Immune Checkpoint Inhibitor-Associated Thrombotic Thrombocytopenic Purpura in a Patient With Metastatic Non-Small-Cell Lung Cancer

Assessing hemorrhagic risks in combination therapy: implications of angiogenesis inhibitors and immune checkpoint inhibitors

Objective

This study aims to evaluate the hemorrhage risk in solid tumor patients receiving angiogenesis inhibitors (AGIs), immune checkpoint inhibitors (ICIs), and their combination using the FDA Adverse Event Reporting System (FAERS) database.

Methods

Data from Q1 2011 to Q4 2023 were extracted from the FAERS database for solid tumor patients treated with AGIs, ICIs, or their combination. A disproportionality analysis was conducted by calculating the reporting odds ratio (ROR) and corresponding 95% confidence interval (CI), as well as the Proportional Reporting Ratio (PRR), to identify potential safety signals. To assess whether the hemorrhage risk is higher with combination therapy compared to monotherapy, additive and multiplicative models were employed to evaluate the interactions between combination and single-agent treatments.

Results

The combination of AGIs and ICIs significantly increased the risk of hemorrhagic adverse events, particularly tumor and pulmonary hemorrhage. Hemorrhagic events were common in females (50.97%) and older patients (aged 64+), frequently occurring within the first 30 days of treatment (38.11%). Gingival hemorrhage (ROR 3, PRR 418.9) and tumor hemorrhage (ROR 9.65, PRR 1893.36) were most common in the AGI group, while tumor hemorrhage (ROR 9.49, PRR 1350.78) and pulmonary hemorrhage (ROR 2.6, PRR 98.97) were prominent in the ICI group. In the combination group, esophageal variceal hemorrhage (ROR 40.72, PRR 2344.72) and tumor hemorrhage (ROR 19.31, PRR 1056.63) exhibited significantly increased risks Additive and multiplicative models indicated that the excess risk (RDAB = 0.01025, P<0.001) and relative risk (RRAB = 1.99277, P<0.001) of combination therapy were significantly higher than those of monotherapy, suggesting a positive interaction between the drugs that further increases the risk of hemorrhage.

Conclusion

Our study demonstrates that the combination of AGIs and ICIs significantly raises the risk of hemorrhage, underscoring the urgent need for enhanced monitoring protocols in clinical practice to improve treatment efficacy and safety.

Nivolumab-induced Thrombotic Thrombocytopenic Purpura in Patients with Gastric Tube Cancer

Recently, immune checkpoint inhibitors (ICIs) have been used to treat several cancer types. ICIs have been reported to cause a wide variety of immune-related adverse events, including endocrine, neurologic, gastrointestinal, and cutaneous disorders. Thrombotic thrombocytopenic purpura (TTP) is an autoimmune hematologic disorder characterized by the presence of autoantibodies against a disintegrin and metalloprotease with thrombospondin-1, member 13. Several previous cases of TTP were thought to have been caused by ICI treatment. We herein report a rare case of TTP that developed after long-term treatment with an ICI (nivolumab) for gastric tube cancer.

Renal-Limited Thrombotic Microangiopathy in a Patient Who Received Gemcitabine, Ramucirumab, and Pembrolizumab: A Case Report and Literature Review

Cancer drug-induced thrombotic microangiopathy (DITMA) is an important and serious cause of kidney disease in cancer patients. In addition to classical chemotherapy, the increasing use of targeted therapy and immunotherapy has led to more oncotherapy-associated thrombotic microangiopathy (TMA). It is important for clinicians to recognize this potentially life-threatening adverse effect and gain knowledge of the patient's clinical course and treatment response. In this paper, we report a patient with lung cancer, who was treated with three different classes of anti-neoplastic agents, gemcitabine, ramucirumab, and pembrolizumab. This patient subsequently developed renal-limited thrombotic microangiopathy(rTMA) requiring hemodialysis. The varying features of TMA caused by these therapies were discussed. We also described the clinical course, diagnostic challenges, and management of this patient.

Rare Immune-Related Adverse Events (irAEs): Approach to Diagnosis and Management

Immune checkpoint inhibitors (ICIs) have revolutionised the treatment landscape across many solid organ malignancies and form part of routine clinical practice in many tumours. As indications for monotherapy, doublet therapy and combination approaches with chemotherapy and targeted agents expand, clinicians must be aware of the wide range of possible immune-related adverse events (irAEs). Common toxicities, including rash, colitis, hepatitis and pneumonitis are well described in the literature, and have established diagnostic and management algorithms. Rarer toxicities, often with an incidence of less than 1%, are less defined. These syndromes can be poorly recognised, may take on a fulminant course and do not have established or evidence-based diagnostic and management strategies. As such, patients may experience increased morbidity, mortality and poorer outcomes, related both to these irAEs as well as how the treatment of these may affect the management of their underlying malignancy. In this review, we aim to explore the incidence, potential biomarkers, pathogenesis, diagnostic work-up and clinical sequelae of a selection of uncommon irAEs, with a focus on myocarditis, neurological and haematologic syndromes. Further prospective research is required to accurately define the incidence and pathogenesis of these conditions, with the aim of increasing clinician awareness of rare irAEs and to assist with a more personalised and mechanism-based approach to these syndromes.

Thrombotic microangiopathy (TMA) in adult patients with solid tumors: a challenging complication in the era of emerging anticancer therapies

Thrombotic microangiopathy (TMA) is a syndrome that encompasses a group of disorders defined by the presence of endothelial damage leading to abnormal activation of coagulation, microangiopathic hemolytic anemia and thrombocytopenia, occlusive (micro)vascular dysfunction, and organ damage. TMA may occur in patients with malignancy as a manifestation of cancer-related coagulopathy itself or tumor-induced TMA (Ti-TMA) as a paraneoplastic uncommon manifestation of Trousseau syndrome. TMA can also be triggered by other overlapping conditions such as infections or more frequently as an adverse effect of anticancer drugs (drug-induced TMA or Di-TMA) due to direct dose-dependent toxicity or a drug-dependent antibody reaction. The clinical spectrum of TMA may vary widely from asymptomatic abnormal laboratory tests to acute severe potentially life-threatening forms due to massive microvascular occlusion. While TMA is a rare condition, its incidence may progressively increase within the context of the great development of anticancer drugs and the emerging scenarios in supportive care in cancer. The objective of the present narrative review is to provide a general perspective of the main causes, the key work-up clues that allow clinicians to diagnose and manage TMA in patients with solid tumors who develop anemia and thrombocytopenia due to frequent overlapping causes.