Severe inflammatory ileitis resulting in ileal perforation in association with combination immune checkpoint blockade for metastatic malignant melanoma

Management of liver and gastrointestinal toxicity induced by immune checkpoint inhibitors: Position statement of the AEEH-AEG-SEPD-SEOM-GETECCU

The development of the immune checkpoint inhibitors (ICI) is one of the most remarkable achievements in cancer therapy in recent years. However, their exponential use has led to an increase in immune-related adverse events (irAEs). Gastrointestinal and liver events encompass hepatitis, colitis and upper digestive tract symptoms accounting for the most common irAEs, with incidence rates varying from 2 % to 40 %, the latter in patients undergoing combined ICIs therapy. Based on the current scientific evidence derived from both randomized clinical trials and real-world studies, this statement document provides recommendations on the diagnosis, treatment and prognosis of the gastrointestinal and hepatic ICI-induced adverse events.

Adverse Effects of Immune-Checkpoint Inhibitors: A Comprehensive Imaging-Oriented Review

Immune-checkpoint inhibitors (ICIs) are immunomodulatory monoclonal antibodies, which increase antitumor immunity of the host and facilitate T-cell-mediated actions against tumors. These medications have been used in recent years as a weapon against advanced stage malignancies, such as melanoma, renal cell carcinoma, lymphoma, small or non-small cell lung cancer, and colorectal cancer. Unfortunately, they are not free from possible adverse effects (immune-related adverse events-irAEs) that mainly affect skin, gastrointestinal, hepatic, and endocrine systems. Early diagnosis of irAEs is essential to correctly and rapidly manage patients, with ICIs suspension and therapies administration. Deep knowledge of the imaging and clinical patterns of irAEs is the key to promptly rule out other diagnoses. Here, we performed a review of the radiological signs and differential diagnosis, based on the organ involved. The aim of this review is to provide guidance to recognize the most significant radiological findings of the main irAEs, based on incidence, severity, and the role of imaging.

Emerging Management Approach for the Adverse Events of Immunotherapy of Cancer

Immunotherapy, which stimulates the body’s immune system, has received a considerable amount of press in recent years because of its powerful benefits. Cancer immunotherapy has shown long-term results in patients with advanced disease that are not seen with traditional chemotherapy. Immune checkpoint inhibitors, cytokines like interleukin 2 (IL-2) and interferon-alpha (IFN), and the cancer vaccine sipuleucel-T have all been licensed and approved by the FDA for the treatment of various cancers. These immunotherapy treatments boost anticancer responses by stimulating the immune system. As a result, they have the potential to cause serious, even fatal, inflammatory and immune-related side effects in one or more organs. Immune checkpoint inhibitors (ICPIs) and chimeric antigen receptor (CAR) T-cell therapy are two immunotherapy treatments that are increasingly being used to treat cancer. Following their widespread usage in the clinic, a wave of immune-related adverse events (irAEs) impacting virtually every system has raised concerns about their unpredictability and randomness. Despite the fact that the majority of adverse effects are minimal and should be addressed with prudence, the risk of life-threatening complications exists. Although most adverse events are small and should be treated with caution, the risk of life-threatening toxicities should not be underestimated, especially given the subtle and unusual indications that make early detection even more difficult. Treatment for these issues is difficult and necessitates a multidisciplinary approach involving not only oncologists but also other internal medicine doctors to guarantee quick diagnosis and treatment. This study’s purpose is to give a fundamental overview of immunotherapy and cancer-related side effect management strategies.

Gastrointestinal adverse events of immunotherapy

Cancer immunotherapy with immune-checkpoint inhibitors (ICIs) has emerged as an effective treatment for different types of cancer. ICIs are monoclonal antibodies that inhibit the signaling pathway that suppress antitumor T-cell activity. Patients benefit from increased overall and progression-free survival, but the enhancement of normal immunity can result in autoimmune manifestations, called immune-related adverse events (IRAEs), which may lead to a discontinuation of cancer therapy and to severe also life-threating events. IRAEs may affect any organs or system in the human body, being the gastrointestinal (GI) tract one of the most involved districts. Imaging plays an important role in recognizing GI IRAEs and radiologist should be familiar with the main spectrum of radiological appearance. Indeed, early detection of GI IRAEs is crucial for proper patient management and reduces morbidity and mortality. The purpose of this review is to present the most relevant imaging manifestation of GI IRAEs.

Abdominal CT manifestations of adverse events to immunotherapy: a primer for radiologists

Immunotherapy is a rapidly growing field within oncology and is being increasingly used in the management of several malignancies. Due to their unique mechanism of action on the immune system and neoplastic cells, the response pattern and adverse events of this novel therapy are distinct from conventional systemic therapies. Accordingly, the imaging appearances following immunotherapy including adverse events are unique and at times perplexing. Imaging is integral to management of patients on immunotherapeutic agents and a thorough understanding of its mechanism, response patterns and adverse events is crucial for precise interpretation of imaging studies. This review provides a description of the mechanism of action of current immunotherapeutic agents and the organ-wise description of their side effects.

Molecular targeted therapy-related life-threatening toxicity in patients with malignancies. A systematic review of published cases

Background

Molecular targeted therapy increased overall and disease-free survival in a wide range of malignancies. Although generally well tolerated compared to chemotherapy, molecular targeted therapy may be associated with adverse events requiring ICU admission. Informing clinicians about clinical features of these toxic events might maintain awareness and favor early recognition, prompt diagnosis and treatment.

Methods

We performed a systematic review of published case reports of molecular targeted therapy-related life-threatening toxicity that led to ICU admission. The search used the Pubmed database using medical subject heading (Mesh) terms, including all FDA-approved molecular targeted therapy (TT), up to March 2019. No language restriction was applied. All cases reports of patients admitted to the ICU for molecular targeted therapy-related toxicity were included. Non-FDA-approved combinations of treatments or hormonal therapy were not included.

Results

Two hundred and fifty-three cases were identified. Nearly half of them (n = 102; 40.3%) were related to anti-angiogenic agents, mostly for gastrointestinal and cardiovascular complications. Other molecules responsible for adverse events were chiefly immune checkpoint inhibitors (n = 85, 33.6%), EGFR inhibitors (n = 33; 13.0%), and anti-HER2 (n = 10; 4.0%). They were associated with adverse events such as respiratory or hypersensitivity events. Management and outcomes associated with these life-threatening complications are reported.

Conclusions

Based on the vast number of treated patients, only 253 cases of molecular therapy-related severe toxicity are reported in cancer patients. Symptoms and biomarkers that depict these events need to be better identified as to allow appropriate reporting and improving dose and schedule of the treatment adapted to each patient.

Electronic supplementary material

The online version of this article (10.1007/s00134-019-05650-w) contains supplementary material, which is available to authorized users.

Management of Small Bowel Perforation by a Bizarre Foreign Body in a 55-Year-Old Woman

Introduction

Ingestion of foreign bodies including dentures, fishbone, screw, and/or surgical devices can be a cause of morbidity, and it rarely could be fatal.

Presentation of Case

We present the first hitherto reported case of mussel shell ingestion, which caused acute abdominal pain in a 55-year-old woman. The shell pierced ileal loops, and it was found in the abdominal cavity.

Discussion

The accidental or voluntary ingestion of a foreign body is an uncommon event compared to the other causes of bowel perforation. It is fundamental to immediately remove the intestinal fluid, repair the tear, and prevent sepsis, because each delay in diagnosis can lead to a worst outcome.

Conclusion

In case of bowel perforation, it important for surgeons, who are dealing with these acute care patients, to be aware of different designs and constructions of possible foreign bodies, in order to be prepared to deal with different possible scenarios and be able to manage them properly.