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Chen S, Ouyang L, Li L, Xiao Y, Wang S. PD-1/PD-L1 inhibitors associated hypophysitis: An analysis from the FAERS database and case reports. Drug Discov Ther 2024; 18:34-43. [PMID: 38382932 DOI: 10.5582/ddt.2023.01092] [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] [Indexed: 02/23/2024]
Abstract
To get a thorough understanding of PD-1/L1 inhibitor-related hypophysitis (PD-1/L1-irH), we utilized a combination of disproportionality analysis and case analysis to comprehensively characterize the clinical features of PD-1/L1-irH. Significant signals of hypophysitis were detected for all PD-1/PD-L1 inhibitors in the FAERS (FDA Adverse Event Reporting System). As revealed by both FAERS and the case analysis, PD-1/L1-irH occurred more commonly in males, PD-1 inhibitors users and patients older than 65 years. The median onset time was 101 days in FAERS and 8 cycles in the case analysis. In the case analysis, eight late-onset PD-1/L1-irHs occurred even after a discontinuation of several months (4-15 months). As revealed in FAERS, the outcome of PD-1/L1-irH tended to be poor, generally resulting in 64.66% hospitalization and 12.59% death. Fatigue was the most prominent symptom of PD-1/L1-irH, followed by anorexia, hyponatremia, and hypotension, as revealed by the analysis of 84 cases. Meanwhile isolated adrenocorticotropic (ACTH) deficiency was particularly prevalent for PD-1/L1-irH (85.71%), while gonadal hormones or posterior pituitary hormones deficiencies were rare. Glucocorticoids were administered to almost all cases (81/84), with a physiologic or stress dosage in 61.9% of cases, and a high-dose in 26.2% of cases. Most cases (58.3%) showed a favorable tumor response before diagnosis of PD-1/L1-irH. PD-1/L1-irH may occur throughout the whole therapy period even after discontinuation. Clinicians should pay more attention to PD-1 inhibitor users, males and older patients. Early diagnosis and prompt managements are crucial for PD-1/L1-irH as its potentially life-threatening nature.
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Affiliation(s)
- Shanshan Chen
- Department of Pharmacy, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Linqi Ouyang
- Department of Pharmacy, The First Hospital of Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Lian Li
- Department of Information, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Yuyang Xiao
- Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Shengfeng Wang
- Department of Pharmacy, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
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Iwamoto Y, Tatsumi F, Ohnishi M, Katakura Y, Kimura T, Shimoda M, Nakanishi S, Mune T, Kaneto H. A case of Empty Sella syndrome with adrenal insufficiency masked by prednisolone after administration of immune checkpoint inhibitors. Medicine (Baltimore) 2024; 103:e37204. [PMID: 38457550 PMCID: PMC10919508 DOI: 10.1097/md.0000000000037204] [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: 11/11/2023] [Accepted: 01/18/2024] [Indexed: 03/10/2024] Open
Abstract
INTRODUCTION The use of immune checkpoint inhibitors (ICIs) is gradually increasing; ICIs produce a variety of immune-related adverse events (irAEs), especially ICI-induced hypoadrenocorticism, which can be a lethal complication if treatment is delayed. PATIENT CONCERNS A 63-year-old man received chemotherapy with pembrolizumab for nonsmall cell lung cancer. He developed drug-induced interstitial pneumonia 366 days after receiving pembrolizumab and was treated with prednisolone. Five hundred thirty-seven days later, he developed drug-induced eosinophilic enteritis, and pembrolizumab was discontinued and prednisolone was continued. After discontinuation of prednisolone, general malaise and edema of the lower extremities appeared, and adrenal insufficiency was suspected. DIAGNOSIS In blood tests on admission adrenocorticotropic hormone (ACTH) was 2.2 pg/mL and cortisol was 15 μg/dL, with no apparent cortisol deficiency. However, the cortisol circadian rhythm disappeared and remained low throughout the day; a corticotropin-releasing hormone stimulation test showed decreased reactive secretion of ACTH. Pituitary magnetic resonance imaging showed pituitary emptying, suggesting Empty Sella syndrome. INTERVENTIONS AND OUTCOMES We started hydrocortisone and his symptoms were improved. CONCLUSIONS The administration of high-dose steroids after ICI administration may mask the symptoms of hypoadrenocorticism as irAEs. Therefore, we should bear in mind the possibility of hypoadrenocorticism when we stop steroid therapy in patients who are treated with steroids after ICI administration.
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Affiliation(s)
- Yuichiro Iwamoto
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki-city, Okayama, Japan
| | - Fuminori Tatsumi
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki-city, Okayama, Japan
| | - Mana Ohnishi
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki-city, Okayama, Japan
| | - Yukino Katakura
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki-city, Okayama, Japan
| | - Tomohiko Kimura
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki-city, Okayama, Japan
| | - Masashi Shimoda
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki-city, Okayama, Japan
| | - Shuhei Nakanishi
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki-city, Okayama, Japan
| | - Tomoatsu Mune
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki-city, Okayama, Japan
| | - Hideaki Kaneto
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki-city, Okayama, Japan
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Tanaka Y, Amano T, Takahashi A, Nishimura H, Yamanaka H, Yoneoka Y, Tsuji S, Murakami T. Locally advanced endometrial cancer with multiple immune-related adverse events coinciding with the complete response to radiotherapy after immune checkpoint inhibitor therapy: A case report. Gynecol Oncol Rep 2023; 49:101265. [PMID: 37705723 PMCID: PMC10495623 DOI: 10.1016/j.gore.2023.101265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/25/2023] [Accepted: 08/26/2023] [Indexed: 09/15/2023] Open
Abstract
We report a case of a 70-year-old female patient with locally advanced endometrial cancer with primary empty sella who developed multiple immune-related adverse events (irAEs), including hypopituitarism coinciding with the complete response to radiotherapy after receiving immune checkpoint inhibitors. A computed tomography scan acquired after a traffic accident led to the discovery of endometrial cancer that had invaded the vulva and primary empty sella. Following adriamycin and cisplatin, pembrolizumab was administered for three cycles. No irAEs were observed during treatment, but the tumor was progressive. The patient underwent radiotherapy for the residual tumor. Four months after the last dose of pembrolizumab, hypopituitarism caused secondary adrenal insufficiency, primary hypothyroidism, and pseudogout at the end of radiotherapy. The tumor later achieved a complete response. In conclusion, radiotherapy after immune checkpoint inhibitor (ICI) therapy is expected to have an antitumor effect by stimulating tumor-specific immunity. However, proper management of irAEs is necessary. Patients with primary empty sella may be prone to pituitary insufficiency induced by ICIs.
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Affiliation(s)
- Yuji Tanaka
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, 520-2192 / Seta Tsukinowa-cho, Otsu, Shiga, JAPAN
| | - Tsukuru Amano
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, 520-2192 / Seta Tsukinowa-cho, Otsu, Shiga, JAPAN
| | - Akimasa Takahashi
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, 520-2192 / Seta Tsukinowa-cho, Otsu, Shiga, JAPAN
| | - Hiroki Nishimura
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, 520-2192 / Seta Tsukinowa-cho, Otsu, Shiga, JAPAN
| | - Hiroyuki Yamanaka
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, 520-2192 / Seta Tsukinowa-cho, Otsu, Shiga, JAPAN
| | - Yutaka Yoneoka
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, 520-2192 / Seta Tsukinowa-cho, Otsu, Shiga, JAPAN
| | - Shunichiro Tsuji
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, 520-2192 / Seta Tsukinowa-cho, Otsu, Shiga, JAPAN
| | - Takashi Murakami
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, 520-2192 / Seta Tsukinowa-cho, Otsu, Shiga, JAPAN
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Nagai T, Mogami T, Takeda T, Tomiyama N, Yasui T. A case of secondary adrenocortical insufficiency due to isolated adrenocorticotropic hormone deficiency with empty sella syndrome after pembrolizumab treatment in a patient with metastatic renal pelvic cancer. Urol Case Rep 2021; 39:101766. [PMID: 34285878 PMCID: PMC8273353 DOI: 10.1016/j.eucr.2021.101766] [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] [Received: 06/13/2021] [Revised: 06/28/2021] [Accepted: 06/30/2021] [Indexed: 11/20/2022] Open
Abstract
Pembrolizumab, an anti-programmed death-1 specific monoclonal antibody is a second-line treatment for metastatic urothelial carcinoma. Physicians should be aware of adverse immune-related events associated with the use of immune checkpoint inhibitors, particularly adrenocortical insufficiency, which poses a risk of death. We report a case of secondary adrenocortical insufficiency due to isolated adrenocorticotropic hormone deficiency with empty sella syndrome after pembrolizumab treatment in a patient with metastatic renal pelvic cancer. Fortunately, a therapeutic effect was observed 4 months after discontinuation of pembrolizumab, and a durable antitumor response has persisted for 5 months.
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Affiliation(s)
- Takashi Nagai
- Department of Urology, Komono Kosei Hospital, Komono, Japan.,Department of Nephro-Urology, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
| | - Tohru Mogami
- Department of Urology, Komono Kosei Hospital, Komono, Japan
| | - Tomoki Takeda
- Department of Urology, Komono Kosei Hospital, Komono, Japan.,Department of Nephro-Urology, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
| | - Nami Tomiyama
- Department of Nephro-Urology, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
| | - Takahiro Yasui
- Department of Nephro-Urology, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
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Abstract
OBJECTIVE It is an exciting time in oncology nursing as new treatments are continually emerging to improve oncological outcomes for people affected by cancer. Immunotherapy is one such innovation in contemporary oncology practice, but the side effects of its treatment can be life threatening. Oncology nurses must be educated in the early identification of life-threatening side effects, and deliver evidence-based interventions to manage consequences of therapy such as, immune checkpoint inhibitor-related adrenal insufficiency. DATA SOURCE This article utilizes a case study to emphasize the need for early identification and interventions for clinical management of immunotherapy related adrenal insufficiency. A review of the current evidence is included to provide recommendations for oncology nurses who are involved in providing care for people affected by cancer receiving immunotherapy. IMPLICATIONS FOR NURSING PRACTICE Oncology nurses are the frontline caregivers to assess, recognize, so that early intervention and treament can lead to optimal patient outcomes. CONCLUSION Adrenal insufficiency is a life-threatening condition that is difficult to diagnose but if recognized early, morbidity can be prevented, quality of life improved, treatment initiated and life saving immunotherapy treatment can safely continue. Oncology nurses play an active role in ensuring the safe administration of immunotherapy by recognizing this important immune related adverse event. I would like to give credit to Patricia Jakel, RN, MSN, UCLA CNS and Dr. Melissa Lechner, UCLA endocrinologist for their invaluable input in this article.
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Stelmachowska-Banaś M, Czajka-Oraniec I. Management of endocrine immune-related adverse events of immune checkpoint inhibitors: an updated review. Endocr Connect 2020; 9:R207-R228. [PMID: 33064663 PMCID: PMC7576644 DOI: 10.1530/ec-20-0342] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/16/2020] [Indexed: 12/18/2022]
Abstract
Immune checkpoint inhibitors (ICIs) belong to a new group of anticancer drugs targeting T-cell proteins involved in the activation of immune response toward malignancies. Their introduction into clinical practice was a milestone in modern cancer treatment. However, the significant advantage of ICIs over conventional chemotherapy in terms of therapeutic efficacy is accompanied by new challenges related to specific side effects. ICI-induced immune system activation could lead to the loss of self-tolerance, presenting as autoimmune inflammation and dysfunction of various tissues and organs. Thus, the typical side effects of ICIs include immune-related adverse events (irAEs), among which endocrine irAEs, affecting numerous endocrine glands, have been commonly recognized. This review aimed to outline the current knowledge regarding ICI-induced endocrine disorders from a clinical perspective. We present updated information on the incidence and clinical development of ICI-induced endocrinopathies, including the most frequent thyroiditis and hypophysitis, the rarely observed insulin-dependent diabetes mellitus and primary adrenal insufficiency, and the recently described cases of hypoparathyroidism and lipodystrophy. Practical guidelines for monitoring, diagnosis, and treatment of ICI-related endocrine toxicities are also offered. Rising awareness of endocrine irAEs among oncologists, endocrinologists, and other health professionals caring for patients receiving ICIs could contribute to better safety and efficacy. As immunotherapy becomes widespread and approved for new types of malignancies, increased incidences of endocrine irAEs are expected in the future.
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Affiliation(s)
- Maria Stelmachowska-Banaś
- Department of Endocrinology, The Centre of Postgraduate Medical Education, Warsaw, Polska, Poland
- Correspondence should be addressed to M Stelmachowska-Banaś:
| | - Izabella Czajka-Oraniec
- Department of Endocrinology, The Centre of Postgraduate Medical Education, Warsaw, Polska, Poland
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Dudzińska M, Szczyrek M, Wojas-Krawczyk K, Świrska J, Chmielewska I, Zwolak A. Endocrine Adverse Events of Nivolumab in Non-Small Cell Lung Cancer Patients-Literature Review. Cancers (Basel) 2020; 12:cancers12082314. [PMID: 32824462 PMCID: PMC7466155 DOI: 10.3390/cancers12082314] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/04/2020] [Accepted: 08/12/2020] [Indexed: 12/11/2022] Open
Abstract
In recent years, we have observed significant progress in cancer treatment associated with the development of immunotherapy. A programmed cell death 1 molecule (PD-1) on the surface of T lymphocytes may be stimulated via a specific PD-ligand 1 (PD-L1), which inhibits lymphocyte activation and leads to apoptosis. Some malignant cells are characterized by high PD-L1 expression. Nivolumab, an anti-PD-1 antibody, blocks the interaction between PD-1 and its ligands and inhibits the signaling pathway by preventing the tumor-derived PD-L1 from blocking T lymphocytes. In patients with non-small cell lung cancer (NSCLC), it is used either in monotherapy or in combination with other drugs. Immunotherapy is associated with the possibility of immune-related adverse effects (irAE) including endocrinopathies (3–23%). Thyroid disorders are the most common, with severity rarely exceeding grade 2. Hypophysitis, adrenal insufficiency and diabetes are possible complications which require immediate treatment. Individuals with autoimmune diseases diagnosed prior to immunotherapy are at risk of its exacerbation. In the management of patients receiving immunotherapy, evaluation of history of autoimmune diseases, awareness and early diagnosis of irAE are crucial and may affect treatment outcomes.
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Affiliation(s)
- Marta Dudzińska
- Chair of Internal Medicine and Department of Internal Medicine in Nursing, Medical University of Lublin, 20-093 Lublin, Poland; (J.Ś.); (A.Z.)
- Correspondence: ; Tel.: +48-81-448-77-20
| | - Michał Szczyrek
- Department of Pneumology, Oncology and Allergology, Medical University of Lublin, 20-090 Lublin, Poland; (M.S.); (K.W.-K.); (I.C.)
| | - Kamila Wojas-Krawczyk
- Department of Pneumology, Oncology and Allergology, Medical University of Lublin, 20-090 Lublin, Poland; (M.S.); (K.W.-K.); (I.C.)
| | - Joanna Świrska
- Chair of Internal Medicine and Department of Internal Medicine in Nursing, Medical University of Lublin, 20-093 Lublin, Poland; (J.Ś.); (A.Z.)
| | - Izabela Chmielewska
- Department of Pneumology, Oncology and Allergology, Medical University of Lublin, 20-090 Lublin, Poland; (M.S.); (K.W.-K.); (I.C.)
| | - Agnieszka Zwolak
- Chair of Internal Medicine and Department of Internal Medicine in Nursing, Medical University of Lublin, 20-093 Lublin, Poland; (J.Ś.); (A.Z.)
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Martins Machado C, Almeida Santos L, Barroso A, Oliveira MJ. Nivolumab-induced hypothyroidism followed by isolated ACTH deficiency. BMJ Case Rep 2019; 12:12/8/e231236. [PMID: 31466960 DOI: 10.1136/bcr-2019-231236] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Cancer immunotherapy has been used in several malignancies with clinical benefit. Despite the clinical success, immune-related adverse events are frequent and endocrinopathies can be particularly severe. We report a 55-year-old male patient with stage IV pulmonary carcinoma treated with nivolumab who presented with thyroid dysfunction after the sixth administration of the drug. One year after thyroid dysfunction, the patient complained of severe fatigue, asthenia and weight loss. Laboratory testing showed low morning cortisol with undetected adrenocorticotropic hormone; other pituitary hormones were normal and MRI showed homogeneous enhancement of the pituitary gland and no space-occupying lesions. The diagnosis of nivolumab-induced hypophysitis was made and replacement treatment with hydrocortisone was started with clinical improvement. This case demonstrates that patients under immunotherapy are at risk for a large spectrum of endocrine dysfunctions that may worsen their prognosis. Close monitoring of these patients is warranted.
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Affiliation(s)
- Catarina Martins Machado
- Department of Endocrinology, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
| | - Lúcia Almeida Santos
- Department of Endocrinology, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
| | - Ana Barroso
- Department of Respiratory Medicine, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
| | - Maria João Oliveira
- Department of Endocrinology, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
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