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Gelsleichter NE, de Souza PO, Teixeira FC, Debom GN, Lenz GS, Roliano GG, de Cássia Sant'ana R, Visioli F, Fachel FNS, Michels LR, Azambuja JH, Teixeira HF, Braganhol E. Metastatic Melanoma: A Preclinical Model Standardization and Development of a Chitosan-Coated Nanoemulsion Containing Temozolomide to Treat Brain Metastasis. Cell Mol Neurobiol 2023:10.1007/s10571-023-01338-4. [PMID: 37055607 DOI: 10.1007/s10571-023-01338-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/13/2023] [Indexed: 04/15/2023]
Abstract
Melanoma is the most aggressive type of skin cancer. Brain metastasis is the worst scenario in metastatic melanoma and the treatment options for these patients are limited. Temozolomide (TMZ) is a chemotherapy agent used to treat primary central nervous system tumors. Our objective was to develop chitosan-coated nanoemulsion containing temozolomide (CNE-TMZ) for nasal route administration to melanoma brain metastasis treatment. A preclinical model of metastatic brain melanoma was standardized, and the efficiency of the developed formulation was further determined in vitro and in vivo. The nanoemulsion was done by spontaneous emulsification method and the formulation was characterized by size, pH, polydispersity index, and zeta potential. Culture assessments to determine cell viability were done in the A375 human melanoma cell line. To determine the safety of formulation, healthy C57/BL6 mice were treated with a nanoemulsion without TMZ. The model in vivo used B16-F10 cells implanted by stereotaxic surgery in C57/BL6 mice brains. The results demonstrate that the preclinical model used showed to be useful to analyze the efficiency of new candidate drugs to treat melanoma brain metastasis. The chitosan-coated nanoemulsions with TMZ showed the expected physicochemical characteristics and demonstrated safety and efficacy, reducing around 70% the tumor size compared to control mice, and presenting a tendency in mitotic index reduction, becoming an interesting approach to treat melanoma brain metastasis.
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Affiliation(s)
- Nicolly Espindola Gelsleichter
- Programa de Pós-Graduação em Biociências, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite Street, 245, Centro Histórico, Porto Alegre, RS, 90050-170, Brazil
| | - Priscila Oliveira de Souza
- Programa de Pós-Graduação em Biociências, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite Street, 245, Centro Histórico, Porto Alegre, RS, 90050-170, Brazil
| | - Fernanda Cardoso Teixeira
- Programa de Pós-Graduação em Biociências, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite Street, 245, Centro Histórico, Porto Alegre, RS, 90050-170, Brazil
| | - Gabriela Nogueira Debom
- Programa de Pós-Graduação em Biociências, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite Street, 245, Centro Histórico, Porto Alegre, RS, 90050-170, Brazil
| | - Gabriela Spies Lenz
- Programa de Pós-Graduação em Biociências, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite Street, 245, Centro Histórico, Porto Alegre, RS, 90050-170, Brazil
| | - Gabriela Gonçalves Roliano
- Programa de Pós-Graduação em Biociências, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite Street, 245, Centro Histórico, Porto Alegre, RS, 90050-170, Brazil
| | - Rita de Cássia Sant'ana
- Programa de Pós-Graduação em Biociências, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite Street, 245, Centro Histórico, Porto Alegre, RS, 90050-170, Brazil
| | - Fernanda Visioli
- Faculdade de Odontologia, Universidade Federal Do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Flávia Nathiely Silveira Fachel
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande Do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Luana Roberta Michels
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande Do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Juliana Hofstätter Azambuja
- Programa de Pós-Graduação em Biociências, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite Street, 245, Centro Histórico, Porto Alegre, RS, 90050-170, Brazil
| | - Helder Ferreira Teixeira
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande Do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Elizandra Braganhol
- Programa de Pós-Graduação em Biociências, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite Street, 245, Centro Histórico, Porto Alegre, RS, 90050-170, Brazil.
- Instituto de Cardiologia do Rio Grande do Sul/Fundação Universitária do Instituto de Cardiologia (IC-FUC), Porto Alegre, RS, Brazil.
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Martens A, Schauwvlieghe PP, Madoe A, Casteels I, Aspeslagh S. Ocular adverse events associated with immune checkpoint inhibitors, a scoping review. J Ophthalmic Inflamm Infect 2023; 13:5. [PMID: 36811715 PMCID: PMC9947214 DOI: 10.1186/s12348-022-00321-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/11/2022] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) have become an important part of the treatment of multiple cancers, especially for advanced melanoma and non-small cell lung cancer. Some tumors are capable of escaping immunosurveillance by stimulating checkpoints on T-cells. ICIs prevent activation of these checkpoints and thereby stimulate the immune system and indirectly the anti-tumor response. However, the use of ICIs is associated with various adverse events. Ocular side effects are rare but may have a major impact on the quality of life of the patient. METHODS A comprehensive literature search of the medical databases Web of Science, Embase and PubMed was performed. Articles that provided a comprehensive description of a case report containing 1) cancer patient(s) treated with (a combination of) immune checkpoint inhibitors, and 2) assessed occurrence of ocular adverse events, were included. A total of 290 case reports were included. RESULTS Melanoma (n = 179; 61.7%) and lung cancer (n = 56; 19.3%) were the most frequent reported malignancies. The primary used ICIs were nivolumab (n = 123; 42.5%) and ipilimumab (n = 116; 40.0%). Uveitis was most the common adverse event (n = 134; 46.2%) and mainly related to melanoma. Neuro-ophthalmic disorders, including myasthenia gravis and cranial nerve disorders, were the second most common adverse events (n = 71; 24.5%), mainly related to lung cancer. Adverse events affecting the orbit and the cornea were reported in 33 (11.4%) and 30 cases (10.3%) respectively. Adverse events concerning the retina were reported in 26 cases (9.0%). CONCLUSION The aim of this paper is to provide an overview of all reported ocular adverse events related to the use of ICIs. The insights retrieved from this review might contribute to a better understanding of the underlying mechanisms of these ocular adverse events. Particularly, the difference between actual immune-related adverse events and paraneoplastic syndromes might be relevant. These findings might be of great value in establishing guidelines on how to manage ocular adverse events related to ICIs.
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Affiliation(s)
- A. Martens
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - P. P. Schauwvlieghe
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - A. Madoe
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - I. Casteels
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - S. Aspeslagh
- grid.411326.30000 0004 0626 3362Department of Medical Oncology, University Hospital Brussels, Brussels, Belgium
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Diffusion-Weighted Imaging Combined with Perfusion-Weighted Imaging under Segmentation Algorithm in the Diagnosis of Melanoma. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:1968189. [PMID: 35833068 PMCID: PMC9252681 DOI: 10.1155/2022/1968189] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 05/28/2022] [Accepted: 06/02/2022] [Indexed: 11/18/2022]
Abstract
This study is aimed at exploring the value of magnetic resonance diffusion-weighted imaging (DWI) combined with perfusion-weighted imaging (PWI) for diagnosing melanoma under a three-dimensional (3D) hybrid segmentation algorithm. 40 patients with melanoma were collected as research objects and subjected to magnetic resonance imaging (MRI) examination. A segmentation model was constructed and the original images were input. The noise contained in the images was preprocessed and normalized, and the mixed level set segmentation was performed after linear fusion of the images. Imaging findings were analyzed to find that the combined diagnosis of DWI and PWI with a 3D hybrid segmentation algorithm had the advantage of being clear and accurate. 10 primary cases were detected, which occurred in the cerebral meninges; 30 cases of metastases occurred inside the skull, mostly adjacent to the surface of the brain. The typical T1-weighted imaging (T1WI) and T2-weighted imaging (T2WI) of melanoma showed high signal and low signal, respectively, and the enhanced scan showed obvious enhancement. Atypical melanoma was manifested variously in MRI; a few had cystic necrosis, and an enhanced scan of the solid area revealed significant enhancement. Patients with multiple metastatic melanomas mainly showed low signal on DWI, and patients with primary or single metastatic melanoma mainly showed high signal or mixed high signal. Patients with perfusion imaging showed high perfusion on PWI. The 3D hybrid segmentation algorithm helped to improve the accuracy of DWI combined with PWI in the diagnosis of melanoma. This work provided a certain reference for the clinical diagnosis of melanoma.
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Urban H, Steidl E, Hattingen E, Filipski K, Meissner M, Sebastian M, Koch A, Strzelczyk A, Forster MT, Baumgarten P, Ronellenfitsch MW, Steinbach JP, Voss M. Immune Checkpoint Inhibitor-Induced Cerebral Pseudoprogression: Patterns and Categorization. Front Immunol 2022; 12:798811. [PMID: 35046955 PMCID: PMC8761630 DOI: 10.3389/fimmu.2021.798811] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/06/2021] [Indexed: 12/18/2022] Open
Abstract
Background The inclusion of immune checkpoint inhibitors (ICIs) in therapeutic algorithms has led to significant survival benefits in patients with various metastatic cancers. Concurrently, an increasing number of neurological immune related adverse events (IRAE) has been observed. In this retrospective analysis, we examine the ICI-induced incidence of cerebral pseudoprogression and propose a classification system. Methods We screened our hospital information system to identify patients with any in-house ICI treatment for any tumor disease during the years 2007-2019. All patients with cerebral MR imaging (cMRI) of sufficient diagnostic quality were included. cMRIs were retrospectively analyzed according to immunotherapy response assessment for neuro-oncology (iRANO) criteria. Results We identified 12 cases of cerebral pseudoprogression in 123 patients treated with ICIs and sufficient MRI. These patients were receiving ICI therapy for lung cancer (n=5), malignant melanoma (n=4), glioblastoma (n=1), hepatocellular carcinoma (n=1) or lymphoma (n=1) when cerebral pseudoprogression was detected. Median time from the start of ICI treatment to pseudoprogression was 5 months. All but one patient developed neurological symptoms. Three different patterns of cerebral pseudoprogression could be distinguished: new or increasing contrast-enhancing lesions, new or increasing T2 predominant lesions and cerebral vasculitis type pattern. Conclusion Cerebral pseudoprogression followed three distinct patterns and was detectable in 3.2% of all patients during ICI treatment and in 9.75% of the patients with sufficient brain imaging follow up. The fact that all but one of the affected patients developed neurological symptoms, which would be classified as progressive disease according to iRANO criteria, mandates vigilance in the diagnosis and treatment of ICI-induced cerebral lesions.
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Affiliation(s)
- Hans Urban
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany
| | - Eike Steidl
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Elke Hattingen
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany.,Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Katharina Filipski
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany.,Institute of Neurology (Edinger Institute), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Markus Meissner
- Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Martin Sebastian
- Department of Medicine II, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Agnes Koch
- Department of Thoracic Surgery, Agaplesion Markuskrankenhaus, Frankfurt/Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (Cepter), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Marie-Thérèse Forster
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany.,Department of Neurosurgery, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Peter Baumgarten
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,Department of Neurosurgery, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Michael W Ronellenfitsch
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (Cepter), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Joachim P Steinbach
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany
| | - Martin Voss
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz; and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Frankfurt Cancer Institute (FCI), Georg-Speyer-Haus, Frankfurt/Main, Germany
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Gattozzi DA, Rosso C, Schatmeyer BA, Kabangu JLK, Doolittle GC, Wang F, Stepp T. Incidence of Intracranial Melanoma Progression in the Setting of Positive Extracranial Response to Targeted Therapy and Immunotherapy: An Indication for More Frequent Screening in This Population? Cureus 2021; 13:e13648. [PMID: 33824801 PMCID: PMC8013837 DOI: 10.7759/cureus.13648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and objective The incidence of intracranial metastases from melanoma is on the rise. In this study, we aimed to determine the incidence of intracranial disease progression in patients on BRAF/MEK targeted therapy and immunotherapy in the setting of controlled or improving extracranial disease. Methods This was a single-center, retrospective review that involved patients who underwent stereotactic radiosurgery (SRS) for intracranial metastatic melanoma between January 1, 2014, and December 31, 2018. We focused on BRAF/MEK mutation status and dates of treatment with BRAF/MEK targeted therapy, immunotherapy [ipilimumab (Yervoy), nivolumab (Opdivo), or pembrolizumab (Keytruda)], and combination targeted and immunotherapy. Results A total of 51 patients were enrolled: 36 males and 15 females. The average age of the patients was 58.6 years, and 26 among them were BRAF mutation-positive. Seventeen had prior surgery with SRS as adjuvant therapy. The other 34 had SRS as primary treatment. Forty-two patients had extracranial disease present at the time of SRS. There were 34 patients treated with targeted and immune therapy. Overall, 16 patients (47.1%) demonstrated controlled or improving extracranial disease, and 18 (52.9%) demonstrated progressing extracranial disease at the time of SRS. In the subgroup analysis, patients treated with BRAF/MEK targeted therapy demonstrated a 75% rate of extracranial disease control. The extracranial disease was controlled in 43.75% of patients on immunotherapy with intracranial progression, while it was controlled in 30% of patients on both BRAF/MEK targeted therapy and immunotherapy with intracranial progression. Sixteen patients (47.1%) developed intracranial metastasis in our study while having a stable systemic disease with BRAF/MEK targeted therapy, immunotherapy, or a combination of the two. Conclusion Based on our findings, a systemic response to targeted therapy and immunotherapy does not necessarily parallel intracranial protection.
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Affiliation(s)
| | - Casey Rosso
- Neurosurgery, University of Kansas Medical School, Kansas City, USA
| | | | | | - Gary C Doolittle
- Hematology/Oncology, University of Kansas Medical Center, Kansas City, USA
| | - Fen Wang
- Radiation Oncology, University of Kansas Medical Center, Kansas City, USA
| | - Timothy Stepp
- Neurosurgery, University of Kansas Medical Center, Kansas City, USA
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Gutzmer R, Vordermark D, Hassel JC, Krex D, Wendl C, Schadendorf D, Sickmann T, Rieken S, Pukrop T, Höller C, Eigentler TK, Meier F. Melanoma brain metastases - Interdisciplinary management recommendations 2020. Cancer Treat Rev 2020; 89:102083. [PMID: 32736188 DOI: 10.1016/j.ctrv.2020.102083] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 12/12/2022]
Abstract
Melanoma brain metastases (MBM) are common and associated with a particularly poor prognosis; they directly cause death in 60-70% of melanoma patients. In the past, systemic treatments have shown response rates around 5%, whole brain radiation as standard of care has achieved a median overall survival of approximately three months. Recently, the combination of immune checkpoint inhibitors and combinations of MAP-kinase inhibitors both have shown very promising response rates of up to 55% and 58%, respectively, and improved survival. However, current clinical evidence is based on multi-cohort studies only, as prospectively randomized trials have been carried out rarely in MBM, independently whether investigating systemic therapy, radiotherapy or surgical techniques. Here, an interdisciplinary expert team reviewed the outcome of prospectively conducted clinical studies in MBM, identified evidence gaps and provided recommendations for the diagnosis, treatment, outcome evaluation and monitoring of MBM patients. The recommendations refer to four distinct scenarios: patients (i) with 'brain-only' disease, (ii) with oligometastatic asymptomatic intra- and extracranial disease, (iii) with multiple asymptomatic metastases, and (iv) with multiple symptomatic MBM or leptomeningeal disease. Changes in current management recommendations comprise the use of immunotherapy - preferably combined anti-CTLA-4/PD-1-immunotherapy - in asymptomatic MBM minus/plus stereotactic radiosurgery which remains the mainstay of local brain therapy being safe and effective. Adjuvant whole-brain radiotherapy provides no clinical benefit in oligometastatic MBM. Among the systemic therapies, combined MAPK-kinase inhibition provides, in BRAFV600-mutated patients with rapidly progressing or/and symptomatic MBM, an alternative to combined immunotherapy.
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Affiliation(s)
- Ralf Gutzmer
- Department of Dermatology and Allergy, Skin Cancer Center Hannover, Hannover Medical School, Germany.
| | - Dirk Vordermark
- Department for Radiation Oncology, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Jessica C Hassel
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Dietmar Krex
- Department of Neurosurgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Christina Wendl
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital Essen, Essen, Germany
| | | | - Stefan Rieken
- Policlinic for Radiation Therapy and Radiation Oncology, University Hospital Göttingen, Göttingen, Germany
| | - Tobias Pukrop
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Höller
- Department of Dermatology, Medical University Vienna, Vienna, Austria
| | - Thomas K Eigentler
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Friedegund Meier
- Skin Cancer Center at the University Cancer Centre and National Center for Tumor Diseases, Department of Dermatology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
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Acute neurological adverse events during immune checkpoint inhibition therapy in patients with melanoma brain metastases. Melanoma Res 2020; 29:516-521. [PMID: 30870272 DOI: 10.1097/cmr.0000000000000597] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The common adverse effects of immune checkpoint blockade therapy are well recognised. However, neurological adverse effects of checkpoint inhibitor therapy are less widely appreciated, and their clinical management remains challenging. Therefore, we report our experience of managing acute, life-threatening neurological toxicity during immune checkpoint inhibitor therapy. Five male patients with stage IV melanoma underwent anti-programmed cell death protein 1 therapy (monotherapy or combination therapy with anti-cytotoxic T-lymphocyte antigen-4 antibodies) and developed severe neurological symptoms and signs including headache, hemiparesis and dysarthria. The initial diagnosis of brain metastases actually occurred after initiation of checkpoint inhibitor therapy in three of the patients, whereas two patients had pre-existing central nervous metastases and developed cerebral oedema and haemorrhage during immunotherapy. A rapidly fatal outcome occurred in two patients treated with immunotherapy following the development of BRAF-inhibitor and MEK-inhibitor resistance. Four of the patients died owing to neurological complications, and one achieved a complete cerebral response. Immunotherapy and tumour progression can both result in the development of neurological symptoms and signs, making it difficult to determine causality. However, the temporal relationship between the development of neurological symptoms and the first administration of therapy means that patients should be closely monitored for the development of neurological sequelae, which may even herald the presence of occult brain metastases. The decision on whether to continue immunotherapy must balance the risks of symptom - versus disease progression. However, in our case series, it is encouraging to note that the initial acute neurological symptoms were often transient. Nevertheless, pretherapeutic brain imaging to exclude occult brain metastases and stratify the risk of intracerebral oedema and haemorrhage should be considered.
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Francis JH, Berry D, Abramson DH, Barker CA, Bergstrom C, Demirci H, Engelbert M, Grossniklaus H, Hubbard B, Iacob CE, Jaben K, Kurli M, Postow MA, Wolchok JD, Kim IK, Wells JR. Intravitreous Cutaneous Metastatic Melanoma in the Era of Checkpoint Inhibition: Unmasking and Masquerading. Ophthalmology 2020; 127:240-248. [PMID: 31708274 PMCID: PMC7003537 DOI: 10.1016/j.ophtha.2019.09.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 09/10/2019] [Accepted: 09/17/2019] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Cutaneous melanoma metastatic to the vitreous is very rare. This study investigated the clinical findings, treatment, and outcome of patients with metastatic cutaneous melanoma to the vitreous. Most patients received checkpoint inhibition for the treatment of systemic disease, and the significance of this was explored. DESIGN Multicenter, retrospective cohort study. PARTICIPANTS Fourteen eyes of 11 patients with metastatic cutaneous melanoma to the vitreous. METHODS Clinical records, including fundus photography and ultrasound results, were reviewed retrospectively, and relevant data were recorded for each patient eye. MAIN OUTCOME MEASURES Clinical features at presentation, ophthalmic and systemic treatments, and outcomes. RESULTS The median age at presentation of ophthalmic disease was 66 years (range, 23-88 years), and the median follow-up from diagnosis of ophthalmic disease was 23 months. Ten of 11 patients were treated with immune checkpoint inhibition at some point in the treatment course. The median time from starting immunotherapy to ocular symptoms was 17 months (range, 4.5-38 months). Half of eyes demonstrated amelanotic vitreous debris. Five eyes demonstrated elevated intraocular pressure, and 4 eyes demonstrated a retinal detachment. Six patients showed metastatic disease in the central nervous system. Ophthalmic treatment included external beam radiation (30-40 Gy) in 6 eyes, intravitreous melphalan (10-20 μg) in 4 eyes, enucleation of 1 eye, and local observation while receiving systemic treatment in 2 eyes. Three eyes received intravitreous bevacizumab for neovascularization. The final Snellen visual acuity ranged from 20/20 to no light perception. CONCLUSIONS The differential diagnosis of vitreous debris in the context of metastatic cutaneous melanoma includes intravitreal metastasis, and this seems to be particularly apparent during this era of treatment with checkpoint inhibition. External beam radiation, intravitreous melphalan, and systemic checkpoint inhibition can be used in the treatment of ophthalmic disease. Neovascular glaucoma and retinal detachments may occur, and most eyes show poor visual potential. Approximately one quarter of patients demonstrated ocular disease that preceded central nervous system metastasis. Patients with visual symptoms or vitreous debris in the context of metastatic cutaneous melanoma would benefit from evaluation by an ophthalmic oncologist.
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Affiliation(s)
- Jasmine H Francis
- Ophthalmic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical Center, New York, New York.
| | - Duncan Berry
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - David H Abramson
- Ophthalmic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical Center, New York, New York
| | - Christopher A Barker
- Weill Cornell Medical Center, New York, New York; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Hakan Demirci
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan
| | - Michael Engelbert
- Vitreous Retina Macula Consultant of New York, New York, New York; Department of Ophthalmology, New York University Langone Health, New York, New York
| | - Hans Grossniklaus
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Baker Hubbard
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Codrin E Iacob
- Department of Pathology, The New York Eye and Ear Infirmary of Mount Sinai, New York, New York
| | - Korey Jaben
- Ophthalmic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical Center, New York, New York
| | - Madhavi Kurli
- Advanced Retina & Eye Cancer Center, Phoenix, Arizona
| | - Michael A Postow
- Weill Cornell Medical Center, New York, New York; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jedd D Wolchok
- Weill Cornell Medical Center, New York, New York; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ivana K Kim
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Jill R Wells
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
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