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Pacholczak-Madej R, Kosałka-Węgiel J, Kuszmiersz P, Mituś JW, Püsküllüoğlu M, Grela-Wojewoda A, Korkosz M, Bazan-Socha S. Immune Checkpoint Inhibitor Related Rheumatological Complications: Cooperation between Rheumatologists and Oncologists. Int J Environ Res Public Health 2023; 20:4926. [PMID: 36981837 PMCID: PMC10049070 DOI: 10.3390/ijerph20064926] [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] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 06/18/2023]
Abstract
In cancer, immune checkpoint inhibitors (ICIs) improve patient survival but may lead to severe immune-related adverse events (irAEs). Rheumatic irAEs are a distinct entity that are much more common in a real-life than in clinical trial reports due to their unspecific symptoms and them being a rare cause of hospitalization. This review focuses on an interdisciplinary approach to the management of rheumatic irAEs, including cooperation between oncologists, rheumatologists, and immunologists. We discuss the immunological background of rheumatic irAEs, as well as their unique clinical characteristics, differentiation from other irAEs, and treatment strategies. Importantly, steroids are not the basis of therapy, and nonsteroidal anti-inflammatory drugs should be administered in the front line with other antirheumatic agents. We also address whether patients with pre-existing rheumatic autoimmune diseases can receive ICIs and how antirheumatic agents can interfere with ICIs. Interestingly, there is a preclinical rationale for combining ICIs with immunosuppressants, particularly tumor necrosis factor α and interleukin 6 inhibitors. Regardless of the data, the mainstay in managing irAEs is interdisciplinary cooperation between oncologists and other medical specialties.
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Affiliation(s)
- Renata Pacholczak-Madej
- Department of Clinical Oncology, The Maria Skłodowska-Curie National Research Institute of Oncology, Kraków Branch, 31-115 Kraków, Poland
- Department of Anatomy, Jagiellonian University Medical College, 33-332 Kraków, Poland
| | - Joanna Kosałka-Węgiel
- Department of Rheumatology and Immunology, Jagiellonian University Medical Kraków, 30-688 Krakow, Poland
- Division of Rheumatology and Immunology Clinical, University Hospital, 30-688 Kraków, Poland
| | - Piotr Kuszmiersz
- Department of Rheumatology and Immunology, Jagiellonian University Medical Kraków, 30-688 Krakow, Poland
- Division of Rheumatology and Immunology Clinical, University Hospital, 30-688 Kraków, Poland
| | - Jerzy W. Mituś
- Department of Anatomy, Jagiellonian University Medical College, 33-332 Kraków, Poland
- Department of Surgical Oncology, National Research Institute of Oncology, Kraków Branch, 31-115 Kraków, Poland
| | - Mirosława Püsküllüoğlu
- Department of Clinical Oncology, The Maria Skłodowska-Curie National Research Institute of Oncology, Kraków Branch, 31-115 Kraków, Poland
| | - Aleksandra Grela-Wojewoda
- Department of Clinical Oncology, The Maria Skłodowska-Curie National Research Institute of Oncology, Kraków Branch, 31-115 Kraków, Poland
| | - Mariusz Korkosz
- Department of Rheumatology and Immunology, Jagiellonian University Medical Kraków, 30-688 Krakow, Poland
- Division of Rheumatology and Immunology Clinical, University Hospital, 30-688 Kraków, Poland
| | - Stanisława Bazan-Socha
- Department of Internal Medicine, Jagiellonian University Medical College, 30-688 Kraków, Poland
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Ichihara S, Ogino H, Yoneda H, Haji K, Kagawa K, Murakami K, Mima M, Aoi Y, Mitsuhashi A, Tsukazaki Y, Yabuki Y, Ozaki R, Sato S, Nokihara H, Nishioka Y. Immune checkpoint inhibitor-related pneumonitis with atypical radiologic features in a patient with anti-aminoacyl-tRNA synthetase antibody. Respir Med Case Rep 2023; 41:101797. [PMID: 36583061 DOI: 10.1016/j.rmcr.2022.101797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/03/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
A man with non-small-cell lung cancer who was negative for anti-nuclear antibodies was admitted for dyspnea after immune checkpoint inhibitor (ICI) administration. Computed tomography (CT) showed complexed radiologic features, including subpleural and basal predominant reticular shadow with cystic structures and peribronchovascular consolidation. Although we treated him with high-dose steroid under a diagnosis of ICI-related pneumonitis, he developed acute exacerbation of pneumonitis with progressive fibrosis and volume loss. A re-evaluation identified anti-aminoacyl-tRNA synthetase antibody in the serum collected before ICI administration. This case highlights the importance of re-evaluating pre-existing autoimmune disorders in patients who develop ICI-related pneumonitis with atypical radiologic features.
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Key Words
- ALK, anaplastic lymphoma kinase
- ANAs, anti-nuclear antibodies
- ARS, aminoacyl tRNA synthetases
- ASS, anti-synthetase syndrome
- Anti-aminoacyl-tRNA synthetase antibody
- CTCAE, common terminology criteria for adverse events
- EGFR, epidermal growth factor receptor
- GGO, ground-glass opacity
- HP, hypersensitivity pneumonitis
- HRCT, high-resolution computed tomography
- ICIs, immune checkpoint inhibitors
- IIM, idiopathic inflammatory myopathy
- ILD, interstitial lung disease
- Immune checkpoint inhibitor
- NSCLC, non-small-cell lung cancer
- NSIP, nonspecific interstitial pneumonia
- Non-small-cell lung cancer
- OP, organizing pneumonia
- OS, overall survival
- PD-1, programmed cell death-1
- PD-L1, programmed cell death-ligand-1
- PFS, progression-free survival
- Pneumonitis
- RR, response rate
- UIP, usual interstitial pneumonia
- irAEs, immune-related adverse events
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Tanimura R, Nishino K, Iwade R, Abe R, Okauchi S, Sasatani Y, Satoh H. Lung cancer and combined pulmonary fibrosis and emphysema with anti-ARS antibody. Romanian Journal of Internal Medicine 2022; 60:193-196. [DOI: 10.2478/rjim-2022-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Indexed: 11/20/2022] Open
Abstract
Abstract
A 59-year-old man who had smoked for 23 pack-years was admitted to our hospital because of two-month history of back pain. The chest computed tomography scan demonstrated combined pulmonary fibrosis and emphysema (CPFE) and an irregular shaped nodule in the left lower lobe of the lung. A biopsy obtained from samples from subcarinal lymph nodes revealed non-small cell lung cancer. Anti-aminoacyl-tRNA synthetase (ARS) antibody was elevated up to 166 U/mL, although he had no symptoms suggestive connective tissue diseases. It is well known that most of CPFE patients are current or former heavy smokers, and some researchers described the relationship between CPFE and connective tissue diseases. To our best knowledge, this was the first report of lung cancer in patient with anti-ARS antibody-positive CPFE. In some anti-ARS antibody-positive patients, smoking might have a relationship with development of CPFE and lung cancer.
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Hamada N, Maeda A, Takase-Minegishi K, Kirino Y, Sugiyama Y, Namkoong H, Horita N, Yoshimi R, Nakajima H. Incidence and Distinct Features of Immune Checkpoint Inhibitor-Related Myositis From Idiopathic Inflammatory Myositis: A Single-Center Experience With Systematic Literature Review and Meta-Analysis. Front Immunol 2021; 12:803410. [PMID: 34938300 PMCID: PMC8686164 DOI: 10.3389/fimmu.2021.803410] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/22/2021] [Indexed: 01/12/2023] Open
Abstract
Immune checkpoint inhibitor (ICI)-related myositis is a rare, potentially fatal condition that warrants further studies. Its incidence, clinical features, and prognosis remain poorly understood. To address these gaps, we conducted a systematic review and meta-analysis to evaluate the risk of myositis associated with ICI for solid tumors by analyzing phase III randomized controlled trials of anti-programmed death-1/ligand-1 (PD-1/PD-L1) and anti-cytotoxic T-lymphocyte antigen-4 (CTLA-4). To complement this analysis with clinical data, we evaluated published ICI case reports along with cases from our institutional registry. This registry comprised 422 patients treated with ICIs alone or in combination from September 2014 to June 2021. The analysis revealed an incidence of ICI-related myositis in 6,838 patients in 18 randomized controlled trials of 0.38% (odds ratio 1.96; 95% confidence interval 1.02–3.75) for patients receiving ICIs compared with controls. Detailed analysis of 88 cases from the literature search and our registry showed that myositis induced by PD-1 inhibitors was more frequent than that induced by anti-CTLA-4 agents, revealing a clinically diverse trend including myasthenia gravis and myocarditis. Importantly, having ptosis at the time of onset was significantly associated with the development of concomitant myocarditis (odds ratio 3.81; 95% CI 1.48–9.83), which is associated with poor prognosis. Regarding treatment, most patients received glucocorticoids, and some received immunosuppressants. Our study revealed the incidence of ICI-mediated myositis and the clinical features of myocarditis, highlighting the need for recognition and early intervention.
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Affiliation(s)
- Naoki Hamada
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ayaka Maeda
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kaoru Takase-Minegishi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yohei Kirino
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yumiko Sugiyama
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ho Namkoong
- Department of Infectious Diseases, Keio University School of Medicine, Tokyo, Japan
| | - Nobuyuki Horita
- Chemothrapy Center, Yokohama City University Hospital, Yokohama, Japan
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hideaki Nakajima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Luo YB, Tang W, Zeng Q, Duan W, Li S, Yang X, Bi F. Case Report: The Neuromusclar Triad of Immune Checkpoint Inhibitors: A Case Report of Myositis, Myocarditis, and Myasthenia Gravis Overlap Following Toripalimab Treatment. Front Cardiovasc Med 2021; 8:714460. [PMID: 34485412 PMCID: PMC8415306 DOI: 10.3389/fcvm.2021.714460] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 06/10/2021] [Accepted: 07/22/2021] [Indexed: 12/17/2022] Open
Abstract
The neuromuscular adverse events of immune checkpoint inhibitor (ICI) treatment include myositis, polymyalgia rheumatica, myocarditis, and myasthenia syndrome. We report a 47-year old female presenting with external ophthalmoplegia, generalized muscle weakness, and third-degree atrioventricular block 4 weeks after toripalimab treatment for metastatic thymoma. Creatine kinase was elevated to 25,200 U/l and cardiac troponin I to 2.796 ng/ml. Autoantibody profiling shows positive anti-ryanodine receptor and anti-acetylcholine receptor antibodies and negative myositis specific antibodies. Repetitive nerve stimulation did not reveal decrement of compound muscle action potentials. Pulse methylprednisolone and immunoglobulin infusion, together with temporary pacemaker insertion normalized her muscle enzyme levels and cardiac rhythm. This is the first report of overlaping neuromuscular adverse event of toripalimab.
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Affiliation(s)
- Yue-Bei Luo
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Weiting Tang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Qiuming Zeng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Weiwei Duan
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Shuyu Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Xiaosu Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Fangfang Bi
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
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Steven NM, Fisher BA. Management of rheumatic complications of immune checkpoint inhibitor therapy - an oncological perspective. Rheumatology (Oxford) 2020; 58:vii29-vii39. [PMID: 31816079 PMCID: PMC6900910 DOI: 10.1093/rheumatology/kez536] [Citation(s) in RCA: 16] [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: 05/20/2019] [Revised: 09/30/2019] [Indexed: 02/06/2023] Open
Abstract
Immune checkpoint inhibitors (CPIs) are an effective treatment for many cancers but cause diverse immune-related adverse events (IrAEs). Rheumatological IrAEs include arthralgia, arthritis, tenosynovitis, myositis, polymyalgia rheumatica and sicca syndrome. CPI use can unmask RA as well as causing flares of prior autoimmune or connective tissue disease. Oncologists categorize and grade IrAEs using the Common Terminology Criteria for Adverse Events and manage them according to international guidelines. However, rheumatological events are unfamiliar territory: oncologists need to work with rheumatologists to elicit and assess symptoms, signs, results of imaging and autoantibody testing and to determine the use of steroids and DMARDs. Myositis may overlap with myasthenic crisis and myocarditis and can be life-threatening. Treatment should be offered on balance of risk and benefit, including whether to continue CPI treatment and recognizing the uncertainty over whether glucocorticoids and DMARDs might compromise cancer control.
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Affiliation(s)
- Neil M Steven
- Institute of Immunology and Immunotherapy, Birmingham, UK.,Cancer Centre, University Hospital Birmingham, Birmingham, UK
| | - Benjamin A Fisher
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,National Institute of Health Research Birmingham Biomedical Research Centre and Department of Rheumatology, University Hospital Birmingham, Birmingham, UK
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