Imaging assessment of toxicity related to immune checkpoint inhibitors

Adoptive T-Cell Therapy in Melanoma: How This Will Impact Surgical Practice and the Role of Surgeons

Melanoma is one of a small number of cancers where there is a clear role for surgery in selected patients with metastatic disease. However, the role of surgery for metastatic melanoma in the age of immune checkpoint blockade is not clearly delineated. Adoptive cell therapies, which include tumor-infiltrating lymphocytes and chimeric antigen receptor T cells, often require metastasectomy to obtain the tumor-specific immune cells and/or antigens necessary to create personalized cell-based products. It is, therefore, essential that the surgeon be well-versed in techniques for procuring appropriate tissue and familiar with their delivery to ensure appropriate preoperative planning and postoperative recovery.

Muscle atrophy and organ enlargement associated with quality of life during systemic therapy for melanoma: findings from an AI-based body composition analysis

INTRODUCTION

Health-related quality of life (HRQoL) is emerging as an endpoint, adjunct to survival, in cancer treatment. For this reason, the European Organization for Research and Treatment of Cancer (EORTC) has developed standardized quality-of-life questionnaires to collect patient-reported outcome measurement (PROM), which so far have been widely used in clinical trials to evaluate the impact of new drugs on cancer patients. However, while these questionnaires comprehensively describe patient functions, little is known about their association with patient characteristics. This study aims to bridge this gap and investigate the association between patient body composition and HRQoL.

MATERIALS AND METHODS

A retrospective cohort of melanoma patients treated with systemic therapy who completed HRQoL questionnaires and had regular imaging follow-ups was included. The primary endpoint was the association between n = 116 AI-measured longitudinal volumes of thoracic and abdominal organs, subcutaneous and visceral fat, skeleton and muscles (estimated by TotalSegmentator), and physical functioning (PF), role functioning (RF) and fatigue (FA) (estimated by the EORTC-QLQ-C30).

RESULTS

The n = 358 patients were included. Our findings show larger liver, spleen, and gallbladder volumes associated with decreased PF and RF and an increase in FA (p < 0.05). Furthermore, larger muscle volumes were associated with an increase in PF and RF and a decrease in FA (p < 0.01).

DISCUSSION

Our findings show significant associations between AI-measured body and organ analysis and HRQoL in patients with melanoma on systemic treatment. Future research is needed to understand the underlying cause and determine the possible predictive ability of these imaging features.

KEY POINTS

Question Are changes in body composition associated with changes in HRQoL in melanoma patients undergoing systemic therapy? Findings AI-based body composition analysis shows that larger muscle volumes are linked to improved HRQoL, while organ enlargement is associated with a decline in it. Clinical relevance Our findings indicate new imaging biomarkers that can help monitor patients and evaluate treatment responses. These biomarkers link patient function to physical changes during treatment, offering insights for creating response evaluation criteria that also consider improvements in quality of life.

Multimodality Imaging and Immune-Related Adverse Events During Immune Checkpoint Inhibitors Treatment: Where Do We Stand?

Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy, significantly improving survival across various malignancies. However, these therapies are associated with various types of immune-related adverse events (irAEs), including cardiotoxicity, a spectrum of rare but potentially life-threatening complications impacting significantly morbidity and mortality. Cardiovascular imaging has become key in cardio-oncology, providing essential diagnostic tools for early detection and monitoring. This review synthesizes current evidence and underlines the pivotal role of early and tailored imaging strategies in managing ICI-induced cardiotoxicity. By bridging the knowledge gap, it aims to provide targetable insights to optimize the clinical management in patients undergoing immunotherapy.

Radiomics and Deep Learning Prediction of Immunotherapy-Induced Pneumonitis From Computed Tomography

PURPOSE

Primary barriers to application of immune checkpoint inhibitor (ICI) therapy for cancer include severe side effects (such as potentially life threatening pneumonitis [PN]), which can cause the discontinuation of treatment. Predicting which patients may develop PN while on ICI would improve both safety and potential efficacy because treatments could be safely administered for longer or discontinued before severe toxicity.

METHODS

Starting from a cohort of 3,351 patients with cancer who received previous ICI therapy at the Vanderbilt University Medical Center, we curated 2,700 contrast chest computed tomography (CT) volumes for 671 patients. Three different pure imaging models predicted the potential for PN using only a single time point before the first ICI dose.

RESULTS

The first model used 109 radiomics features only and achieved an AUC of 0.747 (CI, 0.705 to 0.789) with a positive predictive value (PPV) of 0.244 (CI, 0.211 to 0.276) at a sensitivity of 0.553 (CI, 0.485 to 0.621) using mainly features describing the global lung properties. The second model used a convolutional neural network (CNN) on the raw CTs to improve to an AUC of 0.819 (CI, 0.781 to 0.857) with a PPV of 0.244 (CI, 0.203 to 0.284) at a sensitivity of 0.743 (CI, 0.681 to 0.806). The third model combined both radiomics and deep learning but, with an AUC of 0.829 (CI, 0.797 to 0.862) and a PPV of 0.254 (CI, 0.228 to 0.281) at a sensitivity of 0.780 (CI, 0.721 to 0.840), did not show a significant improvement on the CNN-only model.

CONCLUSION

This new model suggests the utility of deep learning in PN prediction over traditional pure radiomics and promises better management for patients receiving ICI and the ability to better stratify patients in immunotherapy drug trials.

Is 18F-FDG-PET/CT an Optimal Imaging Modality for Detecting Immune-Related Adverse Events after Immune-Checkpoint Inhibitor Therapy? Pros and Cons

Immunotherapy with immune checkpoint inhibitors (ICIs) has revolutionized contemporary oncology, presenting efficacy in various solid tumors and lymphomas. However, ICIs may potentially overstimulate the immune system, leading to immune-related adverse events (irAEs). IrAEs may affect multiple organs, such as the colon, stomach, small intestine, kidneys, skin, lungs, joints, liver, lymph nodes, bone marrow, brain, heart, and endocrine glands (e.g., pancreas, thyroid, or adrenal glands), exhibiting autoimmune inflammation. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) is commonly used in oncology for staging and assessment of therapy responses, but it may also serve as a tool for detecting irAEs. This review aims to present various patterns of metabolic activation associated with irAEs due to ICI treatment, identifiable through 18F-FDG PET/CT. It describes the advantages of early detection of irAEs, but also presents the challenges in differentiating them from tumor progression. It also delves into aspects of molecular response assessment within the context of pseudoprogression and hyperprogression, along with typical imaging findings related to these phenomena. Lastly, it summarizes the role of functional PET imaging in oncological immunotherapy, speculating on its future significance and limitations.

Cancer Immunotherapy and Medical Imaging Research Trends from 2003 to 2023: A Bibliometric Analysis

Purpose

With the rapid development of immunotherapy, cancer treatment has entered a new phase. Medical imaging, as a primary diagnostic method, is closely related to cancer immunotherapy. However, until now, there has been no systematic bibliometric analysis of the state of this field. Therefore, the main purpose of this article is to clarify the past research trajectory, summarize current research hotspots, reveal dynamic scientific developments, and explore future research directions.

Patients and Methods

A comprehensive search was conducted on the Web of Science Core Collection (WoSCC) database to identify publications related to immunotherapy specifically for the medical imaging of carcinoma. The search spanned the period from the year 2003 to 2023. Several analytical tools were employed. These included CiteSpace (6.2.4), and the Microsoft Office Excel (2016).

Results

By searching the database, a total of 704 English articles published between 2003 and 2023 were obtained. We have observed a rapid increase in the number of publications since 2018. The two most active countries are the United States (n=265) and China (n=170). Pittock, Sean J and Abu-sbeih, Hamzah are very concerned about the relationship between cancer immunotherapy and medical images and have published more academic papers (n = 5; n = 4). Among the top 10 co-cited authors, Topalian Sl (n=43) cited ranked first, followed by Graus F (n=40) cited. According to clustering, timeline, and burst word analysis, the results show that the current research focus is on "MRI", "deep learning", "tumor microenvironment" and so on.

Conclusion

Medical imaging and cancer immunotherapy are hot topics. The United States is the country with the most publications and the greatest influence in this field, followed by China. "MRI", "PET/PET-CT", "deep learning", "immune-related adverse events" and "tumor microenvironment" are currently hot research topics and potential targets.

[Imaging in immunotherapy for tumor diseases]

Immunotherapeutic agents and in particular immune checkpoint inhibitors (ICI) have opened up extensive new therapeutic possibilities in oncology over the last decade. For numerous entities these substances have improved the clinical outcome, sometimes as monotherapy but also in combination with cytostatic or targeted treatment. In routine clinical practice the type of radiological response often differs from what is seen under cytostatic treatment: a mixed response of individual lesions is more frequently observed and occasionally also a response after an initial progress (so-called pseudoprogression). Furthermore, there is a diverse spectrum of toxicity in the form of immune-related adverse events (irAE), which is observed in large temporal variability to the application. Therefore, early detection and rapid side effect management are essential.

Enterocolitis and other immunotherapy and targeted therapy-related gastrointestinal manifestations: A review for gastroenterologist

New oncologic treatments, particularly immunotherapy (IT), have revolutionized the treatment of advanced-stage malignant tumors. Immune checkpoint inhibitors are the main form of IT and act by increasing T cell activity and the organism's immune response against neoplastic cells. Targeted therapy is another form of IT that acts by inhibiting oncogenes or inflammation signaling and tumor angiogenesis pathways. However, these mechanisms of tumor destruction can interfere with the host's immune self-tolerance or with the mechanisms of epithelial tissue repair and predispose to immune system-mediated adverse events that can affect multiple organs, including the digestive tract. The gastrointestinal manifestations of damage caused by IT can range from low-grade mucositis to ulceration, and in some cases, necrosis and perforation. Any part of the gastrointestinal tract can be affected, but there is greater involvement of the small bowel and colon, with a pattern similar to that seen in inflammatory bowel disease. The most common clinical manifestation is chronic diarrhea. The differential diagnosis includes enteropathogenic infections, especially those caused by opportunistic microorganisms; adverse drug reactions; and other inflammatory and malabsorption disorders. Treatment is guided by damage severity. Mild cases can be treated with antidiarrheals and rehydration in the outpatient setting; moderate cases with hospitalization, systemic steroids, and temporary suspension of IT; and severe cases with immunosuppressants or biologic agents and definitive suspension of IT.

Recurrent Pericardial Effusion in a Patient With Delayed Progression of Melanoma Treated With Immune Checkpoint Inhibitors

Two commonly used immune checkpoint inhibitors (ICIs) utilized in the treatment of metastatic melanoma are nivolumab, a programmed death (PD-1) checkpoint inhibitor, and ipilimumab, a cytotoxic T-lymphocyte antigen (CTLA-4) checkpoint inhibitor. However, due to the activation of the immune system, ICIs have been associated with cardiotoxic immune-related adverse events (irAEs). Here, we present a 40-year-old male with stage 4 metastatic melanoma treated with nivolumab and ipilimumab who developed recurrent pericardial effusions and subsequent constrictive pericarditis 10 months after initiation of treatment. He initially received a total of four cycles and was started on maintenance nivolumab on 8/2022. On 3/23/2023, he complained of chest pain and was found to be hypotensive. He subsequently underwent an emergent pericardiocentesis where 330cc of serosanguinous fluid was drained. Repeat echo on 3/24 demonstrated a re-accumulation of a moderate-sized pericardial effusion, and a subxiphoid pericardial window was placed. He again presented on 5/24/2023 with similar complaints, and a CT scan of chest showed enlarged pericardial effusion with new bilateral pleural effusions.  To our knowledge, this is one of few case reports discussing pericardial effusions in the setting of nivolumab and ipilimumab ICI immunotherapy.

Neoadjuvant Immunotherapy for Localized Pancreatic Cancer: Challenges and Early Results

Pancreatic ductal adenocarcinoma (PDAC) is a highly lethal disease due to its late presentation and tendency to recur early even after optimal surgical resection. Currently, there are limited options for effective systemic therapy. In addition, PDAC typically generates an immune-suppressive tumor microenvironment; trials of immunotherapy in metastatic PDAC have yielded disappointing results. There is considerable interest in using immunotherapy approaches in the neoadjuvant setting in order to prime the immune system to detect and prevent micrometastatic disease and recurrence. A scoping review was conducted to identify published and ongoing trials utilizing preoperative immunotherapy. In total, 9 published trials and 27 ongoing trials were identified. The published trials included neoadjuvant immune checkpoint inhibitors, cancer vaccines, and other immune-modulating agents that target mechanisms distinct from that of immune checkpoint inhibition. Most of these are early phase trials which suggest improvements in disease-free and overall survival when combined with standard neoadjuvant therapy. Ongoing trials are exploring various combinations of these agents with each other and with chemotherapy and/or radiation. Rational combination immunotherapy in addition to standard neoadjuvant therapy has the potential to improve outcomes in PDAC, but further clinical trials are needed, particularly those which utilize an adaptive trial design.