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Zhao P, Li J, Yu L, Ma W, Zhao T. Clinical manifestations and risk factors of immune-related thyroid adverse events in patients treated with PD-1 inhibitors: a case-control study. Front Immunol 2025; 16:1581057. [PMID: 40356893 PMCID: PMC12066586 DOI: 10.3389/fimmu.2025.1581057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2025] [Accepted: 04/04/2025] [Indexed: 05/15/2025] Open
Abstract
Background Immune checkpoint inhibitors (ICPIs) have emerged as a powerful strategy to cancer treatment. However, while demonstrating antitumor efficacy, they can also induce a range of immune-related adverse events (irAEs). Immune-related thyroid dysfunction is one of the most common irAEs. This study aims to investigate the clinical characteristics and identify potential risk factors associated with PD-1 inhibitor-induced immune-related thyroid dysfunction in real-world. Methods A retrospective analysis was conducted on the clinical data of cancer patients treated with PD-1 inhibitors at Weifang People's Hospital from January 2021 to December 2024. The incidence, clinical subtypes, onset time, and prognostic outcomes of thyroid dysfunction were analyzed. Univariate and multivariate logistic regression analyses were performed to identify risk factors. Results 119 patients of PD-1 inhibitor-associated thyroid dysfunction were identified. The overall incidence of thyroid dysfunction was 2.97%, with hypothyroidism occurring in 1.20%, hyperthyroidism in 1.77%, and thyroiditis in 0.50% of patients. Tislelizumab exhibited the highest incidence at 3.48%, followed by camrelizumab at 3.10%, sintilimab at 2.24%, and toripalimab at 1.75%. The median time from the initiation of immunotherapy to the onset of thyroid dysfunction was 67 days, with hypothyroidism and hyperthyroidism developing at median times of 64.5 and 69 days, respectively. 77.31% of cases occurred within the first four months of immunotherapy. Female gender, lower baseline FT3 levels, history of targeted therapy, and baseline TgAb positivity were identified as independent risk factors for PD-1 inhibitor-associated thyroid dysfunction. Furthermore, higher baseline TSH levels, younger age, and treatment with tislelizumab or camrelizumab were associated with an increased risk of immune-related hypothyroidism, whereas lower baseline TSH levels were linked to a higher risk of immune-related hyperthyroidism. Conclusions Close clinical and hormonal monitoring is recommended for patients with high-risk factors before and throughout the course of immunotherapy, particularly during the initial 2 to 4 months of PD-1 inhibitor treatment.
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Affiliation(s)
- Pengfei Zhao
- Department of Clinical Pharmacy, Weifang People’s Hospital, Shandong Second Medical University, Weifang, Shandong, China
| | - Jia Li
- Department of Adverse Drug Reaction Monitoring, Weifang Market Regulation Development Service Center, Weifang, Shandong, China
| | - Lihong Yu
- Department of Clinical Pharmacy, Weifang People’s Hospital, Shandong Second Medical University, Weifang, Shandong, China
| | - Wenming Ma
- Department of Clinical Pharmacy, Weifang People’s Hospital, Shandong Second Medical University, Weifang, Shandong, China
| | - Ting Zhao
- Department of Clinical Pharmacy, Weifang People’s Hospital, Shandong Second Medical University, Weifang, Shandong, China
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Savino A, Rossi A, Fagiuoli S, Invernizzi P, Gerussi A, Viganò M. Hepatotoxicity in Cancer Immunotherapy: Diagnosis, Management, and Future Perspectives. Cancers (Basel) 2024; 17:76. [PMID: 39796705 PMCID: PMC11718971 DOI: 10.3390/cancers17010076] [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: 12/08/2024] [Revised: 12/26/2024] [Accepted: 12/27/2024] [Indexed: 01/13/2025] Open
Abstract
Cancer immunotherapy, particularly immune checkpoint inhibitors, has positively impacted oncological treatments. Despite its effectiveness, immunotherapy is associated with immune-related adverse events (irAEs) that can affect any organ, including the liver. Hepatotoxicity primarily manifests as immune-related hepatitis and, less frequently, cholangitis. Several risk factors, such as pre-existing autoimmune and liver diseases, the type of immunotherapy, and combination regimens, play a role in immune-related hepatotoxicity (irH), although reliable predictive markers or models are still lacking. The severity of irH ranges from mild to severe cases, up to, in rare instances, acute liver failure. Management strategies require regular monitoring for early diagnosis and interventions, encompassing strict monitoring for mild cases to the permanent suspension of immunotherapy for severe forms. Corticosteroids are the backbone of treatment in moderate and high-grade damage, alone or in combination with additional immunosuppressive drugs for resistant or refractory cases. Given the relatively low number of events and the lack of dedicated prospective studies, much uncertainty remains about the optimal management of irH, especially in the most severe cases. This review presents the main features of irH, focusing on injury patterns and mechanisms, and provides an overview of the management landscape, from standard care to the latest evidence.
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Affiliation(s)
- Alberto Savino
- Department of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy (M.V.)
- Gastroenterology, Hepatology and Transplantation Unit, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Alberto Rossi
- Department of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy (M.V.)
- Gastroenterology, Hepatology and Transplantation Unit, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Stefano Fagiuoli
- Department of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy (M.V.)
- Gastroenterology, Hepatology and Transplantation Unit, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Pietro Invernizzi
- Department of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy (M.V.)
- Centre for Autoimmune Liver Diseases, Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, ERN-RARE LIVER, 20900 Monza, Italy
| | - Alessio Gerussi
- Department of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy (M.V.)
- Centre for Autoimmune Liver Diseases, Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, ERN-RARE LIVER, 20900 Monza, Italy
| | - Mauro Viganò
- Department of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy (M.V.)
- Gastroenterology, Hepatology and Transplantation Unit, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
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Durán-Pacheco G, Chandler GS, Maiya V, Socinski MA, Sonpavde G, Puente J, Essioux L, Carter C, Cardona JV, Mohindra R, Naidoo J. Correlation of safety and efficacy of atezolizumab therapy across indications. J Immunother Cancer 2024; 12:e010158. [PMID: 39537212 PMCID: PMC11575237 DOI: 10.1136/jitc-2024-010158] [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] [Accepted: 10/18/2024] [Indexed: 11/16/2024] Open
Abstract
BACKGROUND The association between safety and efficacy of immune checkpoint inhibitors is known, but the correlation between severity and impact of specific organ involvement by immune-related adverse events (irAE) and cancer outcomes is poorly understood. Most irAEs are mild-to-moderate but severe irAEs may pose clinical management challenges and affect patient outcomes. METHODS We assessed the association between irAE grade (G) and specific organ involvement with overall survival (OS) in 9,521 patients across 14 studies involving atezolizumab as mono (IO) or with chemo/targeted (C-IO) therapy as compared with chemo/targeted therapy (C) in advanced non-small cell lung, small-cell lung, renal cell, urothelial, and triple-negative breast cancers. We used a mixed-effect Cox proportional hazard model for time-varying covariates to address immortal-time bias; adjusted for baseline factors associated with irAEs and OS to control for confounding bias; and focused on five common irAEs (dermatologic, thyroid dysfunction, hepatitis, pneumonitis, and colitis) to avoid low statistical power for rare events. RESULTS For patients treated with IO or C-IO, G1-2 irAEs were associated with improved OS (HR=0.65, p<0.01) and G3-4 irAEs showed a slight increased risk of death (HR=1.18, p=0.10) versus patients without irAEs. By specific irAE, G1-2 cutaneous irAEs, thyroid dysfunction, or pneumonitis were associated with improved OS (p<0.05), while G3-4 pneumonitis and colitis were associated with worse OS (p<0.01). There was no association between hepatitis and OS by any grade. Findings were consistent across indications. CONCLUSIONS This analysis demonstrates a correlation between irAEs and improved OS with atezolizumab by severity grade and the most common irAEs by organ involvement. Low-grade irAEs are significantly associated with improved OS, while specific high-grade irAEs are associated with poorer OS, underscoring the importance of early recognition and management of toxicity to optimize benefit/risk balance.
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Affiliation(s)
| | - G Scott Chandler
- F Hoffmann-La Roche Ltd, Basel, Switzerland
- Precision Safety, F Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Vidya Maiya
- Genentech Inc, South San Francisco, California, USA
| | | | - Guru Sonpavde
- AdventHealth Cancer Institute, Orlando, Florida, USA
- Medical Oncology, AdventHealth Central Florida, Orlando, Florida, USA
| | - Javier Puente
- Medical Oncology Department, CIBERONC, Madrid, Spain
| | | | - Corey Carter
- Genentech Inc, South San Francisco, California, USA
| | | | - Rajat Mohindra
- Precision Safety, F Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Jarushka Naidoo
- Royal College of Surgeons, Ireland, Cancer Centre, Beaumont Hospital, Dublin, Dublin, Ireland
- Johns Hopkins Medicine, Baltimore, Maryland, USA
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Kuczmarski TM, Lynch RC. Managing common toxicities associated with checkpoint inhibitor and chemotherapy combinations for untreated classic Hodgkin lymphoma. Br J Haematol 2024; 205:100-108. [PMID: 38698683 DOI: 10.1111/bjh.19478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 05/05/2024]
Abstract
Combination checkpoint inhibitor (CPI) and chemotherapy is an effective and safe treatment strategy for patients with untreated classic Hodgkin lymphoma. Recent studies of programmed cell death protein 1 inhibitors combined with doxorubicin, vinblastine and dacarbazine have demonstrated high overall and complete response rates. This combination has a unique toxicity profile that should be managed appropriately so as not to compromise treatment efficacy. Common toxicities include rash, hepatoxicity, neutropenia and thyroid dysfunction. Here, we present four cases and the management strategies around such toxicities. In addition, we highlight key clinical decision-making around the administration of subsequent doses of CPI and chemotherapy.
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Affiliation(s)
- Thomas M Kuczmarski
- Fred Hutchinson Cancer Center, University of Washington, Seattle, Washington, USA
| | - Ryan C Lynch
- Fred Hutchinson Cancer Center, University of Washington, Seattle, Washington, USA
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Kawano M, Yano Y, Yamamoto A, Yasutomi E, Inoue Y, Kitadai J, Yoshida R, Matsuura T, Shiomi Y, Ueda Y, Kodama Y. Risk Factors for Immune Checkpoint Inhibitor-Induced Liver Injury and the Significance of Liver Biopsy. Diagnostics (Basel) 2024; 14:815. [PMID: 38667461 PMCID: PMC11049019 DOI: 10.3390/diagnostics14080815] [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: 02/12/2024] [Revised: 04/07/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
Immune checkpoint inhibitor (ICI)-induced liver injury (LI) is a common adverse event, but the clinical characteristics based on the classification of hepatocellular injury and cholestatic types are not fully evaluated. This study aims to analyze risk factors and histological findings in relation to the classification of ICI-induced LI. In total, 254 ICI-induced LI patients among 1086 treated with ICIs between September 2014 and March 2022 were classified according to the diagnostic criteria for drug-induced LI (DILI), and their risk factors and outcomes were evaluated. Kaplan-Meier analyses showed that overall survival in patients with hepatocellular-injury-type LI was significantly longer than others (p < 0.05). Regarding pre-treatment factors, the lymphocyte count was significantly higher in patients with ICI-induced LI, especially in hepatocellular-injury-type LI. Gamma glutamyl transferase (γGTP) and alkaline phosphatase (ALP) were also significantly lower in patients with ICI-induced LI (p < 0.05). Multivariate analyses revealed that malignant melanoma, high lymphocyte count, and low ALP levels were extracted as factors contributing to hepatocellular-injury-type LI. The histological findings among 37 patients diagnosed as ICI-induced LI via liver biopsy also revealed that the spotty/focal necrosis was significantly frequent in hepatocellular-injury-type LI, whereas ductular reactions were frequently observed in cholestatic-type LI. It is suggested that the histological inflammation pattern in patients with LI is closely correlated with the type of DILI.
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Affiliation(s)
- Miki Kawano
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan; (M.K.); (A.Y.); (Y.I.); (J.K.); (R.Y.); (T.M.); (Y.S.); (Y.U.); (Y.K.)
| | - Yoshihiko Yano
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan; (M.K.); (A.Y.); (Y.I.); (J.K.); (R.Y.); (T.M.); (Y.S.); (Y.U.); (Y.K.)
| | - Atsushi Yamamoto
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan; (M.K.); (A.Y.); (Y.I.); (J.K.); (R.Y.); (T.M.); (Y.S.); (Y.U.); (Y.K.)
| | - Eiichiro Yasutomi
- Department of Gastroenterology, Hyogo Prefectural Kakogawa Medical Center, Kakogawa 675-8555, Japan;
| | - Yuta Inoue
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan; (M.K.); (A.Y.); (Y.I.); (J.K.); (R.Y.); (T.M.); (Y.S.); (Y.U.); (Y.K.)
| | - Jun Kitadai
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan; (M.K.); (A.Y.); (Y.I.); (J.K.); (R.Y.); (T.M.); (Y.S.); (Y.U.); (Y.K.)
| | - Ryutaro Yoshida
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan; (M.K.); (A.Y.); (Y.I.); (J.K.); (R.Y.); (T.M.); (Y.S.); (Y.U.); (Y.K.)
| | - Takanori Matsuura
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan; (M.K.); (A.Y.); (Y.I.); (J.K.); (R.Y.); (T.M.); (Y.S.); (Y.U.); (Y.K.)
| | - Yuuki Shiomi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan; (M.K.); (A.Y.); (Y.I.); (J.K.); (R.Y.); (T.M.); (Y.S.); (Y.U.); (Y.K.)
| | - Yoshihide Ueda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan; (M.K.); (A.Y.); (Y.I.); (J.K.); (R.Y.); (T.M.); (Y.S.); (Y.U.); (Y.K.)
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan; (M.K.); (A.Y.); (Y.I.); (J.K.); (R.Y.); (T.M.); (Y.S.); (Y.U.); (Y.K.)
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Bedke J, Black PC, Szabados B, Guerrero-Ramos F, Shariat SF, Xylinas E, Brinkmann J, Blake-Haskins JA, Cesari R, Redorta JP. Optimizing outcomes for high-risk, non-muscle-invasive bladder cancer: The evolving role of PD-(L)1 inhibition. Urol Oncol 2023; 41:461-475. [PMID: 37968169 DOI: 10.1016/j.urolonc.2023.10.004] [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] [Received: 04/18/2023] [Revised: 09/27/2023] [Accepted: 10/16/2023] [Indexed: 11/17/2023]
Abstract
Transurethral resection of bladder tumor followed by intravesical Bacillus Calmette-Guérin (BCG) is the standard of care in high-risk, non-muscle-invasive bladder cancer (NMIBC). Although many patients respond, recurrence and progression are common. In addition, patients may be unable to receive induction + maintenance due to intolerance or supply issues. Therefore, alternative treatment options are urgently required. Programmed cell death (ligand) 1 (PD-[L]1) inhibitors show clinical benefit in phase 1/2 trials in BCG-unresponsive NMIBC patients. This review presents the status of PD-(L)1 inhibition in high-risk NMIBC and discusses future directions. PubMed and Google scholar were searched for articles relating to NMIBC immunotherapy and ClinicalTrials.gov for planned and ongoing clinical trials. Preclinical and early clinical studies show that BCG upregulates PD-L1 expression in bladder cancer cells and, when combined with a PD-(L)1 inhibitor, a potent antitumor response is activated. Based on this mechanism, several PD-(L)1 inhibitors are in phase 3 trials in BCG-naïve, high-risk NMIBC in combination with BCG. Whereas PD-(L)1 inhibitors are well characterized in patients with advanced malignancies, the impact of immune-related adverse events (irAE) on the benefit/risk ratio in NMIBC should be determined. Alternative routes to intravenous administration, like subcutaneous and intravesical administration, may facilitate adherence and access. The outcomes of combination of PD-(L)1 inhibitors and BCG in NMIBC are highly anticipated. There will be a need to address treatment resources, optimal management of irAEs and education and training related to use of this therapy in clinical practice.
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Affiliation(s)
- Jens Bedke
- Department of Urology and Transplantation Surgery, Kilinikum Stuttgart, Stuttgart, Germany.
| | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, Canada
| | - Bernadett Szabados
- University College London Hospital, London, UK; Bart's Cancer Institute, Queen Mary University of London, London, UK
| | | | | | - Evanguelos Xylinas
- Department of Urology, Hôpital Bichat - Claude-Bernard, Université de Paris Cité, Paris, France
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ZHANG J, CHEN X, MA S. [Advances in Predictive Research of Immune Checkpoint Inhibitors-related
Adverse Events]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2023; 26:789-794. [PMID: 37989342 PMCID: PMC10663778 DOI: 10.3779/j.issn.1009-3419.2023.106.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Indexed: 11/23/2023]
Abstract
The era of tumor treatment has been revolutionized by the advent of immune checkpoint inhibitors. However, while immunotherapy benefits patients, it can also lead to immune-related adverse events that may affect multiple organs and systems throughout the body, potentially even posing a life-threatening risk. The diverse clinical manifestations and onset times of these adverse events further complicate their prediction and diagnosis. The purpose of this paper is to review the clinical characteristics and predicted biomarkers of adverse events related to inhibitors at immune checkpoints, in order to help clinicians evaluate drug risks and early warn adverse events.
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Rieder D, Trajanoski Z. Checking immunotoxicity risks of checkpoint blockade. NATURE CANCER 2023; 4:779-780. [PMID: 37308677 DOI: 10.1038/s43018-023-00561-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Dietmar Rieder
- Biocenter, Institute of Bioinformatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Zlatko Trajanoski
- Biocenter, Institute of Bioinformatics, Medical University of Innsbruck, Innsbruck, Austria.
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