Ocular Paraneoplastic Syndromes

Ocular Immune-Related Adverse Events Associated with PD-1 Inhibitors: From Molecular Mechanisms to Clinical Management

Purpose: To help ophthalmologists and oncologists better understand the ocular irAEs secondary to PD-1 inhibitors , enabling early detection and management of ocular complications.Methods: We reviewed case reports and related literatures on ocular irAEs secondary to PD-1 inhibitors in PubMed, including a total of 70 case reports, summarizing and analyzing the specific conditions of these patients.Results: The most common malignant tumors were melanoma (n = 41; 58.6%) and lung cancer (n = 13; 18.6%). The main PD-1 inhibitors used were pembrolizumab (n = 38; 54.3%) and nivolumab (n = 28; 40%). They may result in various ocular complications, with the most common being uveitis (n = 35; 50%) and myasthenia gravis (n = 13; 18.57%). Adverse events concerning the cornea and the retina were reported in 8 cases each (11.43%). Neuro-ophthalmic adverse events were reported in 6 cases (8.57%). Most of these toxicities responded to topical and systemic steroids. Severe manifestations, however, may require temporary or permanent cessation of PD-1 inhibitors treatment.Conclusions: With the increasing use of PD-1 inhibitors, ophthalmologists need to remain sensitive to the clinical manifestations of adverse events to ensure timely diagnosis and management. To improve their quality of life and reduce mortality, oncologists and ophthalmologists should maintain close cooperation and implement multi-disciplinary treatment.

NOVEL MULTIMODAL IMAGING IN BILATERAL DIFFUSE UVEAL MELANOCYTIC PROLIFERATION AND CHANGE IN THE FINDINGS DURING FOLLOW-UP AND TREATMENT

PURPOSE

To describe the advanced multimodal imaging findings of patients with bilateral diffuse uveal melanocytic proliferation and the changes in these findings over time.

METHODS

Fundus photography, fundus autofluorescence, fundus fluorescein angiography, spectral domain optical coherence tomography, B-scan ultrasonography, and ultrasound biomicroscopy images of the patients diagnosed with bilateral diffuse uveal melanocytic proliferation at a single institution between years 2006 and 2023 were evaluated.

RESULTS

Sixteen eyes of eight patients with bilateral diffuse uveal melanocytic proliferation were included. The median age was 68 years (range: 49-77 years), and the median follow-up time was 11 months (range: 1-79 months). The most common fundus photography findings were pigmentary changes and diffuse orange pigment patches in the posterior pole. The giraffe/leopard pattern of hyperfluorescence on the posterior pole was the most prominent finding in fundus autofluorescence and fluorescein angiography. Different from previous reports, intraretinal hyperreflective foci, outer retinal tubulations, subretinal fibrosis, and bacillary layer detachment in optical coherence tomography; optic disc hyperfluorescence and peripheral vascular leakage in fluorescein angiography; 360° ciliary body thickening; and anterior rotation of the ciliary body in ultrasound biomicroscopy were detected.

CONCLUSION

We presented various novel multimodal imaging features of bilateral diffuse uveal melanocytic proliferation that may warrant updating current diagnostic criteria and their changes over time. Our newly defined findings also suggest a possible inflammatory component to bilateral diffuse uveal melanocytic proliferation pathogenesis, which may have implications for treatment.

Cancer-associated retinopathy secondary to gallbladder carcinoma

Objective

To present a rare case of cancer-associated retinopathy secondary to gallbladder carcinoma.

Methods

Retrospective case report. Drugs used in case report: methylprednisolone (Medrol), CAS number: 83-43-2, producer: Pfizer; carboplatin, CAS number: 41575-94-4, producer: Accor; etoposide, CAS number: 33419-42-0, producer: Teva; methotrexate (Ledertrexate), CAS number: 59-05-2, producer: Pfizer.

Results

A 57-year-old Moroccan man was referred with bilateral progressive vision loss in the last 4 months. At presentation, best corrected visual acuity (BCVA) was counting fingers for the right eye and 20/500 for the left eye. Examination demonstrated signs of vitritis, an electronegative full-field electroretinography (FF-ERG), ocular coherence tomography (OCT) abnormalities and multiple hyperautofluorescent round lesions on fundus autofluorescence imaging (FAF). The diagnosis of cancer-associated retinopathy (CAR) was considered, thus a positron emission tomography-computed tomography (PET-CT) was performed and revealed the presence of a metastasized gallbladder carcinoma. Additional fluorescence in situ hybridization (FISH) showed seropositivity for anti-retinal autoantibodies. High-dose corticosteroids together with anti-tumoral medication (carboplatin-etoposide) gradually improved the BCVA to 20/66 for the right eye and 20/20 for the left eye.

Conclusions

Consider the diagnosis of CAR in patients with progressive concentric visual field loss, uveitis and fundus abnormalities, especially if bilateral. If CAR is suspected, perform a full work-up: FF-ERG, OCT, and whole-body PET-CT. In the treatment of CAR, immunosuppressives are mostly used, combined with antitumoral therapy. However, in the long-term, progressive visual loss is expected in most cases.

Red blood cell-derived materials for cancer therapy: Construction, distribution, and applications

Cancer has become an increasingly important public health issue owing to its high morbidity and mortality rates. Although traditional treatment methods are relatively effective, they have limitations such as highly toxic side effects, easy drug resistance, and high individual variability. Meanwhile, emerging therapies remain limited, and their actual anti-tumor effects need to be improved. Nanotechnology has received considerable attention for its development and application. In particular, artificial nanocarriers have emerged as a crucial approach for tumor therapy. However, certain deficiencies persist, including immunogenicity, permeability, targeting, and biocompatibility. The application of erythrocyte-derived materials will help overcome the above problems and enhance therapeutic effects. Erythrocyte-derived materials can be acquired via the application of physical and chemical techniques from natural erythrocyte membranes, or through the integration of these membranes with synthetic inner core materials using cell membrane biomimetic technology. Their natural properties such as biocompatibility and long circulation time make them an ideal choice for drug delivery or nanoparticle biocoating. Thus, red blood cell-derived materials are widely used in the field of biomedicine. However, further studies are required to evaluate their efficacy, in vivo metabolism, preparation, design, and clinical translation. Based on the latest research reports, this review summarizes the biology, synthesis, characteristics, and distribution of red blood cell-derived materials. Furthermore, we provide a reference for further research and clinical transformation by comprehensively discussing the applications and technical challenges faced by red blood cell-derived materials in the treatment of malignant tumors.

Case Report of Seronegative Cancer-Associated Retinopathy in a Patient with Small Cell Lung Carcinoma

Cancer-associated retinopathy (CAR) is a rare paraneoplastic syndrome characterized by autoimmune destruction of photoreceptor cells. It is associated with several tumor types, including small cell lung carcinoma (SCLC). Corticosteroids have been the mainstay treatment for CAR, although no therapeutic standard has truly been established. A 66-year-old female with significant smoking history and age-related macular degeneration (ARMD) presented with rapidly declining bilateral visual acuity. Ophthalmologic examination findings appeared consistent with the known diagnosis of ARMD but did not otherwise present a clear alternative etiology. Imaging with a computed tomography (CT) scan revealed a right hilar mass which was confirmed to be limited stage SCLC based on a subsequent biopsy and further imaging with a positron emission tomography/computed tomography (PET/CT) scan. Antibody testing was negative for anti-recoverin antibodies. The patient experienced a complete response to chemoradiation with cisplatin and etoposide; however, her ocular symptoms did not respond to a combined treatment approach with corticosteroids, plasmapheresis, and intravenous immunoglobulin (IVIG). While CAR represents a rare condition in SCLC, cases that are seronegative for anti-recoverin are even less common. Further, the diagnosis of CAR by ophthalmologic examination may be more challenging in patients with pre-existing ocular diseases, such as macular degeneration. Clinicians should have suspicion for paraneoplastic blindness in patients with known risk factors for malignancy, whose ocular symptoms are inconsistent with exam findings.

Paraneoplastic syndrome in neuroophthalmology

Paraneoplastic syndrome is a group of clinical symptoms that occur in the state of systemic malignant tumors. Paraneoplastic syndrome of the nervous system can affect any part of the central and peripheral nervous system and may also affect the eyes. In neuroophthalmology, paraneoplastic syndrome has a variety of manifestations that can affect both the afferent and efferent visual systems. The afferent system may involve the optic nerve, retina and uvea; the efferent system may involve eye movement, neuromuscular joints or involuntary eye movements and pupil abnormalities and may also have other neurological symptoms outside the visual system. This article discusses the clinical manifestations, pathological mechanisms, detection methods and treatment methods of paraneoplastic syndrome in neuroophthalmology. The performance of paraneoplastic syndrome is diverse, the diagnosis is difficult, and the treatment should be considered systematically. Differential diagnosis, optimal evaluation and management of these manifestations is not only the key to treatment but also a challenge.

Iris pigment epithelial (IPE) cysts secondary to Hodgkin's lymphoma: A case report

Purpose

To describe a unique case of a white male who presented with reduced visual acuity, growing bilateral iris pigment epithelial (IPE) cysts and granulomatous panuveitis, probably related to Hodgkin's lymphoma.

Observations

The granulomatous panuveitis was reactive to corticosteroids, but the IPE cysts were not. After extensive work-up, the patient was diagnosed with Hodgkin's lymphoma (HL) mixed cellularity type with cervical and mediastinal lymph node involvement. After starting chemotherapy, the IPE cysts shrank.

Conclusions and importance

To our knowledge, IPE cysts have not been described in HL before. Therefore, this case can contribute to our knowledge of the relation between IPE cysts and hematological malignancy.

BILATERAL SERPIGINOUS-LIKE CHORIORETINITIS ASSOCIATED WITH CILIOCHOROIDAL MELANOMA: A Clinicopathologic Correlation

PURPOSE

To report the clinicopathologic correlation of a case of bilateral serpiginous-like chorioretinitis (SLC) associated with unilateral ciliochoroidal melanoma.

METHODS

A 71-year-old white woman was diagnosed with progressive SLC in both eyes associated with ciliochoroidal melanoma in the right eye. Clinical findings and imaging before and after enucleation in the right eye were correlated to histologic and immunohistochemistry sections.

RESULTS

Examination and imaging identified a peripheral bilobed amelanotic lesion with low reflectivity on B-scan ultrasound with an associated exudative detachment in the right eye. Additionally, multiple areas of new SLC lesions in the macula and peripapillary region in the right eye and along the inferior arcade in the left eye were observed. Oncologic evaluation confirmed a Class 2, ciliochoroidal melanoma, and the eye was enucleated. Autoimmune and infectious laboratory evaluations for the etiology of the SLC lesions were negative. Histopathology of the enucleated eye confirmed the diagnosis of uveal melanoma with lymphocytic inflammation at the edges of the tumor itself and in the areas of discrete SLC lesions. Immunohistochemistry identified similar predominantly CD3 and CD8 T cells and fewer CD20 B cells in both regions.

CONCLUSION

Serpiginous-like chorioretinitis may present as a paraneoplastic, predominantly T-lymphocyte inflammation associated with intraocular tumor such as uveal melanoma.

Ocular Paraneoplastic Syndromes: A Critical Review of Diffuse Uveal Melanocytic Proliferation and Autoimmune Retinopathy

Background: Dozens of paraneoplastic syndromes affect the visual system ranging from conjunctival pemphigoid to encephalopathy of the occipital cortex. The most profiled ocular syndromes are bilateral diffuse uveal melanocytic proliferation (BDUMP) and the autoimmune retinopathies.Purpose: To review the critical features of these 2 entities then concentrate on advancements in treatment made within the last 10 years.Study Design: Literature review with structured data abstraction.Results: Major insights into pathogenesis have been wanting. Plasmapheresis appears to improve vision in a substantial proportion of patients with BDUMP. The number of clinical variables that influence visual outcome in paraneoplastic retinopathies combined with the variety of local and systemic treatment options makes interpretation of clinical effectiveness difficult.Conclusions: The rarity of these disorders makes randomized clinical trials unlikely. It may be time for a clinical professional organization to use a modified Delphi method to establish a consensus algorithm for the diagnosis and management of retinal paraneoplastic syndromes to augment clinical communications and clinical trials.

Retrobulbar Optic Neuritis Induced by Pembrolizumab in a Patient with Lung Adenocarcinoma

Pembrolizumab is a monoclonal antibody with anti-tumor effects. Only a few reports have previously described retrobulbar optic neuritis induced by pembrolizumab. We herein report the case of a 63-year-old man with advanced lung adenocarcinoma who received cisplatin, pemetrexed, and pembrolizumab combination therapy for six months. Following treatment, a visual field test showed a left central scotoma. Imaging studies showed left optic neuritis without brain metastasis. Blood tests showed an elevated serum creatinine level. He was diagnosed with retrobulbar optic neuritis and pembrolizumab-induced renal failure. After receiving corticosteroid treatment, his renal function rapidly improved. The optic neuritis improved somewhat, but it was not adequately resolved.

Beneficial autoimmunity improves cancer prognosis

Many tumour antigens that do not arise from cancer cell-specific mutations are targets of humoral and cellular immunity despite their expression on non-malignant cells. Thus, in addition to the expected ability to detect mutations and stress-associated shifts in the immunoproteome and immunopeptidome (the sum of MHC class I-bound peptides) unique to malignant cells, the immune system also recognizes antigens expressed in non-malignant cells, which can result in autoimmune reactions against non-malignant cells from the tissue of origin. These autoimmune manifestations include, among others, vitiligo, thyroiditis and paraneoplastic syndromes, concurrent with melanoma, thyroid cancer and non-small-cell lung cancer, respectively. Importantly, despite the undesirable effects of these symptoms, such events can have prognostic value and correlate with favourable disease outcomes, suggesting 'beneficial autoimmunity'. Similarly, the occurrence of dermal and endocrine autoimmune adverse events in patients receiving immune-checkpoint inhibitors can have a positive predictive value for therapeutic outcomes. Neoplasias derived from stem cells deemed 'not essential' for survival (such as melanocytes, thyroid cells and most cells in sex-specific organs) have a particularly good prognosis, perhaps because the host can tolerate autoimmune reactions that destroy tumour cells at some cost to non-malignant tissues. In this Perspective, we discuss examples of spontaneous as well as therapy-induced autoimmunity that correlate with favourable disease outcomes and make a strong case in favour of this 'beneficial autoimmunity' being important not only in patients with advanced-stage disease but also in cancer immunosurveillance.

Paraneoplastic optic neuropathy secondary to adenocarcinoma of the lung

We describe an uncommon cause of paraneoplastic optic neuropathy in adenocarcinoma of the lung. A 45-year-old healthy woman presented with seizure and encephalitis, followed by an acute visual loss in both eyes for 1 week. Her visual acuity was no perception of light in the right eye and hand movement in the left eye. There was a generalised restriction of extraocular muscle movements in both eyes. Funduscopy showed a bilateral pale optic disc. A paraneoplastic antigen autoimmune profile showed a positive anti-CV2/CRMP-5 antibody. CT of the thorax revealed the presence of right apical lung mass, confirmed to be adenocarcinoma through a biopsy. She was scheduled for lung lobectomy and chemotherapy. Unfortunately, her health deteriorated and she passed away eventually.