Molecular Mechanisms of Cutaneous Immune-Related Adverse Events (irAEs) Induced by Immune Checkpoint Inhibitors

Opportunities and challenges of immuno-oncology: A bibliometric analysis from 2014 to 2023

The emergence of immuno-oncology (IO) has led to revolutionary changes in the field of cancer treatment. Despite notable advancements in this field, a thorough exploration of its full depth and extent has yet to be performed. This study provides a comprehensive overview of publications pertaining to IO. Publications on IO from 2014 to 2023 were retrieved by searching the Web of Science Core Collection database (WoSCC). VOSviewer software and Citespace software were used for the visualized analysis. A total of 1,874 articles have been published in the IO domain. The number of publications and citations has been increasing annually. This study also examines the primary research directions within the field of IO. In conclusion, this study offers a comprehensive overview of the opportunities and challenges associated with IO, illuminating the current status of research and indicating potential future trajectories in this rapidly progressing field. This study provides a comprehensive survey of the current research status and hot spots within the field of IO. It will assist researchers in comprehending the current research emphasis and development trends in this field and offers guidance for future research directions.

Dermatologic toxicities related to cancer immunotherapy

Immunotherapy has revolutionized cancer treatment, offering significant survival superiority for advanced malignancies. However, immunotherapy is associated with various immune-related adverse events, one of the most common of them being dermatologic toxicities. Previous studies have reported dermatologic adverse events in almost half of the cancer patients undergoing immunotherapy. The spectrum of dermatologic toxicities ranges from mild, self-limiting reactions to severe, life-threatening conditions, and includes maculopapular rash, pruritus, vitiligo-like depigmentation, psoriasiform eruption, lichenoid eruption, bullae, photosensitivity, hair loss, nail changes, Stevens-Johnson syndrome, and toxic epidermal necrolysis. The management strategies are based on personalized treatment plans, multidisciplinary approaches, and timely therapeutic interventions aimed at addressing dermatologic toxicities while preserving immunotherapy efficacy. Based on the latest findings, this paper offers a novel perspective and provides an evidence-based review of the pathogenesis, manifestations, incidence, grading, clinical management, and prognostic significance of these toxicities, underlining the importance of balancing the efficacy of immunotherapy with timely and proactive management of their dermatological toxicities to enhance patient outcomes and quality of life.

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.

Case Report: Multiple cutaneous keratoacanthoma-like lesions in a colorectal cancer patient treated with sintilimab

Immune checkpoint inhibitors are increasingly being utilized for the treatment of advanced neoplastic disease, and Sintilimab as a selective anti-PD-1 antibody that inhibits interactions between PD-1 and its ligand, is a typical representative of them. Among all the adverse effects(AEs) of sintilimab, skin AEs had affected many people. Though exceedingly rare, eruptive keratoacanthomas-like lesion have been associated with the use of immune checkpoint inhibitors before. Here, we report a case of numerous eruptive keratoacanthoma-like lesions arising in a patient 2 weeks after initiation of sintilimab for rectal adenocarcinoma with liver metastasis. Although eruptive keratoacanthoma-like lesions secondary to sintilimab are exceptionally rarely reported, physicians should be aware of this cutaneous adverse effect as its use becomes more widespread.

Case Report: The immune architecture of immunotherapy-induced cutaneous sarcoidosis resembles peritumoral inflammation

Avelumab, is an anti-PD-L1 immune checkpoint inhibitor (ICI). Like other ICI, avelumab can cause immune-related adverse events. Although rare, sarcoidosis-like granulomatous reactions have been described in patients on anti-CTLA-4 and anti-PD-1 immunotherapy. Here we report a case of treatment emergent cutaneous sarcoidosis in a patient who received avelumab for metastatic colon cancer. A 56-year-old African American woman with metastatic colon cancer that had progressed after multiple lines of treatment, including other immunotherapy agents, was enrolled on a clinical trial with avelumab. While on treatment, the patient developed two skin lesions, and histopathological examination of both biopsies demonstrated chronic granulomatous inflammation in the dermis with multinucleated giant cells containing asteroid bodies, consistent with cutaneous sarcoidosis. Multiplex immunofluorescence revealed parallels between the immune architecture of the patient's cutaneous sarcoidal lesion and an excised tumor metastasis. Recognizing cutaneous sarcoidosis as a rare adverse effect of ICI immunotherapy is important because sarcoidal lesions can be mistaken for metastatic disease on clinical exam and medical imaging. We noticed similar immune composition of the sarcoidal granuloma and tumor microenvironment. However, further studies are needed to fully elucidate the mechanism of ICI associated sarcoidosis.

Adverse skin reactions secondary to sintilimab for advanced gastric adenocarcinoma: A case report and literature review

Immune checkpoint inhibitors, a class of anticancer drugs, which act via enhancing T cell responses against tumor cells, are associated with immune-related adverse events. The skin is one of the most commonly affected organs. In the present study, a case of a 78-year-old man, who developed systemic eczema dermatitis due to neoadjuvant treatment of locally advanced gastric adenocarcinoma with sintilimab combined with Tigio plus oxaliplatin regimen, was reported. The eczema dermatitis completely subsided after treatment with methylprednisolone. The patient and his family strongly requested surgical intervention. Postoperative pathology revealed a pathological complete response.

Immune Checkpoint Inhibitor-Associated Cutaneous Adverse Events: Mechanisms of Occurrence

Immunotherapy, particularly that based on blocking checkpoint proteins in many tumors, including melanoma, Merkel cell carcinoma, non-small cell lung cancer (NSCLC), triple-negative breast (TNB cancer), renal cancer, and gastrointestinal and endometrial neoplasms, is a therapeutic alternative to chemotherapy. Immune checkpoint inhibitor (ICI)-based therapies have the potential to target different pathways leading to the destruction of cancer cells. Although ICIs are an effective treatment strategy for patients with highly immune-infiltrated cancers, the development of different adverse effects including cutaneous adverse effects during and after the treatment with ICIs is common. ICI-associated cutaneous adverse effects include mostly inflammatory and bullous dermatoses, as well as severe cutaneous side reactions such as rash or inflammatory dermatitis encompassing erythema multiforme; lichenoid, eczematous, psoriasiform, and morbilliform lesions; and palmoplantar erythrodysesthesia. The development of immunotherapy-related adverse effects is a consequence of ICIs' unique molecular action that is mainly mediated by the activation of cytotoxic CD4+/CD8+ T cells. ICI-associated cutaneous disorders are the most prevalent effects induced in response to anti-programmed cell death 1 (PD-1), anti-cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4), and anti-programmed cell death ligand 1 (PD-L1) agents. Herein, we will elucidate the mechanisms regulating the occurrence of cutaneous adverse effects following treatment with ICIs.

Physiological markers for immunotherapeutics: a review

Immunotherapy has been advanced through multiple approaches, including immunogenic cytokines, monoclonal antibodies, therapeutic vaccinations, adoptive cell transfer, stem cell transplantation, and oncolytic viruses. This review analyses various strategies in genomics, transcriptomics, single-cell techniques, computational analysis, big data, and imaging technologies for the identification of tumour microbiota and microenvironments. Immunotherapy is becoming acknowledged as a feasible cancer treatment method, facilitating innovative cancer medicines and personalized medicine techniques.

Symptom clusters and symptom network analysis during immunotherapy in lung cancer patients

OBJECTIVE

This study analyzes symptoms in lung cancer patients undergoing immunotherapy to identify core symptom clusters through network analysis and lay a foundation for effective symptom management programs.

METHODS

The sample comprised 240 lung cancer patients receiving immunotherapy. Participants were assessed using the Memorial Symptom Assessment Scale. Exploratory factor analysis was used to extract symptom clusters, and network analysis using JASP 0.17.3 was performed to explore the centrality indices and density of the symptom network.

RESULTS

Five symptom clusters were identified, i.e., emotion-related, lung cancer-related, physical, skin, and neural symptom clusters, with a cumulative variance contribution rate of 55.819%. Network analysis revealed that sadness was the most intense symptom (rs = 2.189), dizziness was the most central symptom (rc = 1.388), and fatigue was the most significant bridging symptom (rb = 2.575).

CONCLUSION

This study identified five symptom clusters and a symptom network among lung cancer patients during immunotherapy. The network analysis's centrality indices and network density results can assist healthcare professionals in devising more precise symptom management strategies.

Immune Checkpoint Inhibitors for Pediatric Cancers: Is It Still a Stalemate?

The knowledge surrounding the application of immune checkpoint inhibitors (ICIs) in the treatment of pediatric cancers is continuously expanding and evolving. These therapies work by enhancing the body's natural immune response against tumors, which may have been suppressed by certain pathways. The effectiveness of ICIs in treating adult cancers has been widely acknowledged. However, the results of early phase I/II clinical trials that exclusively targeted the use of ICIs for treating different pediatric cancers have been underwhelming. The response rates to ICIs have generally been modest, except for cases of pediatric classic Hodgkin lymphoma. There seems to be a notable disparity in the immunogenicity of childhood cancers compared to adult cancers, potentially accounting for this phenomenon. On average, childhood cancers tend to have significantly fewer neoantigens. In recent times, there has been a renewed sense of optimism regarding the potential benefits of ICI therapies for specific groups of children with cancer. In initial research, individuals diagnosed with pediatric hypermutated and SMARCB1-deficient cancers have shown remarkable positive outcomes when treated with ICI therapies. This is likely due to the underlying biological factors that promote the expression of neoantigens and inflammation within the tumor. Ongoing trials are diligently assessing the effectiveness of ICIs for pediatric cancer patients in these specific subsets. This review aimed to analyze the safety and effectiveness of ICIs in pediatric patients with different types of highly advanced malignancies.

Glucocorticoids in lung cancer: Navigating the balance between immunosuppression and therapeutic efficacy

Glucocorticoids (GCs), a class of hormones secreted by the adrenal glands, are released into the bloodstream to maintain homeostasis and modulate responses to various stressors. These hormones function by binding to the widely expressed GC receptor (GR), thereby regulating a wide range of pathophysiological processes, especially in metabolism and immunity. The role of GCs in the tumor immune microenvironment (TIME) of lung cancer (LC) has been a focal point of research. As immunosuppressive agents, GCs exert a crucial impact on the occurrence, progression, and treatment of LC. In the TIME of LC, GCs act as a constantly swinging pendulum, simultaneously offering tumor-suppressive properties while diminishing the efficacy of immune-based therapies. The present study reviews the role and mechanisms of GCs in the TIME of LC.

Symptom clusters and their impacts on the quality of life of patients with lung cancer receiving immunotherapy: A cross-sectional study

AIM

The objective of this study was to identify symptom clusters in lung cancer patients receiving immunotherapy and explore their impact on the quality of life of patients.

BACKGROUND

Immunotherapy is widely used in lung cancer; however, there is little understanding of symptom clusters and their impacts on the quality of life of this population.

DESIGN

Cross-sectional study.

METHODS

The survey contained the Memorial Symptom Assessment Scale (MSAS), Quality of Life Questionnaire-Lung Cancer 43 and a self-designed General Information Evaluation Form. Symptom clusters were identified using exploratory factor analysis (EFA) based on the symptom scores. Spearman correlation analysis was performed to evaluate the associations between each symptom cluster and the patients' quality of life. Multiple linear regression analysis was employed to examine the impact of the symptom clusters on quality of life. This study adhered to the STROBE guidelines.

RESULTS

In total, 240 participants completed the survey. Five symptom clusters were identified and named according to their characteristics: emotional-related symptom cluster, lung cancer-related symptom cluster, physical symptom cluster, skin symptom cluster and neural symptom cluster. All symptom clusters, except for the neural symptom cluster, had a significantly detrimental impact on patient quality of life.

CONCLUSION

Lung cancer patients undergoing immunotherapy experience a range of symptoms, which can be categorized into five clusters. These symptom clusters have a negative impact on patients' quality of life. Future research should focus on developing interventions for each symptom cluster and their influencing factors.

PATIENT OR PUBLIC CONTRIBUTION

In the data collection phase, lung cancer patients undergoing immunotherapy were recruited to participate in the survey.

Immune checkpoint inhibitors and renal toxicity

Immune checkpoint inhibitors (ICIs) have transformed the management of a broad spectrum of cancers as metastatic melanoma, non-small lung cancer or renal cell carcinoma. These humanized monoclonal antibodies target immune-regulatory receptors expressed on T lymphocytes, antigen presenting cells and tumor cells and induce an immunological anti-tumor response. If on the one hand these molecules have led to considerable improvement in survival outcomes, on the other hand these therapies can be associated with immune-related adverse effects (irAEs). While these side effects have become well known, the best diagnostic and therapeutic approaches are still under investigation. The authors discuss pathophysiology, clinical presentation and histological features of ICIs renal toxicity. Furthermore, we focus on kidney transplant (KT) recipients, including the therapeutic adaptation approach to immunosuppression and the risk of rejection.

Immunological landscape of solid cancer: Interplay between tumor and autoimmunity

The immune system, a central player in maintaining homeostasis, emerges as a pivotal factor in the pathogenesis and progression of two seemingly disparate yet interconnected categories of diseases: autoimmunity and cancer. This chapter delves into the intricate and multifaceted role of the immune system, particularly T cells, in orchestrating responses that govern the delicate balance between immune surveillance and self-tolerance. T cells, pivotal immune system components, play a central role in both diseases. In autoimmunity, aberrant T cell activation drives damaging immune responses against normal tissues, while in cancer, T cells exhibit suppressed responses, allowing the growth of malignant tumors. Immune checkpoint receptors, example, initially explored in autoimmunity, now revolutionize cancer treatment via immune checkpoint blockade (ICB). Though effective in various tumors, ICB poses risks of immune-related adverse events (irAEs) akin to autoimmunity. This chapter underscores the importance of understanding tumor-associated antigens and their role in autoimmunity, immune checkpoint regulation, and their implications for both diseases. It also explores autoimmunity resulting from cancer immunotherapy and shared molecular pathways in solid tumors and autoimmune diseases, highlighting their interconnectedness at the molecular level. Additionally, it sheds light on common pathways and epigenetic features shared by autoimmunity and cancer, and the potential of repurposing drugs for therapeutic interventions. Delving deeper into these insights could unlock therapeutic strategies for both autoimmunity and cancer.

Emerging Insights into Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Induced by Immune Checkpoint Inhibitor and Tumor-Targeted Therapy

Objective

Anticancer drugs have revolutionized tumor therapy, with cutaneous toxicities such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) being common immune-related adverse events. The debate over the efficacy of systemic corticosteroids in treating these conditions persists, while tumor necrosis factor (TNF)-alpha inhibitors show promise. This study aims to evaluate the effectiveness and safety of combination therapy involving the TNF-α inhibitor adalimumab for SJS/TEN induced by anticancer drugs.

Methods

A literature review of SJS/TEN cases induced by anticancer drugs from 1992 to 2023 was conducted, alongside an analysis of patients admitted to the First Affiliated Hospital of Fujian Medical University during the same period. Clinical characteristics, skin healing time, mortality, and adverse events were evaluated in two treatment groups: SJS/TEN patients treated with targeted anticancer therapies and immunotherapies.

Results

Among the 27 patients studied (18 with SJS or SJS-TEN overlapping and 9 with TEN), combination therapy with adalimumab significantly reduced mucocutaneous reepithelization time and healing duration compared to corticosteroid monotherapy. Patients receiving adalimumab combined with corticosteroids had lower actual mortality rates than those on corticosteroid monotherapy. The combination therapy also showed a trend towards reducing standardized mortality rates based on the Score of Toxic Epidermal Necrolysis (SCORTEN).

Conclusion

The findings suggest that adalimumab in combination with corticosteroids provides significant clinical benefits and is safer than corticosteroids alone for treating SJS/TEN induced by targeted anticancer therapies and immunotherapies. This study contributes valuable insights into potential treatment strategies for severe cutaneous adverse reactions to anticancer drugs, highlighting the importance of exploring alternative therapies such as TNF-α inhibitors in managing these conditions effectively.

Case report: Envafolimab causes local skin necrosis

Envafolimab is a Chinese domestic innovative fusion of a humanized single-domain programmed death-ligand 1 (PD-L1) antibody (dAb) and human immunoglobulin IgG1 crystalline fragment (Fc) developed for subcutaneous injections. It was granted conditional market authorization by the China National Medical Product Administration (NMPA) in December 2021. Envafolimab is used to treat adult patients with previously treated microsatellite instability-high (MSI-H) or deficient mismatch repair (dMMR) advanced solid tumors, including patients with advanced colorectal cancer disease progression who were previously administered fluorouracil, oxaliplatin, and irinotecan, as well as other patients with advanced solid tumors who experienced disease progression after receiving standard treatment and had no other alternative treatment options. However, the lack of post-marketing clinical trial data requires conducting more clinical studies on the safety and efficacy of envafolimab in order to provide scientific basis and a reference for future therapeutic applications. In this paper, we report a case of severe skin necrosis and bleeding in the area of injection after subcutaneous administration of envafolimab in a patient diagnosed with hepatocellular carcinoma. We discuss issues that must be considered before administration of a PD-L1 inhibitor subcutaneously, which could induce immune mechanisms leading to skin necrosis in the area of injection.