1
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Myers SP, Sevilimedu V, Jones VM, Abuhadra N, Montagna G, Plitas G, Morrow M, Downs-Canner SM. Impact of Neoadjuvant Chemoimmunotherapy on Surgical Outcomes and Time to Radiation in Triple-Negative Breast Cancer. Ann Surg Oncol 2024:10.1245/s10434-024-15359-w. [PMID: 38767803 DOI: 10.1245/s10434-024-15359-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/09/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND We examined the association between immunotherapy-containing and standard chemotherapy regimens with treatment delays and postoperative complications in stage II-III triple-negative breast cancer. The effect of immune-related adverse events (irAEs) was compared. PATIENTS AND METHODS We compared 139 women treated with neoadjuvant pembrolizumab plus chemotherapy (KEYNOTE-522 regimen) from August 2021 to September 2022 with 287 consecutive patients who received neoadjuvant chemotherapy alone prior to July 2021 and underwent surgery. Baseline characteristics, time to treatments, and surgical complications were compared using two-sample non-parametric tests. Linear regression evaluated association of irAEs with time to surgery and radiation. Logistic regression identified factors associated with surgical complications. RESULTS Age, body mass index, race, American Society of Anesthesiologists (ASA) class, and mastectomy rates were similar among cohorts. No clinically relevant difference in time from end of neoadjuvant treatment to surgery was observed [KEYNOTE-522: median 32 (IQR 27, 43) days; non-KEYNOTE-522: median 31 (IQR 26, 37) days; P = 0.048]. Time to radiation did not differ (P = 0.7). A total of 26 patients (9%; non-KEYNOTE-522) versus 11 (8%; KEYNOTE-522) experienced postoperative complications (P = 0.6). In the KEYNOTE-522 cohort, 59 (43%) of 137 patients experienced 82 irAEs; 40 (68%) required treatment. Older age (P = 0.018) and ASA class 4 (P = 0.007) were associated with delays to surgery after adjusting for clinical factors. Experiencing ≥ 1 irAE was associated with delay to radiation (P = 0.029). IrAEs were not associated with surgical complications (P = 0.4). CONCLUSIONS We observed no clinically meaningful difference between times to surgery/adjuvant radiation or postoperative complications and type of preoperative chemotherapy. IrAEs were associated with delay to adjuvant radiation but not with postoperative complications or delay to surgery.
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Affiliation(s)
- Sara P Myers
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - V Morgan Jones
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nour Abuhadra
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - George Plitas
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stephanie M Downs-Canner
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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2
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Tang YH, Bergmann J, Vaidya D, Faraday N. Association of Preoperative Immune Checkpoint Inhibitor Therapy With Cardiopulmonary Instability and Organ Injury After High-Risk Surgery. Crit Care Explor 2024; 6:e1068. [PMID: 38562380 PMCID: PMC10984666 DOI: 10.1097/cce.0000000000001068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVES To assess the relationship between prior exposure to immune checkpoint inhibitors (ICIs) and the risk of postoperative complications in cancer patients. DESIGN Single-center retrospective cohort study. INTERVENTIONS The main exposure was treatment with an FDA-approved ICI within 6 months before surgery. MEASUREMENTS AND MAIN RESULTS Exposure to ICIs and covariates was determined from the electronic health record. The primary outcome was a composite of postoperative complications, including prolonged pressor or oxygen dependence, kidney injury, or myocardial injury. Secondary outcomes included each subcomponent of the primary outcome. Of 7674 subjects with cancer admitted to the ICU after surgery, 247 were exposed to one or more ICIs in the 6 months before surgery. After propensity score matching, 197 ICI-exposed subjects were matched to 777 nonexposed. The composite outcome occurred in 70 of 197 (35.5%) ICI-exposed subjects and 251 of 777 (32.3%) nonexposed. There was no difference between exposed and nonexposed groups in the primary composite outcome (odds ratio [OR], 1.12; 95% CI, 0.80-1.58) by conditional logistic regression. Risk of the secondary outcome of prolonged pressor dependence was significantly higher in ICI-exposed subjects (OR, 1.64; 95% CI, 1.01-2.67). Risks of oxygen dependence (OR, 1.13; 95% CI, 0.75-1.73), kidney injury (OR, 1.15; 95% CI, 0.77-1.71), and myocardial injury (OR, 1.76; 95% CI, 1.00-3.10) were not significantly different. There was no difference between groups in the time to hospital discharge alive (p = 0.62). CONCLUSIONS Exposure to ICIs within 6 months before high-risk surgery was not associated with the composite outcome of cardiopulmonary instability or organ injury in patients with cancer. The potential for an association with the secondary outcomes of cardiac instability and injury is worthy of future study.
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Affiliation(s)
- Ying-Hung Tang
- Department of Anesthesiology, Mackay Memorial Hospital, Taipei, Taiwan
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Jules Bergmann
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dhananjay Vaidya
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nauder Faraday
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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3
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Philips R, Alnemri A, Amin D, Patel J, Topf MC, Johnson JM, BarAd V, Axelrod R, Argiris A, Fundakowski C, Luginbuhl AJ, Cognetti DM, Curry JM. Effect of preoperative programmed death-1 or programmed death ligand-1 immune check point inhibition on complications after surgery for primary head and neck cancer. Cancer 2024; 130:863-875. [PMID: 37788128 DOI: 10.1002/cncr.35045] [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: 09/05/2022] [Revised: 07/29/2023] [Accepted: 08/03/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND There is sparse literature on the effect of preoperative immunotherapy on complications after surgery for primary head and neck squamous cell carcinoma (HNSCC). The objectives are to compare complication rates in patients receiving surgery with and without neoadjuvant immune checkpoint inhibitors (nICI) for primary HNSCC and to evaluate factors associated with increased odds of surgical complications. METHODS A retrospective review of patients who underwent ablation and free flap reconstruction or transoral robotic surgery (TORS) for primary HNSCC between 2017-2021 was conducted. Complications were compared between patients who underwent surgery with or without nICI before and after propensity score matching. Regression analysis to estimate odds ratios was performed. RESULTS A total of 463 patients met inclusion criteria. Free flap reconstruction constituted 28.9% of patients and TORS constituted 71.1% of patients. nICI was administered in 83 of 463 (17.9%) patients. There was no statistically significant difference in surgical, medical, or overall complications between patients receiving surgery with or without nICI. In the unmatched cohort, multivariable model identified non-White race, former/current smoking history, free flap surgery, and perineural invasion as factors significantly associated with increased complications. In the matched cohort, multivariable model identified advanced age and free flap surgery as factors significantly associated with increased complications. PLAIN LANGUAGE SUMMARY It is safe to give immunotherapy before major surgery in patients who have head and neck cancer. Advanced age, non-White race, current/former smoking, free flap surgery, and perineural invasion may be associated with increased the odds of surgical complications.
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Affiliation(s)
- Ramez Philips
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Angela Alnemri
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Dev Amin
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jena Patel
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael C Topf
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jennifer M Johnson
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
- Department of Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Voichita BarAd
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Rita Axelrod
- Department of Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Athanassios Argiris
- Department of Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Christopher Fundakowski
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Adam J Luginbuhl
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - David M Cognetti
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Joseph M Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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4
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Popovich SM, Vetter TR. Preoperative Management of the Adult Oncology Patient. Anesthesiol Clin 2024; 42:145-158. [PMID: 38278586 DOI: 10.1016/j.anclin.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
Anesthesiologists are experiencing first-hand the aging population, given older patients more frequently presenting for surgery, often with geriatric syndromes influencing their anesthetic management. The overall incidence and health burden of cancer morbidity and mortality are also rapidly increasing worldwide. This growth in the cancer population, along with the associated risk factors and comorbidities often accompanying a cancer diagnosis, underscores the need for anesthesiologists to become well versed in the preoperative evaluation and management of the adult patient with cancer. This article will focus on the unique challenges and opportunities for the anesthesiologist caring for the adult oncology patient presenting for surgery.
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Affiliation(s)
- Shannon M Popovich
- Department of Anesthesiology and Perioperative Medicine, Division of Anesthesiology, Critical Care Medicine and Pain Medicine, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Thomas R Vetter
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Health Discovery Building, Room 6.812, 1701 Trinity Street, Austin, TX 78712-1875, USA.
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5
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Talbot LJ, Lautz TB, Aldrink JH, Ehrlich PF, Dasgupta R, Mattei P, Tracy ET, Glick RD, Grant CM, Brown EG, Christison-Lagay ER, Rodeberg DA. Implications of Immunotherapy for Pediatric Malignancies: A Summary from the APSA Cancer Committee. J Pediatr Surg 2023; 58:2119-2127. [PMID: 37550134 DOI: 10.1016/j.jpedsurg.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 06/01/2023] [Accepted: 07/01/2023] [Indexed: 08/09/2023]
Abstract
Although survival for many pediatric cancers has improved with advances in conventional chemotherapeutic regimens and surgical techniques in the last several decades, it remains a leading cause of disease-related death in children. Outcomes in patients with recurrent, refractory, or metastatic disease are especially poor. Recently, the advent of alternative classes of therapies, including immunotherapies, have revolutionized systemic treatment for pediatric malignancies. Several classes of immunotherapies, including chimeric antigen receptor (CAR) T cell therapy, transgenic T-cell receptor (TCR)-T cell therapy, bispecific T-cell engagers, and monoclonal antibody checkpoint inhibitors have been FDA-approved or entered early-phase clinical trials in children and young adults. The pediatric surgeon is likely to encounter these therapies during the care of children with malignancies and should be familiar with the classes of therapy, indications, adverse events, and potential need for surgical intervention in these cases. This review from the APSA Cancer Committee offers a brief discussion of the three most encountered classes of immunotherapy in children and young adults and discusses surgical relevance. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
| | - Timothy B Lautz
- Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Peter F Ehrlich
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Peter Mattei
- General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa, USA
| | - Elisabeth T Tracy
- Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Richard D Glick
- Division of Pediatric Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Christa M Grant
- Division of Pediatric Surgery, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY, USA
| | - Erin G Brown
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Emily R Christison-Lagay
- Division of Pediatric Surgery, Department of Surgery, Yale School of Medicine, Yale-New Haven Children's Hospital, New Haven, CT, USA
| | - David A Rodeberg
- Division of Pediatric Surgery, Department of Surgery, East Carolina University, Greenville, NC, USA
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6
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Sindt JE, Fitzgerald LA, Kuznicki J, Prelewicz S, Odell DW, Brogan SE. Antiplatelet and Wound Healing Implications of Immunotherapy and Targeted Cancer Therapies in the Perioperative Period. Anesthesiology 2023; 139:511-522. [PMID: 37698434 DOI: 10.1097/aln.0000000000004669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
The traditional paradigm of oncologic treatment centered on cytotoxic chemotherapy has undergone tremendous advancement during the last 15 yr with the advent of immunotherapy and targeted cancer therapies. These agents, including small molecule inhibitors, monoclonal antibodies, and immune-checkpoint inhibitors, are highly specific to individual tumor characteristics and can prevent cell growth and tumorigenesis by inhibiting specific molecular targets or single oncogenes. While generally better tolerated than traditional chemotherapy, these therapies are associated with unique constellations of adverse effects. Of particular importance in the perioperative and periprocedural settings are hematologic abnormalities, particularly antiplatelet effects with increased risk of bleeding, and implications for wound healing. This narrative review discusses targeted cancer therapies and provides recommendations for physicians managing these patients' care as it relates to procedural or surgical interventions.
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Affiliation(s)
- Jill E Sindt
- Division of Pain Medicine, Department of Anesthesiology, University of Utah-Huntsman Cancer Institute, Salt Lake City, Utah
| | - Lindsey A Fitzgerald
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah-Huntsman Cancer Institute, Salt Lake City, Utah
| | - Joanne Kuznicki
- Department of Pharmacy, University of Utah-Huntsman Cancer Institute, Salt Lake City, Utah
| | - Stacy Prelewicz
- Department of Pharmacy, University of Utah-Huntsman Cancer Institute, Salt Lake City, Utah
| | - Daniel W Odell
- Division of Pain Medicine, Department of Anesthesiology, University of Utah-Huntsman Cancer Institute, Salt Lake City, Utah
| | - Shane E Brogan
- Division of Pain Medicine, Department of Anesthesiology, University of Utah-Huntsman Cancer Institute, Salt Lake City, Utah
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7
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Nahm WJ, de Imus G, Mathe CA, Saap L, Joseph S, Chen S, Falanga V. A case of markedly impaired wound repair with angiostatic pazopanib in a patient who had Mohs surgery for a basal cell carcinoma. SAGE Open Med Case Rep 2023; 11:2050313X231200967. [PMID: 37736143 PMCID: PMC10510339 DOI: 10.1177/2050313x231200967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/21/2023] [Indexed: 09/23/2023] Open
Abstract
This case report highlights the adverse effects of pazopanib, a vascular endothelial growth factor receptor inhibitor, on wound healing after Mohs surgery. A 79-year-old male with metastatic renal cell carcinoma of the lung, on 600 mg daily pazopanib, underwent Mohs surgery for a nodular basal cell carcinoma on his right leg. Despite multiple wound care strategies, his wound deteriorated over 4 months. Discontinuing pazopanib resulted in rapid wound closure within 2 months. However, metastatic lung nodules grew, prompting treatment with immune checkpoint inhibitors, nivolumab, and ipilimumab, which were discontinued due to complications. Near-complete wound healing was observed prior to reintroducing pazopanib (6 months after initial discontinuation), which again led to wound deterioration. Pazopanib negatively impacts wound repair by inhibiting cell proliferation and angiogenesis. Depending on the malignancy or tumor, cessation of pazopanib, or switching to a course of immune checkpoint inhibitors may be warranted perioperatively.
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Affiliation(s)
| | - Gail de Imus
- Dermatology and Skin Surgery, Providence Medical Group, Mukilteo, WA, USA
| | - Christopher A Mathe
- California University of Science and Medicine School of Medicine, Colton, CA, USA
| | | | | | - Stanley Chen
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Vincent Falanga
- Department of Dermatology, Dartmouth-Mary Hitchcock Medical Center, Lebanon, NH, USA
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8
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De Camilli A, Fischer G. Novel Cellular and Immunotherapy: Toxicities and Perioperative Implications. Curr Oncol 2023; 30:7638-7653. [PMID: 37623035 PMCID: PMC10453139 DOI: 10.3390/curroncol30080554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/19/2023] [Accepted: 08/04/2023] [Indexed: 08/26/2023] Open
Abstract
Targeted cellular and immunotherapies have welcomed a new chapter in multi-modal cancer therapy. These agents harness our innate immune system and destroy malignant cells in a precise way as compared with "legacy" chemotherapeutic agents that largely rely on abolishing cell division. New therapies can augment the T-cell recognition of tumor antigens and effectively prevent tumor cells from their historically successful ability to evade immune recognition. These novel agents cause acute and chronic toxicities to a variety of organ systems (enteritis, pneumonitis, hypophysitis, and hepatitis), and this may masquerade as other chronic illnesses or paraneoplastic effects. As the perioperative footprint of cancer patients increases, it is essential that perioperative providers-anesthesiologists, surgeons, nurse anesthetists, and inpatient hospital medicine providers-be up to date on the physiologic mechanisms that underlie these new therapies as well as their acute and subacute toxicity profiles. Immunotherapy toxicity can significantly impact perioperative morbidity as well as influence perioperative management, such as prophylaxis for adrenal insufficiency, preoperative pulmonary assessment, and screening for thyroid dysfunction, among others.
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Affiliation(s)
| | - Gregory Fischer
- Memorial Sloan Kettering, 1275 York Avenue, New York, NY 10065, USA
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9
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Barbosa EC, Bucar EEC, Jubé GR, Silveira LB, Silva NCD, Faria PCC, Ramos PLC, Moraes VRY, Barros JOB. Fecal microbiota transplantation and its repercussions in patients with melanoma refractory to anti-PD-1 therapy: scope review. Rev Col Bras Cir 2023; 50:e20233490. [PMID: 37222345 PMCID: PMC10508684 DOI: 10.1590/0100-6991e-20233490-en] [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: 10/24/2022] [Accepted: 02/24/2023] [Indexed: 05/25/2023] Open
Abstract
INTRODUCTION despite being extremely effective in some cases, up to 70% of patients with melanoma do not respond to anti-PD-1/PD-L1 (primary resistance) and many of the responders eventually progress (secondary resistance). Extensive efforts are being made to overcome this resistance through new strategies, especially aimed at modulating the intestinal microbiota. OBJECTIVE to assess whether fecal microbiota transplantation (FMT), associated with immunotherapy, is beneficial in the clinical course of patients with refractory melanoma. METHODS this is a scope review, based on studies collected on the MEDLINE, ScienceDirect, The Cochrane Library, Embase and BMJ Journals; using the terms: "Antibodies, Monoclonal"; "Drug Resistance, Neoplasm"; "Fecal Microbiota Transplantation"; "Host Microbial Interactions"; "Immunotherapy"; "Melanoma"; and "Microbiota". Clinical trials, in English, with relevant data on the subject and fully available were included. A cut-off period was not determined, due to the limited amount of evidence on the topic. RESULTS crossing the descriptors allowed the identification of 342 publications and, after applying the eligibility criteria, allowed the selection of 4 studies. From the analyses, it was observed that a considerable part of those studied overcame resistance to immune checkpoint inhibitors after FMT, with better response to treatment, less tumor growth and increased beneficial immune response. CONCLUSION it is noted that FMT favors the response of melanoma to immunotherapy, translated into significant clinical benefit. However, further studies are necessary for the complete elucidation of the bacteria and the mechanisms involved, as well as for the translation of new evidence to oncological care practice.
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Affiliation(s)
| | | | | | | | | | | | | | | | - João Ormindo Beltrão Barros
- - Universidade Evangélica de Goiás, Medicina - Anápolis - GO - Brasil
- - Hospital Santa Casa de Anápolis, Cancerologia Cirúrgica - Anápolis - GO - Brasil
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10
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Review to Understand the Crosstalk between Immunotherapy and Tumor Metabolism. MOLECULES (BASEL, SWITZERLAND) 2023; 28:molecules28020862. [PMID: 36677919 PMCID: PMC9863813 DOI: 10.3390/molecules28020862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 01/19/2023]
Abstract
Immune checkpoint inhibitors have ushered in a new era of cancer treatment by increasing the likelihood of long-term survival for patients with metastatic disease and by introducing fresh therapeutic indications in cases where the disease is still in its early stages. Immune checkpoint inhibitors that target the proteins cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) or programmed death-1/programmed death ligand-1 have significantly improved overall survival in patients with certain cancers and are expected to help patients achieve complete long-lasting remissions and cures. Some patients who receive immune checkpoint inhibitors, however, either experience therapeutic failure or eventually develop immunotherapy resistance. Such individuals are common, which necessitates a deeper understanding of how cancer progresses, particularly with regard to nutritional regulation in the tumor microenvironment (TME), which comprises metabolic cross-talk between metabolites and tumor cells as well as intracellular metabolism in immune and cancer cells. Combination of immunotherapy with targeted metabolic regulation might be a focus of future cancer research despite a lack of existing clinical evidence. Here, we reviewed the significance of the tumor microenvironment and discussed the most significant immunological checkpoints that have recently been identified. In addition, metabolic regulation of tumor immunity and immunological checkpoints in the TME, including glycolysis, amino acid metabolism, lipid metabolism, and other metabolic pathways were also incorporated to discuss the possible metabolism-based treatment methods being researched in preclinical and clinical settings. This review will contribute to the identification of a relationship or crosstalk between tumor metabolism and immunotherapy, which will shed significant light on cancer treatment and cancer research.
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11
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Masada KM, Blumenthal SR, Cipriano CA. Fixation Principles for Pathologic Fractures in Metasatic Disease. Orthop Clin North Am 2023; 54:47-57. [PMID: 36402510 DOI: 10.1016/j.ocl.2022.08.010] [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: 11/18/2022]
Abstract
The management of pathologic fractures differs from nonpathologic fractures with respect to preoperative evaluation, surgical strategies, adjuvant therapies, and complication rates. These issues must be understood to provide appropriate musculoskeletal care for patients with metastatic disease.
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Affiliation(s)
- Kendall M Masada
- Department of Orthopaedic Surgery, University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA.
| | - Sarah R Blumenthal
- Department of Orthopaedic Surgery, University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA
| | - Cara A Cipriano
- Hospital of the University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA
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12
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Panian J, Hirotsu KE, Loh TY, Jiang SIB. Post-Operative Complications in Patients on Immune Checkpoint Inhibitors Undergoing Mohs Micrographic Surgery. J Cutan Med Surg 2023; 27:71-73. [PMID: 36411993 DOI: 10.1177/12034754221139275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Justine Panian
- 8784 School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Kelsey E Hirotsu
- 8784 Department of Dermatology, University of California San Diego, San Diego, CA, USA
| | - Tiffany Y Loh
- 8784 Department of Dermatology, University of California San Diego, San Diego, CA, USA
| | - Shang I Brian Jiang
- 8784 Department of Dermatology, University of California San Diego, San Diego, CA, USA
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13
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Childers BG, Donovan E, Lo WM, Janowak LM, Sussman J, Janowak CF. Operative management of immune checkpoint colitis following in-transit melanoma: Case report. Front Oncol 2023; 13:1120808. [PMID: 37152059 PMCID: PMC10157394 DOI: 10.3389/fonc.2023.1120808] [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] [Received: 12/10/2022] [Accepted: 03/27/2023] [Indexed: 05/09/2023] Open
Abstract
Immune checkpoint inhibitors are increasingly used as powerful anti-neoplastic therapies in the setting of melanoma. Colitis is a known complication of immune checkpoint inhibitors that if often medically managed. We present a patient with stage IV melanoma with demonstrated in-transit disease undergoing immune checkpoint inhibitor therapy. The patient subsequently developed recalcitrant severe colitis that necessitated operative intervention and bowel resection. The association of immune check point inhibitors and immune related adverse effects are discussed as well as treatments of advanced colitis, including the possibility of surgical management in the setting of severe colitis with complications.
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Affiliation(s)
| | - Eileen Donovan
- College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Winifred M. Lo
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Lauren M. Janowak
- College of Nursing, University of Cincinnati, Cincinnati, OH, United States
| | - Jeffrey Sussman
- College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Christopher F. Janowak
- College of Medicine, University of Cincinnati, Cincinnati, OH, United States
- *Correspondence: Christopher F. Janowak,
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14
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Baldwin XL, Spanheimer PM, Downs-Canner S. A Review of Immune Checkpoint Blockade for the General Surgeon. J Surg Res 2023; 281:289-298. [PMID: 36228339 PMCID: PMC10029124 DOI: 10.1016/j.jss.2022.08.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/01/2022] [Accepted: 08/20/2022] [Indexed: 11/21/2022]
Abstract
The immune system is a complex and interconnected system that has evolved to protect its host from foreign pathogens. CD8+ T cells are a type of immune cell that can be directly lethal to tumor cells. However, their tumor killing capabilities can be inhibited by checkpoint molecules. During the last decade, the development of medications that block these checkpoint molecules has revolutionized treatment for some cancer types and indications for use continue to grow. As usage of immunotherapy increases, toxicities and adverse events unique to immunotherapy are becoming more prevalent. Here, we review the commonly targeted inhibitory molecules along with their food and drug administration-approved indications in various cancer therapeutic regimens, immunotherapy-related toxicities, and how this may impact surgical planning.
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Affiliation(s)
- Xavier L Baldwin
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Philip M Spanheimer
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Stephanie Downs-Canner
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, New York.
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15
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Wang Y, Wang Y, Ren Y, Zhang Q, Yi P, Cheng C. Metabolic modulation of immune checkpoints and novel therapeutic strategies in cancer. Semin Cancer Biol 2022; 86:542-565. [PMID: 35151845 DOI: 10.1016/j.semcancer.2022.02.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 12/08/2021] [Accepted: 02/05/2022] [Indexed: 02/07/2023]
Abstract
Cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) or programmed death-1 (PD-1)/programmed death-ligand 1 (PD-L1)-based immune checkpoint inhibitors (ICIs) have led to significant improvements in the overall survival of patients with certain cancers and are expected to benefit patients by achieving complete, long-lasting remissions and cure. However, some patients who receive ICIs either fail treatment or eventually develop immunotherapy resistance. The existence of such patients necessitates a deeper understanding of cancer progression, specifically nutrient regulation in the tumor microenvironment (TME), which includes both metabolic cross-talk between metabolites and tumor cells, and intracellular metabolism in immune and cancer cells. Here we review the features and behaviors of the TME and discuss the recently identified major immune checkpoints. We comprehensively and systematically summarize the metabolic modulation of tumor immunity and immune checkpoints in the TME, including glycolysis, amino acid metabolism, lipid metabolism, and other metabolic pathways, and further discuss the potential metabolism-based therapeutic strategies tested in preclinical and clinical settings. These findings will help to determine the existence of a link or crosstalk between tumor metabolism and immunotherapy, which will provide an important insight into cancer treatment and cancer research.
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Affiliation(s)
- Yi Wang
- Health Management Center, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China; Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China
| | - Yuya Wang
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, 401120, China
| | - Yifei Ren
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, 401120, China; Department of Obstetrics and Gynecology, Daping Hospital, Army Medical Center, Chongqing, 400038, China
| | - Qi Zhang
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610054, China
| | - Ping Yi
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, 401120, China.
| | - Chunming Cheng
- Department of Radiation Oncology, James Comprehensive Cancer Center and College of Medicine at The Ohio State University, Columbus, OH, 43221, United States.
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16
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Yoshino M, Ishihara H, Nemoto Y, Nakamura K, Nishimura K, Tachibana H, Fukuda H, Toki D, Yoshida K, Kobayashi H, Iizuka J, Shimmura H, Hashimoto Y, Tanabe K, Kondo T, Takagi T. Therapeutic role of deferred cytoreductive nephrectomy in patients with metastatic renal cell carcinoma treated with nivolumab plus ipilimumab. Jpn J Clin Oncol 2022; 52:1208-1214. [PMID: 35780441 DOI: 10.1093/jjco/hyac099] [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: 03/29/2022] [Accepted: 05/31/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To explore the therapeutic role of deferred cytoreductive nephrectomy in patients with metastatic renal cell carcinoma treated with nivolumab plus ipilimumab. PATIENTS AND METHODS Forty-one patients with synchronous metastatic renal cell carcinoma who received nivolumab plus ipilimumab as first-line systemic therapy at our affiliated institutions were retrospectively evaluated. We focused on the prognosis, including tumor responses in primary kidney and metastatic lesions in patients treated with deferred cytoreductive nephrectomy. In addition, the overall survival according to nephrectomy status (i.e. deferred cytoreductive nephrectomy vs. upfront cytoreductive nephrectomy vs. without cytoreductive nephrectomy) was compared. RESULTS During a median follow-up period of 12.0 months, seven (30%) patients received deferred cytoreductive nephrectomy at a median time of 10.4 months after nivolumab plus ipilimumab initiation. All the patients showed tumor shrinkage in their primary kidney lesions, including six (86%) patients with ≥30% of shrinkage. Metastatic lesions were also shrunk by ≥30% in six (86%) patients, including two (29%) obtaining complete response. At the last time of follow-up, three (43%) patients were disease-free. The overall survival rate after nivolumab plus ipilimumab initiation tended to be higher in patients with deferred cytoreductive nephrectomy compared with those with upfront cytoreductive nephrectomy (1-year survival rate: 100% vs. 72.4%, P = 0.0587) and those without cytoreductive nephrectomy (vs. 58.2%, P = 0.0613). CONCLUSIONS The present retrospective data showed that deferred cytoreductive nephrectomy had the potential to exert a therapeutic effect in a subset of patients who obtained favorable tumor responses to nivolumab plus ipilimumab for a certain period. Prospective randomized clinical trials are needed to confirm the prognostic impact of deferred cytoreductive nephrectomy after frontline immunotherapy in synchronous metastatic renal cell carcinoma.
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Affiliation(s)
- Maki Yoshino
- Department of Urology, Tokyo Women's Medical University Adachi Medical Center, Tokyo, Japan
| | - Hiroki Ishihara
- Department of Urology, Tokyo Women's Medical University Adachi Medical Center, Tokyo, Japan
| | - Yuki Nemoto
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan.,Department of Urology, Saiseikai Kawaguchi General Hospital, Kawaguchi, Japan
| | - Kazutaka Nakamura
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan.,Department of Urology, Jyoban Hospital, Iwaki, Japan
| | - Koichi Nishimura
- Department of Urology, Tokyo Women's Medical University Adachi Medical Center, Tokyo, Japan
| | | | - Hironori Fukuda
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Daisuke Toki
- Department of Urology, Tokyo Women's Medical University Adachi Medical Center, Tokyo, Japan
| | - Kazuhiko Yoshida
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hirohito Kobayashi
- Department of Urology, Tokyo Women's Medical University Adachi Medical Center, Tokyo, Japan
| | - Junpei Iizuka
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Yasunobu Hashimoto
- Department of Urology, Saiseikai Kawaguchi General Hospital, Kawaguchi, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Tsunenori Kondo
- Department of Urology, Tokyo Women's Medical University Adachi Medical Center, Tokyo, Japan
| | - Toshio Takagi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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17
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Ackerman RS, Muncey AR, Aldawoodi NN, Kotha R, Getting REG. Cancer Immunotherapies: What the Perioperative Physician Needs to Know. Curr Oncol Rep 2022; 24:399-414. [PMID: 35141856 PMCID: PMC9056594 DOI: 10.1007/s11912-022-01202-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 11/26/2022]
Abstract
Purpose of Review For patients with cancer, treatment may include combination therapy, including surgery and immunotherapy. Here, we review perioperative considerations for the patient prescribed immunotherapeutic agents. Recent Findings The perioperative period is a poignant moment in the journey of a patient with cancer, potentially deemed most influential compared to other moments in the care continuum. Several immunotherapeutic medications have been employed near the time of surgery to potentially increase effectiveness. Of the various drug classes, including immune checkpoint inhibitors, cytokines, toll-like receptor agonists, and oncolytic viruses, among others, several notable immune-related adverse effects were noted. They range from minor effects to more serious ones, such as renal failure, myocarditis, and tumor growth. Summary Surgery and immunotherapy are often employed in combination for primary treatment and prevention of cancer recurrence. Careful review and consideration of the pharmacokinetics, pharmacodynamics, and toxicities of immunotherapy benefit the perioperative physician and their patients.
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Affiliation(s)
- Robert S Ackerman
- Department of Anesthesiology, Duke University Medical Center, 134 Research Drive, Durham, NC, 27710, USA.
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
| | - Aaron R Muncey
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Nasrin N Aldawoodi
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Rohini Kotha
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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18
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Das R, Langou S, Le TT, Prasad P, Lin F, Nguyen TD. Electrical Stimulation for Immune Modulation in Cancer Treatments. Front Bioeng Biotechnol 2022; 9:795300. [PMID: 35087799 PMCID: PMC8788921 DOI: 10.3389/fbioe.2021.795300] [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: 10/14/2021] [Accepted: 12/17/2021] [Indexed: 12/17/2022] Open
Abstract
Immunotherapy is becoming a very common treatment for cancer, using approaches like checkpoint inhibition, T cell transfer therapy, monoclonal antibodies and cancer vaccination. However, these approaches involve high doses of immune therapeutics with problematic side effects. A promising approach to reducing the dose of immunotherapeutic agents given to a cancer patient is to combine it with electrical stimulation, which can act in two ways; it can either modulate the immune system to produce the immune cytokines and agents in the patient's body or it can increase the cellular uptake of these immune agents via electroporation. Electrical stimulation in form of direct current has been shown to reduce tumor sizes in immune-competent mice while having no effect on tumor sizes in immune-deficient mice. Several studies have used nano-pulsed electrical stimulations to activate the immune system and drive it against tumor cells. This approach has been utilized for different types of cancers, like fibrosarcoma, hepatocellular carcinoma, human papillomavirus etc. Another common approach is to combine electrochemotherapy with immune modulation, either by inducing immunogenic cell death or injecting immunostimulants that increase the effectiveness of the treatments. Several therapies utilize electroporation to deliver immunostimulants (like genes encoded with cytokine producing sequences, cancer specific antigens or fragments of anti-tumor toxins) more effectively. Lastly, electrical stimulation of the vagus nerve can trigger production and activation of anti-tumor immune cells and immune reactions. Hence, the use of electrical stimulation to modulate the immune system in different ways can be a promising approach to treat cancer.
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Affiliation(s)
- Ritopa Das
- Department of Biomedical Engineering, University of Connecticut, Mansfield, CT, United States
| | - Sofia Langou
- Department of Physiology and Neurobiology, University of Connecticut, Mansfield, CT, United States
| | - Thinh T. Le
- Department of Mechanical Engineering, University of Connecticut, Mansfield, CT, United States
| | - Pooja Prasad
- Department of Cell and Molecular Biology, University of Connecticut, Mansfield, CT, United States
| | - Feng Lin
- Department of Mechanical Engineering, University of Connecticut, Mansfield, CT, United States
| | - Thanh D. Nguyen
- Department of Biomedical Engineering, University of Connecticut, Mansfield, CT, United States
- Department of Mechanical Engineering, University of Connecticut, Mansfield, CT, United States
- Institute of Materials Science, University of Connecticut, Mansfield, CT, United States
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19
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Johansson I, Levin M, Akyürek LM, Olofsson Bagge R, Ny L. PD-1 inhibitor therapy of basal cell carcinoma with pulmonary metastasis. J Eur Acad Dermatol Venereol 2021; 36 Suppl 1:70-73. [PMID: 34855248 DOI: 10.1111/jdv.17530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/07/2021] [Indexed: 11/26/2022]
Abstract
Basal cell carcinoma (BCC) may be challenging to differentiate from basaloid squamous cell carcinoma (bSCC), both clinically and histologically. BCC constitutes one of the most common tumours and metastatic behaviour is extremely rare. In contrast, bSCC is a rare entity with an increased propensity for distant metastasis. If these conditions develop into inoperable metastatic disease, the therapeutic alternatives are different, but the use of PD-1 inhibitors may be a valid option for both. Here, we report a case with complex histology with a component initially classified as bSCC with lung metastases and treated with the PD-1 inhibitor cemiplimab resulting in radiological and clinical responses. Re-examination of the lung biopsy using routine histomorphology in combination with immunohistochemical staining for cytokeratin 14, cytokeratin17 and BerEp4 has, however, revealed a histopathological pattern of BCC, which is in concordance with a similar analysis of the cutaneous primary tumour in the face that the patient underwent surgery for more than 5 years earlier.
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Affiliation(s)
- I Johansson
- Department of Clinical Pathology, Institute of Biomedicine, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - M Levin
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - L M Akyürek
- Department of Clinical Pathology, Institute of Biomedicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - R Olofsson Bagge
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Center for Cancer Research, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Sweden
| | - L Ny
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
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20
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Rzeniewicz K, Larkin J, Menzies AM, Turajlic S. Immunotherapy use outside clinical trial populations: never say never? Ann Oncol 2021; 32:866-880. [PMID: 33771665 PMCID: PMC9246438 DOI: 10.1016/j.annonc.2021.03.199] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Based on favourable outcomes in clinical trials, immune checkpoint inhibitors (ICIs), most notably programmed cell death protein 1 (PD-1) and cytotoxic T-lymphocyte antigen-4 (CTLA-4) inhibitors, are now widely used across multiple cancer types. However, due to their strict inclusion and exclusion criteria, clinical studies often do not address challenges presented by non-trial populations. DESIGN This review summarises available data on the efficacy and safety of ICIs in trial-ineligible patients, including those with autoimmune disease, chronic viral infections, organ transplants, organ dysfunction, poor performance status, and brain metastases, as well as the elderly, children, and those who are pregnant. In addition, we review data concerning other real-world challenges with ICIs, including timing of therapy switch, relationships to radiotherapy or surgery, re-treatment after an immune-related toxicity, vaccinations in patients on ICIs, and current experience around ICI and coronavirus disease-19. Where possible, we provide recommendations to aid the often-difficult decision-making process in those settings. CONCLUSIONS Data suggest that ICIs are often active and have an acceptable safety profile in the populations described above, with the exception of PD-1 inhibitors in solid organ transplant recipients. Decisions about whether to treat with ICIs should be personalised and require multidisciplinary input and careful counselling of patients with respect to potential risks and benefits. Clinical judgements need to be carefully weighed, considering factors such as underlying cancer type, feasibility of alternative treatment options, or activity in trial-eligible patients.
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Affiliation(s)
- K Rzeniewicz
- Warwick Medical School, University of Warwick, Warwick, UK; Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
| | - J Larkin
- Renal and Skin Units, The Royal Marsden NHS Foundation Trust, London, UK
| | - A M Menzies
- Melanoma Institute Australia and The University of Sydney, Sydney, Australia; Royal North Shore and Mater Hospitals, Sydney, Australia
| | - S Turajlic
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK; Renal and Skin Units, The Royal Marsden NHS Foundation Trust, London, UK.
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21
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Calini G, Abd El Aziz MA, Abdalla S, Saeed HA, Lovely JK, D'Angelo ALD, Behm KT, Colibaseanu DT, Mathis KL, Larson DW. Patient colon and rectal operative outcomes when treated with immune checkpoint inhibitors. Eur J Surg Oncol 2021; 47:2436-2440. [PMID: 33883088 DOI: 10.1016/j.ejso.2021.03.257] [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: 02/12/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022] Open
Abstract
There is limited data about the safety of colorectal surgery after immune checkpoint inhibitors (ICI). We aimed to share our experience about postoperative outcomes of colorectal surgery for patients treated with ICI. Overall, 31 patients were identified, 22 (71%) underwent elective and nine (29%) underwent emergent/urgent surgery. The 30-day Clavien Dindo class ≥ III complication rates were 27.3% (n = 6) for elective and 55.5% (n = 5) for emergent/urgent cases. Four patients underwent emergency surgery for immune-related colonic perforation and developed postoperative septic shock; two died. Considering patients' comorbidities, cancer stage, and surgical complexity, elective colorectal surgery after ICI seems relatively safe. However, emergent/urgent colorectal surgery was associated with high postoperative morbidity. Indeed, colonic perforation in the setting of ICI treatment has a significant risk of postoperative mortality. Therefore, for patients on ICI with any acute abdominal symptoms, surgical consult should be involved, and colon perforation should be ruled out.
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Affiliation(s)
- Giacomo Calini
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Solafah Abdalla
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Hamedelneel A Saeed
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jenna K Lovely
- Department of Pharmacy Services, Mayo Clinic, Rochester, MN, USA
| | - Anne-Lise D D'Angelo
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kevin T Behm
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Dorin T Colibaseanu
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Kellie L Mathis
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - David W Larson
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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22
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Mays AC, Yarlagadda B, Achim V, Jackson R, Pipkorn P, Huang AT, Rajasekaran K, Sridharan S, Rosko AJ, Orosco RK, Coughlin AM, Wax MK, Shnayder Y, Spanos WC, Farwell DG, McDaniel LS, Hanasono MM. Examining the relationship of immunotherapy and wound complications following flap reconstruction in patients with head and neck cancer. Head Neck 2021; 43:1509-1520. [PMID: 33417293 DOI: 10.1002/hed.26601] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/12/2020] [Accepted: 12/30/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Immunotherapy agents are used to treat advanced head and neck lesions. We aim to elucidate relationship between immunotherapy and surgical wound complications. METHODS Retrospective multi-institutional case series evaluating patients undergoing ablative and flap reconstructive surgery and immunotherapy treatment. MAIN OUTCOME wound complications. RESULTS Eight-two (62%) patients received preoperative therapy, 89 (67%) postoperative, and 33 (25%) in both settings. Forty-one (31%) patients had recipient site complications, 12 (9%) had donor site. Nineteen (14%) had major recipient site complications, 22 (17%) had minor. There was no statistically significant difference in complications based on patient or tumor-specific variables. Preoperative therapy alone demonstrated increased major complications (odds ratio [OR] 3.7, p = 0.04), and trend to more donor site complications (OR 7.4, p = 0.06), however treatment in both preoperative and postoperative therapy was not. CONCLUSIONS Preoperative immunotherapy may be associated with increased wound complications. Controlled studies are necessary to delineate this association and potential risks of therapy.
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Affiliation(s)
- Ashley C Mays
- Department of Otolaryngology, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Bharat Yarlagadda
- Department of Otolaryngology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Virginie Achim
- Department of Otolaryngology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ryan Jackson
- Department of Otolaryngology, Washington University - St Louis, St Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology, Washington University - St Louis, St Louis, Missouri, USA
| | - Andrew T Huang
- Department of Otolaryngology, Baylor College of Medicine, Houston, Texas, USA
| | - Karthik Rajasekaran
- Department of Otolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shaum Sridharan
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew J Rosko
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ryan K Orosco
- Department of Otolaryngology, University of California San Diego, San Diego, California, USA
| | - Andrew M Coughlin
- Department of Otolaryngology, Nebraska Methodist Health System, Omaha, Nebraska, USA
| | - Mark K Wax
- Department of Otolaryngology, Oregon Health Sciences University, Portland, Oregon, USA
| | | | - William C Spanos
- Department of Otolaryngology, Sanford Health, Sioux Falls, South Dakota, USA
| | - Donald Gregory Farwell
- Department of Otolaryngology, University of California Davis, Sacramento, California, USA
| | - Lee S McDaniel
- Louisiana State University Health Sciences Center School of Public Health, New Orleans, Louisiana, USA
| | - Matthew M Hanasono
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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23
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Holmberg CJ, Katsarelias D, Jespersen H, Carneiro A, Elander NO, Helgadottir H, Isaksson K, Jansson M, Wirén S, Ullenhag GJ, Ny L, Olofsson Bagge R. Surgery of metastatic melanoma after systemic therapy - the SUMMIST trial: study protocol for a randomized controlled trial. Acta Oncol 2021; 60:52-55. [PMID: 33252282 DOI: 10.1080/0284186x.2020.1846213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Carl Jacob Holmberg
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Dimitrios Katsarelias
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Henrik Jespersen
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Akershus University Hospital, Nordbyhagen, Norway
| | - Ana Carneiro
- Department of Oncology, Lund University Hospital, Lund, Sweden
| | - Nils O. Elander
- Department of Oncology and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Hildur Helgadottir
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Karolin Isaksson
- Department of Clinical Sciences, Surgery, Lund University, Lund, Sweden
- Department of Surgery, Central Hospital Kristianstad, Kristianstad, Sweden
| | - Malin Jansson
- Department of Surgical and Perioperative Sciences, Umeå University and Umeå University Hospital, Umeå, Sweden
| | - Sara Wirén
- Department of Radiation Sciences, Oncology, Umeå University Hospital, Umeå, Sweden
| | - Gustav J. Ullenhag
- Department of Immunology, Genetics and Pathology, Science of Life Laboratory, Uppsala University, Uppsala, Sweden
- Department of Oncology, Uppsala University Hospital, Uppsala, Sweden
| | - Lars Ny
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Oncology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Roger Olofsson Bagge
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
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24
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Immune Checkpoint Inhibitors and Perioperative Considerations. J Perianesth Nurs 2020; 35:687-691. [PMID: 33077359 DOI: 10.1016/j.jopan.2020.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 08/08/2020] [Indexed: 12/26/2022]
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25
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Judge SJ, Ji J, Liu J, Kaur M, Kim E, Gong J, Tam KW, Kirane AR, Gholami S, Canter RJ, Bold RJ, Gangi A, Fakih M, Cho M. The Role of Palliative Surgery for Malignant Bowel Obstruction and Perforation in Advanced Microsatellite Instability-High Colorectal Carcinoma in the Era of Immunotherapy: Case Report. Front Oncol 2020; 10:581. [PMID: 32373540 PMCID: PMC7186327 DOI: 10.3389/fonc.2020.00581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 03/30/2020] [Indexed: 11/13/2022] Open
Abstract
The role of palliative surgery in the management of acute complications in patients with disseminated malignancy remains controversial given the complexity of assessing acute surgical risk and long-term oncologic outcome. With the emergence of checkpoint blockade immunotherapy, there appears to be an increasing role for historically palliative procedures as a bridge to systemic immunotherapy. This is especially evident in advanced microsatellite instability-high (MSI-H) colorectal cancer where malignant obstruction and fistula formation are more common and where immunotherapy with checkpoint blockade (anti-PD-1/PD-L1, anti-CTLA-4) has a high response rate with potential for favorable oncologic outcomes. We present a series of three patients with MSI-H metastatic colorectal cancer complicated by malignant bowel obstruction and fistula formation, who having progressed on standard chemotherapy, underwent palliative intervention as a bridge to immune checkpoint blockade with durable and clinically meaningful anti-cancer responses. These cases highlight the need to re-evaluate the role of historically palliative operations in the setting of disease progression for immunotherapy-responsive tumors.
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Affiliation(s)
- Sean J Judge
- Division of Surgical Oncology, Department of Surgery, University of California, Davis, Sacramento, CA, United States
| | - Jingran Ji
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, United States
| | - James Liu
- Division of Hematology and Oncology, Department of Medicine, University of California, Davis, Sacramento, CA, United States
| | - Manmeet Kaur
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, United States
| | - Edward Kim
- Division of Hematology and Oncology, Department of Medicine, University of California, Davis, Sacramento, CA, United States
| | - Jun Gong
- Division of Hematology and Oncology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Kit W Tam
- Division of Hematology and Oncology, Department of Medicine, University of California, Davis, Sacramento, CA, United States
| | - Amanda R Kirane
- Division of Surgical Oncology, Department of Surgery, University of California, Davis, Sacramento, CA, United States
| | - Sepideh Gholami
- Division of Surgical Oncology, Department of Surgery, University of California, Davis, Sacramento, CA, United States
| | - Robert J Canter
- Division of Surgical Oncology, Department of Surgery, University of California, Davis, Sacramento, CA, United States
| | - Richard J Bold
- Division of Surgical Oncology, Department of Surgery, University of California, Davis, Sacramento, CA, United States
| | - Alexandra Gangi
- Division of Surgical Oncology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Marwan Fakih
- Division of Hematology and Oncology, Department of Medicine, City of Hope National Medical Center, Duarte, CA, United States
| | - May Cho
- Division of Hematology and Oncology, Department of Medicine, University of California, Davis, Sacramento, CA, United States
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Tsushima N, Shinozaki T, Fujisawa T, Tomioka T, Okano W, Ikeda M, Tahara M, Higashino T, Hayashi R. Salvage Reconstructive Surgery During Nivolumab Therapy for a Patient With Hypopharyngeal Cancer. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2020; 13:1179547620908854. [PMID: 32341668 PMCID: PMC7169354 DOI: 10.1177/1179547620908854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 01/22/2020] [Indexed: 12/26/2022]
Abstract
Objectives: Nivolumab, a fully IgG4-programmed death-1 inhibitor antibody, led to improved overall survival compared with single-agent therapy in patients with platinum-refractory recurrent head and neck cancers. In general, nivolumab is used in inoperable patients. To the best of our knowledge, there have been no reports of salvage surgery during nivolumab therapy for patients with head and neck cancer. We report the case of a woman treated with salvage reconstructive surgery during nivolumab therapy. Method: Case report and literature review. Results: The patient underwent nivolumab therapy for recurrent primary and neck disease after induction chemotherapy, followed by concurrent chemoradiation therapy. The neck disease shrunk, whereas the primary disease temporarily shrunk but later progressed again. Recurrent primary disease led to a narrowing of her airway, and she required airway management. We performed total pharyngolaryngectomy with free jejunal reconstruction, and her quality of life improved. The surgery was performed without complications and the postoperative course was uneventful. She was discharged postoperative day 18 with oral intake function and a safer airway. Conclusion: As far as we know, this is the first report of salvage surgery during nivolumab therapy for patients with head and neck cancer. The salvage reconstructive surgery in this case proceeded uneventfully.
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Affiliation(s)
- Nayuta Tsushima
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Takeshi Shinozaki
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Takao Fujisawa
- Department of Head and Neck Medical Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Toshifumi Tomioka
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Wataru Okano
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Masakazu Ikeda
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Makoto Tahara
- Department of Head and Neck Medical Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Takuya Higashino
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Ryuichi Hayashi
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
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Lewis AL, Chaft J, Girotra M, Fischer GW. Immune checkpoint inhibitors: a narrative review of considerations for the anaesthesiologist. Br J Anaesth 2020; 124:251-260. [PMID: 32007241 PMCID: PMC7890563 DOI: 10.1016/j.bja.2019.11.034] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 11/04/2019] [Accepted: 11/15/2019] [Indexed: 02/08/2023] Open
Abstract
Immunotherapy has revolutionised the treatment of oncologic malignancies. Immune checkpoint inhibitors represent a new class of immunotherapy drugs. Although these drugs show promise, they are associated with immune-related adverse reactions. An increasing number of patients who undergo surgery will have had treatment with immune checkpoint inhibitors. In this narrative review article, we discuss their mechanism of action, therapeutic effects, pertinent toxicities, and address specific perioperative considerations for patients treated with immune checkpoint inhibitors.
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Affiliation(s)
- Alexandra L Lewis
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Jamie Chaft
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Girotra
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Gregory W Fischer
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Complete Recovery of Immune Checkpoint Inhibitor–induced Colitis by Diverting Loop Ileostomy. J Immunother 2020; 43:145-148. [DOI: 10.1097/cji.0000000000000309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Helmink BA, Roland CL, Kiernan CM, Wargo JA. Toxicity of Immune Checkpoint Inhibitors: Considerations for the Surgeon. Ann Surg Oncol 2020; 27:1533-1545. [PMID: 31965370 DOI: 10.1245/s10434-019-08183-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The use of immunotherapeutic agents, specifically immune checkpoint inhibitors (ICIs) for solid malignancies, is rapidly rising, and many new agents and treatment combinations are in development. However, ICIs have a unique side-effect profile of immune-related adverse events (irAEs) compared with chemotherapeutic agents or targeted therapies. METHODS In this report the diverse spectrum of irAEs is highlighted using two patients with metastatic melanoma undergoing treatment with ICIs. We supplement these case reports with a brief literature review of the data regarding the safety of surgical intervention in patients taking irAEs. RESULTS The report describes the basic approach to the detection and management of irAEs, notes important perioperative considerations, and discusses the safety of surgical intervention for these patients. CONCLUSIONS Overall, these irAEs represent a diverse group of pathologies with variable timing and sometimes subtle presentation requiring careful monitoring and heightened clinical suspicion for potential toxicity by all providers, including surgeons.
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Affiliation(s)
- Beth A Helmink
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Colleen M Kiernan
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Jennifer A Wargo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA. .,Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA.
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30
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Sun J, Kirichenko DA, Chung JL, Carr MJ, Eroglu Z, Khushalani NI, Markowitz J, Messina JL, Sondak VK, Zager JS, Patel SY. Perioperative Outcomes of Melanoma Patients Undergoing Surgery After Receiving Immunotherapy or Targeted Therapy. World J Surg 2019; 44:1283-1293. [DOI: 10.1007/s00268-019-05314-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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31
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Singla N, Elias R, Ghandour RA, Freifeld Y, Bowman IA, Rapoport L, Enikeev M, Lohrey J, Woldu SL, Gahan JC, Bagrodia A, Brugarolas J, Hammers HJ, Margulis V. Pathologic response and surgical outcomes in patients undergoing nephrectomy following receipt of immune checkpoint inhibitors for renal cell carcinoma. Urol Oncol 2019; 37:924-931. [DOI: 10.1016/j.urolonc.2019.08.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/26/2019] [Accepted: 08/19/2019] [Indexed: 01/16/2023]
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Targeting Negative and Positive Immune Checkpoints with Monoclonal Antibodies in Therapy of Cancer. Cancers (Basel) 2019; 11:cancers11111756. [PMID: 31717326 PMCID: PMC6895894 DOI: 10.3390/cancers11111756] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 02/06/2023] Open
Abstract
The immune checkpoints are regulatory molecules that maintain immune homeostasis in physiological conditions. By sending T cells a series of co-stimulatory or co-inhibitory signals via receptors, immune checkpoints can both protect healthy tissues from adaptive immune response and activate lymphocytes to remove pathogens effectively. However, due to their mode of action, suppressive immune checkpoints may serve as unwanted protection for cancer cells. To restore the functioning of the immune system and make the patient’s immune cells able to recognize and destroy tumors, monoclonal antibodies are broadly used in cancer immunotherapy to block the suppressive or to stimulate the positive immune checkpoints. In this review, we aim to present the current state of application of monoclonal antibodies in clinics, used either as single agents or in a combined treatment. We discuss the limitations of these therapies and possible problem-solving with combined treatment approaches involving both non-biological and biological agents. We also highlight the most promising strategies based on the use of monoclonal or bispecific antibodies targeted on immune checkpoints other than currently implemented in clinics.
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Hartl DM, Guerlain J, Bresuskin I, Baudin E, Lamartina L, Hadoux J, Leboulleux S, Schlumberger M. Surgery in the context of kinase inhibitor therapy for locally invasive thyroid cancer. Eur J Surg Oncol 2019; 46:650-655. [PMID: 31582321 DOI: 10.1016/j.ejso.2019.09.184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 09/24/2019] [Indexed: 01/08/2023] Open
Abstract
Kinase inhibitors (KI) for advanced and aggressive forms of differentiated, medullary and anaplastic thyroid carcinoma have been shown to provide significant tumor response, locally and in distant metastases. Their use, however, may also increase the risk for local complications such as fistula formation and bleeding, and head and neck surgeons may be solicited to palliatively remove potentially dangerous lesions before initiating these systemic treatments. During KI therapy for progressive metastatic and/or locally invasive disease, surgery may be urgently necessary to secure the airway or for symptomatic neck lesions. Finally, there are more and more reports of surgery following KI therapy that suggest a new neoadjuvant paradigm for extensive lesions. In this review, we aim to discuss the literature regarding surgery before, during and after KI therapy in the context of progressive metastatic and/or locally invasive thyroid cancer.
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Affiliation(s)
- Dana M Hartl
- Department of Head and Neck Oncology, Thyroid Surgery Unit, Gustave Roussy, Villejuif, France.
| | - Joanne Guerlain
- Department of Head and Neck Oncology, Thyroid Surgery Unit, Gustave Roussy, Villejuif, France
| | - Ingrid Bresuskin
- Department of Head and Neck Oncology, Thyroid Surgery Unit, Gustave Roussy, Villejuif, France
| | - Eric Baudin
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy and Paris Saclay University, Villejuif, France
| | - Livia Lamartina
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy and Paris Saclay University, Villejuif, France
| | - Julien Hadoux
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy and Paris Saclay University, Villejuif, France
| | - Sophie Leboulleux
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy and Paris Saclay University, Villejuif, France
| | - Martin Schlumberger
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy and Paris Saclay University, Villejuif, France
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Lee SL, Al-Shamkhani A, Mirnezami A. Immuno-oncology for surgeons. Br J Surg 2019; 106:1273-1282. [PMID: 31318438 DOI: 10.1002/bjs.11224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/03/2019] [Accepted: 04/04/2019] [Indexed: 12/19/2022]
Abstract
Cancer has traditionally been treated with surgery, cytotoxic chemotherapy and/or radiotherapy. The focus of treatment has been the mutated neoplastic cell. Critical advances in genomic and molecular techniques herald the potential for personalized treatments. Incremental breakthroughs in immunology have translated to a step-change in care by providing a mechanistic understanding of the immune system and how it may be mobilized to target cancer cells. As a result, clinical trials of immune-modifying agents have increased at an exponential rate and are revolutionizing cancer care. It is increasingly likely that the surgical oncologist will find themself caring for patients who have had immuno-oncology therapies as part of their neoadjuvant or adjuvant treatment. This review provides an update on immuno-oncology for the surgeon, covering the mechanisms of action of the agents in use. Emerging and surgically relevant toxicities are discussed, and available data on combining and sequencing cancer surgery with immuno-oncology treatments are summarized.
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Affiliation(s)
- S L Lee
- Southampton Cancer Research UK Centre, University of Southampton, Southampton, UK
- Centre for Cancer Immunology, University of Southampton, Southampton, UK
- University Surgical Unit, University of Southampton, MP127, Faculty of Medicine, University Hospital Southampton, Southampton, UK
| | - A Al-Shamkhani
- Centre for Cancer Immunology, University of Southampton, Southampton, UK
| | - A Mirnezami
- Southampton Cancer Research UK Centre, University of Southampton, Southampton, UK
- University Surgical Unit, University of Southampton, MP127, Faculty of Medicine, University Hospital Southampton, Southampton, UK
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35
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Hwang V, Mendez E, Chow LQM, Futran ND, Andersen P, Li R, Divi V, Rodriguez CP. Wound Complications in Head and Neck Squamous Cell Carcinomas After Anti–PD‐1 Therapy. Laryngoscope 2019; 129:E428-E433. [DOI: 10.1002/lary.27902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 12/28/2018] [Accepted: 02/11/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Victoria Hwang
- Loyola University Chicago Stritch School of Medicine Maywood Illinois
| | - Eduardo Mendez
- Department of OtolaryngologyFred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, University of Washington Seattle Washington
| | - Laura Q. M. Chow
- Department of Medicine, Division of Medical OncologyFred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, University of Washington Seattle Washington
| | - Neal David Futran
- Department of OtolaryngologyFred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, University of Washington Seattle Washington
| | - Peter Andersen
- Department of OtolaryngologyOregon Health and Sciences University Portland Oregon
| | - Ryan Li
- Department of OtolaryngologyOregon Health and Sciences University Portland Oregon
| | - Vasu Divi
- Department of OtolaryngologyStanford University Medical Center Palo Alto California U.S.A
| | - Cristina P. Rodriguez
- Department of Medicine, Division of Medical OncologyFred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, University of Washington Seattle Washington
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36
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Psutka SP, Chang SL, Cahn D, Uzzo RG, McGregor BA. Reassessing the Role of Cytoreductive Nephrectomy for Metastatic Renal Cell Carcinoma in 2019. Am Soc Clin Oncol Educ Book 2019; 39:276-283. [PMID: 31099657 DOI: 10.1200/edbk_237453] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Cytoreductive nephrectomy (CRN) has long been considered a standard of care in the management of mRCC. This is largely based on randomized trials in the era of interferon (IFN) that demonstrate an improvement in overall survival (OS). With the advent of targeted therapies, the role of CRN has been questioned and multiple retrospective analyses have shown a potential benefit, particularly in intermediate-risk disease. Two long-awaited prospective trials have been published in the past year that explore the role of CRN. The CARMENA trial randomly assigned patients to therapy with sunitinib with or without CRN, showing noninferiority of sunitinib alone versus sunitinib plus CRN with a median OS of 18.4 months versus 13.9 months, respectively (hazard ratio [HR] for mortality, 0.89; 95% CI, 0.71-1.1). The SURTIME trial randomly assigned patients to immediate CRN followed by sunitinib versus a deferred CRN after three cycles of sunitinib. Analysis is limited by early termination as a result of low accrual. Although there was no difference in progression-free survival (PFS), median OS was significantly improved among patients in the deferred CRN arm (HR, 0.57; 95% CI, 0.34-0.95; p = .032). Early systemic therapy is paramount, but there are patients who may derive benefit by incorporating the removal of the primary tumor in their multimodal therapy, perhaps in a deferred setting. As systemic treatment paradigms shift and immunotherapy again moves to the frontline setting with the potential for novel therapeutic approaches, the role of CRN will continue to evolve with the potential to offer surgical interventions with minimal, if any, delay in systemic treatment.
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Affiliation(s)
- Sarah P Psutka
- 1 Department of Urology, University of Washington, Seattle, WA
| | - Steven L Chang
- 2 Brigham and Women's Hospital, Boston, MA
- 3 Dana-Farber Cancer Institute, Boston, MA
| | - David Cahn
- 4 Fox Chase Cancer Center, Philadelphia, PA
| | | | - Bradley A McGregor
- 3 Dana-Farber Cancer Institute, Boston, MA
- 5 Harvard Medical School, Boston, MA
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37
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Bello DM. Indications for the surgical resection of stage IV disease. J Surg Oncol 2018; 119:249-261. [PMID: 30561079 DOI: 10.1002/jso.25326] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 11/16/2018] [Indexed: 12/12/2022]
Abstract
Tumor biology and careful patient selection weigh heavily in determining the appropriate role of surgical resection in stage IV melanoma. Historically, surgical resection for highly selected patients with metastatic melanoma was the only treatment modality associated with improved long-term survival and the ability to provide palliation. With the new age of effective systemic therapies, the treatment of metastatic melanoma has become more intricate and future work is needed to better define the role for surgery within the current treatment paradigm.
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Affiliation(s)
- Danielle M Bello
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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38
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Abstract
Palliative care is the multidisciplinary focus on patient symptoms and quality of life. The emphasis of minimally invasive surgery on reduced pain and faster recovery aligns well with the goals of palliative care. Minimally invasive approaches can be safely and effectively used to address several common complications of solid organ malignancies as well as the complications of cytotoxic therapy. A patient-centered, minimally invasive approach will not only help alleviate disabling symptoms and improve patient quality of life but will also minimize the pain and adverse effects of the intervention itself.
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Affiliation(s)
- Jordan M Cloyd
- Department of Surgery, The Ohio State University, 410 West 10th Avenue, N-907, Columbus, OH 43210, USA.
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39
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Kawai H, Saito Y, Demura R, Odaka H, Takahashi S, Takahashi K, Kurokawa H, Enomoto K. Case of advanced pulmonary squamous cell carcinoma cured by resection through preoperative induction of immune checkpoint inhibitor. Thorac Cancer 2018; 9:495-497. [PMID: 29418077 PMCID: PMC5879048 DOI: 10.1111/1759-7714.12592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 12/14/2017] [Accepted: 12/14/2017] [Indexed: 11/29/2022] Open
Abstract
The options for lung cancer treatment have increased due to the development of immune checkpoint inhibitors, but there has been no report of inoperable cases whereby the treatment effects rendered the case operable, an operation was subsequently performed, and histological assessment of the surgical specimen was carried out. Here, we report a 67‐year‐old man who was given pembrolizumab for T3N0 lung squamous cell carcinoma suspected of pericardial infiltration and judged inoperable. Treatment effect was evaluated after four courses. Computed tomography indicated a partial response, and operability was feasible. Therefore, thoracoscopic left upper lobectomy was performed after six courses of pembrolizumab, and histological assessment of the treatment effect was determined to be Ef 3, a complete response. The postoperative course was uneventful and he was discharged on the third postoperative day. We encountered a case that could be surgically treated after pembrolizumab administration. This treatment was safe and effective for advanced lung cancer.
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Affiliation(s)
- Hideki Kawai
- Department of Thoracic Surgery, Akita Red Cross Hospital, Akita, Japan
| | - Yoshitaro Saito
- Department of Thoracic Surgery, Akita Red Cross Hospital, Akita, Japan
| | - Ryo Demura
- Department of Thoracic Surgery, Akita Red Cross Hospital, Akita, Japan
| | - Hidesato Odaka
- Department of Respiratory Medicine, Akita Red Cross Hospital, Akita, Japan
| | - Susumu Takahashi
- Department of Respiratory Medicine, Akita Red Cross Hospital, Akita, Japan
| | - Kento Takahashi
- Department of Respiratory Medicine, Akita Red Cross Hospital, Akita, Japan
| | - Hirokazu Kurokawa
- Department of Respiratory Medicine, Akita Red Cross Hospital, Akita, Japan
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40
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Yuza K, Nagahashi M, Watanabe S, Takabe K, Wakai T. Hypermutation and microsatellite instability in gastrointestinal cancers. Oncotarget 2017; 8:112103-112115. [PMID: 29340115 PMCID: PMC5762383 DOI: 10.18632/oncotarget.22783] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 11/13/2017] [Indexed: 02/07/2023] Open
Abstract
Recent progress in cancer genome analysis using next-generation sequencing has revealed a high mutation burden in some tumors. The particularly high rate of somatic mutation in these tumors correlates with the generation of neo-antigens capable of eliciting an immune response. Identification of hypermutated tumors is therefore clinically valuable for selecting patients suitable for immunotherapy treatment. There are several known causes of hypermutation in tumors, such as ultraviolet light in melanoma, tobacco smoke in lung cancer, and excessive APOBEC (apolipoprotein B mRNA editing enzyme, catalytic polypeptide-like) activity in breast and gastric cancer. In gastrointestinal cancers, one of the leading causes of hypermutation is a defect in DNA mismatch repair, which results in microsatellite instability (MSI). This review will focus on the frequency, characteristics and genomic signature of hypermutated gastrointestinal cancers with MSI. Detection of tumor hypermutation in cancer is expected to not only predict the clinical benefit of immune checkpoint inhibitor treatment, but also to provide better surgical strategies for the patients with hypermutated tumors. Thus, in an era of precision medicine, identification of hypermutation and MSI will play an important role directing surgical and chemotherapeutic treatment.
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Affiliation(s)
- Kizuki Yuza
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Chuo-ku, Niigata City, Niigata 951-8510, Japan
| | - Masayuki Nagahashi
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Chuo-ku, Niigata City, Niigata 951-8510, Japan
| | - Satoshi Watanabe
- Department of Respiratory Medicine and Infectious Diseases, Niigata University Graduate School of Medical and Dental Sciences, Chuo-ku, Niigata City, Niigata 951-8510, Japan
| | - Kazuaki Takabe
- Breast Surgery, Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY 14263, USA
- Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, The State University of New York, Buffalo, NY 14203, USA
| | - Toshifumi Wakai
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Chuo-ku, Niigata City, Niigata 951-8510, Japan
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41
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Santos DA, Alseidi A, Shannon VR, Messick C, Song G, Ledet CR, Lee H, Ngo-Huang A, Francis GJ, Asher A. Management of surgical challenges in actively treated cancer patients. Curr Probl Surg 2017; 54:612-654. [DOI: 10.1067/j.cpsurg.2017.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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42
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McCormick B, Meissner MA, Karam JA, Wood CG. Surgical Complications of Presurgical Systemic Therapy for Renal Cell Carcinoma: A Systematic Review. KIDNEY CANCER 2017; 1:115-121. [PMID: 30334013 PMCID: PMC6179118 DOI: 10.3233/kca-170016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background Locally advanced and metastatic renal cell carcinoma (RCC) is associated with poor survival outcomes. The integration of presurgical systemic therapy with targeted molecular agents prior to surgical resection of RCC tumors has been utilized to improve on these outcomes. These agents may be associated with an increased risk of perioperative complications due to their action on angiogenesis and cell proliferation. Objective To examine the evidence for the incidence and severity of perioperative complications following presurgical targeted therapy for locally advanced or metastatic RCC. Methods We performed a systematic review of retrospective studies, prospective clinical trials, and meta-analyses using key search terms in PubMed and Medline. Studies were screened for eligibility and data were extracted by the authors. A qualitative analysis was performed and the complications for available targeted agents was reported. Results Retrospective analyses and small prospective trials indicate varying complication rates and types based on presurgical therapies. While some studies indicate a possible increase in wound-related complications, other studies did not show similar results. Additional unique complications reported include an increase in surgical adhesions. There was not any significant difference in overall or bleeding complications. Conclusions Overall, these studies demonstrate an acceptable level of surgical complications that should not discourage the clinician considering presurgical therapy. The results of pending trials looking at presurgical therapies will provide further information.
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Affiliation(s)
| | | | - Jose A Karam
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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