Service de Neurologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Antonio Farina
- Centre de Référence Maladies Rares pour les Syndromes Neurologiques Paranéoplasiques et les Encéphalites Auto-Immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL-CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France; Service de Neurologie, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Bastien Joubert
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Centre de Référence Maladies Rares pour les Syndromes Neurologiques Paranéoplasiques et les Encéphalites Auto-Immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL-CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France; Service de Neurologie, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Delphine Leclercq
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; AP-HP, Service de Neuroradiologie, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Sorbonne Universités, Paris, France
| | - Lucia Nichelli
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; AP-HP, Service de Neuroradiologie, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Sorbonne Universités, Paris, France
| | - Alberto Picca
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Service de Neurologie 2-Mazarin, Sorbonne Université, Paris, France
| | - Camille Tafani
- Service de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France; OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France
| | - Nicolas Weiss
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Dipartimento di Neuroscienze, Psicologia, Area del Farmaco e Salute del Bambino. Università di Firenze, Firenze, Italy; AP-HP, Service de Soins Intensifs en Neurologie, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Sorbonne Universités, Paris, France; École du Val-de-Grâce, Service de Santé des Armées, Paris, France
| | - Dimitri Psimaras
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Service de Neurologie 2-Mazarin, Sorbonne Université, Paris, France
| | - Damien Ricard
- Service de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France; UMR 9010 Centre Borelli, Université Paris-Saclay, École Normale Supérieure Paris-Saclay, CNRS, Service de Santé des Armées, Université Paris Cité, Inserm, Saclay, France; OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; École du Val-de-Grâce, Service de Santé des Armées, Paris, France.
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6
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Grümme L, Schulze-Koops H. [Rheumatological side effects of checkpoint inhibitors and their treatment]. Z Rheumatol 2023; 82:187-194. [PMID: 36607420 DOI: 10.1007/s00393-022-01311-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 01/07/2023]
Abstract
The spectrum of tumors for which checkpoint inhibitor (CI) treatment is used is constantly expanding. The European Medicines Agency has currently approved nine CIs: one anti-cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) CI, one anti-lymphocyte activation gene 3 (LAG-3) CI, four anti-programmed cell death protein 1 (PD-1) CIs and three anti-programmed death ligand 1 (PD-L1) CIs. By blocking immune checkpoints the physiological downregulation of T cell activity against autologous tissue is prevented. This results in an immunologically unregulated activation of T cells directed against malignant cells. Healthy tissue also expresses antigens and thereby continuously activates autologous T cells. Thus, the blockade of immune checkpoints can lead to T cell activity against healthy tissue (immune-related adverse events, irAE). The irAEs can occur in any organ system and approximately 10% of all patients under CI treatment develop rheumatological irAEs, mostly arthralgia and myalgia. The classification criteria of rheumatological diseases do not need to be met to initiate treatment and the primary goal of treatment of irAEs is to enable continuation of CI treatment. Rheumatological irAEs should be recognized and treated quickly. In the treatment of musculoskeletal irAEs, three stages can be defined. In the first stage, nonsteroidal anti-inflammatory drugs or intra-articular as well as systemic glucocorticoids are used. In the second stage, conventional synthetic and in the third stage, biologic disease-modifying antirheumatic drugs are used. The most severe musculoskeletal irAE is myositis with cardiac and/or respiratory involvement and/or myasthenia gravis. In addition to high-dose glucocorticoids, intravenous immunoglobulins or plasma exchange are used in treatment.
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Affiliation(s)
- Lea Grümme
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, LMU Klinikum München, Pettenkoferstr. 8a, 80336, München, Deutschland.
| | - Hendrik Schulze-Koops
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, LMU Klinikum München, Pettenkoferstr. 8a, 80336, München, Deutschland.
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7
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Onwuemene OA, Nnoruka CI, Patriquin CJ, Connelly-Smith LS. Therapeutic plasma exchange in the management of immune checkpoint inhibitor-associated immune-related adverse effects: A review. Transfusion 2022; 62:2370-2390. [PMID: 36134464 DOI: 10.1111/trf.17114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/31/2022] [Accepted: 08/31/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Oluwatoyosi A Onwuemene
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Chizoba I Nnoruka
- Division of Hematology/Oncology, Sibley Memorial Hospital, Sibley Memorial Hospital John Hopkins University, Washington, DC, USA
| | - Christopher J Patriquin
- Department of Medicine, Division of Medical Oncology & Hematology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Laura S Connelly-Smith
- Department of Medicine, University of Washington and Fred Hutchinson Cancer Center, Seattle, Washington, USA
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8
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Manenti S, Orrico M, Masciocchi S, Mandelli A, Finardi A, Furlan R. PD-1/PD-L Axis in Neuroinflammation: New Insights. Front Neurol 2022; 13:877936. [PMID: 35756927 PMCID: PMC9222696 DOI: 10.3389/fneur.2022.877936] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/29/2022] [Indexed: 12/27/2022] Open
Abstract
The approval of immune checkpoint inhibitors (ICIs) by the Food and Drug Administration (FDA) led to an improvement in the treatment of several types of cancer. The main targets of these drugs are cytotoxic T-lymphocyte antigen 4 (CTLA-4) and programmed cell death protein-1/programmed death-ligand 1 pathway (PD-1/PD-L1), which are important inhibitory molecules for the immune system. Besides being generally safer than common chemotherapy, the use of ICIs has been associated with several immune-related adverse effects (irAEs). Although rare, neurological adverse effects are reported within the irAEs in clinical trials, particularly in patients treated with anti-PD-1 antibodies or a combination of both anti-CTLA-4 and PD-1 drugs. The observations obtained from clinical trials suggest that the PD-1 axis may play a remarkable role in the regulation of neuroinflammation. Moreover, numerous studies in preclinical models have demonstrated the involvement of PD-1 in several neurological disorders. However, a comprehensive understanding of these cellular mechanisms remains elusive. Our review aims to summarize the most recent evidence concerning the regulation of neuroinflammation through PD-1/PD-L signaling, focusing on cell populations that are involved in this pathway.
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Affiliation(s)
- Susanna Manenti
- Clinical Neuroimmunology Unit, Division of Neuroscience, Institute of Experimental Neurology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Mario Orrico
- Clinical Neuroimmunology Unit, Division of Neuroscience, Institute of Experimental Neurology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Stefano Masciocchi
- Neuroimmunology Laboratory and Research Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Alessandra Mandelli
- Clinical Neuroimmunology Unit, Division of Neuroscience, Institute of Experimental Neurology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Annamaria Finardi
- Clinical Neuroimmunology Unit, Division of Neuroscience, Institute of Experimental Neurology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Roberto Furlan
- Clinical Neuroimmunology Unit, Division of Neuroscience, Institute of Experimental Neurology, IRCCS Ospedale San Raffaele, Milan, Italy
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Mechanism and Management of Checkpoint Inhibitor-Related Toxicities in Genitourinary Cancers. Cancers (Basel) 2022; 14:cancers14102460. [PMID: 35626064 PMCID: PMC9139183 DOI: 10.3390/cancers14102460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 05/06/2022] [Accepted: 05/11/2022] [Indexed: 12/10/2022] Open
Abstract
The use of immune checkpoint inhibitors (ICIs) is rapidly increasing as more combinations and clinical indications are approved in the field of genitourinary malignancies. Most immunotherapeutic agents being approved are for the treatment of renal cell carcinoma and bladder cancer, which mainly involve PD-1/PD-L1 and CTLA-4 pathways. There is an ongoing need for recognizing and treating immunotherapy-related autoimmune adverse effects (irAEs). This review aims to critically appraise the recent literature on the mechanism, common patterns, and treatment recommendations of irAEs in genitourinary malignancies. We review the epidemiology of these adverse effects as well as general treatment strategies. The underlying mechanisms will also be discussed. Diagnostic considerations including differential diagnosis are also included in this review.
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10
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Nebenwirkungsmanagement immunonkologischer Therapien – was gibt es zu beachten? DER GYNÄKOLOGE 2022; 55:344-350. [PMID: 35494537 PMCID: PMC9041287 DOI: 10.1007/s00129-022-04941-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 12/02/2022]
Abstract
Die immunonkologischen Therapieprinzipien haben unterschiedliche Nebenwirkungsspektren. Neben den akuten therapiebedingten unerwünschten Ereignissen („adverse events“, AE), die bisweilen zu Therapieabbrüchen führen, gibt es AE, die mit einer zeitlichen Latenz, auch lange nach Absetzen der Immunonkologika, auftreten können, etwa autoimmune Reaktionen. Ein Monitoring dieser „immune-related adverse events“ (irAE) ist essenziell. Entscheidend ist es, den Schweregrad möglicher AE abzuschätzen und zu graduieren und andererseits Differenzialdiagnosen in Betracht zu ziehen und auszuschließen. Anhand des mittels der Common Terminology Criteria for Adverse Events Skala graduierten Schweregrads von AE erfolgen ggf. klinisch-therapeutische Reaktionen und Konsequenzen.
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11
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Shi J, Tan Y, Huang Y, Li K, Yan J, Guan Y, Zhang L. Association Between Clinical Factors and Result of Immune Checkpoint Inhibitor Related Myasthenia Gravis: A Single Center Experience and Systematic Review. Front Neurol 2022; 13:858628. [PMID: 35463153 PMCID: PMC9022009 DOI: 10.3389/fneur.2022.858628] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/15/2022] [Indexed: 01/20/2023] Open
Abstract
Background Neurological immune-related adverse events (nirAEs) are rare toxicities of immune-checkpoint inhibitors (ICI). With the increase use of ICIs, incidence of nirAEs is growing, among which ICI related MG (irMG) is causing high fatality rate. Given the limited evidence, data from a large cohort of patients with irMG is needed to aid in recognition and management of this fatal complication. Objective This study aimed to summarize clinical characteristics of irMG and explore predictors of irMG clinical outcome. Methods We summarized our institution's patients who were diagnosed as irMG between Sep 2019 and Oct 2021. We systematically reviewed the literature through Oct 2021 to identify all similar reported patients who met inclusion criteria. As the control group, patients with idiopathic MG were used. We collected data on clinical features, management, and outcomes of both irMG and idioMG cases. Further statistical analysis was conducted. Results Sixty three irMG patients and 380 idioMG patients were included in the final analysis. For irMG patients, six were from our institution while the rest 57 were from reported cases. The average age of irMG patients is 70.16 years old. Forty three were male. Average time from first ICI injection to symptom onset was 5.500 weeks. Eleven patients had a past history of MG. Higher MGFA classification and higher QMGS rates were observed in irMG patients compared to idioMG patients. For complication, more irMG patients had myositis or myocarditis overlapping compared to idioMG patients. The most commonly used treatment was corticosteroids for both idioMG and irMG. Twenty one patients (35%) with irMG had unfavorable disease outcome. Single variate and multivariate binary logistic regression proved that association with myocarditis, high MGFA classification or QMGS rates at first visit were negatively related to disease outcome in irMG patients. Conclusion irMG is a life-threatening adverse event. irMG has unique clinical manifestations and clinical outcome compared to idioMG. When suspicious, early evaluation of MGFA classification, QMGS rates and myositis/myocarditis evaluation are recommended.
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Affiliation(s)
- Jiayu Shi
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ying Tan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yangyu Huang
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ke Li
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jingwen Yan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuzhou Guan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Yuzhou Guan
| | - Li Zhang
- Department of Respiratory and Critical Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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12
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Shalabi H, Nellan A, Shah NN, Gust J. Immunotherapy Associated Neurotoxicity in Pediatric Oncology. Front Oncol 2022; 12:836452. [PMID: 35265526 PMCID: PMC8899040 DOI: 10.3389/fonc.2022.836452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/20/2022] [Indexed: 11/30/2022] Open
Abstract
Novel immunotherapies are increasingly being employed in pediatric oncology, both in the upfront and relapsed/refractory settings. Through various mechanisms of action, engagement and activation of the immune system can cause both generalized and disease site-specific inflammation, leading to immune-related adverse events (irAEs). One of the most worrisome irAEs is that of neurotoxicity. This can present as a large spectrum of neurological toxicities, including confusion, aphasia, neuropathies, seizures, and/or death, with variable onset and severity. Earlier identification and treatment, generally with corticosteroids, remains the mainstay of neurotoxicity management to optimize patient outcomes. The pathophysiology of neurotoxicity varies across the different therapeutic strategies and remains to be elucidated in most cases. Furthermore, little is known about long-term neurologic sequelae. This review will focus on neurotoxicity seen with the most common immunotherapies used in pediatric oncology, including CAR T cell therapy, alternative forms of adoptive cell therapy, antibody therapies, immune checkpoint inhibitors, and tumor vaccines. Herein we will discuss the incidence, pathophysiology, symptomatology, diagnosis, and management strategies currently being utilized for immunotherapy-associated neurotoxicity with a focus on pediatric specific considerations.
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Affiliation(s)
- Haneen Shalabi
- National Cancer Institute, Pediatric Oncology Branch, National Institutes of Health, Bethesda, MD, United States
| | - Anandani Nellan
- National Cancer Institute, Pediatric Oncology Branch, National Institutes of Health, Bethesda, MD, United States
| | - Nirali N Shah
- National Cancer Institute, Pediatric Oncology Branch, National Institutes of Health, Bethesda, MD, United States
| | - Juliane Gust
- Seattle Children's Research Institute, Seattle, WA, United States.,Department of Neurology, University of Washington, Seattle, WA, United States
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Fatal myositis and myasthenia induced by atezolizumab for the treatment of hepatocellular carcinoma. Clin Res Hepatol Gastroenterol 2022; 46:101854. [PMID: 34936927 DOI: 10.1016/j.clinre.2021.101854] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 02/04/2023]
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