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Gosangi B, Wang Y, Rubinowitz AN, Kwan J, Traube L, Gange C, Bader AS. Cardiothoracic complications of immune checkpoint inhibitors. Clin Imaging 2023; 102:98-108. [PMID: 37659356 DOI: 10.1016/j.clinimag.2023.08.001] [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: 02/19/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 09/04/2023]
Abstract
A paradigm shift in cancer treatment occurred with the advent of immune checkpoint inhibitors (ICI). ICI therapy has improved tumor response and increased overall survival in patients with solid tumors and hematologic malignancies. While ICI therapy has improved overall patient outcomes in oncology, it has also introduced novel adverse effects called immune-related adverse effects (irAEs). Studies have shown that the development of irAEs is associated with improved overall survival, but certain irAEs like pneumonitis and myocarditis are life threatening, and could result in death if not identified and treated early. Therefore, it is important for radiologists to be aware of complications arising from ICI administration, especially those related to the heart and lungs as they are associated with greater mortality. This paper will review the imaging features of cardiothoracic toxicities, recurrent and chronic irAEs, and atypical tumor responses associated with irAEs.
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Affiliation(s)
- Babina Gosangi
- Yale School of Medicine, New Haven, CT 06510, United States of America.
| | - Yifan Wang
- Yale School of Medicine, New Haven, CT 06510, United States of America
| | - Ami N Rubinowitz
- Yale School of Medicine, New Haven, CT 06510, United States of America
| | - Jennifer Kwan
- Yale School of Medicine, New Haven, CT 06510, United States of America
| | - Leah Traube
- Yale School of Medicine, New Haven, CT 06510, United States of America
| | - Christopher Gange
- Yale School of Medicine, New Haven, CT 06510, United States of America
| | - Anna S Bader
- Yale School of Medicine, New Haven, CT 06510, United States of America
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Bukamur H, Alkrekshi A, Katz H, Alsharedi M, Shweihat YR, Munn NJ. Immune Checkpoint Inhibitor-Related Pulmonary Toxicity: A Comprehensive Review, Part II. South Med J 2021; 114:614-619. [PMID: 34480197 PMCID: PMC8389348 DOI: 10.14423/smj.0000000000001295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The development of immune checkpoint inhibitors has changed how many cancers are treated. They work by unleashing the body’s immune response to attack the cancer cells. In part 1 of this review published in the November 2020 of the Southern Medical Journal, the authors discussed nivolumab. In this second part, they review the other immune checkpoint inhibitors and combination therapy related to pulmonary toxicities. The development of immune checkpoint inhibitors (ICIs) has changed the treatment paradigm for cancer. The ICIs nivolumab, pembrolizumab, and cemiplimab target programmed cell death protein 1, and durvalumab, avelumab, and atezolizumab target programmed death ligand 1. Ipilimumab targets cytotoxic T lymphocyte–associated antigen-4. Used as monotherapy or in combination, they have shown remarkable efficacy in melanoma, lung cancer, and many other solid tumors, and indications continue to evolve. These checkpoint inhibitors are typically well tolerated; however, they may cause immune-mediated adverse effects, resulting in inflammation of any organ system. Pulmonary toxicity is vital to recognize, and it can be more challenging to diagnose in patients with lung cancer, given the nature of the disease course and treatment.
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Affiliation(s)
- Hazim Bukamur
- From the Departments of Pulmonary and Critical Care Medicine and Hematology and Oncology Medicine, Marshall University, Joan C. Edwards School of Medicine, the Huntington Veterans Administration Medical Center, Huntington, West Virginia, and the MetroHealth System Campus of Case Western Reserve University, Cleveland, Ohio
| | - Akram Alkrekshi
- From the Departments of Pulmonary and Critical Care Medicine and Hematology and Oncology Medicine, Marshall University, Joan C. Edwards School of Medicine, the Huntington Veterans Administration Medical Center, Huntington, West Virginia, and the MetroHealth System Campus of Case Western Reserve University, Cleveland, Ohio
| | - Heather Katz
- From the Departments of Pulmonary and Critical Care Medicine and Hematology and Oncology Medicine, Marshall University, Joan C. Edwards School of Medicine, the Huntington Veterans Administration Medical Center, Huntington, West Virginia, and the MetroHealth System Campus of Case Western Reserve University, Cleveland, Ohio
| | - Mohamed Alsharedi
- From the Departments of Pulmonary and Critical Care Medicine and Hematology and Oncology Medicine, Marshall University, Joan C. Edwards School of Medicine, the Huntington Veterans Administration Medical Center, Huntington, West Virginia, and the MetroHealth System Campus of Case Western Reserve University, Cleveland, Ohio
| | - Yousef R Shweihat
- From the Departments of Pulmonary and Critical Care Medicine and Hematology and Oncology Medicine, Marshall University, Joan C. Edwards School of Medicine, the Huntington Veterans Administration Medical Center, Huntington, West Virginia, and the MetroHealth System Campus of Case Western Reserve University, Cleveland, Ohio
| | - Nancy J Munn
- From the Departments of Pulmonary and Critical Care Medicine and Hematology and Oncology Medicine, Marshall University, Joan C. Edwards School of Medicine, the Huntington Veterans Administration Medical Center, Huntington, West Virginia, and the MetroHealth System Campus of Case Western Reserve University, Cleveland, Ohio
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Gupta K, Uchel T, Karamian G, Loschner A. Pulmonary complications of tyrosine kinase inhibitors and immune checkpoint inhibitors in patients with non-small cell lung cancer. Cancer Treat Res Commun 2021; 28:100439. [PMID: 34333246 DOI: 10.1016/j.ctarc.2021.100439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 11/29/2022]
Abstract
The understanding of cancer biology and the identification of various molecular pathways and targeted oncogenic drivers have led to a paradigm shift in treatment of non-small cell lung cancer. In the last two decades, the therapeutic approach for non-small cell lung cancer (NSCLC) has gradually transitioned from empiric treatment with chemotherapeutic regimens to personalized medicine with precision targets. The major key players in these novel approaches involve targeted therapy, such as tyrosine kinase inhibitors (TKI) and immunotherapy, such as immune checkpoint inhibitors (ICI) blocking intrinsic down regulators of immunity, to achieve anti-cancer effects. These novel agents are generally better tolerated than chemotherapeutics and it is essential to be cognizant of the various drug related adverse effects. Regular follow up of patients with NSCLC by chest computed tomography (CT) surveillance to monitor for disease progression or recurrence is a prerequisite. It is becoming increasingly challenging to identify pulmonary complications related to the use of novel TKI and ICI. Our review focuses on various pulmonary complications of TKI and ICI in patients undergoing treatment for NSCLC, chest CT manifestations, management strategies, and treatment outcomes described in various case reports and case series.
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Affiliation(s)
- Kushagra Gupta
- Department of Pulmonary and Critical Care Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, United States.
| | - Toribiong Uchel
- Department of Pulmonary and Critical Care Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, United States
| | - Gregory Karamian
- Department of Pulmonary and Critical Care Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, United States
| | - Anthony Loschner
- Department of Pulmonary and Critical Care Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, United States
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Li S, Sharma N, Kazmierski D, Amjad MA, Dong Y, Wang Y, Sharma N, Ramakrishna S, Ochieng P. Diffuse Alveolar Hemorrhage With Avelumab Maintenance Therapy. Cureus 2021; 13:e15805. [PMID: 34306873 PMCID: PMC8294017 DOI: 10.7759/cureus.15805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 12/14/2022] Open
Abstract
Immune checkpoint blockade is a rapidly expanding therapeutic modality in oncology. However, its adverse effects extend beyond the cytotoxicity of conventional chemotherapy. Pneumotoxicity associated with immune checkpoint therapy presents a diagnostic conundrum that has been further complicated by the COVID-19 pandemic. We report a case of a patient with metastatic urothelial carcinoma who developed diffuse alveolar hemorrhage (DAH) following treatment with avelumab.
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Affiliation(s)
- Si Li
- Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, USA
| | - Nishant Sharma
- Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, USA
| | - Daniel Kazmierski
- Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, USA
| | - Mohammad Asim Amjad
- Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, USA
| | - Yishan Dong
- Internal Medicine, Rochester Regional Health, Rochester General Hospital, Rochester, USA
| | - Yichen Wang
- Mercy Internal Medicine Service, Trinity Health of New England, Springfield, USA
| | - Namita Sharma
- Hematology and Oncology, Geisinger Commonwealth School of Medicine, Scranton, USA
| | | | - Pius Ochieng
- Pulmonary and Critical Care Medicine, Geisinger Commonwealth School of Medicine, Scranton, USA
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Kanaoka K, Ikebe S, Ihara S, Tsuji H, Yasuoka H, Minami S. Durvalumab-Induced Diffuse Alveolar Hemorrhage: An Autopsy Case Report. Case Rep Oncol 2020; 13:696-701. [PMID: 32774259 PMCID: PMC7383190 DOI: 10.1159/000507848] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 12/26/2022] Open
Abstract
Durvalumab, a programmed cell death ligand 1 inhibitor, induces various immune-related adverse events (irAEs), including lung injury. However, diffuse alveolar hemorrhage (DAH) is a rare type of lung injury due to immune checkpoint inhibitors. A 76-year-old man with c-stage IIIA squamous cell carcinoma of the lung received maintenance durvalumab therapy after chemoradiotherapy. He developed dyspnea and malaise after 11 cycles of durvalumab. Chest computed tomography showed rapidly spreading bilateral ground-glass opacity in the lungs. We diagnosed DAH by hemosiderin-laden macrophages in bloody bronchoalveolar lavage fluid. Despite mechanical ventilation, steroids, and cyclophosphamide, he died of respiratory failure. The autopsy revealed that fresh and old bleeding areas coexisted, and neither pulmonary vasculitis nor diffuse alveolar damage was detected microscopically. Furthermore, CD3+ and CD8+ lymphocytes were observed in the lung interstitium, whereas CD20+ and CD4+ lymphocytes were scarcely detected. We report the first case of durvalumab-induced DAH. We should be alert to irAEs with DAH as a potential differential diagnosis of lung injury during durvalumab treatment.
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Affiliation(s)
- Kensuke Kanaoka
- Department of Respiratory Medicine, Osaka Police Hospital, Osaka, Japan
| | - Saori Ikebe
- Department of Respiratory Medicine, Osaka Police Hospital, Osaka, Japan
| | - Shouichi Ihara
- Department of Respiratory Medicine, Osaka Police Hospital, Osaka, Japan
| | - Hiromi Tsuji
- Department of Pathology, Osaka Police Hospital, Osaka, Japan
| | - Hironao Yasuoka
- Department of Pathology, Osaka Police Hospital, Osaka, Japan
| | - Seigo Minami
- Department of Respiratory Medicine, Osaka Police Hospital, Osaka, Japan
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Pembrolizumab-induced pneumonitis with a perilymphatic nodular pattern in a lung cancer patient: A radio-pathologic correlation. Respir Med Case Rep 2019; 26:168-170. [PMID: 30671338 PMCID: PMC6327904 DOI: 10.1016/j.rmcr.2019.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/03/2019] [Accepted: 01/03/2019] [Indexed: 01/26/2023] Open
Abstract
A 66-year-old Japanese man with recurrent adenocarcinoma of the lung p-stage IIIA (pT2bN2M0; version 8) on pembrolizumab was present with gradually worsening dyspnea. Although history and physical examination were unremarkable, high-resolution CT showed the perilymphatic distribution of the pembrolizumab-induced pneumonitis. Consistent with the CT result, biopsy revealed the aggregation of the cytotoxic (CD8+) T-lymphocytes around the lymph tracts. Given the clinical, radiological and pathological findings, pembrolizumab-induced pneumonitis was confirmed. The patient was discharged after terminating the pembrolizumab with ameliorated symptoms. This report, in conjunction with existing literature, illustrates the wide variety of the pembrolizumab-induced pneumonitis and bolsters the current understanding of its pathophysiology.
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