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Lin J, Lin ZQ, Zheng SC, Chen Y. Immune checkpoint inhibitor-associated gastritis: Patterns and management. World J Gastroenterol 2024; 30:1941-1948. [PMID: 38681126 PMCID: PMC11045486 DOI: 10.3748/wjg.v30.i14.1941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/23/2024] [Accepted: 03/28/2024] [Indexed: 04/12/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) are widely used due to their effectiveness in treating various tumors. Immune-related adverse events (irAEs) are defined as adverse effects resulting from ICI treatment. Gastrointestinal irAEs are a common type of irAEs characterized by intestinal side effects, such as diarrhea and colitis, which may lead to the cessation of ICIs. Although irAE gastritis is rarely reported, it may lead to serious complications such as gastrorrhagia. Furthermore, irAE gastritis is often difficult to identify early due to its diverse symptoms. Although steroid hormones and immunosuppressants are commonly used to reverse irAEs, the best regimen and dosage for irAE gastritis remains uncertain. In addition, the risk of recurrence of irAE gastritis after the reuse of ICIs should be considered. In this editorial, strategies such as early identification, pathological diagnosis, management interventions, and immunotherapy rechallenge are discussed to enable clinicians to better manage irAE gastritis and improve the prognosis of these patients.
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Affiliation(s)
- Jing Lin
- Department of Medical Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou 350000, Fujian Province, China
| | - Zhong-Qiao Lin
- Phase I Clinical Trial Ward, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou 350000, Fujian Province, China
| | - Shi-Cheng Zheng
- School of Basic Medical Sciences, Fujian Medical University, Fuzhou 350000, Fujian Province, China
| | - Yu Chen
- Department of Medical Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou 350000, Fujian Province, China
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Riveiro-Barciela M, Carballal S, Díaz-González Á, Mañosa M, Gallego-Plazas J, Cubiella J, Jiménez-Fonseca P, Varela M, Menchén L, Sangro B, Fernández-Montes A, Mesonero F, Rodríguez-Gandía MÁ, Rivera F, Londoño MC. Management of liver and gastrointestinal toxicity induced by immune checkpoint inhibitors: Position statement of the AEEH-AEG-SEPD-SEOM-GETECCU. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:401-432. [PMID: 38228461 DOI: 10.1016/j.gastrohep.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/28/2023] [Accepted: 10/19/2023] [Indexed: 01/18/2024]
Abstract
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.
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Affiliation(s)
- Mar Riveiro-Barciela
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Universitat Autònoma de Barcelona (UAB), Department of Medicine, Spain.
| | - Sabela Carballal
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Gastroenterology Department, Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Universitat de Barcelona, Spain
| | - Álvaro Díaz-González
- Gastroenterology Department, Grupo de Investigación Clínica y Traslacional en Enfermedades Digestivas, Instituto de Investigación Valdecilla (IDIVAL), Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Míriam Mañosa
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | - Joaquín Cubiella
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Gastroenterology Department, Hospital Universitario de Ourense, Grupo de Investigación en Oncología Digestiva-Ourense, Spain
| | - Paula Jiménez-Fonseca
- Medical Oncology Department, Hospital Universitario Central de Asturias, ISPA, Oviedo, Spain
| | - María Varela
- Gastroenterology Department, Hospital Universitario Central de Asturias, IUOPA, ISPA, FINBA, University of Oviedo, Oviedo, Spain
| | - Luis Menchén
- Servicio de Aparato Digestivo - CEIMI, Instituto de Investigación Sanitaria Gregorio, Marañón, Spain; Departamento de Medicina, Universidad Complutense, Madrid, Spain
| | - Bruno Sangro
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Liver Unit, Cancer Center Clinica Universidad de Navarra, Pamplona-Madrid, Spain
| | - Ana Fernández-Montes
- Medical Oncology Department, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Francisco Mesonero
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Universidad de Alcalá de Henares, Spain
| | - Miguel Ángel Rodríguez-Gandía
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRyCIS), Madrid, Spain
| | - Fernando Rivera
- Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - María-Carlota Londoño
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Universitat de Barcelona, Spain; Liver Unit, Hospital Clínic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Spain
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Riveiro-Barciela M, Carballal S, Díaz-González Á, Mañosa M, Gallgo-Plazas J, Cubiella J, Jiménez-Fonseca P, Varela M, Menchén L, Sangro B, Fernández-Montes A, Mesonero F, Rodríguez-Gandía MÁ, Rivera F, Londoño MC. Management of liver and gastrointestinal toxicity induced by immune checkpoint inhibitors: Position statement of the AEEH-AEG-SEPD-SEOM-GETECCU. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:83-113. [PMID: 38226597 DOI: 10.17235/reed.2024.10250/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
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.
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Affiliation(s)
| | | | | | - Miriam Mañosa
- Gastroenterology, Hospital Universitari Germans Trias i Pujol
| | | | | | | | - María Varela
- Gastroenterology, Hospital Universitario Central de Asturias
| | - Luis Menchén
- Digestive Diseases, Instituto de Investigación Sanitaria Gregorio Marañón
| | | | | | | | | | - Fernando Rivera
- Hospital Universitario Marqués de Valdecilla, Medical Oncology
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Tsukaguchi A, Yamaguchi N, Ogawa H, Ikeda T. Concurrent Nivolumab-Induced Gastritis and Cholangitis Accompanied by Biliary Tract Hemorrhage in a Patient With Stage IV Lung Adenocarcinoma. Cureus 2023; 15:e46392. [PMID: 37927718 PMCID: PMC10620473 DOI: 10.7759/cureus.46392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
Immune checkpoint inhibitors, including nivolumab, can result in immune-related adverse events (irAEs) that may affect multiple organ systems. Among irAEs, both gastritis and cholangitis are uncommon. We present the case of a 65-year-old man who received nivolumab for lung adenocarcinoma presented with epigastric pain. He was diagnosed with immune-related gastritis and cholangitis based on imaging and pathological findings. We administered prednisolone (1 mg/kg/day), which improved the patient's gastritis and relieved his pain. However, he experienced recurrent epigastric pain during corticosteroid tapering, and magnetic resonance imaging showed biliary tract hemorrhage. After watchful waiting, the hemorrhage improved without additional immunosuppressants. Immune-related gastritis, immune-related cholangitis, and their coexistence should be considered in patients who develop epigastric pain during immune checkpoint inhibitor therapy. When patients with concurrent immune-related gastritis and cholangitis complain of recurrent epigastric pain, it is important to assess which of these two irAEs is worsening because the optimal immunosuppressants differ between the two.
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Affiliation(s)
- Akihiro Tsukaguchi
- Department of Respiratory Medicine, Nishinomiya Municipal Central Hospital, Nishinomiya, JPN
| | - Norihiko Yamaguchi
- Department of Respiratory Medicine, Nishinomiya Municipal Central Hospital, Nishinomiya, JPN
| | - Hiroyuki Ogawa
- Department of Gastroenterology, Nishinomiya Municipal Central Hospital, Nishinomiya, JPN
| | - Toshiyuki Ikeda
- Department of Respiratory Medicine, Nishinomiya Municipal Central Hospital, Nishinomiya, JPN
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Cijauskaite E, Kazenaite E, Strainiene S, Sadauskaite G, Kurlinkus B. Nivolumab-induced tumour-like gastritis: A case report. World J Clin Cases 2023; 11:4350-4359. [PMID: 37449232 PMCID: PMC10336988 DOI: 10.12998/wjcc.v11.i18.4350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/23/2023] [Accepted: 05/09/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors are one of the modern treatment methods for advanced malignancies. However, this group of medications is also associated with various immune-related adverse events, such as colitis or pneumonitis. Immune checkpoint inhibitor-induced gastritis is a less common adverse event.
CASE SUMMARY We describe a 64-year-old woman presenting with diarrhea, nausea, and discomfort in the upper abdominal region. The patient had a history of metastatic lung cancer, which was treated with nivolumab. During the first endoscopy, an infiltrating gastric tumour was suspected. Later, based on endoscopic, histological and radiological findings, nivolumab-induced gastritis was diagnosed. The patient was successfully treated with three courses of omeprazole.
CONCLUSION As a consequence of the increased use of immune checkpoint inhibitors, a growing number of reported immune-related adverse events could be expected. The diagnosis of immune checkpoint inhibitor-induced gastritis should be considered when assessing a patient treated with nivolumab with upper gastrointestinal distress.
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Affiliation(s)
| | - Edita Kazenaite
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius 01513, Lithuania
- Vilnius University Hospital Santaros Clinics, Center of Hepatology, Gastroenterology and Dietology, Vilnius 08661, Lithuania
| | - Sandra Strainiene
- Department of Internal Medicine and Surgery, Antakalnis Clinic, Vilnius 10207, Lithuania
| | - Goda Sadauskaite
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius 01513, Lithuania
- Vilnius University Hospital Santaros Clinics, Center of Hepatology, Gastroenterology and Dietology, Vilnius 08661, Lithuania
| | - Benediktas Kurlinkus
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius 01513, Lithuania
- Vilnius University Hospital Santaros Clinics, Center of Hepatology, Gastroenterology and Dietology, Vilnius 08661, Lithuania
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Clinical Characteristics and Outcomes of Gastritis Associated With Immune Checkpoint Inhibitors: Scoping Review. J Immunother 2022; 45:363-369. [PMID: 35972801 DOI: 10.1097/cji.0000000000000435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/30/2022] [Indexed: 11/25/2022]
Abstract
Among immune-related adverse events associated with immune checkpoint inhibitors, immune-mediated gastritis (IMG) has been rarely described in the literature and has not yet been well characterized. This scoping review aimed to characterize IMG in terms of precipitating agents, clinical presentations, and prognosis. After the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, we searched MEDLINE and EMBASE for all peer-reviewed articles using keywords including "gastritis," "immune checkpoint inhibitor," and "immune-related adverse event" from their inception to December 28, 2021. Twenty-two articles, including 5 observational studies and 17 case reports and case series, were included. Nivolumab, pembrolizumab, and combination therapy with those and cytotoxic T-lymphocyte-associated antigen-4 inhibitor (ipilimumab) were commonly used in those with IMG. 59.8% had epigastric pain, and 50% had erosive gastritis. 87.5% had Common Terminology Criteria for Adverse Events (CTCAE) grade 3 gastritis, and 91.2% received corticosteroids. Recurrence was noted in 16.7%, and only 1 expiration was noted. 4.3% had positive helicobacter pylori and cytomegalovirus from the gastric specimen. Similar to immune-related colitis, patients with IMG may have a favorable prognosis with a better response to immune checkpoint inhibitors if treated appropriately. The diagnosis of IMG is made by exclusion, and a thorough workup is necessary to rule out concurrent helicobacter pylori and cytomegalovirus involvement. Further studies are critical for a better understanding of this complication.
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Alalawi M, Bakr AS, Reda R, Sadak KT, Nagy M. Late-onset toxicities of monoclonal antibodies in cancer patients. Immunotherapy 2022; 14:1067-1083. [PMID: 35892252 DOI: 10.2217/imt-2022-0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cancer therapy duration is variable and may take years, adding a new challenge of maintaining the best life quality for cancer survivors. In cancer patients, late-onset toxicities have been reported with monoclonal antibodies and may involve several body organs or systems. They are defined as an autoimmune illnesses that can happen months to years after treatment discontinuation. Late-onset toxicities have become a focus of clinical care and related research. After cancer therapy is completed, the patient should receive longitudinal follow-up to detect these late effects as early as possible. The current review summarizes the recently reported late-onset toxicities of four classes of monoclonal antibodies (anti-CD52, anti-CTLA-4, anti-PD-1 and anti-CD20) with guidance for the diagnostic tools, appropriate management and treatment.
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Affiliation(s)
- Mai Alalawi
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt, Cairo, 57357, 4260102, Egypt.,Department of Pharmaceutical Sciences, Fakeeh College for Medical Sciences, Jeddah, 23323, Saudi Arabia
| | - Abrar Saeed Bakr
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt, Cairo, 57357, 4260102, Egypt.,Department of Clinical Pharmacy, Alexandria Vascular Center, Alexandria, 5431118, Egypt
| | - Rowaida Reda
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt, Cairo, 57357, 4260102, Egypt.,Department of Clinical Pharmacy, Woman Health Hospital, Assiut University, Assiut, 2074020, Egypt
| | - Karim Thomas Sadak
- University of Minnesota Masonic Cancer Center, Minneapolis, MN 55455, USA.,University of Minnesota Masonic Children's Hospital, Minneapolis, MN 55455, USA
| | - Mohamad Nagy
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt, Cairo, 57357, 4260102, Egypt.,Personalized Medication Management Unit, Children's Cancer Hospital Egypt, Cairo, 57357, 4260102, Egypt
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Sugiyama Y, Tanabe H, Matsuya T, Kobayashi Y, Murakami Y, Sasaki T, Kunogi T, Takahashi K, Ando K, Ueno N, Kashima S, Moriichi K, Tanino M, Mizukami Y, Fujiya M, Okumura T. Severe immune checkpoint inhibitor-associated gastritis: A case series and literature review. Endosc Int Open 2022; 10:E982-E989. [PMID: 35845030 PMCID: PMC9286772 DOI: 10.1055/a-1839-4303] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/28/2022] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Recent advances in cancer treatment have involved the clinical application of immune checkpoint inhibitors (ICIs) for various type of cancers. The adverse events associated with ICIs are generally referred to as immune-related adverse events (irAEs). Gastrointestinal irAEs are a major disorder, but gastritis is not frequently observed. The aims of this study were to elucidate the clinical, endoscopic, and histological characteristics of irAE gastritis. Patients and methods Information on patients treated with ICIs were collected from a single institute over 3 years. IrAE gastritis was identified based on the clinical course and endoscopic and histopathological findings. Of the 359 patients treated with ICIs, four cases of irAE gastritis were identified in clinical records from the endoscopy unit. The endoscopic and histopathological findings were analyzed, and further immunohistochemical studies with immune subtype markers and programmed cell death ligand-1 (PD-L1) antibody were conducted. Results Among four patients with irAE gastritis, the remarkable endoscopic characteristics were network-pattern erosion, erythematous and edematous mucosa with thick purulent discharge, and fragile mucosa. Corresponding histological features were fibrinopurulent exudate, severe inflammatory cell infiltration, and epithalaxia, respectively. The PD-L1 expression rate was ≥ 1 % in the gastric tissue of all patients with gastritis. These patients were treated with prednisolone (PSL) and their symptoms improved within a few days to 2 weeks. Conclusions IrAE gastritis were characterized by specific endoscopic findings. The appropriate endoscopic diagnosis may lead to effective treatment with PSL.
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Affiliation(s)
- Yuya Sugiyama
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Hiroki Tanabe
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Taisuke Matsuya
- Department of Dermatology, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yu Kobayashi
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yuki Murakami
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Takahiro Sasaki
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Takehito Kunogi
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Keitaro Takahashi
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Katsuyoshi Ando
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Nobuhiro Ueno
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Shin Kashima
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Kentaro Moriichi
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Mishie Tanino
- Department of Diagnostic Pathology, Asahikawa Medical University Hospital, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yusuke Mizukami
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Mikihiro Fujiya
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Toshikatsu Okumura
- Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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Tatar G, Alçin G, Sengul Samanci N, Erol Fenercioglu Ö, Beyhan E, Cermik TF. Diagnostic impact of 18F-FDG PET/CT imaging on the detection of immune-related adverse events in patients treated with immunotherapy. Clin Transl Oncol 2022; 24:1903-1913. [PMID: 35594002 DOI: 10.1007/s12094-022-02840-9] [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: 02/09/2022] [Accepted: 04/11/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Immunotherapy is an effective treatment method for cancer cells with humoral and cellular immune mechanisms of action but triggers an inflammatory response and disrupts standard protective immune tolerance. Early detection of immune-related adverse events (irAEs) on PET/CT is crucial for patient management and subsequent therapy decisions. In this study, we aimed to evaluate the impact of 18F-FDG PET/CT on detecting of irAEs in patients receiving immunotherapy. PATIENTS AND METHODS Forty-six patients with advanced RCC (n: 32), malign melanoma (n: 9), lung cancer (n: 4), and laryngeal carcinoma (n: 1), who underwent 18F-FDG PET/CT imaging for response assessment after immunotherapy, were enrolled in the study. Newly detected findings associated with irAEs on posttreatment PET/CT images were compared with the pretreatment PET/CT, both qualitatively and semi-quantitatively. RESULTS Twenty-eight (61%) patients developed irAEs as observed on PET/CT. Enteritis/colitis was the most frequent irAE visualized on PET/CT with 13 patients (28.2%), followed by gastritis (17.3%), thyroiditis (13%), and myositis/arthritis (13%). Hepatitis (6.5%), pneumonitis (6.5%), sarcoid-like reaction (4.3%), and hypophysitis (4.3%) were observed to a lesser extent. The median time between the appearance of irAEs on PET/CT and the initiation of immunotherapy was 4.3 months. There were no significant differences in age, sex, and treatment response status of patients with and without irAEs. CONCLUSION 18F-FDG PET/CT plays a fundamental role in cancer immunotherapy with the potential to show significant irAEs both in the diagnosis and in follow-up of irAEs. IrAEs were present on PET/CT images of more than half of the patients who received immunotherapy in our study.
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Affiliation(s)
- Gamze Tatar
- Department of Nuclear Medicine, Istanbul Bagcılar Training and Research Hospital, University of Health Sciences, 34200, Bagcılar, Istanbul, Turkey.
| | - Göksel Alçin
- Department of Nuclear Medicine, Istanbul Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Nilay Sengul Samanci
- Division of Medical Oncology, Istanbul Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Özge Erol Fenercioglu
- Department of Nuclear Medicine, Istanbul Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ediz Beyhan
- Department of Nuclear Medicine, Istanbul Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Tevfik Fikret Cermik
- Department of Nuclear Medicine, Istanbul Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
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Léger MA, Routy B, Juneau D. FDG PET/CT for Evaluation of Immunotherapy Response in Lung Cancer Patients. Semin Nucl Med 2022; 52:707-719. [DOI: 10.1053/j.semnuclmed.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 11/11/2022]
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Kataoka S, Moriguchi M, Okishio S, Takahashi A, Okuda K, Seko Y, Umemura A, Yamaguchi K, Miyagawa-Hayashino A, Itoh Y. Re-administration of nivolumab after immune checkpoint inhibitor-induced cholangitis: the first reported case. Clin J Gastroenterol 2022; 15:467-474. [PMID: 35201598 DOI: 10.1007/s12328-022-01590-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/05/2022] [Indexed: 12/19/2022]
Abstract
Immune checkpoint inhibitors (ICIs) cause various immune-related adverse events (irAEs). We encountered a patient in whom nivolumab was re-administered effectively and safely treat laryngeal cancer after nivolumab-induced cholangitis. A 60-year-old man with metastatic laryngeal squamous cell carcinoma received 3rd-line treatment with nivolumab. After the 8th cycle of chemotherapy, laboratory tests revealed grade 3 elevations of gamma-glutamyl transpeptidase and alkaline phosphatase. Computed tomography and endoscopic retrograde cholangiopancreatography showed diffuse hypertrophy, dilation of bile ducts, and intrahepatic bile ducts with irregular walls and mild stenosis. The histologic findings of a liver biopsy revealed portal inflammation and cholangitis, mainly composed of T cell infiltration. We diagnosed nivolumab-induced cholangitis and administered 30 mg of prednisolone (0.5 mg/kg) and ursodeoxycholic acid (600 mg) per day. Although we initiated 4th-line cytotoxic anticancer drug after the cholangitis improved, the laryngeal cancer progressed rapidly. Based on the improvement in hematologic parameters, radiologic imaging, and pathologic findings, we cautiously restarted nivolumab. During the 30 months after re-administration of nivolumab, the cholangitis did not recur and the disease was well-controlled.
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Affiliation(s)
- Seita Kataoka
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Michihisa Moriguchi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Shinya Okishio
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Aya Takahashi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Keiichiro Okuda
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Yuya Seko
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Atushi Umemura
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Kanji Yamaguchi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Aya Miyagawa-Hayashino
- Departoment of Surgical Pathology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Yoshito Itoh
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
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12
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Saito K, Ozono D, Nagumo H, Yoshimura M, Masuzawa Y. Temporal observation of endoscopic and histological findings of gastritis after administration of an immune checkpoint inhibitor: a case report. Clin J Gastroenterol 2022; 15:368-373. [PMID: 34985687 PMCID: PMC8956546 DOI: 10.1007/s12328-021-01582-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/22/2021] [Indexed: 11/04/2022]
Abstract
A 71-year-old Japanese man was treated with 200 mg of pembrolizumab for lung adenocarcinoma with multiple bone metastases at the Department of Respiratory Medicine of Kameda General Hospital. After 19 treatment courses, he complained of epigastric pain before meals. Upper gastrointestinal endoscopy showed multiple erosions in the gastric antrum, and antacids were administered at follow-up. After 27 treatment courses, the patient underwent another endoscopy because of anorexia. The erosions were enlarged and had increased from the gastric antrum to the greater curvature of the body. Histological biopsy showed lymphocytic infiltration with a predominance of CD8-positive T cells. The patient had previously been treated for Helicobacter pylori infection, and we suspected drug-induced gastritis due to the administration of immune checkpoint inhibitors in the course of the disease. Pembrolizumab was discontinued, and the patient’s symptoms gradually improved. Endoscopic examinations were performed 2, 5, and 9 months after discontinuation of pembrolizumab, and improvement in mucosal findings and decreased lymphocyte infiltration were confirmed each time. The patient has remained without any relapse of symptoms for more than 1 year after discontinuing treatment.
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Affiliation(s)
- Keita Saito
- Department of Gastroenterology, Kameda General Hospital, 929, Higashi-cho, Kamogawa, Chiba, 296-8602, Japan.
| | - Daiki Ozono
- Department of Gastroenterology, Kameda General Hospital, 929, Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
| | - Hironobu Nagumo
- Department of Gastroenterology, Kameda General Hospital, 929, Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
| | - Masayo Yoshimura
- Department of Anatomic Pathology, Kameda General Hospital, Chiba, Japan
| | - Yoko Masuzawa
- Department of Anatomic Pathology, Kameda General Hospital, Chiba, Japan
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13
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Immune-related cholangitis induced by immune checkpoint inhibitors: a systematic review of clinical features and management. Eur J Gastroenterol Hepatol 2021; 33:e858-e867. [PMID: 34482313 PMCID: PMC8734631 DOI: 10.1097/meg.0000000000002280] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AIMS Immune checkpoint inhibitors (ICIs) improve the survival of patients with advanced tumors. However, immune-related adverse events limit the use of ICIs. Although liver toxicity has been concerned gradually, little is known about bile duct injury associated with ICIs. Hence, this review aims to describe clinicopathological features, imaging, and management of immune-mediated cholangitis (IMC) induced by ICIs. METHODS We retrieved the literature from the PubMed database for case reports and series of IMC induced by ICIs. IMC was then classified as small-ducts type, large-ducts type and mixed type. Biochemical parameters, pathological characteristics, imaging features, treatment and response were evaluated and compared among three patterns. RESULTS Fifty-three cases of IMC were enrolled. The median values of alkaline phosphatase and alanine transaminase of IMC were 1328 and 156 IU/L. The ALP level of the large-ducts type was higher than that of the small-ducts type (P = 0.021). The main pathological characteristics of small-ducts cholangitis were portal inflammation, bile duct injury and ductular reaction. The imaging features of large-duct cholangitis were bile duct dilatation, stenosis and bile duct wall thickening and irregularity. Forty-eight (90%) cases received immunosuppression therapy. Biliary enzymes reduced in 79% of cases receiving immunosuppression therapy, but only 8.5% of cases returned to normal. It took a long time for biliary enzymes to recover. CONCLUSIONS The clinicians should be aware of the possibility of IMC if the biliary enzymes increase significantly after the use of ICIs. The liver function can be improved partially by immunosuppressive therapy in the majority of IMC.
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14
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Bisschop C, de Heer E, Brouwers A, Hospers G, Jalving M. Rational use of 18F-FDG PET/CT in patients with advanced cutaneous melanoma: A systematic review. Crit Rev Oncol Hematol 2020; 153:103044. [DOI: 10.1016/j.critrevonc.2020.103044] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/13/2020] [Accepted: 06/29/2020] [Indexed: 02/07/2023] Open
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15
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Novel Nuclear Medicine Imaging Applications in Immuno-Oncology. Cancers (Basel) 2020; 12:cancers12051303. [PMID: 32455666 PMCID: PMC7281332 DOI: 10.3390/cancers12051303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/11/2020] [Accepted: 05/19/2020] [Indexed: 12/12/2022] Open
Abstract
The global immuno-oncology pipeline has grown progressively in recent years, leading cancer immunotherapy to become one of the main issues of the healthcare industry. Despite their success in the treatment of several malignancies, immune checkpoint inhibitors (ICIs) perform poorly in others. Again, ICIs action depends on such a multitude of clinico-pathological features, that the attempt to predict responders/long-responders with ad-hoc built immunograms revealed to be quite complex. In this landscape, the role of nuclear medicine might be crucial, with first interesting evidences coming from small case series and pre-clinical studies. Positron-emission tomography (PET) techniques provide functional information having a predictive and/or prognostic value in patients treated with ICIs or adoptive T-cell therapy. Recently, a characterization of the tumor immune microenvironment (TiME) pattern itself has been shown to be feasible through the use of different radioactive tracers or image algorithms, thus adding knowledge about tumor heterogeneity. Finally, nuclear medicine exams permit an early detection of immune-related adverse events (irAEs), with on-going clinical trials investigating their correlation with patients’ outcome. This review depicts the recent advances in molecular imaging both in terms of non-invasive diagnosis of TiME properties and benefit prediction from immunotherapeutic agents.
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Vindum HH, Agnholt JS, Nielsen AWM, Nielsen MB, Schmidt H. Severe steroid refractory gastritis induced by Nivolumab: A case report. World J Gastroenterol 2020; 26:1971-1978. [PMID: 32390707 PMCID: PMC7201147 DOI: 10.3748/wjg.v26.i16.1971] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/05/2020] [Accepted: 04/17/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors are widely used for treatment of many advanced malignancies. Lower gastrointestinal (GI) side effects, such as diarrhea and colitis, are common, but upper GI side effects are rarely reported. Consequently, the correct treatment of upper GI adverse events has been less frequently described.
CASE SUMMARY We describe a case of a 16-year-old woman with stage IIIb malignant melanoma treated with adjuvant monotherapy using Nivolumab. The patient developed severe gastritis after six series of Nivolumab with weight loss, nausea, and vomiting. There was no effect of intravenous steroids, but the patient´s condition resolved after administration of Infliximab.
CONCLUSION This case report supports the same treatment for gastritis as for colitis, which is in line with current guidelines.
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Affiliation(s)
| | - Jørgen S Agnholt
- Department of Gastroenterology, Aarhus University Hospital, Aarhus 8200, Denmark
| | | | - Mette Bak Nielsen
- Department of Pathology, Aarhus University Hospital, Aarhus 8200, Denmark
| | - Henrik Schmidt
- Department of Oncology, Aarhus University Hospital, Aarhus 8200, Denmark
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Onoyama T, Takeda Y, Yamashita T, Hamamoto W, Sakamoto Y, Koda H, Kawata S, Matsumoto K, Isomoto H. Programmed cell death-1 inhibitor-related sclerosing cholangitis: A systematic review. World J Gastroenterol 2020; 26:353-365. [PMID: 31988594 PMCID: PMC6969883 DOI: 10.3748/wjg.v26.i3.353] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 01/07/2020] [Accepted: 01/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Programmed cell death-1 (PD-1) inhibitor has been indicated for many types of malignancies. However, these inhibitors also cause immune-related adverse events. Hepatobiliary disorder is a phenotype of immune-related adverse event affecting 0%–4.5% of patients treated with PD-1 inhibitors. Recent studies have reported PD-1 inhibitor-related sclerosing cholangitis (SC); however, the associated clinical and pathological features are unclear.
AIM To evaluate the clinical and pathological features of PD-1 inhibitor-related SC through a systematic review of the literature.
METHODS The review, conducted using electronic databases in PubMed, was restricted to the period from January 2014 to September 2019 and focused on case reports/series on PD-1 inhibitor-related SC published in English. We scanned the references of the selected literature to identify any further relevant studies. Six cases previously studied by us, including three that have not yet been published, were included in this review.
RESULTS Thirty-one PD-1 inhibitor-related SC cases were evaluated. Median age of patients was 67 years (range, 43–89), with a male to female ratio of 21:10. The main disease requiring PD-1 inhibitor treatment was non-small cell lung cancer. Agents that caused PD-1 inhibitor-related SC were nivolumab (19 cases), pembrolizumab (10 cases), avelumab (1 case), and durvalumab (1 case). The median number of cycles until PD-1 inhibitor-related SC onset was 5.5 (range, 1–27). Abdominal pain or discomfort (35.5%, 11/31) was the most frequent symptom. Blood serum tests identified liver dysfunction with a notable increase in biliary tract enzymes relative to hepatic enzymes, and a normal level of serum immunoglobulin G4. Biliary dilation without obstruction (76.9%, 20/26), diffuse hypertrophy of the extrahepatic biliary tract (90.5%, 19/21), and multiple strictures of the intrahepatic biliary tract (30.4%, 7/23) were noted. In 11/23 (47.8%) cases, pathological examination indicated that CD8+ T cells were the dominant inflammatory cells in the bile duct or peribiliary tract. Although corticosteroids were mainly used for PD inhibitor-related SC treatment, the response rate was 11.5% (3/26).
CONCLUSION Some clinical and pathological features of PD-1 inhibitor-related SC were revealed. To establish diagnostic criteria for PD-1 inhibitor-related SC, more cases need to be evaluated.
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Affiliation(s)
- Takumi Onoyama
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori prefecture 683-8504, Japan
| | - Yohei Takeda
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori prefecture 683-8504, Japan
| | - Taro Yamashita
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori prefecture 683-8504, Japan
| | - Wataru Hamamoto
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori prefecture 683-8504, Japan
| | - Yuri Sakamoto
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori prefecture 683-8504, Japan
| | - Hiroki Koda
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori prefecture 683-8504, Japan
| | - Soichiro Kawata
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori prefecture 683-8504, Japan
| | - Kazuya Matsumoto
- Internal Medicine, Irisawa Medical Clinic, Shimane prefecture 690-0025, Japan
| | - Hajime Isomoto
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori prefecture 683-8504, Japan
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Qualls D, Seethapathy H, Bates H, Tajmir S, Heidari P, Endres P, Reynolds K, Lawrence D, Sise M. Positron emission tomography as an adjuvant diagnostic test in the evaluation of checkpoint inhibitor-associated acute interstitial nephritis. J Immunother Cancer 2019; 7:356. [PMID: 31864416 PMCID: PMC6925427 DOI: 10.1186/s40425-019-0820-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/13/2019] [Indexed: 11/21/2022] Open
Abstract
Background Acute interstitial nephritis is an immune-related adverse event that can occur in patients receiving immune checkpoint inhibitor therapy. Differentiating checkpoint inhibitor-associated acute interstitial nephritis from other causes of acute kidney injury in patients with cancer is challenging and can lead to diagnostic delays and/or unwarranted immunosuppression. In this case report, we assess the use of 18F-flourodeoxyglucose positron-emission tomography imaging as an alternative diagnostic modality in the evaluation of potential acute interstitial nephritis. Case presentation A 55-year-old woman with metastatic vulvar melanoma underwent treatment with two cycles of ipilimumab plus nivolumab, followed by seven cycles of nivolumab combined with radiation therapy. During her treatment, she developed non-oliguric acute kidney injury to a creatinine of 4.5 mg/dL from a baseline of 0.5 mg/dL. A clinical diagnosis of acute interstitial nephritis was made, and steroids were initiated, with rapid improvement of her acute kidney injury. Retrospectively, four positron-emission tomography scans obtained for cancer staging purposes were reviewed. We found a markedly increased 18F-flourodeoxyglucose uptake in the renal cortex at the time acute interstitial nephritis was diagnosed compared to baseline. In three cases of acute kidney injury due to alternative causes there was no increase in 18F-flourodeoxyglucose uptake from baseline. Conclusions To our knowledge, this is the first report describing increased 18F-flourodeoxyglucose uptake in the renal cortex in a patient with checkpoint inhibitor-associated acute interstitial nephritis. Our findings suggest that 18F-flourodeoxyglucose positron-emission tomography may be a valuable test for diagnosing immune-mediated nephritis, particularly in patients where timely kidney biopsy is not feasible.
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Affiliation(s)
- David Qualls
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Harish Seethapathy
- Division of Nephrology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge Street Suite 302, Boston, MA, 02114, USA
| | | | - Shahein Tajmir
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Pedram Heidari
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Paul Endres
- Division of Nephrology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge Street Suite 302, Boston, MA, 02114, USA
| | - Kerry Reynolds
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Donald Lawrence
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Meghan Sise
- Division of Nephrology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge Street Suite 302, Boston, MA, 02114, USA.
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