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Zhang D, Wang Y, Zhou F. Case report: Resolution of Guillain-Barré syndrome in a patient with dual primary tumors after treatment with rituximab. Front Neurol 2024; 15:1348304. [PMID: 38450071 PMCID: PMC10915274 DOI: 10.3389/fneur.2024.1348304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/12/2024] [Indexed: 03/08/2024] Open
Abstract
Guillain-Barré syndrome (GBS) is a rare immune-related adverse event (irAE) that can occur in solid tumors such as hepatocellular carcinoma, gastric cancer, breast cancer, and colorectal cancer. It is characterized by progressive myasthenia and mild sensory abnormalities. The emergence of immune checkpoint inhibitors (ICIs) has significantly improved cancer patients' life expectancy but can also trigger various irAEs, including GBS. We report a rare case of GBS in a 64-year-old male patient with dual primary tumors of the colon and stomach who received toripalimab and chemotherapy for liver metastases. After five treatments, the patient experienced weakness and numbness in his limbs. Lumbar puncture, electromyography, and other tests confirmed the diagnosis of GBS. Intravenous immunoglobulin (IVIG) and methylprednisolone did not improve the patient's symptoms, but rituximab, which is not a standard regimen for GBS, was effective in eliminating B cells and improving symptoms. Following this, we effectively shifted from a regimen combining immunotherapy and chemotherapy to a targeted therapy regimen, resulting in prolonged patient survival. Currently, limited studies have been undertaken to evaluate the efficacy of rituximab in managing refractory neurological adverse events associated with ICI therapy. Using this case, we reviewed similar cases and formed our views.
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Affiliation(s)
| | - You Wang
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Fuxiang Zhou
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China
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2
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Neurotoxicity and safety of the rechallenge of immune checkpoint inhibitors: a growing issue in neuro-oncology practice. Neurol Sci 2022; 43:2339-2361. [DOI: 10.1007/s10072-022-05920-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
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Guillain-Barré Syndrome-Like Polyneuropathy Associated with Immune Checkpoint Inhibitors: A Systematic Review of 33 Cases. BIOMED RESEARCH INTERNATIONAL 2021; 2021:9800488. [PMID: 34458371 PMCID: PMC8390151 DOI: 10.1155/2021/9800488] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/08/2021] [Accepted: 08/05/2021] [Indexed: 01/10/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have been increasingly used in the treatment of various types of tumors with favorable results. But these treatments also led to a variety of immune-related adverse events (irAEs). Neurological irAEs such as Guillain-Barré Syndrome are rare and may have serious consequences once they occur. A systematic literature search was performed in PubMed and Embase for all case reports of GBS associated with ICIs published in English reporting on human beings from 1990 up to date. A total of 30 case reports (total patients = 33) were used for final analysis. The included cases were from 11 countries, covering 10 tumor types, with melanoma accounting for the largest number. The mean age was 62.2 ± 11.1 years old, and males were dominant (male: 26 and female: 7). The median time of initial symptoms was 8.2 weeks after the 1st dose of ICIs. The most common manifestations of GBS associated with ICIs were weakness, hyporeflexia or areflexia, and paresthesia in order. The GBS subtypes suggested by electrophysiological results were acute inflammatory demyelinating polyneuropathy (AIDP), acute motor axonal neuropathy (AMAN), and Miller Fisher syndrome (MFS). The protein level of CSF in patients with GBS related to ICIs was 180.68 ± 152.51 mg/dl. Immediate termination of ICIs followed by intravenous immunoglobulin was the preferred treatment option. 72.7% of patients recovered or had residual mild dysfunction after treatment. Elderly male patients with melanoma were most likely to develop ICI-related GBS. The specific neurological symptoms, CSF analysis, and electrophysiological examination were important means of diagnosis.
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Oguri T, Sasada S, Shimizu S, Shigematsu R, Tsuchiya Y, Ishioka K, Takahashi S, Oki K, Kimura Y, Seki R, Hirose S, Nakamura M. A Case of Guillain-Barré Syndrome and Stevens-Johnson Syndrome/Toxic Epidermal Necrosis Overlap After Pembrolizumab Treatment. J Investig Med High Impact Case Rep 2021; 9:23247096211037462. [PMID: 34344201 PMCID: PMC8358493 DOI: 10.1177/23247096211037462] [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] [Indexed: 12/17/2022] Open
Abstract
A 76-year-old man was admitted to our hospital with Guillain-Barré syndrome (GBS), presenting with facial palsy, dysarthria, and dysphagia as Grade 3 immune-related adverse events (irAEs) due to pembrolizumab administration for Stage IV lung adenocarcinoma. Although prednisolone (1 mg/kg) was started for GBS due to the irAE, dark erythema and skin eruptions appeared on the patient's torso. Then erosion was observed on 18% of the body surface area and skin biopsy was performed. Finally, the patient was diagnosed with Stevens-Johnson syndrome/toxic epidermal necrosis overlap. Intravenous immunoglobulin therapy was started, and the skin symptoms improved, with the erosion becoming epithelial. He died of aspiration pneumonia related to GBS, although his neurological symptoms had improved after steroid and intravenous immunoglobulin therapy. This is the first reported case of pembrolizumab-induced GBS and Stevens-Johnson syndrome/toxic epidermal necrosis overlap. It is necessary to be careful that the possibility of other severe irAEs may occur simultaneously.
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Affiliation(s)
- Tomoyo Oguri
- Tokyo Saiseikai Central Hospital, Tokyo, Japan.,St Marianna University, Kawasaki, Kanagawa, Japan
| | | | | | | | | | | | | | - Koichi Oki
- Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | | | - Reishi Seki
- Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | | | - Morio Nakamura
- Tokyo Saiseikai Central Hospital, Tokyo, Japan.,National Hospital Organization Kanagawa Hospital, Kawasaki, Kanagawa, Japan
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Bruno F, Palmiero RA, Ferrero B, Franchino F, Pellerino A, Milanesi E, Soffietti R, Rudà R. Pembrolizumab-Induced Isolated Cranial Neuropathy: A Rare Case Report and Review of Literature. Front Neurol 2021; 12:669493. [PMID: 34046006 PMCID: PMC8144636 DOI: 10.3389/fneur.2021.669493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 03/25/2021] [Indexed: 12/14/2022] Open
Abstract
Introduction: Anti-PD1 agents are widely used in the treatment of solid tumors. This has prompted the recognition of a class of immune-related adverse events (irAEs), due to the activation of autoimmune T-cells. Pembrolizumab is an anti-PD1 agent, which has been related to an increased risk of various neurological irAE (n-irAEs). Here, we present a rare case of pembrolizumab-induced neuropathy of cranial nerves. Case Report: A 72-year-old patient was diagnosed with a lung adenocarcinoma in February 2018 (EGFR-, ALK-, and PDL1 90%). According to the molecular profile, pembrolizumab was started. After three administrations, the patient developed facial paresis, ptosis, ophthalmoplegia, and dysphonia. As brain metastases and paraneoplastic markers were excluded, a drug-related disorder was suspected and pembrolizumab was discontinued. A nerve conduction study and electromyography excluded signs of neuropathy and myopathy at four limbs, and repetitive nerve stimulation was negative. However, altered blink reflex and nerve facial conduction were consistent with an acute neuropathy of the cranial district. Thus, the patient was treated with two cycles of intravenous immunoglobulins (IVIg), which rapidly allowed improvement of both symptoms and neurophysiological parameters. However, the patient died in October 2018 for a progression of lung tumor. Discussion: Only 16 cases of pembrolizumab-related neuropathies have been described so far. Our case is of particular interest for the isolated involvement of cranial nerves and the prompt response to IVIg. Conclusion: N-irAEs are insidious conditions that require solid knowledge of onco-immunotherapy complications: it is mandatory not to delay any treatment that would potentially modify the course of a neurological complication.
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Affiliation(s)
- Francesco Bruno
- Department of Neuro Oncology, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Rosa Antonietta Palmiero
- Department of Neuro Oncology, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Bruno Ferrero
- Department of Neurology, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Federica Franchino
- Department of Neuro Oncology, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Alessia Pellerino
- Department of Neuro Oncology, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Enrica Milanesi
- Department of Oncology, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Riccardo Soffietti
- Department of Neuro Oncology, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Roberta Rudà
- Department of Neurology, Castelfranco Veneto Hospital, Castelfranco Veneto, Italy
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Brzezinska BN, Higgins RV, Rungruang B. Guillain-Barre Syndrome in a patient with uterine adenocarcinoma undergoing treatment with immune-checkpoint inhibitor therapy: A case report and review of the literature. Gynecol Oncol Rep 2021; 36:100739. [PMID: 33748382 PMCID: PMC7967007 DOI: 10.1016/j.gore.2021.100739] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/10/2021] [Accepted: 02/23/2021] [Indexed: 12/11/2022] Open
Abstract
Use of immune checkpoint inhibitors in treatment of gynecologic malignancies is increasing. Immune checkpoint inhibitors such as pembrolizumab may cause a variety of immune-related adverse effects. Guillain-Barre Syndrome is a rare but potentially fatal adverse effect that requires prompt evaluation and treatment.
Background Use of immune checkpoint inhibitors in treatment of gynecologic malignancies is increasing. Rare, but potentially fatal, immune-related neurologic adverse events may occur as a result of treatment. Case A 72 year old female with recurrent metastatic uterine adenocarcinoma received pembrolizumab and lenvatinib combination therapy. Following her second dose of pembrolizumab, the patient developed multiple neurologic symptoms. She was ultimately diagnosed with Guillain-Barre Syndrome based on neurologic evaluation with imaging, serum studies, and cerebrospinal fluid analysis. The patient was successfully treated with high-dose intravenous corticosteroids and intravenous immunoglobulin. Conclusion Neurologic complications related to immune checkpoint inhibitor therapy are rare. It is imperative for gynecologic oncologists to be familiar with potentially fatal hazards of therapy to allow for rapid diagnosis and treatment.
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Affiliation(s)
- Bogna N Brzezinska
- Division of Gynecologic Oncology, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Robert V Higgins
- Division of Gynecologic Oncology, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Bunja Rungruang
- Division of Gynecologic Oncology, Medical College of Georgia at Augusta University, Augusta, GA, United States
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Bolz S, Ramakrishnan T, Fleischer M, Livingstone E, Stolte B, Thimm A, Kizina K, Ugurel S, Kleinschnitz C, Glas M, Zimmer L, Hagenacker T. Detect it so you can treat it: A case series and proposed checklist to detect neurotoxicity in checkpoint therapy. eNeurologicalSci 2021; 22:100324. [PMID: 33604462 PMCID: PMC7876540 DOI: 10.1016/j.ensci.2021.100324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/13/2020] [Accepted: 01/31/2021] [Indexed: 12/11/2022] Open
Abstract
Background Checkpoint inhibitors show impressive and durable responses in various cancer types and provide new avenues for cancer immunotherapy. However, these drugs have a variety of adverse events. Common autoimmune-related adverse effects include fatigue, hepatitis, skin rash, endocrine deficiencies, and colitis. Neurotoxicity has been reported, but its incidence and course remain unclear. Methods To illustrate the broad spectrum of neurotoxicity, we exemplarily report the neurological adverse events of five patients with melanoma and one patient with differentiated thyroid cancer who received checkpoint inhibitors at Essen University Hospital (Essen, Germany). Results After treatment with ipilimumab, nivolumab or pembrolizumab, neurotoxic effects included hypophysitis-associated neck pain and headache, Guillain-Barré syndrome, transverse myelitis, acute brachial plexus neuritis, and ocular myasthenia gravis. Conclusions Checkpoint inhibitor therapy remains a success story; however, neurological immune-related adverse events may cause severe life-threatening conditions. We propose a guide for the early detection of neurological adverse events during routine clinical treatment to prevent more severe courses of checkpoint inhibitor-induced neurotoxicity. We present neurological immune-related adverse events under checkpoint-inhibitors to underline the spectrums of manifestations. Neurological immune-related adverse events may cause severe life-threatening conditions. Practitioners should be aware of red flags symptoms to detect neurological immune-related adverse events
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Key Words
- AIDP, acute inflammatory demyelinating polyneuropathy
- CIDP, chronic inflammatory demyelinating polyneuropathy
- CNS, central nervous system
- CSF, cerebrospinal fluid
- Checkpoint inhibitor
- Guide
- ICI, immune checkpoint inhibitor
- IVIG, intravenous immunoglobulin
- Ipilimumab
- MG, Myasthenia Gravis
- MRI, magnetic resonance imaging
- Melanoma
- Neurotoxicity
- Nivolumab
- PD-L1, programmed cell death protein 1 ligand
- anti-CTLA-4, anti-cytotoxic T-lymphocyte-associated protein 4
- anti-PD-1, anti-programmed cell death protein 1
- i.v, intravenous
- irAE, immune-related adverse events
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Affiliation(s)
- Saskia Bolz
- Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
| | - Thivyah Ramakrishnan
- Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
| | - Michael Fleischer
- Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
| | - Elisabeth Livingstone
- Department of Dermatology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Benjamin Stolte
- Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
| | - Andreas Thimm
- Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
| | - Kathrin Kizina
- Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
| | - Selma Ugurel
- Department of Dermatology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Christoph Kleinschnitz
- Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
| | - Martin Glas
- Division of Clinical Neurooncology, Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
| | - Lisa Zimmer
- Department of Dermatology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Tim Hagenacker
- Department of Neurology, Essen University Hospital, Hufelandstrasse 55, 45147 Essen, Germany
- Corresponding author at: Department of Neurology, University Hospital, Essen, Germany.
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Inflammatory Myeloradiculitis Secondary to Pembrolizumab: A Case Report and Literature Review. Case Rep Oncol Med 2020; 2020:8819296. [PMID: 32908747 PMCID: PMC7450342 DOI: 10.1155/2020/8819296] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/01/2020] [Accepted: 08/05/2020] [Indexed: 11/17/2022] Open
Abstract
Immune checkpoint inhibitors are the most important new medications in oncology and include inhibitors of programmed cell death protein-1 (PD-1) such as Pembrolizumab, Nivolumab, and Cemiplimab. These anticancer agents prevent tumour immune evasion and have been associated with a range of immune-related adverse events (irAEs) including those involving the nervous system. In this case report and literature review, we present the first case of inflammatory myeloradiculitis secondary to Pembrolizumab. We also summarise the characteristics, treatment, and outcomes of other cases reported in the literature which include a component of myelitis. Finally, we make general recommendations on management.
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9
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Han C, Ma JA, Zhang Y, Jiang Y, Hu C, Wu Y. Guillain-Barre syndrome induced by pembrolizumab and sunitinib: A case report. Mol Clin Oncol 2020; 13:38-42. [PMID: 32499912 PMCID: PMC7265222 DOI: 10.3892/mco.2020.2042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 03/05/2020] [Indexed: 12/26/2022] Open
Abstract
Pembrolizumab, an immune checkpoint inhibitor against the programmed death-1 pathway, has been used in combination with acitinib for the first-line treatment of advanced renal cell carcinoma. Neurotoxicity is a rare immune-related adverse event (irAE). The present study reports a case of Guillain-Barre syndrome (GBS) induced by pembrolizumab and sunitinib, and reviews other previous studies to elucidate the clinical characteristics and suitable management of this rare irAE. An advanced renal cell carcinoma patient who received several cycles of pembrolizumab combined with sunitinib developed limb weakness and numbness of the extremities, and was diagnosed with GBS by electrodiagnostic and cerebrospinal fluid examination. The patient improved after treatment with intravenous immunoglobulin along with prednisone. To the best of our knowledge, this is the first case of GBS during treatment with pembrolizumab in combination with sunitinib in advanced renal cell carcinoma.
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Affiliation(s)
- Chen Han
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, P.R. China
| | - Jin-An Ma
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, P.R. China
| | - Ying Zhang
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, P.R. China
| | - Yuna Jiang
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, P.R. China
| | - Chunhong Hu
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, P.R. China
| | - Yuanqiang Wu
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, P.R. China
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Arora A, Shere A, Patel K, Gunawardhana N, LiFuentes E. A Rare Case of Autoimmune Demyelinating Polyneuropathy and Hydrocephalus Secondary to Pembrolizumab. J Investig Med High Impact Case Rep 2020; 8:2324709620916358. [PMID: 32321302 PMCID: PMC7180301 DOI: 10.1177/2324709620916358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Pembrolizumab is a humanized monoclonal antibody that targets the programmed cell
death 1 protein (PD-1) receptor and blocks the inhibitory checkpoint interaction
between PD-1 and its ligands. This interaction leads to the upregulation of
effector T-cells and downregulating regulatory T-cell production. Although this
mechanism is essential for the management of cancer, it may lead to decreased
self-tolerance with an autoimmune reaction toward healthy functioning tissue.
One of the less commonly reported and less understood immune-related adverse
events includes neuromuscular complications. We present a rare case of
autoimmune demyelinating polyneuropathy and hydrocephalus secondary to
pembrolizumab use for cutaneous squamous cell carcinoma of the cheek.
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Affiliation(s)
| | - Amar Shere
- Hackensack University Medical Center, Hackensack, NJ, USA
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Muralikrishnan S, Ronan LK, Coker S, Rauschkolb PK, Shirai K. Treatment Considerations for Patients with Unresectable Metastatic Melanoma Who Develop Pembrolizumab-Induced Guillain-Barré Toxicity: A Case Report. Case Rep Oncol 2020; 13:43-48. [PMID: 32110218 PMCID: PMC7036588 DOI: 10.1159/000504930] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 11/20/2019] [Indexed: 11/27/2022] Open
Abstract
Immunotherapy has improved outcomes in many malignancies, most notably in melanoma, lung cancer, and bladder cancer. Understanding the side effects associated with these medications is an important part of managing our patients. Although fatigue, rash, and diarrhea are commonly reported side effects, it is important to be cognizant of rarer ones, such as neuropathy. Amongst the different neurological toxicities that have been reported in the literature, Guillain-Barré-like neuropathies are quite rare. However, the occurrence of such neuropathies in a patient can be life threatening. The problem this poses in treating cancers such as melanoma is that it eliminates an effective class of medication available to the patient, which can ultimately affect their prognosis. We present a case of a 65-year-old female with unresectable metastatic melanoma who developed Guillain-Barré-like neuropathy after two doses of pembrolizumab. Her clinical course was complicated by three separate hospitalizations over 3 months due to recurring bouts of neuropathy, which resulted in a significant decline in performance status and delay in subsequent treatment of her melanoma. Her prolonged recovery eventually resulted in progression of her melanoma nearly 1 year later, while off therapy. Instead of discontinuing immunotherapy completely, she agreed to a re-challenge with ipilimumab. After one dose, her melanoma regressed and continues to show a sustained response nearly 1 year after treatment without any signs of relapse in her neuropathy. Guillain-Barré toxicity resulting from immune checkpoint inhibition poses a difficult challenge to an oncologist who is determining the next line of treatment for patients with unresectable metastatic melanoma that have progressed while off therapy and who have no targetable mutations. Our case raises the question of whether a re-challenge with a different class of immunotherapy agent is a reasonable option.
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Affiliation(s)
- Sivraj Muralikrishnan
- Department of Hematology/Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Lara K. Ronan
- Department of Neurology and Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | | | | | - Keisuke Shirai
- Department of Hematology/Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Safe Transition to Pembrolizumab following Ipilimumab-Induced Guillain-Barré Syndrome: A Case Report and Review of the Literature. Case Rep Oncol Med 2019; 2019:5490707. [PMID: 31885974 PMCID: PMC6893263 DOI: 10.1155/2019/5490707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 11/15/2019] [Indexed: 12/17/2022] Open
Abstract
Background Immune checkpoint inhibitors are novel therapies with indications for treating several solid cancers. They are associated with immune-related adverse events, which are generally well tolerated. Though rare, severe side effects may be life-threatening. One such adverse event is Guillain-Barré syndrome, which requires cessation of the immunotherapy and intravenous immunoglobulin and/or high-dose steroids to treat. No recommendations have been published regarding restarting cancer treatment after development of immunotherapy-induced Guillain-Barré syndrome. Case Presentation A 71-year-old gentleman with recurrent, stage IIIB melanoma was started on ipilimumab (cytotoxic T lymphocyte antigen-4 inhibitor) for adjuvant treatment following radical neck dissection and radiation therapy. After completing his third cycle of ipilimumab, he developed rapidly progressive ascending paralysis. He was diagnosed with ipilimumab-induced atypical Guillain-Barré syndrome and was treated with intravenous immunoglobulin and corticosteroids. Ipilimumab was discontinued, and the patient was monitored via surveillance imaging, as there was no evidence of active disease at that time. Several months later, he was found to have recurrent disease involving the lung, requiring right lower lobectomy. Restaging revealed thoracic lymph node involvement, and he was then started on pembrolizumab (programmed cell death protein-1 inhibitor). He experienced a complete tumoral response to pembrolizumab, and he tolerated treatment well without recurrent weakness. Conclusions Guillain-Barré syndrome is a rare but severe complication associated with immunotherapy. Our findings suggest that in patients with a history of ipilimumab-induced Guillain-Barré syndrome, pembrolizumab may possibly be a safe and effective alternative for cancer therapy.
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Möhn N, Beutel G, Gutzmer R, Ivanyi P, Satzger I, Skripuletz T. Neurological Immune Related Adverse Events Associated with Nivolumab, Ipilimumab, and Pembrolizumab Therapy-Review of the Literature and Future Outlook. J Clin Med 2019; 8:jcm8111777. [PMID: 31653079 PMCID: PMC6912719 DOI: 10.3390/jcm8111777] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/21/2019] [Accepted: 10/21/2019] [Indexed: 12/11/2022] Open
Abstract
Immune checkpoint inhibitor (ICI) therapy has revolutionized the management of various cancers with previously poor prognosis. Despite its great efficacy, the therapy is associated with a wide spectrum of immune-related adverse events (irAE) including neurological symptoms which can affect all parts of the central and peripheral nervous system. Even though these events are rare, they are of high relevance as the rate of residual symptoms or even fatal outcomes is remarkable. To provide a detailed overview of neurological adverse events associated with immune checkpoint-inhibitor therapy we conducted a literature search. While focusing on ipilimumab, nivolumab, and pembrolizumab therapy, all available case reports as well as larger case series and clinical trials have been considered. Eighty-two case reports about checkpoint-inhibitor therapy induced symptoms of the peripheral nervous system have been published, while only 43 case reports addressed central nervous system abnormalities. The frequency of immune checkpoint-inhibitor therapy inducing neurological adverse events is about 1% in larger studies. Especially neuromuscular adverse events exhibit distinct clinical and diagnostic characteristics. Additionally, several affected patients presented with overlap-syndromes, which means that symptoms and diagnostic findings indicating myositis, myasthenia gravis, and neuropathy were present in one individual patient at the same time. Thus, neurological and particularly neuromuscular adverse events of immune checkpoint-inhibitor therapy may constitute a new disease entity.
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Affiliation(s)
- Nora Möhn
- Department of Neurology, Hannover Medical School, Hannover 30625, Germany;
- Center for Immuno-Oncology (IOZ) Hannover Medical School, Hannover 30625, Germany; (G.B.); (R.G.); (P.I.)
| | - Gernot Beutel
- Center for Immuno-Oncology (IOZ) Hannover Medical School, Hannover 30625, Germany; (G.B.); (R.G.); (P.I.)
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover 30625, Germany
| | - Ralf Gutzmer
- Center for Immuno-Oncology (IOZ) Hannover Medical School, Hannover 30625, Germany; (G.B.); (R.G.); (P.I.)
- Skin Cancer Center Hannover, Department of Dermatology and Allergy, Hannover Medical School, Hannover 30625, German
| | - Philipp Ivanyi
- Center for Immuno-Oncology (IOZ) Hannover Medical School, Hannover 30625, Germany; (G.B.); (R.G.); (P.I.)
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover 30625, Germany
| | - Imke Satzger
- Center for Immuno-Oncology (IOZ) Hannover Medical School, Hannover 30625, Germany; (G.B.); (R.G.); (P.I.)
- Skin Cancer Center Hannover, Department of Dermatology and Allergy, Hannover Medical School, Hannover 30625, German
| | - Thomas Skripuletz
- Department of Neurology, Hannover Medical School, Hannover 30625, Germany;
- Center for Immuno-Oncology (IOZ) Hannover Medical School, Hannover 30625, Germany; (G.B.); (R.G.); (P.I.)
- Correspondence: ; Tel.: +49-511-532-3816; Fax: +49-511-532-3115
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