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Rivet V, Sibaud V, Dion J, Volosov T, Biteau M, Pastissier A, Delavigne K, Cougoul P, Rauzy O, Comont T. Immune checkpoint inhibitor-related acquired amegakaryocytosis thrombocytopenia: a case report and literature review. Front Oncol 2024; 14:1353896. [PMID: 38515568 PMCID: PMC10955628 DOI: 10.3389/fonc.2024.1353896] [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: 12/11/2023] [Accepted: 02/14/2024] [Indexed: 03/23/2024] Open
Abstract
Introduction Immune checkpoint inhibitors (ICIs) are used in several advanced malignancies and may cause various immune-related adverse events (irAEs). Among them, hematological irAEs are less described. Acquired amegakaryocytic thrombocytopenia (AAT) is a rare immune hematologic disorder characterized by severe thrombocytopenia and complete absence of megakaryocytes in bone marrow. Case presentation Herein, we present the case of a patient in their 40s with metastatic melanoma who developed an AAT after 12 cycles of nivolumab (anti-PD1). His platelet count decreased by ≤5 × 109/l without other cytopenia. Bone marrow biopsy showed normal cellularity with a complete absence of megakaryocyte and T-CD8+ lymphocyte infiltration. Given the failure of systemic steroids, eltrombopag was started, an oral thrombopoietin receptor agonist (TPO-RA), and his platelet count subsequently increased with complete response. Discussion Four other cases are described on literature with the same features than non-ICI-related AAT. All cases occurred after anti-PD/PD-L1 treatment with a median onset of 5 weeks. The presentation of our case is quite different with delayed cytopenia. Both ciclosporin and TPO-RA seem to be efficient therapies. Conclusion TPO-RA could be preferred in oncologic patients, but safety data are still missing to define clear guidelines for immune-related AAT management.
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Affiliation(s)
- Valérian Rivet
- Internal Medicine and Immunopthology Department, The Cancer University of Toulouse Oncopole, University Hospital Center of Toulouse, Toulouse, France
| | - Vincent Sibaud
- Dermatology Department – Medical Oncology, The Cancer University of Toulouse Oncopole, University Hospital Center of Toulouse, Toulouse, France
| | - Jérémie Dion
- Internal Medicine and Immunopthology Department, The Cancer University of Toulouse Oncopole, University Hospital Center of Toulouse, Toulouse, France
| | - Thibaut Volosov
- The Anatomical Pathology Department, The Cancer University of Toulouse Oncopole, University Hospital Center of Toulouse, Toulouse, France
| | - Mélanie Biteau
- Internal Medicine and Immunopthology Department, The Cancer University of Toulouse Oncopole, University Hospital Center of Toulouse, Toulouse, France
| | - Andréa Pastissier
- Internal Medicine and Immunopthology Department, The Cancer University of Toulouse Oncopole, University Hospital Center of Toulouse, Toulouse, France
| | - Karen Delavigne
- Internal Medicine and Immunopthology Department, The Cancer University of Toulouse Oncopole, University Hospital Center of Toulouse, Toulouse, France
| | - Pierre Cougoul
- Internal Medicine and Immunopthology Department, The Cancer University of Toulouse Oncopole, University Hospital Center of Toulouse, Toulouse, France
| | - Odile Rauzy
- Internal Medicine and Immunopthology Department, The Cancer University of Toulouse Oncopole, University Hospital Center of Toulouse, Toulouse, France
| | - Thibault Comont
- Internal Medicine and Immunopthology Department, The Cancer University of Toulouse Oncopole, University Hospital Center of Toulouse, Toulouse, France
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Meng W, Hua J, Wang J. Successful avatrombopag combined with cyclosporine treatment for carboplatin/pegylated liposomal doxorubicin/bevacizumab-induced acquired amegakaryocytic thrombocytopenia in a patient with recurrent ovarian cancer: case report. Front Oncol 2024; 14:1253230. [PMID: 38406810 PMCID: PMC10884148 DOI: 10.3389/fonc.2024.1253230] [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: 09/26/2023] [Accepted: 01/22/2024] [Indexed: 02/27/2024] Open
Abstract
Carboplatin/pegylated liposomal doxorubicin/bevacizumab is an accepted standard anti-cancer treatment option for recurrent ovarian cancer. However, the occurrence of adverse events associated with this therapeutic regimen limits its continued clinical use. Among these adverse events, acquired amegakaryocytic thrombocytopenia is a rare but often potentially life-threatening adverse effect, and is intolerant to multiple treatment approaches. We report, for the first time, the successful treatment using avatrombopag combined with cyclosporine in one case of carboplatin/pegylated liposomal doxorubicin/bevacizumab-induced acquired amegakaryocytic thrombocytopenia, which was refractory or intolerant to glucocorticoids, intravenous immunoglobulin, recombinant human thrombopoietin, androgen, and even thrombopoietin receptor receptor agonist eltrombopag and herombopag. To date, this case manifests as normal platelet counts that are independent of transfusion. Our findings suggest that this combination is a potential and valuable alternative in acquired amegakaryocytic thrombocytopenia.
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Affiliation(s)
- Weikang Meng
- Department of Hematologic Oncology, Taizhou Municipal Hospital, Taizhou, China
| | - Jinsheng Hua
- Department of Hematologic Oncology, Taizhou Municipal Hospital, Taizhou, China
| | - Jiabing Wang
- Department of Pharmacy, Taizhou Municipal Hospital, Taizhou, China
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Kroll MH. Checkpoint inhibitors. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:209-215. [PMID: 38066867 PMCID: PMC10727098 DOI: 10.1182/hematology.2023000523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Immune checkpoint inhibitors are a class of antineoplastic therapies that unleash immune cells to kill malignant cells. These medications commonly cause immune-related adverse effects due to activated adaptive and innate immune cells, autoantibody production, and/or cytokine dysregulation. Hematologic toxicities are rare and of uncertain mechanism, and therefore management is often based on experiences with familiar conditions involving these perturbed immune responses. Management is challenging because one must attend to the hematologic toxicity while simultaneously attending to the malignancy, with the imperative that therapeutic effects be maintained or minimally interrupted when possible.
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Affiliation(s)
- Michael H. Kroll
- Section of Benign Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Schlüter J, Cunningham S, Zimmermann R, Achenbach S, Kramer R, Erdmann M, Beckmann M, Heinzerling L, Hackstein H. Characterization of the impact of immune checkpoint inhibitors on platelet activation and aggregation. Immunobiology 2023; 228:152311. [PMID: 36495598 DOI: 10.1016/j.imbio.2022.152311] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/18/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
Immune checkpoint inhibitors (ICIs) are effective oncological drugs which block cellular check-point receptors typically targeted by tumor immune evasion strategies. Despite their benefits, clinicians have reported treatment-associated thromboembolism during ICI therapy in recent years. Though several theories on this ICI-associated pathogenesis exist, the direct effects of ICIs on platelets remains unknown. We therefore investigated the potential direct and indirect effect of PD-1, PD-L1 and CTLA-4-targeting ICIs on platelet functionality in multifaceted in vitro experiments. Interestingly, we could not observe a clear effect of ICI on platelet aggregation and primary hemostasis in whole blood and platelet concentrate-based assays. Furthermore, the presence of ICIs in toll-like receptor stimulation had no significant impact on platelet surface marker expression. In a second approach, we investigated the indirect immunological impact of ICIs on platelet activation by exposing platelets to supernatants from ICI- and Staphylococcal enterotoxin B-exposed PBMCs. Whereas ICIs affected IL-2 levels in supernatants, we could not detect clear differences in the secretion of pro-thrombogenic factors and platelet responses. The obtained data suggest that the direct influence of ICIs on platelet activation or the influence of altered T cell function on platelet activation cannot be considered a major factor in the development of thrombotic events.
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Affiliation(s)
- Julian Schlüter
- Department of Transfusion Medicine and Hemostaseology, University Hospital Erlangen, Erlangen 91054, Germany
| | - Sarah Cunningham
- Department of Transfusion Medicine and Hemostaseology, University Hospital Erlangen, Erlangen 91054, Germany.
| | - Robert Zimmermann
- Department of Transfusion Medicine and Hemostaseology, University Hospital Erlangen, Erlangen 91054, Germany
| | - Susanne Achenbach
- Department of Transfusion Medicine and Hemostaseology, University Hospital Erlangen, Erlangen 91054, Germany
| | - Rafaela Kramer
- Department of Gynecology and Obstetrics, University Hospital Erlangen, Erlangen 91054, Germany
| | - Michael Erdmann
- Department of Gynecology and Obstetrics, University Hospital Erlangen, Erlangen 91054, Germany
| | - Malte Beckmann
- Department of Gynecology and Obstetrics, University Hospital Erlangen, Erlangen 91054, Germany
| | - Lucie Heinzerling
- Department of Gynecology and Obstetrics, University Hospital Erlangen, Erlangen 91054, Germany; Department of Dermatology and Allergology, Ludwig-Maximilian University, Munich 80539, Germany
| | - Holger Hackstein
- Department of Transfusion Medicine and Hemostaseology, University Hospital Erlangen, Erlangen 91054, Germany
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Ikeda N, Hisano Y, Kamao T, Uno M, Mizushima T. Acquired Amegakaryocytic Thrombocytopenia Associated With Autoimmune Hemolytic Anemia. Cureus 2022; 14:e27315. [PMID: 36042987 PMCID: PMC9411021 DOI: 10.7759/cureus.27315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2022] [Indexed: 11/05/2022] Open
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Efficacy and Immunomodulating Properties of Eltrombopag in Aplastic Anemia following Autologous Stem Cell Transplant: Case Report and Review of the Literature. Pharmaceuticals (Basel) 2022; 15:ph15040419. [PMID: 35455416 PMCID: PMC9032708 DOI: 10.3390/ph15040419] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/23/2022] [Accepted: 03/28/2022] [Indexed: 12/20/2022] Open
Abstract
Thrombopoietin receptor agonists (TPO-RA) are currently indicated for the treatment of chronic immune thrombocytopenia and relapsed refractory aplastic anemia. However, the off-label use of these drugs is more and more frequent, including in the setting of aplasia secondary to chemotherapy and hemopoietic stem cell transplant (SCT). Growing evidence suggests that mechanisms of action of TPO-RA go beyond the TPO-receptor stimulation and point at the immunomodulating properties of these drugs. Here, we present a case of prolonged bone marrow aplasia secondary to autologous SCT treated with eltrombopag. We describe the clinical efficacy and the immunomodulating effect of this drug on inflammatory cytokine profile and bone marrow histology. Furthermore, we provide a review of the most recent literature highlighting the efficacy and safety of TPO-RA after SCT and chemotherapy for hematologic conditions.
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Tu X, Xue A, Wu S, Jin M, Zhao P, Zhang H. Case Report: Successful Avatrombopag Treatment for Two Cases of Anti-PD-1 Antibody-Induced Acquired Amegakaryocytic Thrombocytopenia. Front Pharmacol 2022; 12:795884. [PMID: 35153753 PMCID: PMC8830913 DOI: 10.3389/fphar.2021.795884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Anti-PD-1/PD-L1 immunotherapy has achieved impressive responses in multiple types of malignancies in recent years. However, immune-related adverse events (irAEs) occur and limit their continuous clinical use. Among these irAEs, acquired amegakaryocytic thrombocytopenia (AAT) is rare but often clinically serious, life-threatening and refractory to multiple treatment approaches. Case summary: We reported for the first time the successful treatment of avatrombopag in two cases of anti-PD1 antibody-induced AAT (in particular, one case had progressed to aplastic anemia), which was refractory or intolerant to glucocorticoids, ciclosporin, intravenous immunoglobulin (IVIG), recombinant human thrombopoietin (rh-TPO) and even TPO receptor agonist (TPO-RA) eltrombopag. To date, the two cases manifested as normal platelet counts and are independent of transfusion. Conclusion: Anti-PD1 antibody-induced AAT occurs with low frequency but is often serious and difficult to manage, for which this study proposed vatrombopag as a potential curative and safe approach.
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Affiliation(s)
- Xiaofang Tu
- Department of Hematology, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ali Xue
- Department of Hematology, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Suye Wu
- Department of Hematology, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Mengmeng Jin
- Department of Hematology, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Pu Zhao
- Department of Hematology, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hao Zhang
- Department of Hematology, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Xie W, Hu N, Cao L. Immune Thrombocytopenia Induced by Immune Checkpoint Inhibitrs in Lung Cancer: Case Report and Literature Review. Front Immunol 2021; 12:790051. [PMID: 34956221 PMCID: PMC8695900 DOI: 10.3389/fimmu.2021.790051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/22/2021] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs), including antibodies targeting programmed cell death protein-1 (PD-1) and programmed cell death ligand-1 (PD-L1), are being extensively used on advanced human malignancies therapy. The treatment with ICIs have acquired durable tumor inhibition and changed the treatment landscape in lung cancer. Immune-related adverse events including pneumonitis and thyroiditis have been well described, but less frequent events, such as ICIs-induced thrombocytopenia, are now emerging and may sometimes be severe or fatal. Since early detection and prompt intervention are crucial to prevent fatal consequences, it is of outmost importance that medical staff is aware of these potential toxicities and learn to recognize and treat them adequately. This review focuses on the epidemiology, clinical presentation, mechanisms, and clinical management of ICIs-induced thrombocytopenia in patients with lung cancer. We also present a patient with advanced lung adenocarcinoma who received the PD-L1 inhibitor atezolizumab and eventually developed severe thrombocytopenia. The case indirectly suggests that cytokine changes might contribute to immune dysregulation in ICIs-induced thrombocytopenia.
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Affiliation(s)
- Wang Xie
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - NaNa Hu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - LeJie Cao
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
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Hematologic complications of immune checkpoint inhibitors. Blood 2021; 139:3594-3604. [PMID: 34610113 PMCID: PMC9227102 DOI: 10.1182/blood.2020009016] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/13/2021] [Indexed: 11/20/2022] Open
Abstract
Immune checkpoint inhibitors are a class of anti-neoplastic therapies that unleash immune cells to kill malignant cells. There are currently 7 medications FDA-approved for the treatment of 14 solid tumors and 2 hematological malignancies. These medications commonly cause immune-related adverse effects due to overactive T lymphocytes, autoantibody production, and/or cytokine dysregulation. Hematological toxicities are rare and of uncertain mechanism, and therefore management is often based on experiences with familiar conditions involving these perturbed immune responses, such as autoimmune hemolytic anemia, immune thrombocytopenia, and idiopathic aplastic anemia. Management is challenging because one must attend to the hematological toxicity while simultaneously attending to the malignancy, with the imperative that effective cancer therapy be maintained or minimally interrupted if possible. The purpose of this review is to assist clinicians by providing a clinical and pathophysiological framework in which to view these problems.
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Makiguchi T, Tanaka H, Kamata K, Taima K, Kurose A, Tasaka S. Immune-mediated thrombocytopenia induced with durvalumab after chemoradiotherapy in a non-small cell lung cancer patient: A case report. Thorac Cancer 2021; 12:2811-2814. [PMID: 34405563 PMCID: PMC8520809 DOI: 10.1111/1759-7714.14106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 12/30/2022] Open
Abstract
We describe a case of a 60-year-old man with a prolonged thrombocytopenia during a durvalumab maintenance therapy after chemoradiotherapy for locally advanced non-small cell lung carcinoma. Bone marrow specimen was normoplastic with the marked megakaryocyte depletion, which was assumed to be an acquired amegakaryocytic thrombocytopenic purpura. Although hematological disorders as immune-related adverse events (irAE) are rare, we should pay more attention to hematological disorders with durvalumab especially after concurrent chemoradiotherapy.
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Affiliation(s)
- Tomonori Makiguchi
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hisashi Tanaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kosuke Kamata
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kageaki Taima
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Akira Kurose
- Department of Pathology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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