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Whyte E, Nezu M, Chik C, Tateno T. Update on Current Evidence for the Diagnosis and Management of Nonfunctioning Pituitary Neuroendocrine Tumors. Endocrinol Metab (Seoul) 2023; 38:631-654. [PMID: 37964483 PMCID: PMC10764990 DOI: 10.3803/enm.2023.1838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/29/2023] [Accepted: 11/01/2023] [Indexed: 11/16/2023] Open
Abstract
Pituitary neuroendocrine tumors (PitNETs) are the third most frequently diagnosed intracranial tumors, with nonfunctioning PitNETs (nfPitNETs) accounting for 30% of all pituitary tumors and representing the most common type of macroPitNETs. NfPitNETs are usually benign tumors with no evidence of hormone oversecretion except for hyperprolactinemia secondary to pituitary stalk compression. Due to this, they do not typically present with clinical syndromes like acromegaly, Cushing's disease or hyperthyroidism and instead are identified incidentally on imaging or from symptoms of mass effects (headache, vision changes, apoplexy). With the lack of effective medical interventions, first-line treatment is transsphenoidal surgical resection, however, nfPitNETs often have supra- or parasellar extension, and total resection of the tumor is often not possible, resulting in residual tumor regrowth or reoccurrence. While functional PitNETs can be easily followed for recurrence using hormonal biomarkers, there is no similar parameter to predict recurrence in nfPitNETs, hence delaying early recognition and timely management. Therefore, there is a need to identify prognostic biomarkers that can be used for patient surveillance and as therapeutic targets. This review focuses on summarizing the current evidence on nfPitNETs, with a special focus on potential new biomarkers and therapeutics.
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Affiliation(s)
- Elizabeth Whyte
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Masahiro Nezu
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Constance Chik
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Toru Tateno
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Grazzini I, Venezia D, Roscio DD, Chiarotti I, Mazzei MA, Cerase A. Morphological and functional neuroradiology of brain metastases. Semin Ultrasound CT MR 2023; 44:170-193. [DOI: 10.1053/j.sult.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
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Simeni Njonnou SR, Aspeslagh S, Ntsama Essomba MJ, Racu ML, Kemta Lekpa F, Vandergheynst F. Isolated adrenocorticotropic hormone deficiency and sialadenitis associated with nivolumab: a case report. J Med Case Rep 2022; 16:456. [PMID: 36482425 PMCID: PMC9733009 DOI: 10.1186/s13256-022-03663-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 10/31/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibition with anti-PD(L)1 and anti-CTLA4 antibodies has significantly changed cancer treatment during the last 10 years. Nevertheless, boosting the immune system with immune checkpoint inhibition can result in immune-related adverse events, affecting different organ systems, among which the endocrine system is the most affected. However, there are few descriptions of the association of immune-related adverse events, and the pathophysiology of some is still lacking. Here, we report a 70-year-old Caucasian patient treated with nivolumab (anti-PD1 monoclonal antibody) after resection of a unique relapse of melanoma in the neck region who presented with sicca syndrome, extreme fatigue, and weight loss 6 months after the start of anti-PD1 therapy. Blood tests revealed hypoglycemia and secondary hypocortisolism due to isolated adrenocorticotrophic hormone deficiency. Interestingly, brain methionine positron emission tomography/magnetic resonance revealed physiological metabolism of the pituitary gland, which was not increased in size, and no hypophyseal metastasis was detected. The sicca syndrome investigation revealed the absence of anti-SSA/SSB antibodies, while the labial salivary gland biopsy showed lymphoplasmatocytic infiltrates with a focus score of 1. To provide new insights into the physiopathology of the anti-PD1-related sialadenitis, we investigated the distribution of aquaporins 5 by immunostaining on the labial salivary gland acini, and compared this distribution with the one expressed in the primary Sjögren's syndrome. Contrary to patients with primary Sjögren's syndrome (in whom aquaporins 5 is mainly expressed at the basolateral side), but similar to the patients with no sialadenitis, we observed expression of aquaporins 5 at the apical pole. This new finding deserves to be confirmed in other patients with anti-PD1-related sialadenitis. Owing to these immune-related adverse events, anti-PD1 was stopped; nevertheless, the patient developed a new relapse 1 year later (March 2020) in the neck region, which was treated by radiotherapy. Since then, no relapse of melanoma was seen (1.5 years after radiotherapy), but the patient still requires hypophyseal replacement therapy. The sialoadenitis resolved partially. CONCLUSION We report a combination of sialoadenitis and hypophysitis explaining extreme fatigue in a patient who was treated in the adjuvant setting with anti-PD1 for a melanoma relapse.
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Affiliation(s)
- Sylvain Raoul Simeni Njonnou
- grid.8201.b0000 0001 0657 2358Department of Internal Medicine and Specialties, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang 96, Cameroon ,grid.412157.40000 0000 8571 829XDepartment of Internal Medicine, Erasmus Hospital, Université Libre de Bruxelles, Route de Lennik 880, 1070 Brussels, Belgium ,Dschang District Hospital, Dschang, Cameroon
| | - Sandrine Aspeslagh
- grid.412157.40000 0000 8571 829XDepartment of Medical Oncology, Erasmus Hospital, Université Libre de Bruxelles, Route de Lennik 880, 1070 Brussels, Belgium
| | - Marie-Josiane Ntsama Essomba
- grid.412661.60000 0001 2173 8504Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Marie-Lucie Racu
- grid.412157.40000 0000 8571 829XDepartment of Pathology, Erasmus Hospital, Université Libre de Bruxelles, Route de Lennik 880, 1070 Brussels, Belgium
| | - Fernando Kemta Lekpa
- grid.8201.b0000 0001 0657 2358Department of Internal Medicine and Specialties, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang 96, Cameroon
| | - Frédéric Vandergheynst
- grid.412157.40000 0000 8571 829XDepartment of Internal Medicine, Erasmus Hospital, Université Libre de Bruxelles, Route de Lennik 880, 1070 Brussels, Belgium
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Yuen KCJ, Samson SL, Bancos I, Gosmanov AR, Jasim S, Fecher LA, Weber JS. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGY (AACE) DISEASE STATE CLINICAL REVIEW EVALUATION AND MANAGEMENT OF IMMUNE CHECKPOINT INHIBITOR-MEDIATED ENDOCRINOPATHIES: A PRACTICAL CASE-BASED CLINICAL APPROACH. Endocr Pract 2022; 28:719-731. [PMID: 35477029 DOI: 10.1016/j.eprac.2022.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/14/2022] [Accepted: 04/18/2022] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The aim of this case-based clinical review is to provide a practical approach for clinicians regarding the management of patients with immune checkpoint inhibitor (ICI)-mediated endocrinopathies. METHODS A literature search was conducted using PubMed, Embase and Scopus, and appropriate keywords. The discussions and strategies for diagnosis and management of ICI-mediated endocrinopathies are based on evidence available from prospective randomized clinical studies, cohort studies, cross-sectional studies, case-based studies, and expert consensus. RESULTS Immunotherapy with ICIs has transformed the treatment landscape of diverse cancer types, but frequently results in immune-mediated endocrinopathies that can cause acute and persistent morbidity, and rarely, death. The patterns of endocrinopathies differ between inhibitors of the CTLA-4 and PD-1/PD-L1 pathways, but most often involve the thyroid and pituitary glands. Less common but important presentations include insulin-deficient diabetes mellitus, primary adrenal insufficiency, primary hypoparathyroidism, central diabetes insipidus, primary hypogonadism, and pancreatitis with or without subsequent progression to diabetes or exocrine insufficiency. CONCLUSION In recent years, with increasing numbers of cancer patients being treated with ICIs, more clinicians in a variety of specialties are called upon to diagnose and treat ICI-mediated endocrinopathies. Herein, we review case scenarios of various clinical manifestations, and emphasize the need for a high index of clinical suspicion by all clinicians caring for these patients including endocrinologists, oncologists, primary care providers, and emergency department physicians. We also provide diagnostic and therapeutic approaches for ICI-induced endocrinopathies, and we propose that patients on ICI-therapy be evaluated and treated in a multidisciplinary team in collaboration with endocrinologists.
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Affiliation(s)
- Kevin C J Yuen
- Co-Chair of Task Force; Professor of Medicine, Department of Medicine, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, Arizona.
| | - Susan L Samson
- Co-Chair of Task Force; Senior Associate Consultant, Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Jacksonville, Florida
| | - Irina Bancos
- Associate Professor of Medicine; Associate Program Director, Endocrinology Fellowship Program, Division of Endocrinology, Metabolism and Nutrition, Mayo Clinic, Rochester, MN
| | - Aidar R Gosmanov
- Professor of Medicine, Division of Endocrinology, Albany Medical College; Chief, Endocrinology Section, Stratton VAMC, Albany, NY
| | - Sina Jasim
- Associate Professor of Medicine, Washington University in St. Louis, School of Medicine, Division of Endocrinology, Metabolism and Lipid Research, St. Louis, Missouri
| | - Leslie A Fecher
- ASCO Representative, Associate Professor of Medicine and Dermatology, University of Michigan, Rogel Cancer Center, Ann Arbor, Michigan
| | - Jeffrey S Weber
- ASCO Representative, Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, New York
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Nguyen H, Shah K, Waguespack SG, Hu MI, Habra MA, Cabanillas ME, Busaidy NL, Bassett R, Zhou S, Iyer PC, Simmons G, Kaya D, Pitteloud M, Subudhi SK, Diab A, Dadu R. Immune checkpoint inhibitor related hypophysitis: diagnostic criteria and recovery patterns. Endocr Relat Cancer 2021; 28:419-431. [PMID: 33890870 PMCID: PMC8183642 DOI: 10.1530/erc-20-0513] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 04/23/2021] [Indexed: 01/11/2023]
Abstract
Data on the diagnosis, natural course and management of immune checkpoint inhibitor (ICI)-related hypophysitis (irH) are limited. We propose this study to validate the diagnostic criteria, describe characteristics and hormonal recovery and investigate factors associated with the occurrence and recovery of irH. A retrospective study including patients with suspected irH at the University of Texas MD Anderson Cancer Center from 5/2003 to 8/2017 was conducted. IrH was defined as: (1) ACTH or TSH deficiency plus MRI changes or (2) ACTH and TSH deficiencies plus headache/fatigue in the absence of MRI findings. We found that of 83 patients followed for a median of 1.75 years (range 0.6-3), the proposed criteria used at initial evaluation accurately identified 61/62 (98%) irH cases. In the irH group (n = 62), the most common presentation was headache (60%), fatigue (66%), central hypothyroidism (94%), central adrenal insufficiency (69%) and MRI changes (77%). Compared with non-ipilimumab (ipi) regimens, ipi has a stronger association with irH occurrence (P = 0.004) and a shorter time to irH development (P < 0.01). Thyroid, gonadal and adrenal axis recovery occurred in 24, 58 and 0% patients, respectively. High-dose steroids (HDS) or ICI discontinuation was not associated with hormonal recovery. In the non-irH group (n = 19), one patient had isolated central hypothyroidism and six had isolated central adrenal insufficiency. All remained on hormone therapy at the last follow-up. We propose a strict definition of irH that identifies the vast majority of patients. HDS and ICI discontinuation is not always beneficial. Long-term follow-up to assess recovery is needed.
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Affiliation(s)
- Ha Nguyen
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Komal Shah
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Steven G Waguespack
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Mimi I Hu
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Mouhammed Amir Habra
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Maria E Cabanillas
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Naifa L Busaidy
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Roland Bassett
- Division of Science, Department of Biostatistics, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Shouhao Zhou
- Division of Science, Department of Biostatistics, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Priyanka C Iyer
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Garrett Simmons
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Diana Kaya
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Marie Pitteloud
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Sumit K Subudhi
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Adi Diab
- Division of Cancer Medicine, Department of Melanoma Medical Oncology, The University of Texas Anderson Cancer Center, Houston, Texas, USA
| | - Ramona Dadu
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas Anderson Cancer Center, Houston, Texas, USA
- Correspondence should be addressed to R Dadu;
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Abstract
Hypopituitarism is defined as one or more partial or complete pituitary hormone deficiencies, which are related to the anterior and/or posterior gland and can have an onset in childhood or adulthood. The most common aetiology is a sellar or suprasellar lesion, often an adenoma, which causes hypopituitarism due to tumour mass effects, or the effects of surgery and/or radiation therapy. However, other clinical conditions, such as traumatic brain injury, and autoimmune and inflammatory diseases, can result in hypopituitarism, and there are also genetic causes of hypopituitarism. Furthermore, the use of immune checkpoint inhibitors to treat cancer is increasing the risk of hypopituitarism, with a pattern of hormone defects that is different from the classic patterns and depends on mechanisms that are specific for each drug. Moreover, autoantibody production against the pituitary and hypothalamus has been demonstrated in studies investigating the development or worsening of some cases of hypopituitarism. Finally, evidence suggests that posterior pituitary damage can affect oxytocin secretion. The aim of this Review is to summarize current knowledge on non-classic and emerging causes of hypopituitarism, so as to help clinicians improve early identification, avoid life-threatening events and improve the clinical care and quality of life of patients at risk of hypopituitarism.
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Affiliation(s)
- Flavia Prodam
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Marina Caputo
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Chiara Mele
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Paolo Marzullo
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Division of General Medicine, I.R.C.C.S. Istituto Auxologico Italiano, Ospedale San Giuseppe, Verbania, Italy
| | - Gianluca Aimaretti
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy.
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Stascheit F, Li L, Mai K, Baum K, Siebert E, Ruprecht K. Delayed onset hypophysitis after therapy with daclizumab for multiple sclerosis - A report of two cases. J Neuroimmunol 2020; 351:577469. [PMID: 33387829 DOI: 10.1016/j.jneuroim.2020.577469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/22/2020] [Accepted: 12/22/2020] [Indexed: 11/25/2022]
Abstract
Daclizumab (DAC), a humanized monoclonal antibody that binds to the interleukin (IL)-2-receptor alpha chain, was approved in May 2016 for treatment of relapsing-remitting multiple sclerosis (RRMS). Approval was suspended in March 2018 after occurrence of severe liver failure and fatal meningoencephalitis in several patients treated with DAC. We report the clinical, laboratory and neuroimaging findings of 2 patients, who developed hypophysitis about 4 months after cessation of therapy with DAC. This report identifies delayed onset hypophysitis as a previously unrecognized severe side effect of DAC, highlighting the importance of continuous pharmacovigilance and patient monitoring even after cessation of DAC therapy.
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Affiliation(s)
- Frauke Stascheit
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany; NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany.
| | - Linna Li
- Department of Endocrinology, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany; Charité Center for Cardiovascular Research, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Clinical Research Unit, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Knut Mai
- Department of Endocrinology, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany; Charité Center for Cardiovascular Research, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Clinical Research Unit, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Karl Baum
- Department of Neurology, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
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8
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Nada A, Bhat R, Cousins J. Magnetic resonance imaging criteria of immune checkpoint inhibitor-induced hypophysitis. Curr Probl Cancer 2020; 45:100644. [PMID: 32888700 DOI: 10.1016/j.currproblcancer.2020.100644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/21/2020] [Accepted: 07/30/2020] [Indexed: 11/28/2022]
Abstract
Autoimmune hypophysitis is a rare complication of immune checkpoint inhibitors. Immune checkpoint inhibitors have been used for advanced stages of melanoma, renal cell carcinoma, and lung cancer. Multiple endocrinopathies, among them hypophysitis, could result as a reverse event from this therapy. MRI is the imaging modality of choice and usually demonstrates pituitary gland hypertrophy, irregular thickening of the pituitary infundibulum, and diffuse enhancement. We present a case of stage IV metastatic renal cell carcinoma complicated with hypophysitis secondary to combined nivolumab and ipilimumab therapy.
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Affiliation(s)
- Ayman Nada
- Department of Radiology, University of Missouri Columbia, Columbia, Missouri.
| | - Roopa Bhat
- Department of Radiology, University of Missouri Columbia, Columbia, Missouri
| | - Joseph Cousins
- Department of Radiology, University of Missouri Columbia, Columbia, Missouri
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Brilli L, Calabrò L, Campanile M, Pilli T, Agostinis C, Cerase A, Maio M, Castagna MG. Permanent diabetes insipidus in a patient with mesothelioma treated with immunotherapy. Arch Endocrinol Metab 2020; 64:483-486. [PMID: 32267349 PMCID: PMC10522091 DOI: 10.20945/2359-3997000000221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 09/02/2019] [Indexed: 11/23/2022]
Abstract
Checkpoint inhibitors have substantially improved the prognosis for patients with advanced malignancy. Treatment with immunomodulants has the ability to reactivate the immune system against tumor cells, but can also trigger the development of immune-related adverse events that reflects a loss of tolerance of the immune system for self-antigens. Regarding the endocrine system, thyroid and pituitary are the most frequent glands involved; in particular hypophysitis is commonly observed with anti-CTLA4 with a variable impaired anterior pituitary dysfunction (mainly ACTH and TSH dysregulation) while a posterior pituitary dysfunction has been rarely described. A 68-year-old man with a diagnosis of metastatic mesothelioma started in September 2016 first-line treatment with tremelimumab and durvalumab. After 3 cycles he presented sudden onset of polydipsia and polyuria without other symptoms. Diagnostic work-up, including a water deprivation test, established a diagnosis of central diabetes insipidus. Patient started sublingual desmopressin 60 mcg three times a day, that was subsequently increased up to 480 mcg/die. At magnetic resonance imaging the posterior lobe of pituitary gland did not show high signal intensity on T1-weighted images. After regression of diabetes insipidus symptoms under desmopressin, patient restarted cancer treatment and received additional 10 doses without worsening of endocrinological toxicity or further treatment-related toxicities, maintaining the same desmopressin dosage. Posterior pituitary dysfunction has been rarely observed in patients treated with immunomodulants. To our knowledge, this is the first observation of permanent central diabetes insipidus in patients treated with combined immune checkpoint inhibitors (tremelimumab and durvalumab).
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Affiliation(s)
- Lucia Brilli
- Unit of EndocrinologyDepartment of Medical, Surgical and Neurological SciencesUniversity Hospital of SienaSienaItalyUnit of Endocrinology, Department of Medical, Surgical and Neurological Sciences, University Hospital of Siena, Siena, Italy
| | - Luana Calabrò
- Center for Immuno-OncologyDepartment of Medical OncologyUniversity Hospital of SienaSienaItaly Medical Oncology and Immunotherapy, Center for Immuno-Oncology, Department of Medical Oncology, University Hospital of Siena, Siena, Italy
| | - Michele Campanile
- Unit of EndocrinologyDepartment of Medical, Surgical and Neurological SciencesUniversity Hospital of SienaSienaItalyUnit of Endocrinology, Department of Medical, Surgical and Neurological Sciences, University Hospital of Siena, Siena, Italy
| | - Tania Pilli
- Unit of EndocrinologyDepartment of Medical, Surgical and Neurological SciencesUniversity Hospital of SienaSienaItalyUnit of Endocrinology, Department of Medical, Surgical and Neurological Sciences, University Hospital of Siena, Siena, Italy
| | - Cristina Agostinis
- Unit of Neuroradiology“Papa Giovanni XXIII” HospitalBergamoItalyUnit of Neuroradiology, “Papa Giovanni XXIII” Hospital, Bergamo, Italy
| | - Alfonso Cerase
- Unit of Neuroimaging and NeurointerventionDepartment of Neurological and Sensorineural SciencesUniversity Hospital of SienaSienaItalyUnit of Neuroimaging and Neurointervention, Department of Neurological and Sensorineural Sciences, University Hospital of Siena, Siena, Italy
| | - Michele Maio
- Center for Immuno-OncologyDepartment of Medical OncologyUniversity Hospital of SienaSienaItaly Medical Oncology and Immunotherapy, Center for Immuno-Oncology, Department of Medical Oncology, University Hospital of Siena, Siena, Italy
| | - Maria Grazia Castagna
- Unit of EndocrinologyDepartment of Medical, Surgical and Neurological SciencesUniversity Hospital of SienaSienaItalyUnit of Endocrinology, Department of Medical, Surgical and Neurological Sciences, University Hospital of Siena, Siena, Italy
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10
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Kubo T, Sugawara T, Shinkawa T, Kurisu T, Kouzen N, Tanaka T, Fukuta F, Yamasaki K, Sugita S, Matsuo K, Morita R, Hirohashi Y, Tsukahara T, Kanaseki T, Hasegawa T, Masumori N, Torigoe T. Fatal fulminant hepatitis induced by combined ipilimumab and nivolumab therapy despite favorable histologic response and confirmed by autopsy in a patient with clear cell renal cell carcinoma. Immunol Med 2020; 44:136-141. [PMID: 32634346 DOI: 10.1080/25785826.2020.1788229] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Effective management of immune-related adverse events in patients receiving immunotherapy for cancer is problematic. In this report, we present the case of a 58-year-old man with advanced clear cell renal cell carcinoma who responded well to a combination of ipilimumab and nivolumab. However, after two courses of treatment, he developed fulminant hepatitis and died. An autopsy confirmed that the primary lesion in the left kidney was more than 99% necrotic with only six small residual tumor lesions. These lesions were infiltrated by large numbers of CD8-positive/TIA-1-positive lymphocytes. However, a metastatic lesion in the right kidney harbored few lymphocytes. Furthermore, the tumor cells in the metastatic lesion and one of the residual lesions showed decreased expression of HLA class I molecules, which are a prerequisite for cytotoxic T-lymphocyte-mediated immunotherapy in tumor cells. In this patient, more than 80% of hepatocytes were destroyed and the parenchyma was infiltrated with CD8-positive/TIA-1-positive lymphocytes. The patient had polyuria, which was attributed to neurohypophysitis caused by the infiltration of CD8-positive/TIA-1-positive lymphocytes. We believe that this is an instructive case for immuno-oncologists.
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Affiliation(s)
- Terufumi Kubo
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Taro Sugawara
- Department of Surgical Pathology, Sapporo Medical University Hospital, Sapporo, Japan
| | - Tomoyo Shinkawa
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Tomoyo Kurisu
- Department of Urology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Nodoka Kouzen
- Department of Urology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Toshiaki Tanaka
- Department of Urology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Fumimasa Fukuta
- Department of Urology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Kouji Yamasaki
- Department of Urology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Shintaro Sugita
- Department of Surgical Pathology, Sapporo Medical University Hospital, Sapporo, Japan
| | | | - Rena Morita
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Yoshihiko Hirohashi
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Tomohide Tsukahara
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Takayuki Kanaseki
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Tadashi Hasegawa
- Department of Surgical Pathology, Sapporo Medical University Hospital, Sapporo, Japan
| | - Naoya Masumori
- Department of Urology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Toshihiko Torigoe
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
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11
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Caranci F, Leone G, Ponsiglione A, Muto M, Tortora F, Muto M, Cirillo S, Brunese L, Cerase A. Imaging findings in hypophysitis: a review. Radiol Med 2019; 125:319-328. [PMID: 31863360 DOI: 10.1007/s11547-019-01120-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 11/28/2019] [Indexed: 12/24/2022]
Abstract
Hypophysitis (HP) is a rare acute or chronic inflammatory condition of the pituitary gland. The greatest challenge in the management of HP is establishing a diagnosis through clinical criteria and non-invasive methods and predicting the patients' clinical outcome. The aim of this review is to describe the neuroradiological findings of this rare disease, providing some information regarding the possible differential diagnosis in order to avoid unnecessary surgery. Gadolinium-enhanced pituitary magnetic resonance imaging (MRI) is considered the neuroradiological investigation of choice. The features suggestive for HP include an enlarged triangular- or dumbbell-shaped gland with a thickened and not obviously deviated stalk, further supported by the absence of posterior pituitary bright spot on T1weighted images, particularly in patients presenting with diabetes insipidus. Contrast enhancement pattern is quite variable; dural enhancement has been reported in some cases after intravenous contrast administration. The characterization of the unusual sellar mass is not straightforward and generally results in a wide differential. HP should be primarily differentiated from pituitary adenomas (including pituitary apoplexy), from pituitary metastases, and from other sellar and parasellar tumors, e.g., craniopharyngiomas, germinomas, gliomas, lymphomas, meningiomas, pituicytomas, chordomas, teratomas, dermoids and epidermoids, Rathke's cleft cysts, and abscesses. In patients suspected for secondary forms related to systemic pathology, additional imaging is helpful in identifying other involved sites. Neuroradiologists need to know MRI appearance of this rare disease, as well as its typical symptoms and serological markers. A strict collaboration with endocrinologists and neurosurgeons is mandatory in order to reach a definitive diagnosis, allowing to promptly initiating an appropriate treatment.
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Affiliation(s)
- Ferdinando Caranci
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Via Francesco De Sanctis 1, 86100, Campobasso, Italy.
| | - Giuseppe Leone
- Department of Neuroradiology, A.O.R.N. Cardarelli, Naples, Italy
| | - Andrea Ponsiglione
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Massimo Muto
- Department of Neuroradiology, A.O.R.N. Cardarelli, Naples, Italy.,Department of Neuroscience and Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Fabio Tortora
- Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Mario Muto
- Department of Neuroradiology, A.O.R.N. Cardarelli, Naples, Italy
| | - Sossio Cirillo
- Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Luca Brunese
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Via Francesco De Sanctis 1, 86100, Campobasso, Italy
| | - Alfonso Cerase
- Department of Neurological and Sensorineural Sciences, Azienda ospedaliero-universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
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12
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Garon-Czmil J, Petitpain N, Rouby F, Sassier M, Babai S, Yéléhé-Okouma M, Weryha G, Klein M, Gillet P. Immune check point inhibitors-induced hypophysitis: a retrospective analysis of the French Pharmacovigilance database. Sci Rep 2019; 9:19419. [PMID: 31857638 DOI: 10.1038/s41598-019-56026-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/30/2019] [Indexed: 12/17/2022] Open
Abstract
Immune control point (ICI) inhibitors represent a significant advance in the management and survival of cancers such as melanoma or non-small cell bronchial carcinoma. However, they induce unusual side effects, such as hypophysitis, which are rarely described elsewhere. This nationwide retrospective study describes the characteristics of hypophysitis reported in the French pharmacovigilance database (FPVD). We requested for all cases of ICI-related hypophysitis registered in the FPVD before May 2018. An endocrinologist and a pharmacologist reviewed all cases. About 94 pituitary cases were selected, involving 49 females and 45 men. Ipilimumab alone or in combination was the most represented ICI (56%). Most cases (61%) were grade 3 severity and the majority (90%) were corticotropic deficiency cases. Cases with thyroid and/or gonadotropic involvement were 21% and 1% respectively. Five patients (8%) had panhypopituitarism. Pituitary MRI, when performed, was in favor of hypophysitis in 50%. No patient recovered his previous hormonal function. The mean time of onset was significantly shorter with ipilimumab than other ICIs. ICI-related hypophysitis generate deficits that do not spontaneously recover, even at a distance from the event, unlike thyroiditis. Patients must then benefit from long-term coordinated onco-endocrinological management, adapted to their own specific deficits.
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13
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Castillero F, Castillo-Fernández O, Jiménez-Jiménez G, Fallas-Ramírez J, Peralta-Álvarez MP, Arrieta O. Cancer immunotherapy-associated hypophysitis. Future Oncol 2019; 15:3159-3169. [DOI: 10.2217/fon-2019-0101] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The advances in cancer therapy have included the development of drugs that inhibit immune checkpoint ligands. Two types of immune checkpoint inhibitors, both antibodies that target CTLA-4 and PD-1, have been approved for its use in NSCLC and melanoma as first-line or second-line therapy. Sadly, not desirable consequences of immunotherapy are immune-related adverse events. immune-related hypophysitis is the most common endocrine adverse event after thyroid disfunction. The particularity of endocrine immune-related adverse events is their non-reversibility, with incidence and prevalence destined to increase in the coming years, particularly if this form of therapy is used in the future for earlier stages of cancer. Therefore, hypophysitis represents a challenge for the physician, sometimes occurring without specific symptomatology and which should be considered for clinical management. In this review, we describe the current data regarding the pathophysiology and management for immune-related hypophysitis.
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Affiliation(s)
| | | | - Geiner Jiménez-Jiménez
- Oncology Department, Hospital Dr. Rafael Ángel Calderón Guardia, San José 10101, Costa Rica
| | - José Fallas-Ramírez
- Instituto de Investigaciones Farmacéuticas, Facultad de Farmacia, Universidad de Costa Rica, San José 11501, Costa Rica
| | - Marco P Peralta-Álvarez
- Thoracic Oncology Unit, Instituto Nacional de Cancerología (INCan), México City 14080, México
- Laboratory of Personalized Medicine, Instituto Nacional de Cancerología (INCan), México City 14080, México
| | - Oscar Arrieta
- Thoracic Oncology Unit, Instituto Nacional de Cancerología (INCan), México City 14080, México
- Laboratory of Personalized Medicine, Instituto Nacional de Cancerología (INCan), México City 14080, México
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Affiliation(s)
- Henry B Burch
- From the Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
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15
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Ceccato F, Scaroni C. Central adrenal insufficiency: open issues regarding diagnosis and glucocorticoid treatment. ACTA ACUST UNITED AC 2019; 57:1125-1135. [DOI: 10.1515/cclm-2018-0824] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/13/2018] [Indexed: 12/15/2022]
Abstract
Abstract
Background
Central adrenal insufficiency (CAI) is characterized by impaired adrenocorticotropin (ACTH) secretion because of a disease or injury to the hypothalamus or the pituitary, leading to a reduced cortisol production. CAI suspicion arises more frequently in patients with pituitary tumors, cranial irradiation/surgery/injury/infections, as well as after exogenous glucocorticoid withdrawal. Nevertheless, a late diagnosis is not uncommon because CAI may present with nonspecific signs or symptoms, as fatigue or hyponatremia.
Content
The PubMed database was searched (years 1980–2018), using “central adrenal insufficiency” and “ACTH deficiency” as keywords. Subsequently, reference sections of the retrieved articles were searched.
Summary
Dynamic tests are needed when morning basal cortisol levels are not sufficient to exclude or to confirm CAI. Short Synacthen Test (SST) is the most used, and Endocrine Society’s guidelines recommend a cortisol peak >500 nmol/L to exclude CAI. Despite thresholds, understanding the pretest probability of ACTH deficiency (the clinical background of the patient) is essential because the diagnostic accuracy of SST in case of a negative result is suboptimal. Glucocorticoid replacement therapy, able to replicate cortisol circadian rhythm, is required in patients with CAI; fludrocortisone treatment is not necessary. Short-acting glucocorticoid drugs (hydrocortisone or cortisone acetate) are the most used; lower doses than previously used are nowadays recommended to reduce cortisol-related comorbidities. Promising results have been obtained with modified-release hydrocortisone, especially regarding glucose metabolism in patients with primary adrenal insufficiency.
Outlook
An accurate clinical diagnosis and a careful individualized therapy are mandatory in patients with CAI.
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Abstract
Hypophysitis is a rare entity characterized by inflammation of the pituitary gland and its stalk that can cause hypopituitarism and/or mass effect. Etiology can be categorized as primary or secondary to systemic disease, but may also be classified according to anatomical and hispathological criteria. Newly recognized causes of hypophysits have been described, mainly secondary to immunomodulatory medications and IgG4-related disease. Diagnosis is based on clinical, laboratory and imaging data, whereas pituitary biopsy, though rarely indicated, may provide a definitive histological diagnosis. For the clinician, obtaining a broad clinical and drug history, and performing a thorough physical examination is essential. Management of hypophysitis includes hormone replacement therapy if hypopituitarism is present and control of the consequences of the inflammatory pituitary mass (e.g. compression of the optic chiasm) using high-dose glucocorticoids, whereas pituitary surgery is reserved for those unresponsive to medical therapy and/or have progressive disease. However, there remains an unmet need for controlled studies to inform clinical practice.
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Affiliation(s)
- Kevin C J Yuen
- Barrow Pituitary Center, Barrow Neurological Institute, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, Arizona, United States.
| | - Vera Popovic
- Faculty of Medicine, University of Belgrade, Dr Subotica 8, 11000, Belgrade, Serbia
| | - Peter J Trainer
- Department of Endocrinology, The Christie NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
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17
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Tan MH, Iyengar R, Mizokami-Stout K, Yentz S, MacEachern MP, Shen LY, Redman B, Gianchandani R. Spectrum of immune checkpoint inhibitors-induced endocrinopathies in cancer patients: a scoping review of case reports. Clin Diabetes Endocrinol 2019; 5:1. [PMID: 30693099 PMCID: PMC6343255 DOI: 10.1186/s40842-018-0073-4] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/29/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Since 2011 six immune checkpoint inhibitors (ICI) have been approved to treat patients with many advanced solid tumor and hematological malignancies to improve their prognosis. Case reports of their endocrine immune-related adverse events [irAEs]) are increasingly published as more real-world patients with these malignancies are treated with these drugs. They alert physicians of a drug's AEs (which may change during a drug's life cycle) and contribute to post-marketing safety surveillance. Using a modified framework of Arksey and O'Malley, we conducted a scoping review of the spectrum and characteristics of ICI-induced endocrinopathies case reports before and after ICIs are marketed. METHODS In July 2017, we searched, without date and language restrictions, 4 citation databases for ICI-induced endocrinopathies. We also hand-searched articles' references, contents of relevant journals, and ran supplemental searches to capture recent reports through January 2018. For this study, a case should have information on type of cancer, type of ICI, clinical presentation, biochemical tests, treatment plus temporal association of ICI initiation with endocrinopathies. Two endocrinologists independently extracted the data which were then summarized and categorized. RESULTS One hundred seventy nine articles reported 451 cases of ICI-induced endocrinopathies - 222 hypopituitarism, 152 thyroid disorders, 66 diabetes mellitus, 6 primary adrenal insufficiencies, 1 ACTH-dependent Cushing's syndrome, 1 hypoparathyroidism and 3 diabetes insipidus cases. Their clinical presentations reflect hormone excess or deficiency. Some were asymptomatic and others life-threatening. One or more endocrine glands could be affected. Polyglandular endocrinopathies could present simultaneously or in sequence. Many occur within 5 months of therapy initiation; a few occurred after ICI was stopped. Mostly irreversible, they required long-term hormone replacement. High dose steroids were used when non-endocrine AEs coexisted or as therapy in adrenal insufficiency. There was variability of information in the case reports but all met the study criteria to make a diagnosis. CONCLUSIONS The spectrum of ICI-induced endocrinopathies is wide (5 glands affected) and their presentation varied (12 endocrinopathies). Clinical reasoning integrating clinical, biochemical and treatment information is needed to properly diagnose and manage them. Physicians should be vigilant for their occurrence and be able to diagnose, investigate and manage them appropriately at onset and follow-up.
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Affiliation(s)
- Meng H. Tan
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
| | - Ravi Iyengar
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
- Present address: Endocrinology, Rush University Medical Center, 1725 West Harrison Street, Chicago, IL 60612 USA
| | - Kara Mizokami-Stout
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
| | - Sarah Yentz
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Mark P. MacEachern
- Taubman Health Sciences Library, University of Michigan, 1135 Catherine Street, Ann Arbor, MI 48109 USA
| | - Li Yan Shen
- Affiliated Hospital of QingDao University, QingDao, 16 Jiangsu Road, Sinan Qu, Qingdao, Shi, Shandong Sheng China
| | - Bruce Redman
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Roma Gianchandani
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
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18
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Nishimura Y, Yasuda M, Ocho K, Iwamuro M, Yamasaki O, Tanaka T, Otsuka F. Severe Gastritis after Administration of Nivolumab and Ipilimumab. Case Rep Oncol 2018; 11:549-556. [PMID: 30186138 PMCID: PMC6120399 DOI: 10.1159/000491862] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 07/04/2018] [Indexed: 12/17/2022] Open
Abstract
Immune checkpoint inhibitors such as ipilimumab, a cytotoxic T-lymphocyte-associated antigen-4 inhibitor, have been widely used for advanced malignancies. As these inhibitors improve antitumor immunity via T-cell modulation, immune-mediated adverse events associated with T-cell activation, such as colitis, might occur. Herein, we describe a 75-year-old Japanese woman with metastatic malignant melanoma who developed hemorrhagic gastritis after ipilimumab treatment. There was no macroscopic or clinical improvement of gastritis after proton pump inhibitor treatment. However, her condition improved after approximately 3 weeks of corticosteroid therapy and Helicobacter pylori eradication. This case suggests a potential association between severe gastritis and immune checkpoint inhibitor treatment. Although several reports have mentioned ipilimumab-associated colitis, gastritis is considered to be rare. In the present case, H. pylori-associated gastritis might have been exacerbated by the T-cell modulation effect of ipilimumab. To date, no report has clarified the mechanism by which ipilimumab modifies H. pylori infection. The present treatment course provides a helpful perspective for similar cases.
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Affiliation(s)
- Yoshito Nishimura
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Miho Yasuda
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Kazuki Ocho
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Masaya Iwamuro
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Osamu Yamasaki
- Department of Dermatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Takehiro Tanaka
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Fumio Otsuka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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19
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Abstract
The increasing recognition of pituitary disorders and their impact on quality of life and longevity has made understanding of this small gland a subject of paramount importance. Pituitary pathology has seen many significant studies that indicate progress in identification and classification of pituitary lesions, as well as improved management strategies for patients. In this review, we outline six major areas of advances: (i) changes in terminology from 'adenoma' to 'pituitary neuroendocrine tumour'; (ii) reclassification of hormone-negative tumours based on transcription factor expression that defines lineage; (iii) updates in new pathogenetic mechanisms, including those that underlie rare lesions such as X-LAG and pituitary blastoma; (iv) clarification of hypophysitis due to immunotherapy, xanthomatous hypophysitis due to rupture of a Rathke's cleft cyst and IgG4 disease as the cause of inflammatory pseudotumour; (v) the consolidation of pituicytoma variants, including spindle cell oncocytoma and granular cell tumour based on thyroid transcription factor-1 (TTF-1) reactivity; and (vi) the pathogenetic mechanisms that distinguish papillary from adamantinomatous craniopharyngioma. The remaining challenge is clarification of the pathogenetic mechanisms underlying the development of many of these disorders.
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Affiliation(s)
- Sylvia L Asa
- Department of Pathology, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Ozgur Mete
- Department of Pathology, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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20
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21
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Abstract
The pathogenesis of non functioning pituitary adenomas (NFPA) is a complex process involving several factors, from molecular to genetic and epigenetic modifications, where tumor suppressor genes, oncogenes, cell cycle derangements have been demonstrated to play an important role. MicroRNAs (miRNAs) have also been identified as possible players in NFPA tumorigenesis and pituitary stem cells have been investigated for their potential role in pituitary tumor initiation. However, a critical role for paracrine signalling has also been highlighted. This review focuses on the current knowledge on the involvement of these factors in NFPA pathogenesis.
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Affiliation(s)
- Maria Chiara Zatelli
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Via Ariosto 35, 44100, Ferrara, Italy.
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22
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Eshghi N, Garland LL, Nia E, Betancourt R, Krupinski E, Kuo PH. 18F-FDG PET/CT Can Predict Development of Thyroiditis Due to Immunotherapy for Lung Cancer. J Nucl Med Technol 2018; 46:260-264. [PMID: 29599403 DOI: 10.2967/jnmt.117.204933] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 01/04/2018] [Indexed: 12/11/2022] Open
Abstract
Our primary purpose was to determine whether increased 18F-FDG uptake in the thyroid gland predicts development of thyroiditis with subsequent hypothyroidism in patients undergoing immunotherapy with nivolumab for lung cancer. Secondarily, we determined whether 18F-FDG uptake in the thyroid gland correlates with number of administered cycles of nivolumab. Methods: Retrospective chart review over 2 y found 18 lung cancer patients treated with nivolumab who underwent 18F-FDG PET/CT before and during therapy. SUVmean, SUVmax, and total lesion glycolysis of the thyroid gland were measured. SUVs were also measured for the pituitary gland, liver, and spleen. Patients underwent monthly thyroid testing. PET/CT parameters were analyzed by unpaired t testing for differences between 2 groups (patients who developed hypothyroidism and those who did not). Correlation between development of thyroiditis and number of cycles of nivolumab was also tested. Results: Six of 18 patients developed hypothyroidism. The t test comparing the 2 groups demonstrated significant differences in SUVmean (P = 0.04), SUVmax (P = 0.04), and total lesion glycolysis (P = 0.02) of the thyroid gland. Two of 4 patients who developed thyroiditis and had increased 18F-FDG uptake in the thyroid gland had a normal TSH level at the time of follow-up 18F-FDG PET/CT. Patients who developed thyroiditis with subsequent hypothyroidism stayed longer on therapy (10.6 cycles) than patients without thyroiditis (7.6 cycles), but the trend was not statistically significant. No significant difference in PET/CT parameters was observed for pituitary gland, liver, or spleen. Conclusion:18F-FDG PET/CT can predict the development of thyroiditis with subsequent hypothyroidism before laboratory testing. Further study is required to confirm the positive trend between thyroiditis and duration of therapy.
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Affiliation(s)
| | - Linda L Garland
- Department of Medicine, Section of Hematology and Medical Oncology, Banner University Medical Center, Tucson, Arizona
| | - Emily Nia
- Breast Imaging Section, Department of Radiology, University of Texas M.D. Anderson Cancer Center, Housten, Texas
| | - Robert Betancourt
- Department of Medicine, Banner University Medical Center, Tucson, Arizona
| | - Elizabeth Krupinski
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; and
| | - Phillip H Kuo
- Departments of Medical Imaging and Medicine, Banner University Medical Center, and Department of Biomedical Engineering, University of Arizona, Tucson, Arizona
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23
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Iglesias P. Cancer immunotherapy-induced endocrinopathies: Clinical behavior and therapeutic approach. Eur J Intern Med 2018; 47:6-13. [PMID: 28826822 DOI: 10.1016/j.ejim.2017.08.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 08/11/2017] [Accepted: 08/16/2017] [Indexed: 12/29/2022]
Abstract
Cancer immunotherapy has proven to be effective in a wide variety of tumors. The use of immune checkpoint blocking monoclonal antibodies has become a standard treatment regimen in some of them as advanced melanoma. However, given the mechanism of action, its use may be associated with immune-related adverse events that may complicate the clinical course and prognosis of patients. Among these are autoimmune endocrine adverse effects, such as hypophysitis, hypo and hyperthyroidism, and adrenal insufficiency. This review focuses on the most relevant and new aspects related to the incidence, clinical presentation, diagnosis and treatment of these adverse effects associated with different types of immune checkpoint inhibitors in cancer immunotherapy.
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Affiliation(s)
- Pedro Iglesias
- Department of Endocrinology, Hospital Ramón y Cajal, Ctra. de Colmenar, Km 9.100, 28034 Madrid, Spain.
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24
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Abstract
INTRODUCTION Cancer immunotherapies were approved in recent years, including immune checkpoint inhibitors. Experience with ipilimumab (CTLA-4 antagonist), nivolumab and pembrolizumab (PD-1 antagonists), and atezolizumab (PD-L1 antagonist) has shown that the impact on overall survival in cancer patients is paramount. Immune checkpoint inhibitors target the immune system and they can be applied across multiple cancers; the response rate is ranging from 20 to 40%. Many studies have shown that thyroid cancer (TC) cells produce cytokines and chemokines, inducing several tumor-promoting effects. Targeting and/or lowering cytokines and chemokines concentrations within the tumor microenvironment would produce a therapeutic benefit. In TC, increased Treg and PD-1+ T cell frequencies are indicative of aggressive disease and PD-L1 expression correlates with a greater risk of recurrence. Area covered: After performing a literature search, a few pioneering studies have evaluated immunotherapy in thyroid cancer. More recently a case has been described involving anaplastic thyroid cancer treated with vemurafenib and nivolumab, with substantial regression and complete radiographic and clinical remission. Expert commentary: The use of immune checkpoint inhibitors in aggressive TC has not yet been extensively investigated and further studies in a large number of TC patients are urgently needed.
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Affiliation(s)
- Alessandro Antonelli
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | | | - Poupak Fallahi
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
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25
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Pérez-De-Lis M, Retamozo S, Flores-Chávez A, Kostov B, Perez-Alvarez R, Brito-Zerón P, Ramos-Casals M. Autoimmune diseases induced by biological agents. A review of 12,731 cases (BIOGEAS Registry). Expert Opin Drug Saf 2017; 16:1255-1271. [DOI: 10.1080/14740338.2017.1372421] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Marta Pérez-De-Lis
- Servicio de Anestesiologia y Reanimación, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Soledad Retamozo
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Hospital Privado Universitario de Córdoba, Córdoba, Argentina
- Instituto De Investigaciones En Ciencias De La Salud (INICSA), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Córdoba, Argentina
| | - Alejandra Flores-Chávez
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Unidad de Investigación Biomédica 02, Unidad de Investigación en Epidemiología Clínica, Centro Médico Nacional de Occidente (CMNO), Instituto Mexicano del Seguro Social (IMSS), Hospital de Especialidades, Guadalajara, Mexico
- Programa de Doctorado en Ciencias Médicas, Centro Universitario de Investigaciones Biomédicas (CUIB), Universidad de Colima, Colima, Mexico
| | | | | | - Pilar Brito-Zerón
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Autoimmune Diseases Unit, Department of Medicine, Hospital CIMA- Sanitas, Barcelona, Spain
| | - Manuel Ramos-Casals
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Department of Medicine, University of Barcelona, Barcelona, Spain
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