1
|
Tsakmaklis A, Farowski F, Zenner R, Lesker TR, Strowig T, Schlößer H, Lehmann J, von Bergwelt-Baildon M, Mauch C, Schlaak M, Knuever J, Schweinsberg V, Heinzerling LM, Vehreschild MJGT. TIGIT + NK cells in combination with specific gut microbiota features predict response to checkpoint inhibitor therapy in melanoma patients. BMC Cancer 2023; 23:1160. [PMID: 38017389 PMCID: PMC10685659 DOI: 10.1186/s12885-023-11551-5] [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] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 10/20/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Composition of the intestinal microbiota has been correlated to therapeutic efficacy of immune checkpoint inhibitors (ICI) in various cancer entities including melanoma. Prediction of the outcome of such therapy, however, is still unavailable. This prospective, non-interventional study was conducted in order to achieve an integrated assessment of the connection between a specific intestinal microbiota profile and antitumor immune response to immune checkpoint inhibitor therapy (anti-PD-1 and/or anti-CTLA-4) in melanoma patients. METHODS We assessed blood and stool samples of 29 cutaneous melanoma patients who received immune checkpoint inhibitor therapy. For functional and phenotypical immune analysis, 12-color flow cytometry and FluoroSpot assays were conducted. Gut microbiome was analyzed with shotgun metagenomics sequencing. To combine clinical, microbiome and immune variables, we applied the Random Forest algorithm. RESULTS A total of 29 patients was analyzed in this study, among whom 51.7% (n = 15) reached a durable clinical benefit. The Immune receptor TIGIT is significantly upregulated in T cells (p = 0.0139) and CD56high NK cells (p = 0.0037) of responders. Several bacterial taxa were associated with response (e.g. Ruminococcus torques) or failure (e.g. Barnesiella intestinihominis) to immune therapy. A combination of two microbiome features (Barnesiella intestinihominis and the Enterobacteriaceae family) and one immune feature (TIGIT+ CD56high NK cells) was able to predict response to ICI already at baseline (AUC = 0.85; 95% CI: 0.841-0.853). CONCLUSIONS Our results reconfirm a link between intestinal microbiota and response to ICI therapy in melanoma patients and furthermore point to TIGIT as a promising target for future immunotherapies.
Collapse
Affiliation(s)
- Anastasia Tsakmaklis
- Department I of Internal Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
- German Center for Infection Research (DZIF), Partner site Bonn-Cologne, Cologne, Germany
| | - Fedja Farowski
- Department I of Internal Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
- German Center for Infection Research (DZIF), Partner site Bonn-Cologne, Cologne, Germany
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Theodor-Stern-Kai 7, Frankfurt, 60590, Germany
| | - Rafael Zenner
- Department I of Internal Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Till Robin Lesker
- Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
| | - Till Strowig
- Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
- German Center for Infection Research (DZIF), partner site Hannover-Braunschweig, Braunschweig, Germany
- Centre for Individualised Infection Medicine (CiiM), a joint venture between the Helmholtz-Centre for Infection Research (HZI) and the Hannover Medical School (MHH), Hannover, Germany
| | - Hans Schlößer
- Department of General, Visceral and Cancer Surgery, University Hospital Cologne, University of Cologne, Cologne, Germany
- Cologne Interventional Immunology, University of Cologne, Cologne, Germany
| | - Jonas Lehmann
- Department of General, Visceral and Cancer Surgery, University Hospital Cologne, University of Cologne, Cologne, Germany
- Cologne Interventional Immunology, University of Cologne, Cologne, Germany
| | | | - Cornelia Mauch
- Department of Dermatology, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Max Schlaak
- Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin, 10117, Germany
| | - Jana Knuever
- Department of Dermatology, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Viola Schweinsberg
- Department of Dermatology, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lucie M Heinzerling
- Department of Dermatology and Allergy, LMU University Hospital, LMU Munich, Munich, Germany
- Department of Dermatology, University Hospital Erlangen, Erlangen, Germany
| | - Maria J G T Vehreschild
- Department I of Internal Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany.
- German Center for Infection Research (DZIF), Partner site Bonn-Cologne, Cologne, Germany.
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Theodor-Stern-Kai 7, Frankfurt, 60590, Germany.
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Branch for Translational Medicine & Pharmacology ITMP, Frankfurt am Main, 60596, Germany.
| |
Collapse
|
2
|
Schmitt C, Hoefsmit EP, Fangmeier T, Kramer N, Kabakci C, Vera González J, Versluis JM, Compter A, Harrer T, Mijočević H, Schubert S, Hundsberger T, Menzies AM, Scolyer RA, Long GV, French LE, Blank CU, Heinzerling LM. Immune checkpoint inhibitor-induced neurotoxicity is not associated with seroprevalence of neurotropic infections. Cancer Immunol Immunother 2023; 72:3475-3489. [PMID: 37606856 PMCID: PMC10576679 DOI: 10.1007/s00262-023-03498-0] [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] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/07/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) substantially improve outcome for patients with cancer. However, the majority of patients develops immune-related adverse events (irAEs), which can be persistent and significantly reduce quality of life. Neurological irAEs occur in 1-5% of patients and can induce severe, permanent sequelae or even be fatal. In order to improve the diagnosis and treatment of neurological irAEs and to better understand their pathogenesis, we assessed whether previous neurotropic infections are associated with neurological irAEs. METHODS Neurotropic infections that might predispose to ICI-induced neurological irAEs were analyzed in 61 melanoma patients from 3 countries, the Netherlands, Australia and Germany, including 24 patients with neurotoxicity and 37 control patients. In total, 14 viral, 6 bacterial, and 1 protozoal infections previously reported to trigger neurological pathologies were assessed using routine serology testing. The Dutch and Australian cohorts (NL) included pre-treatment plasma samples of patients treated with neoadjuvant ICI therapy (OpACIN-neo and PRADO trials; NCT02977052). In the Dutch/Australian cohort a total of 11 patients with neurological irAEs were compared to 27 control patients (patients without neurological irAEs). The German cohort (LMU) consisted of serum samples of 13 patients with neurological irAE and 10 control patients without any documented irAE under ICI therapy. RESULTS The association of neurological irAEs with 21 possible preceding infections was assessed by measuring specific antibodies against investigated agents. The seroprevalence of all the tested viral (cytomegalovirus, Epstein-Barr-Virus, varicella-zoster virus, measles, rubella, influenza A and B, human herpes virus 6 and 7, herpes simplex virus 1 and 2, parvovirus B19, hepatitis A and E and human T-lymphotropic virus type 1 and 2), bacterial (Borrelia burgdorferi sensu lato, Campylobacter jejuni, Mycoplasma pneumoniae, Coxiella burnetti, Helicobacter pylori, Yersinia enterocolitica and Y. pseudotuberculosis) and protozoal (Toxoplasma gondii) infections was similar for patients who developed neurological irAEs as compared to control patients. Thus, the analysis provided no evidence for an association of described agents tested for seroprevalence with ICI induced neurotoxicity. CONCLUSION Previous viral, bacterial and protozoal neurotropic infections appear not to be associated with the development of neurological irAEs in melanoma patients who underwent therapy with ICI across 3 countries. Further efforts are needed to unravel the factors underlying neurological irAEs in order to identify risk factors for these toxicities, especially with the increasing use of ICI in earlier stage disease.
Collapse
Affiliation(s)
- C Schmitt
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - E P Hoefsmit
- Department of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - T Fangmeier
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - N Kramer
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - C Kabakci
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - J Vera González
- Department of Dermatology, Uniklinikum Erlangen and Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - J M Versluis
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - A Compter
- Department of Neuro-Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - T Harrer
- Department of Internal Medicine 3, Infectious Diseases and Immunodeficiency Section, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Deutsches Zentrum Für Immuntherapie (DZI), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany
| | - H Mijočević
- Max Von Pettenkofer Institute of Hygiene and Medical Microbiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - S Schubert
- Max Von Pettenkofer Institute of Hygiene and Medical Microbiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - T Hundsberger
- Departments of Neurology and Medical Oncology/Haematology, Cantonal Hospital, St. Gallen, Switzerland
| | - A M Menzies
- Melanoma Institute of Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, NSW, Australia
| | - R A Scolyer
- Melanoma Institute of Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia
| | - G V Long
- Melanoma Institute of Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, NSW, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - L E French
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
- Dr. Philip Frost, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - C U Blank
- Department of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - L M Heinzerling
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany.
- Department of Dermatology, Uniklinikum Erlangen and Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany.
| |
Collapse
|
3
|
Quinaglia T, Gongora C, Awadalla M, Hassan MZO, Zafar A, Drobni ZD, Mahmood SS, Zhang L, Coelho-Filho OR, Suero-Abreu GA, Rizvi MA, Sahni G, Mandawat A, Zatarain-Nicolás E, Mahmoudi M, Sullivan R, Ganatra S, Heinzerling LM, Thuny F, Ederhy S, Gilman HK, Sama S, Nikolaidou S, Mansilla AG, Calles A, Cabral M, Fernández-Avilés F, Gavira JJ, González NS, García de Yébenes Castro M, Barac A, Afilalo J, Zlotoff DA, Zubiri L, Reynolds KL, Devereux R, Hung J, Picard MH, Yang EH, Gupta D, Michel C, Lyon AR, Chen CL, Nohria A, Fradley MG, Thavendiranathan P, Neilan TG. Global Circumferential and Radial Strain Among Patients With Immune Checkpoint Inhibitor Myocarditis. JACC Cardiovasc Imaging 2022; 15:1883-1896. [PMID: 36357131 PMCID: PMC10334352 DOI: 10.1016/j.jcmg.2022.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/22/2021] [Revised: 05/25/2022] [Accepted: 06/22/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Global circumferential strain (GCS) and global radial strain (GRS) are reduced with cytotoxic chemotherapy. There are limited data on the effect of immune checkpoint inhibitor (ICI) myocarditis on GCS and GRS. OBJECTIVES This study aimed to detail the role of GCS and GRS in ICI myocarditis. METHODS In this retrospective study, GCS and GRS from 75 cases of patients with ICI myocarditis and 50 ICI-treated patients without myocarditis (controls) were compared. Pre-ICI GCS and GRS were available for 12 cases and 50 controls. Measurements were performed in a core laboratory blinded to group and time. Major adverse cardiovascular events (MACEs) were defined as a composite of cardiogenic shock, cardiac arrest, complete heart block, and cardiac death. RESULTS Cases and controls were similar in age (66 ± 15 years vs 63 ± 12 years; P = 0.20), sex (male: 73% vs 61%; P = 0.20) and cancer type (P = 0.08). Pre-ICI GCS and GRS were also similar (GCS: 22.6% ± 3.4% vs 23.5% ± 3.8%; P = 0.14; GRS: 45.5% ± 6.2% vs 43.6% ± 8.8%; P = 0.24). Overall, 56% (n = 42) of patients with myocarditis presented with preserved left ventricular ejection fraction (LVEF). GCS and GRS were lower in myocarditis compared with on-ICI controls (GCS: 17.5% ± 4.2% vs 23.6% ± 3.0%; P < 0.001; GRS: 28.6% ± 6.7% vs 47.0% ± 7.4%; P < 0.001). Over a median follow-up of 30 days, 28 cardiovascular events occurred. A GCS (HR: 4.9 [95% CI: 1.6-15.0]; P = 0.005) and GRS (HR: 3.9 [95% CI: 1.4-10.8]; P = 0.008) below the median was associated with an increased event rate. In receiver-operating characteristic (ROC) curves, GCS (AUC: 0.80 [95% CI: 0.70-0.91]) and GRS (AUC: 0.76 [95% CI: 0.64-0.88]) showed better performance than cardiac troponin T (cTnT) (AUC: 0.70 [95% CI: 0.58-0.82]), LVEF (AUC: 0.69 [95% CI: 0.56-0.81]), and age (AUC: 0.54 [95% CI: 0.40-0.68]). Net reclassification index and integrated discrimination improvement demonstrated incremental prognostic utility of GRS over LVEF (P = 0.04) and GCS over cTnT (P = 0.002). CONCLUSIONS GCS and GRS are lower in ICI myocarditis, and the magnitude of reduction has prognostic significance.
Collapse
Affiliation(s)
- Thiago Quinaglia
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Carlos Gongora
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Magid Awadalla
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Malek Z O Hassan
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amna Zafar
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Zsofia D Drobni
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Syed S Mahmood
- Cardiology Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine, New York, New York, USA
| | - Lili Zhang
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Otavio R Coelho-Filho
- Discipline of Cardiology, Department of Medicine, Faculty of Medical Science, State University of Campinas, Campinas, Brazil
| | | | - Muhammad A Rizvi
- Division of Oncology and Hematology, Department of Medicine, Lehigh Valley Hospital, Allentown, Pennsylvania, USA
| | - Gagan Sahni
- Cardiology-Oncology Program, Mount Sinai Hospital, New York, New York, USA
| | - Anant Mandawat
- Cardio-Oncology Program, Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Eduardo Zatarain-Nicolás
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red CardioVascular (CIBER-CV), Madrid, Spain
| | - Michael Mahmoudi
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Ryan Sullivan
- Massachusetts General Hospital Cancer Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Lucie M Heinzerling
- Department of Dermatology and Allergy, LMU Klinikum, Munich, Germany and Department of Dermatology, University Hospital Erlangen, Germany
| | - Franck Thuny
- Mediterranean University Center of Cardio-Oncology, Aix-Marseille University, North Hospital, Marseille, France
| | - Stephane Ederhy
- Cardio-Oncology Program, Division of Cardiology, Hopitaux Universitaires Est Parisien, Paris, France
| | - Hannah K Gilman
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Supraja Sama
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sofia Nikolaidou
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ana González Mansilla
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red CardioVascular (CIBER-CV), Madrid, Spain
| | - Antonio Calles
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red CardioVascular (CIBER-CV), Madrid, Spain
| | - Marcella Cabral
- Department of Cardiology or Diagnostic Radiology, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Francisco Fernández-Avilés
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red CardioVascular (CIBER-CV), Madrid, Spain
| | - Juan José Gavira
- Cardio-Oncology Program, Department of Cardiology, Clínica Universidad de Navarra, Pamplona and Madrid, Spain
| | - Nahikari Salterain González
- Cardio-Oncology Program, Department of Cardiology, Clínica Universidad de Navarra, Pamplona and Madrid, Spain
| | | | - Ana Barac
- Cardio-Oncology Program, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jonathan Afilalo
- Department of Cardiology or Diagnostic Radiology, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Daniel A Zlotoff
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Leyre Zubiri
- Massachusetts General Hospital Cancer Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kerry L Reynolds
- Massachusetts General Hospital Cancer Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Richard Devereux
- Cardiology Division, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, USA
| | - Judy Hung
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael H Picard
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Dipti Gupta
- Cardiology Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine, New York, New York, USA
| | - Caroline Michel
- Department of Cardiology or Diagnostic Radiology, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Alexander R Lyon
- Cardio-Oncology Service, Royal Brompton Hospital and Imperial College London, London, UK
| | - Carol L Chen
- Cardiology Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine, New York, New York, USA
| | - Anju Nohria
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael G Fradley
- Cardio-Oncology Center of Excellence, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Tomas G Neilan
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
4
|
Müller-Jensen L, Zierold S, Versluis JM, Boehmerle W, Huehnchen P, Endres M, Mohr R, Compter A, Blank CU, Hagenacker T, Meier F, Reinhardt L, Gesierich A, Salzmann M, Hassel JC, Ugurel S, Zimmer L, Banks P, Spain L, Soon JA, Enokida T, Tahara M, Kähler KC, Seggewiss-Bernhardt R, Harvey C, Long GV, Schöberl F, von Baumgarten L, Hundsberger T, Schlaak M, French LE, Knauss S, Heinzerling LM. Characteristics of immune checkpoint inhibitor-induced encephalitis and comparison with HSV-1 and anti-LGI1 encephalitis: A retrospective multicentre cohort study. Eur J Cancer 2022; 175:224-235. [PMID: 36155116 DOI: 10.1016/j.ejca.2022.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 05/20/2022] [Revised: 08/06/2022] [Accepted: 08/10/2022] [Indexed: 11/28/2022]
Abstract
AIM Immune checkpoint inhibitor-induced encephalitis (ICI-iE) is a rare but life-threatening toxicity of immune checkpoint inhibitor treatment. We aim to identify the characteristics of ICI-iE and describe factors that discriminate it from herpes simplex virus (HSV)-1 encephalitis and anti-leucine-rich glioma-inactivated 1 (anti-LGI1) encephalitis, as two alternative entities of encephalitis. METHODS In this retrospective multicentre cohort study, we collected patients with ICI-iE reported to the Side Effect Registry Immuno-Oncology from January 2015 to September 2021 and compared their clinical features and outcome with 46 consecutive patients with HSV-1 or anti-LGI1 encephalitis who were treated at a German neurological referral centre. RESULTS Thirty cases of ICI-iE, 25 cases of HSV-1 encephalitis and 21 cases of anti-LGI1 encephalitis were included. Clinical presentation of ICI-iE was highly variable and resembled that of HSV-1 encephalitis, while impairment of consciousness (66% vs. 5%, p = .007), confusion (83% vs. 43%; p = .02), disorientation (83% vs. 29%; p = .007) and aphasia (43% vs. 0%; p = .007) were more common in ICI-iE than in anti-LGI1 encephalitis. Antineuronal antibodies (17/18, 94%) and MRI (18/30, 60%) were mostly negative in ICI-iE, but cerebrospinal fluid (CSF) showed pleocytosis and/or elevated protein levels in almost all patients (28/29, 97%). Three patients (10%) died of ICI-iE. Early immunosuppressive treatment was associated with better outcome (r = 0.43). CONCLUSIONS ICI-iE is a heterogeneous entity without specific clinical features. CSF analysis has the highest diagnostic value, as it reveals inflammatory changes in most patients and enables the exclusion of infection. Early treatment of ICI-iE is essential to prevent sequelae and death.
Collapse
Affiliation(s)
- Leonie Müller-Jensen
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany.
| | - Sarah Zierold
- SERIO Side Effect Registry Immuno-Oncology, Germany; Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilian Universität Munich, Frauenlobstr. 9-11, 80337 München, Germany
| | - Judith M Versluis
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Wolfgang Boehmerle
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Germany
| | - Petra Huehnchen
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Charitéplatz 1, 10117 Berlin, Germany
| | - Matthias Endres
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Charitéplatz 1, 10117 Berlin, Germany; Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure Cluster of Excellence, 10117 Berlin, Germany; Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Stroke Research Berlin, 10117 Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Germany; German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Raphael Mohr
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Hepatology & Gastroenterology, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Annette Compter
- Department of Neuro-Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Christian U Blank
- Department of Medical Oncology, Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Tim Hagenacker
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Friedegund Meier
- Skin Cancer Center at the University Cancer Center Dresden and National Center for Tumor Diseases, Dresden, Germany; Department of Dermatology, University Hospital Carl Gustav Carus, TU Dresden, Germany
| | - Lydia Reinhardt
- Skin Cancer Center at the University Cancer Center Dresden and National Center for Tumor Diseases, Dresden, Germany; Department of Dermatology, University Hospital Carl Gustav Carus, TU Dresden, Germany
| | - Anja Gesierich
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Martin Salzmann
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica C Hassel
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Selma Ugurel
- Department of Dermatology, Venerology und Allergology, University Hospital Essen, Essen, Germany
| | - Lisa Zimmer
- Department of Dermatology, Venerology und Allergology, University Hospital Essen, Essen, Germany
| | - Patricia Banks
- Andrew Love Cancer Centre, University Hospital Geelong, Geelong, Australia
| | - Lavinia Spain
- Medical Oncology Department, Peter MacCallum Cancer Center, Melbourne, Australia
| | - Jennifer A Soon
- Medical Oncology Department, Peter MacCallum Cancer Center, Melbourne, Australia
| | - Tomohiro Enokida
- Department of Head and Neck Medical Oncology, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa 277-8577, Japan
| | - Makoto Tahara
- Department of Head and Neck Medical Oncology, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa 277-8577, Japan
| | - Katharina C Kähler
- Department of Dermatology, Venerology and Allergology, University of Schleswig-Holstein Hospital, Campus Kiel, Germany
| | | | - Catriona Harvey
- Melanoma Institute Australia, University of Sydney, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - Georgina V Long
- Melanoma Institute Australia, University of Sydney, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - Florian Schöberl
- Department of Neurology, Ludwig-Maximilian Universität, Marchioninistraße 15, 83177 München, Germany
| | - Louisa von Baumgarten
- Department of Neurology, Ludwig-Maximilian Universität, Marchioninistraße 15, 83177 München, Germany; Division of Neuro-Oncology, Department of Neurosurgery, Ludwig-Maximilian Universität, Marchioninistraße 15, 83177 München, Germany
| | - Thomas Hundsberger
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Max Schlaak
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Dermatology, Venerology and Allergology, Charitéplatz 1, 10117 Berlin, Germany
| | - Lars E French
- Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilian Universität Munich, Frauenlobstr. 9-11, 80337 München, Germany; Dr. Philip Frost, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Samuel Knauss
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117 Berlin, Germany; SERIO Side Effect Registry Immuno-Oncology, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany
| | - Lucie M Heinzerling
- SERIO Side Effect Registry Immuno-Oncology, Germany; Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilian Universität Munich, Frauenlobstr. 9-11, 80337 München, Germany; Department of Dermatology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
| |
Collapse
|
5
|
Müller-Jensen L, Zierold S, Versluis JM, Boehmerle W, Huehnchen P, Endres M, Mohr R, Compter A, Blank CU, Hagenacker T, Meier F, Reinhardt L, Gesierich A, Salzmann M, Hassel JC, Ugurel S, Zimmer L, Banks P, Spain L, Soon JA, Enokida T, Tahara M, Kähler KC, Seggewiss-Bernhardt R, Harvey C, Long GV, Schöberl F, von Baumgarten L, Hundsberger T, Schlaak M, French LE, Knauss S, Heinzerling LM. Dataset of a Retrospective Multicenter Cohort Study on Characteristics of Immune Checkpoint Inhibitor-induced Encephalitis and Comparison with HSV-1 and Anti-LGI1 Encephalitis. Data Brief 2022; 45:108649. [DOI: 10.1016/j.dib.2022.108649] [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] [Received: 08/18/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 11/29/2022] Open
|
6
|
Hassan MZ, Zafar A, Drobni Z, Cabral M, Thavendiranathan P, Zhang L, Mahmood SS, Nohria A, Thuny F, Heinzerling LM, Barac A, Chen CL, Gupta D, Michel C, Ganatra S, Gavira JJ, González NS, Afilalo J, Nicolás EZ, Yang EH, Mahmoudi M, Lyon AR, Ederhy S, Fradley MG, Neilan T. NTPROBNP LEVELS AND CARDIAC EVENTS IN PATIENTS WITH IMMUNE CHECKPOINT INHIBITOR-MYOCARDITIS. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)04647-7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
7
|
Zlotoff DA, Hassan MZO, Zafar A, Alvi RM, Awadalla M, Mahmood SS, Zhang L, Chen CL, Ederhy S, Barac A, Banerji D, Jones-O'Connor M, Murphy SP, Armanious M, Forrestal BJ, Kirchberger MC, Coelho-Filho OR, Rizvi MA, Sahni G, Mandawat A, Tocchetti CG, Hartmann S, Gilman HK, Zatarain-Nicolás E, Mahmoudi M, Gupta D, Sullivan R, Ganatra S, Yang EH, Heinzerling LM, Thuny F, Zubiri L, Reynolds KL, Cohen JV, Lyon AR, Groarke J, Thavendiranathan P, Nohria A, Fradley MG, Neilan TG. Electrocardiographic features of immune checkpoint inhibitor associated myocarditis. J Immunother Cancer 2021; 9:jitc-2020-002007. [PMID: 33653803 PMCID: PMC7929895 DOI: 10.1136/jitc-2020-002007] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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] [Accepted: 01/24/2021] [Indexed: 02/07/2023] Open
Abstract
Background Myocarditis is a highly morbid complication of immune checkpoint inhibitor (ICI) use that remains inadequately characterized. The QRS duration and the QTc interval are standardized electrocardiographic measures that are prolonged in other cardiac conditions; however, there are no data on their utility in ICI myocarditis. Methods From an international registry, ECG parameters were compared between 140 myocarditis cases and 179 controls across multiple time points (pre-ICI, on ICI prior to myocarditis, and at the time of myocarditis). The association between ECG values and major adverse cardiac events (MACE) was also tested. Results Both the QRS duration and QTc interval were similar between cases and controls prior to myocarditis. When compared with controls on an ICI (93±19 ms) or to baseline prior to myocarditis (97±19 ms), the QRS duration prolonged with myocarditis (110±22 ms, p<0.001 and p=0.009, respectively). In contrast, the QTc interval at the time of myocarditis (435±39 ms) was not increased compared with pre-myocarditis baseline (422±27 ms, p=0.42). A prolonged QRS duration conferred an increased risk of subsequent MACE (HR 3.28, 95% CI 1.98 to 5.62, p<0.001). After adjustment, each 10 ms increase in the QRS duration conferred a 1.3-fold increase in the odds of MACE (95% CI 1.07 to 1.61, p=0.011). Conversely, there was no association between the QTc interval and MACE among men (HR 1.33, 95% CI 0.70 to 2.53, p=0.38) or women (HR 1.48, 95% CI 0.61 to 3.58, p=0.39). Conclusions The QRS duration is increased in ICI myocarditis and is associated with increased MACE risk. Use of this widely available ECG parameter may aid in ICI myocarditis diagnosis and risk-stratification.
Collapse
Affiliation(s)
- Daniel A Zlotoff
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Malek Z O Hassan
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amna Zafar
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Raza M Alvi
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Magid Awadalla
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Syed S Mahmood
- Cardio-Oncology Program, Cardiology Division, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, New York, USA
| | - Lili Zhang
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Carol L Chen
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine, New York, New York, USA
| | - Stephane Ederhy
- Cardio-Oncology Program, Division of Cardiology, Hopitaux Universitaires Est Parisien, Paris, France
| | - Ana Barac
- Cardio-Oncology Program, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Dahlia Banerji
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maeve Jones-O'Connor
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sean P Murphy
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Merna Armanious
- Cardio-Oncology Program, Division of Cardiovascular Medicine, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida, Tampa, Florida, USA
| | - Brian J Forrestal
- Cardio-Oncology Program, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Michael C Kirchberger
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Otavio R Coelho-Filho
- Discipline of Cardiology, Department of Medicine, Faculty of Medical Science, State University of Campinas, Campinas, Brazil
| | - Muhammad A Rizvi
- Division of Oncology and Hematology, Department of Medicine, Lehigh Valley Hospital, Allentown, Pennsylvania, USA
| | - Gagan Sahni
- Cardiology Division, Mount Sinai Medical Center, New York, New York, USA
| | - Anant Mandawat
- Cardio-Oncology Program, Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Carlo G Tocchetti
- Department of Translational Medical Sciences, Interdepartmental Center of Clinical and Translational Research (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Università degli Studi di Napoli Federico II, Naples, Italy
| | - Sarah Hartmann
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hannah K Gilman
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eduardo Zatarain-Nicolás
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red CardioVascular (CIBER-CV), Madrid, Spain
| | | | - Dipti Gupta
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine, New York, New York, USA
| | - Ryan Sullivan
- Massachusetts General Hospital Cancer Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | | | - Franck Thuny
- Mediterranean University Center of Cardio-Oncology, Aix-Marseille University, North Hospital, Marseille, France
| | - Leyre Zubiri
- Massachusetts General Hospital Cancer Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kerry L Reynolds
- Massachusetts General Hospital Cancer Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Justine V Cohen
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alexander R Lyon
- Cardio-Oncology Service, Royal Brompton Hospital and Imperial College London, London, UK
| | - John Groarke
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anju Nohria
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael G Fradley
- Cardio-Oncology Program, Division of Cardiovascular Medicine, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida, Tampa, Florida, USA
| | - Tomas G Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA .,Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
8
|
Thavendiranathan P, Zhang L, Zafar A, Drobni ZD, Mahmood SS, Cabral M, Awadalla M, Nohria A, Zlotoff DA, Thuny F, Heinzerling LM, Barac A, Sullivan RJ, Chen CL, Gupta D, Kirchberger MC, Hartmann SE, Weinsaft JW, Gilman HK, Rizvi MA, Kovacina B, Michel C, Sahni G, González-Mansilla A, Calles A, Fernández-Avilés F, Mahmoudi M, Reynolds KL, Ganatra S, Gavira JJ, González NS, García de Yébenes Castro M, Kwong RY, Jerosch-Herold M, Coelho-Filho OR, Afilalo J, Zataraín-Nicolás E, Baksi AJ, Wintersperger BJ, Calvillo-Arguelles O, Ederhy S, Yang EH, Lyon AR, Fradley MG, Neilan TG. Myocardial T1 and T2 Mapping by Magnetic Resonance in Patients With Immune Checkpoint Inhibitor-Associated Myocarditis. J Am Coll Cardiol 2021; 77:1503-1516. [PMID: 33766256 DOI: 10.1016/j.jacc.2021.01.050] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [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: 11/20/2020] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Myocarditis is a potentially fatal complication of immune checkpoint inhibitor (ICI) therapy. Data on the utility of cardiovascular magnetic resonance (CMR) T1 and T2 mapping in ICI myocarditis are limited. OBJECTIVES This study sought to assess the value of CMR T1 and T2 mapping in patients with ICI myocarditis. METHODS In this retrospective study from an international registry of patients with ICI myocarditis, clinical and CMR findings (including T1 and T2 maps) were collected. Abnormal T1 and T2 were defined as 2 SD above site (vendor/field strength specific) reference values and a z-score was calculated for each patient. Major adverse cardiovascular events (MACE) were a composite of cardiovascular death, cardiogenic shock, cardiac arrest, and complete heart block. RESULTS Of 136 patients with ICI myocarditis with a CMR, 86 (63%) had T1 maps and 79 (58%) also had T2 maps. Among the 86 patients (66.3 ± 13.1 years of age), 36 (41.9%) had a left ventricular ejection fraction <55%. Across all patients, mean z-scores for T1 and T2 values were 2.9 ± 1.9 (p < 0.001) and 2.2 ± 2.1 (p < 0.001), respectively. On Siemens 1.5-T scanner (n = 67), native T1 (1,079.0 ± 55.5 ms vs. 1,000.3 ± 22.1 ms; p < 0.001) and T2 (56.2 ± 4.9 ms vs. 49.8 ± 2.2 ms; p < 0.001) values were elevated compared with reference values. Abnormal T1 and T2 values were seen in 78% and 43% of the patients, respectively. Applying the modified Lake Louise Criteria, 95% met the nonischemic myocardial injury criteria and 53% met the myocardial edema criteria. Native T1 values had excellent discriminatory value for subsequent MACE, with an area under the curve of 0.91 (95% confidence interval: 0.84 to 0.98). Native T1 values (for every 1-unit increase in z-score, hazard ratio: 1.44; 95% confidence interval: 1.12 to 1.84; p = 0.004) but not T2 values were independently associated with subsequent MACE. CONCLUSIONS The use of T1 mapping and application of the modified Lake Louise Criteria provides important diagnostic value, and T1 mapping provides prognostic value in patients with ICI myocarditis.
Collapse
Affiliation(s)
- Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Lili Zhang
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Amna Zafar
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Zsofia D Drobni
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Syed S Mahmood
- Cardiology Division, NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, USA
| | - Marcella Cabral
- Department of Cardiology or Diagnostic Radiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Magid Awadalla
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anju Nohria
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel A Zlotoff
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Franck Thuny
- University Mediterranean Center of Cardio-Oncology, Nord Hospital, Aix-Marseille University, Marseille, France; Groupe Méditerranéen de Cardio-Oncologie, Marseille, France; Center for CardioVascular and Nutrition Research, INRA 1260, INSERM 1263, Aix-Marseille University, Marseille, France
| | - Lucie M Heinzerling
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany; Department of Dermatology and Allergy, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Ana Barac
- Cardio-Oncology Program, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC, USA
| | - Ryan J Sullivan
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carol L Chen
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York, USA
| | - Dipti Gupta
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York, USA
| | - Michael C Kirchberger
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Sarah E Hartmann
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jonathan W Weinsaft
- Cardiology Division, NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, USA; Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York, USA
| | - Hannah K Gilman
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Muhammad A Rizvi
- Division of Oncology and Hematology, Department of Medicine, Lehigh Valley Hospital, Allentown, Pennsylvania, USA
| | - Bojan Kovacina
- Department of Cardiology or Diagnostic Radiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Caroline Michel
- Department of Cardiology or Diagnostic Radiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Gagan Sahni
- Cardiovascular Institute, Mount Sinai Hospital, New York, New York, USA
| | - Ana González-Mansilla
- Hospital General Universitario Gregorio Marañón, CIBERCV, Instituto de Salud Carlos III, Universidad Complutense de Madrid, Madrid, Spain
| | - Antonio Calles
- Hospital General Universitario Gregorio Marañón, CIBERCV, Instituto de Salud Carlos III, Universidad Complutense de Madrid, Madrid, Spain
| | - Francisco Fernández-Avilés
- Hospital General Universitario Gregorio Marañón, CIBERCV, Instituto de Salud Carlos III, Universidad Complutense de Madrid, Madrid, Spain
| | - Michael Mahmoudi
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Kerry L Reynolds
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Juan José Gavira
- Cardio-Oncology Program, Department of Cardiology, Clínica Universidad de Navarra, Pamplona and Madrid, Spain
| | - Nahikari Salterain González
- Cardio-Oncology Program, Department of Cardiology, Clínica Universidad de Navarra, Pamplona and Madrid, Spain
| | | | - Raymond Y Kwong
- Cardiovascular Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Jerosch-Herold
- Cardiovascular Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Jonathan Afilalo
- Department of Cardiology or Diagnostic Radiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Eduardo Zataraín-Nicolás
- Hospital General Universitario Gregorio Marañón, CIBERCV, Instituto de Salud Carlos III, Universidad Complutense de Madrid, Madrid, Spain
| | - A John Baksi
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Bernd J Wintersperger
- Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Oscar Calvillo-Arguelles
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Stephane Ederhy
- Cardio-Oncology Program, Division of Cardiology, Hôpitaux Universitaires Est Parisien, Paris, France
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Alexander R Lyon
- Cardio-Oncology Program, Royal Brompton Hospital, Imperial College London, London, United Kingdom
| | - Michael G Fradley
- Cardio-Oncology Center of Excellence, Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tomas G Neilan
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
| |
Collapse
|
9
|
Awadalla M, Mahmood SS, Groarke JD, Hassan MZO, Nohria A, Rokicki A, Murphy SP, Mercaldo ND, Zhang L, Zlotoff DA, Reynolds KL, Alvi RM, Banerji D, Liu S, Heinzerling LM, Jones-O'Connor M, Bakar RB, Cohen JV, Kirchberger MC, Sullivan RJ, Gupta D, Mulligan CP, Shah SP, Ganatra S, Rizvi MA, Sahni G, Tocchetti CG, Lawrence DP, Mahmoudi M, Devereux RB, Forrestal BJ, Mandawat A, Lyon AR, Chen CL, Barac A, Hung J, Thavendiranathan P, Picard MH, Thuny F, Ederhy S, Fradley MG, Neilan TG. Global Longitudinal Strain and Cardiac Events in Patients With Immune Checkpoint Inhibitor-Related Myocarditis. J Am Coll Cardiol 2020; 75:467-478. [PMID: 32029128 DOI: 10.1016/j.jacc.2019.11.049] [Citation(s) in RCA: 149] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/03/2019] [Accepted: 11/22/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND There is a need for improved methods for detection and risk stratification of myocarditis associated with immune checkpoint inhibitors (ICIs). Global longitudinal strain (GLS) is a sensitive marker of cardiac toxicity among patients receiving standard chemotherapy. There are no data on the use of GLS in ICI myocarditis. OBJECTIVES This study sought to evaluate the role of GLS and assess its association with cardiac events among patients with ICI myocarditis. METHODS This study retrospectively compared echocardiographic GLS by speckle tracking at presentation with ICI myocarditis (cases, n = 101) to that from patients receiving an ICI who did not develop myocarditis (control subjects, n = 92). Where available, GLS was also measured pre-ICI in both groups. Major adverse cardiac events (MACE) were defined as a composite of cardiogenic shock, arrest, complete heart block, and cardiac death. RESULTS Cases and control subjects were similar in age, sex, and cancer type. At presentation with myocarditis, 61 cases (60%) had a normal ejection fraction (EF). Pre-ICI, GLS was similar between cases and control subjects (20.3 ± 2.6% vs. 20.6 ± 2.0%; p = 0.60). There was no change in GLS among control subjects on an ICI without myocarditis (pre-ICI vs. on ICI, 20.6 ± 2.0% vs. 20.5 ± 1.9%; p = 0.41); in contrast, among cases, GLS decreased to 14.1 ± 2.8% (p < 0.001). The GLS at presentation with myocarditis was lower among cases presenting with either a reduced (12.3 ± 2.7%) or preserved EF (15.3 ± 2.0%; p < 0.001). Over a median follow-up of 162 days, 51 (51%) experienced MACE. The risk of MACE was higher with a lower GLS among patients with either a reduced or preserved EF. After adjustment for EF, each percent reduction in GLS was associated with a 1.5-fold increase in MACE among patients with a reduced EF (hazard ratio: 1.5; 95% confidence interval: 1.2 to 1.8) and a 4.4-fold increase with a preserved EF (hazard ratio: 4.4; 95% confidence interval: 2.4 to 7.8). CONCLUSIONS GLS decreases with ICI myocarditis and, compared with control subjects, was lower among cases presenting with either a preserved or reduced EF. Lower GLS was strongly associated with MACE in ICI myocarditis presenting with either a preserved or reduced EF.
Collapse
Affiliation(s)
- Magid Awadalla
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Syed S Mahmood
- Cardiology Division, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - John D Groarke
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Malek Z O Hassan
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Anju Nohria
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adam Rokicki
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sean P Murphy
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nathaniel D Mercaldo
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lili Zhang
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel A Zlotoff
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kerry L Reynolds
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Raza M Alvi
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Dahlia Banerji
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Shiying Liu
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lucie M Heinzerling
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nurnberg (FAU), Erlangen and Nurnberg, Germany
| | - Maeve Jones-O'Connor
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Rula B Bakar
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Justine V Cohen
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael C Kirchberger
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nurnberg (FAU), Erlangen and Nurnberg, Germany
| | - Ryan J Sullivan
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Dipti Gupta
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York
| | - Connor P Mulligan
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sachin P Shah
- Cardiology Division, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Sarju Ganatra
- Cardiology Division, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Muhammad A Rizvi
- Division of Oncology and Hematology, Department of Medicine, Lehigh Valley Hospital, Allentown, Pennsylvania
| | - Gagan Sahni
- Cardiovascular Institute, School of Medicine, The Mount Sinai Hospital, New York, New York
| | - Carlo G Tocchetti
- Department of Translational Medical Sciences and Interdepartmental Center for Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy
| | - Donald P Lawrence
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Mahmoudi
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Richard B Devereux
- Cardiology Division, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Brian J Forrestal
- Cardio-Oncology Program, Department of Cardiology, Medstar Washington Hospital Center, Medstar Heart and Vascular institute, Washington, DC
| | - Anant Mandawat
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Alexander R Lyon
- Cardio-Oncology Program, Royal Brompton Hospital and Imperial College, London, United Kingdom
| | - Carol L Chen
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York
| | - Ana Barac
- Cardio-Oncology Program, Department of Cardiology, Medstar Washington Hospital Center, Medstar Heart and Vascular institute, Washington, DC
| | - Judy Hung
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael H Picard
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Franck Thuny
- Cardiology Division, Cardiovascular Division, Department of Medicine, Aix-Marseille Universite, Marseille, France
| | - Stephane Ederhy
- UNICO-GRECO, Cardio-Oncology Program, Department of Cardiology, Assistance Publique-Hopitaux de Paris, Saint-Antoine Hospital, Paris, France
| | - Michael G Fradley
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida Division of Cardiovascular Medicine, Tampa, Florida
| | - Tomas G Neilan
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
| |
Collapse
|
10
|
Zhang L, Zlotoff DA, Awadalla M, Mahmood SS, Nohria A, Hassan MZO, Thuny F, Zubiri L, Chen CL, Sullivan RJ, Alvi RM, Rokicki A, Murphy SP, Jones-O'Connor M, Heinzerling LM, Barac A, Forrestal BJ, Yang EH, Gupta D, Kirchberger MC, Shah SP, Rizvi MA, Sahni G, Mandawat A, Mahmoudi M, Ganatra S, Ederhy S, Zatarain-Nicolas E, Groarke JD, Tocchetti CG, Lyon AR, Thavendiranathan P, Cohen JV, Reynolds KL, Fradley MG, Neilan TG. Major Adverse Cardiovascular Events and the Timing and Dose of Corticosteroids in Immune Checkpoint Inhibitor-Associated Myocarditis. Circulation 2020; 141:2031-2034. [PMID: 32539614 DOI: 10.1161/circulationaha.119.044703] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Lili Zhang
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology (L. Zhang, M.A., M.Z.O.H., R.M.A., A.R., T.G.N.), Massachusetts General Hospital, Boston.,Cardio-Oncology Program, Division of Cardiology, Department of Medicine (L. Zhang, D.A.Z., M.A., S.P.M., M.J.-O., T.G.N.), Massachusetts General Hospital, Boston
| | - Daniel A Zlotoff
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine (L. Zhang, D.A.Z., M.A., S.P.M., M.J.-O., T.G.N.), Massachusetts General Hospital, Boston
| | - Magid Awadalla
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology (L. Zhang, M.A., M.Z.O.H., R.M.A., A.R., T.G.N.), Massachusetts General Hospital, Boston.,Cardio-Oncology Program, Division of Cardiology, Department of Medicine (L. Zhang, D.A.Z., M.A., S.P.M., M.J.-O., T.G.N.), Massachusetts General Hospital, Boston
| | - Syed S Mahmood
- Cardiology Division, New York-Presbyterian Hospital, Weill Cornell Medical Center (S.S.M.)
| | - Anju Nohria
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.N., J.D.G.)
| | - Malek Z O Hassan
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology (L. Zhang, M.A., M.Z.O.H., R.M.A., A.R., T.G.N.), Massachusetts General Hospital, Boston
| | - Franck Thuny
- Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille, University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Department of Cardiology, Nord Hospital, Center for Cardiovascular and Nutrition Research, France (F.T.).,Mediterranean Group of Cardio-Oncology, Marseille, France (F.T.)
| | - Leyre Zubiri
- Division of Oncology and Hematology, Department of Medicine (L. Zubiri, R.J.S., J.V.C., K.L.R.), Massachusetts General Hospital, Boston
| | - Carol L Chen
- Cardiology Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York (C.LC., D.G.)
| | - Ryan J Sullivan
- Division of Oncology and Hematology, Department of Medicine (L. Zubiri, R.J.S., J.V.C., K.L.R.), Massachusetts General Hospital, Boston
| | - Raza M Alvi
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology (L. Zhang, M.A., M.Z.O.H., R.M.A., A.R., T.G.N.), Massachusetts General Hospital, Boston
| | - Adam Rokicki
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology (L. Zhang, M.A., M.Z.O.H., R.M.A., A.R., T.G.N.), Massachusetts General Hospital, Boston
| | - Sean P Murphy
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine (L. Zhang, D.A.Z., M.A., S.P.M., M.J.-O., T.G.N.), Massachusetts General Hospital, Boston
| | - Maeve Jones-O'Connor
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine (L. Zhang, D.A.Z., M.A., S.P.M., M.J.-O., T.G.N.), Massachusetts General Hospital, Boston
| | - Lucie M Heinzerling
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Germany (L.M.H., M.C.K.)
| | - Ana Barac
- Cardio-Oncology Program, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC (A.B., B.J.F.)
| | - Brian J Forrestal
- Cardio-Oncology Program, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC (A.B., B.J.F.)
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles (E.H.Y.)
| | - Dipti Gupta
- Cardiology Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York (C.LC., D.G.)
| | - Michael C Kirchberger
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Germany (L.M.H., M.C.K.)
| | - Sachin P Shah
- Cardiology Division, Lahey Hospital and Medical Center, Burlington, MA (S.P.S., S.G.)
| | - Muhammad A Rizvi
- Division of Oncology and Hematology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (M.A.R.)
| | | | - Anant Mandawat
- Cardio-Oncology Program, Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Emory University School of Medicine, Atlanta, GA (A.M.)
| | - Michael Mahmoudi
- Faculty of Medicine, University of Southampton, United Kingdom (M.M.)
| | - Sarju Ganatra
- Cardiology Division, Lahey Hospital and Medical Center, Burlington, MA (S.P.S., S.G.)
| | - Stephane Ederhy
- AP-HP, Saint-Antoine Hospital, Department of Cardiology, UNICO-GRECO Cardio-Oncology Program, Paris, France (S.E.)
| | | | - John D Groarke
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.N., J.D.G.)
| | - Carlo G Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy (C.G.T.)
| | - Alexander R Lyon
- Cardio-Oncology Program, Royal Brompton Hospital, and Imperial College London, United Kingdom (A.R.L.)
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University of Toronto, Ontario, Canada (P.T.)
| | - Justine V Cohen
- Division of Oncology and Hematology, Department of Medicine (L. Zubiri, R.J.S., J.V.C., K.L.R.), Massachusetts General Hospital, Boston
| | - Kerry L Reynolds
- Division of Oncology and Hematology, Department of Medicine (L. Zubiri, R.J.S., J.V.C., K.L.R.), Massachusetts General Hospital, Boston
| | - Michael G Fradley
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania, Philadelphia (M.G.F.)
| | - Tomas G Neilan
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology (L. Zhang, M.A., M.Z.O.H., R.M.A., A.R., T.G.N.), Massachusetts General Hospital, Boston.,Cardio-Oncology Program, Division of Cardiology, Department of Medicine (L. Zhang, D.A.Z., M.A., S.P.M., M.J.-O., T.G.N.), Massachusetts General Hospital, Boston
| |
Collapse
|
11
|
Zhang L, Awadalla M, Mahmood SS, Nohria A, Hassan MZO, Thuny F, Zlotoff DA, Murphy SP, Stone JR, Golden DLA, Alvi RM, Rokicki A, Jones-O’Connor M, Cohen JV, Heinzerling LM, Mulligan C, Armanious M, Barac A, Forrestal BJ, Sullivan RJ, Kwong RY, Yang EH, Damrongwatanasuk R, Chen CL, Gupta D, Kirchberger MC, Moslehi JJ, Coelho-Filho OR, Ganatra S, Rizvi MA, Sahni G, Tocchetti CG, Mercurio V, Mahmoudi M, Lawrence DP, Reynolds KL, Weinsaft JW, Baksi AJ, Ederhy S, Groarke JD, Lyon AR, Fradley MG, Thavendiranathan P, Neilan TG. Cardiovascular magnetic resonance in immune checkpoint inhibitor-associated myocarditis. Eur Heart J 2020; 41:1733-1743. [PMID: 32112560 PMCID: PMC7205467 DOI: 10.1093/eurheartj/ehaa051] [Citation(s) in RCA: 189] [Impact Index Per Article: 47.3] [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: 09/01/2019] [Revised: 10/30/2019] [Accepted: 01/21/2020] [Indexed: 12/27/2022] Open
Abstract
AIMS Myocarditis is a potentially fatal complication of immune checkpoint inhibitors (ICI). Sparse data exist on the use of cardiovascular magnetic resonance (CMR) in ICI-associated myocarditis. In this study, the CMR characteristics and the association between CMR features and cardiovascular events among patients with ICI-associated myocarditis are presented. METHODS AND RESULTS From an international registry of patients with ICI-associated myocarditis, clinical, CMR, and histopathological findings were collected. Major adverse cardiovascular events (MACE) were a composite of cardiovascular death, cardiogenic shock, cardiac arrest, and complete heart block. In 103 patients diagnosed with ICI-associated myocarditis who had a CMR, the mean left ventricular ejection fraction (LVEF) was 50%, and 61% of patients had an LVEF ≥50%. Late gadolinium enhancement (LGE) was present in 48% overall, 55% of the reduced EF, and 43% of the preserved EF cohort. Elevated T2-weighted short tau inversion recovery (STIR) was present in 28% overall, 30% of the reduced EF, and 26% of the preserved EF cohort. The presence of LGE increased from 21.6%, when CMR was performed within 4 days of admission to 72.0% when CMR was performed on Day 4 of admission or later. Fifty-six patients had cardiac pathology. Late gadolinium enhancement was present in 35% of patients with pathological fibrosis and elevated T2-weighted STIR signal was present in 26% with a lymphocytic infiltration. Forty-one patients (40%) had MACE over a follow-up time of 5 months. The presence of LGE, LGE pattern, or elevated T2-weighted STIR were not associated with MACE. CONCLUSION These data suggest caution in reliance on LGE or a qualitative T2-STIR-only approach for the exclusion of ICI-associated myocarditis.
Collapse
Affiliation(s)
- Lili Zhang
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Magid Awadalla
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Syed S Mahmood
- Cardiology Division, Department of Medicine, New York-Presbyterian Hospital, Weill Cornell Medical Center, 1300 York Avenue, New York, NY 10065, USA
| | - Anju Nohria
- Cardio-Oncology Program, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Malek Z O Hassan
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Franck Thuny
- Department of Cardiology, Aix-Marseille University, Assistance Publique–Hôpitaux de Marseille, Mediterranean university, Cardio-Oncology center (MEDI-CO center), Unit of Heart Failure and Valvular Heart Diseases, Hôpital Nord, Jardin du Pharo, 58 Boulevard Charles Livon 13007, Marseille, France
- Groupe Méditerranéen de Cardio-Oncologie (gMEDICO), AP-HM, Chemin des Bourrely, 13015, Marseille, France
- Aix-Marseille University, Center for CardioVascular and Nutrition research (C2VN), Inserm 1263, Inra 1260, 13385 Marseille, France
| | - Daniel A Zlotoff
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Sean P Murphy
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - James R Stone
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Doll Lauren Alexandra Golden
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Raza M Alvi
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Adam Rokicki
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Maeve Jones-O’Connor
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Justine V Cohen
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Lucie M Heinzerling
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Schloßplatz 4, 91054 Erlangen, Germany
| | - Connor Mulligan
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Merna Armanious
- Cardio-Oncology Program, Division of Cardiovascular Medicine, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Ana Barac
- Cardio-Oncology program, MedStar Heart and Vascular Institute, Georgetown University, 110 Irving St NW, Washington, DC 20010, USA
| | - Brian J Forrestal
- Cardio-Oncology program, MedStar Heart and Vascular Institute, Georgetown University, 110 Irving St NW, Washington, DC 20010, USA
| | - Ryan J Sullivan
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Raymond Y Kwong
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Rongras Damrongwatanasuk
- Cardio-Oncology Program, Division of Cardiovascular Medicine, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Carol L Chen
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, 1275 York Avenue, New York, NY 10065, USA
| | - Dipti Gupta
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, 1275 York Avenue, New York, NY 10065, USA
| | - Michael C Kirchberger
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Schloßplatz 4, 91054 Erlangen, Germany
| | - Javid J Moslehi
- Cardio-Oncology Program, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Otavio R Coelho-Filho
- Cardiology Division, State University of Campinas, Cidade Universitária Zeferino Vaz - Barão Geraldo, Campinas, São Paulo 13083-970, Brazil
| | - Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA 01805, USA
| | - Muhammad A Rizvi
- Division of Oncology and Hematology, Department of Medicine, Lehigh Valley Hospital, 1200 S Cedar Crest Blvd, Allentown, PA 18103, USA
| | - Gagan Sahni
- Cardiology Division, The Mount Sinai Hospital, 1468 Madison Ave, New York, NY 10029, USA
| | - Carlo G Tocchetti
- Department of Translational Medical Sciences, Federico II University, via S. Pansini 5, 80131 Naples, NA, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, via S. Pansini 5, 80131 Naples, NA, Italy
| | - Michael Mahmoudi
- Faculty of Medicine, University of Southampton, University Road Southampton SO17 1BJ, UK
| | - Donald P Lawrence
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Kerry L Reynolds
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Jonathan W Weinsaft
- Cardiology Division, Department of Medicine, New York-Presbyterian Hospital, Weill Cornell Medical Center, 1300 York Avenue, New York, NY 10065, USA
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, 1275 York Avenue, New York, NY 10065, USA
| | - A John Baksi
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, Sydney St, Chelsea, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, Kensington, London SW7 2DD, UK
| | - Stephane Ederhy
- UNICO-GRECO cardio-oncology program, sorbonne universite, Hopital Saint Antoine, 27 Rue de Chaligny, 75012 Paris, France
| | - John D Groarke
- Cardio-Oncology Program, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Alexander R Lyon
- Cardio-Oncology Program, Royal Brompton Hospital, Sydney St, Chelsea, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, Cale Street, Chelsea, London, SW3 6LY, United Kingdom
| | - Michael G Fradley
- Cardio-Oncology Program, Division of Cardiovascular Medicine, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Division of Cardiology, Toronto General Hospital, Peter Munk Cardiac Center, University of Toronto, Toronto, ON, Canada
| | - Tomas G Neilan
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| |
Collapse
|
12
|
Zhang L, Awadalla M, Mahmood SS, Groarke JD, Nohria A, Liu S, Hassan MZ, Cohen JV, Jones-O'Connor M, Murphy SP, Heinzerling LM, Sahni G, Chen CL, Gupta D, Moslehi JJ, Ganatra S, Ederhy S, Thuny F, Lyon AR, Tocchetti CG, Rizvi MA, Thavendiranathan P, Fradley MG, Neilan TG. LATE GADOLINIUM ENHANCEMENT IN PATIENTS WITH MYOCARDITIS FROM IMMUNE CHECKPOINT INHIBITORS. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)31283-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
13
|
Awadalla M, Golden DLA, Mahmood SS, Alvi RM, Mercaldo ND, Hassan MZO, Banerji D, Rokicki A, Mulligan C, Murphy SPT, Jones-O'Connor M, Cohen JV, Heinzerling LM, Armanious M, Sullivan RJ, Damrongwatanasuk R, Chen CL, Gupta D, Kirchberger MC, Moslehi JJ, Shah SP, Ganatra S, Thavendiranathan P, Rizvi MA, Sahni G, Lyon AR, Tocchetti CG, Mercurio V, Thuny F, Ederhy S, Mahmoudi M, Lawrence DP, Groarke JD, Nohria A, Fradley MG, Reynolds KL, Neilan TG. Influenza vaccination and myocarditis among patients receiving immune checkpoint inhibitors. J Immunother Cancer 2019; 7:53. [PMID: 30795818 PMCID: PMC6387531 DOI: 10.1186/s40425-019-0535-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [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: 12/12/2018] [Accepted: 02/13/2019] [Indexed: 12/18/2022] Open
Abstract
Background Influenza vaccination (FV) is recommended for patients with cancer. Recent data suggested that the administration of the FV was associated with an increase in immune-related adverse events (irAEs) among patients on immune checkpoint inhibitors (ICIs). Myocarditis is an uncommon but serious complication of ICIs and may also result from infection with influenza. There are no data testing the relationship between FV and the development of myocarditis on ICIs. Methods Patients on ICIs who developed myocarditis (n = 101) (cases) were compared to ICI-treated patients (n = 201) without myocarditis (controls). A patient was defined as having the FV if they were administered the FV from 6 months prior to start of ICI to anytime during ICI therapy. Alternate thresholds for FV status were also tested. The primary comparison of interest was the rate of FV between cases and controls. Patients with myocarditis were followed for major adverse cardiac events (MACE), defined as the composite of cardiogenic shock, cardiac arrest, hemodynamically significant complete heart block and cardiovascular death. Results The FV was administered to 25% of the myocarditis cases compared to 40% of the non-myocarditis ICI-treated controls (p = 0.01). Similar findings of lower rates of FV administration were noted among myocarditis cases when alternate thresholds were tested. Among the myocarditis cases, those who were vaccinated had 3-fold lower troponin levels when compared to unvaccinated cases (FV vs. No FV: 0.12 [0.02, 0.47] vs. 0.40 [0.11, 1.26] ng/ml, p = 0.02). Within myocarditis cases, those administered the FV also had a lower rate of other irAEs when compared to unvaccinated cases (36 vs. 55% p = 0.10) including lower rates of pneumonitis (12 vs. 36%, p = 0.03). During follow-up (175 [IQR 89, 363] days), 47% of myocarditis cases experienced a MACE. Myocarditis cases who received the FV were at a lower risk of cumulative MACE when compared to unvaccinated cases (24 vs. 59%, p = 0.002). Conclusion The rate of FV among ICI-related myocarditis cases was lower than controls on ICIs who did not develop myocarditis. In those who developed myocarditis related to an ICI, there was less myocardial injury and a lower risk of MACE among those who were administered the FV. Electronic supplementary material The online version of this article (10.1186/s40425-019-0535-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Magid Awadalla
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA.
| | - Doll Lauren Alexandra Golden
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Syed S Mahmood
- Cardiology Division, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
| | - Raza M Alvi
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Nathaniel D Mercaldo
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Malek Z O Hassan
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Dahlia Banerji
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Adam Rokicki
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Connor Mulligan
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Sean P T Murphy
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Maeve Jones-O'Connor
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Justine V Cohen
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lucie M Heinzerling
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nurnberg (FAU), Erlangen, Germany
| | - Merna Armanious
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida Division of Cardiovascular Medicine, Tampa, FL, USA
| | - Ryan J Sullivan
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Rongras Damrongwatanasuk
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida Division of Cardiovascular Medicine, Tampa, FL, USA
| | - Carol L Chen
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | - Dipti Gupta
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | - Michael C Kirchberger
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nurnberg (FAU), Erlangen, Germany
| | - Javid J Moslehi
- Cardio-Oncology Program, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sachin P Shah
- Cardiology Division, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Sarju Ganatra
- Cardiology Division, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad A Rizvi
- Division of Oncology and Hematology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA, USA
| | | | | | - Carlo G Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Franck Thuny
- Cardiovascular Division, Department of Medicine, Aix-Marseille Universite, Marseille, France
| | - Stephane Ederhy
- Cardio-Oncology Program, Division of Cardiology, Hopitaux Universitaires est Paris, Paris, France
| | - Michael Mahmoudi
- Division of Cardiology, Department of Medicine, Southampton General Hospital, Southampton, UK
| | - Donald P Lawrence
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - John D Groarke
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Anju Nohria
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael G Fradley
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida Division of Cardiovascular Medicine, Tampa, FL, USA
| | - Kerry L Reynolds
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Tomas G Neilan
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA.,Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
14
|
Mahmood SS, Fradley MG, Cohen JV, Nohria A, Reynolds KL, Heinzerling LM, Sullivan RJ, Damrongwatanasuk R, Chen CL, Gupta D, Kirchberger MC, Awadalla M, Hassan MZO, Moslehi JJ, Shah SP, Ganatra S, Thavendiranathan P, Lawrence DP, Groarke JD, Neilan TG. Myocarditis in Patients Treated With Immune Checkpoint Inhibitors. J Am Coll Cardiol 2018; 71:1755-1764. [PMID: 29567210 DOI: 10.1016/j.jacc.2018.02.037] [Citation(s) in RCA: 861] [Impact Index Per Article: 143.5] [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: 12/14/2017] [Revised: 02/08/2018] [Accepted: 02/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Myocarditis is an uncommon, but potentially fatal, toxicity of immune checkpoint inhibitors (ICI). Myocarditis after ICI has not been well characterized. OBJECTIVES The authors sought to understand the presentation and clinical course of ICI-associated myocarditis. METHODS After observation of sporadic ICI-associated myocarditis cases, the authors created a multicenter registry with 8 sites. From November 2013 to July 2017, there were 35 patients with ICI-associated myocarditis, who were compared to a random sample of 105 ICI-treated patients without myocarditis. Covariates of interest were extracted from medical records including the occurrence of major adverse cardiac events (MACE), defined as the composite of cardiovascular death, cardiogenic shock, cardiac arrest, and hemodynamically significant complete heart block. RESULTS The prevalence of myocarditis was 1.14% with a median time of onset of 34 days after starting ICI (interquartile range: 21 to 75 days). Cases were 65 ± 13 years of age, 29% were female, and 54% had no other immune-related side effects. Relative to controls, combination ICI (34% vs. 2%; p < 0.001) and diabetes (34% vs. 13%; p = 0.01) were more common in cases. Over 102 days (interquartile range: 62 to 214 days) of median follow-up, 16 (46%) developed MACE; 38% of MACE occurred with normal ejection fraction. There was a 4-fold increased risk of MACE with troponin T of ≥1.5 ng/ml (hazard ratio: 4.0; 95% confidence interval: 1.5 to 10.9; p = 0.003). Steroids were administered in 89%, and lower steroids doses were associated with higher residual troponin and higher MACE rates. CONCLUSIONS Myocarditis after ICI therapy may be more common than appreciated, occurs early after starting treatment, has a malignant course, and responds to higher steroid doses.
Collapse
Affiliation(s)
- Syed S Mahmood
- Cardiology Division, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York; Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael G Fradley
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida Division of Cardiovascular Medicine, Tampa, Florida
| | - Justine V Cohen
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Anju Nohria
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kerry L Reynolds
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lucie M Heinzerling
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nurnberg (FAU), Germany
| | - Ryan J Sullivan
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rongras Damrongwatanasuk
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida Division of Cardiovascular Medicine, Tampa, Florida
| | - Carol L Chen
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York
| | - Dipti Gupta
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York
| | - Michael C Kirchberger
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nurnberg (FAU), Germany
| | - Magid Awadalla
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Malek Z O Hassan
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Javid J Moslehi
- Cardio-Oncology Program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sachin P Shah
- Cardiology Division, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Sarju Ganatra
- Cardiology Division, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Donald P Lawrence
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - John D Groarke
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tomas G Neilan
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
| |
Collapse
|
15
|
Mahmood S, Fradley MG, Cohen JV, Nohria A, Reynolds KL, Heinzerling LM, Sullivan RJ, Damrongwatanasuk R, Chen C, Gupta D, Kirchberger MC, Moslehi J, Shah S, Ganatra S, Thavendiranathan P, Lawrence DP, Groarke JD, Neilan TG. MYOCARDITIS IN PATIENTS TREATED WITH IMMUNE CHECKPOINT INHIBITORS. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31240-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
16
|
Buschow SI, Ramazzotti M, Reinieren-Beeren IMJ, Heinzerling LM, Westdorp H, Stefanini I, Beltrame L, Hato SV, Ellebaek E, Gross S, Nguyen VA, Weinlich G, Ragoussis J, Baban D, Schuler-Thurner B, Svane IM, Romani N, Austyn JM, De Vries IJM, Schuler G, Cavalieri D, Figdor CG. Survival of metastatic melanoma patients after dendritic cell vaccination correlates with expression of leukocyte phosphatidylethanolamine-binding protein 1/Raf kinase inhibitory protein. Oncotarget 2017; 8:67439-67456. [PMID: 28978044 PMCID: PMC5620184 DOI: 10.18632/oncotarget.18698] [Citation(s) in RCA: 14] [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: 12/22/2016] [Accepted: 05/22/2017] [Indexed: 02/07/2023] Open
Abstract
Immunotherapy for metastatic melanoma offers great promise but, to date, only a subset of patients have responded. There is an urgent need to identify ways of allocating patients to the most beneficial therapy, to increase survival and decrease therapy-associated morbidity and costs. Blood-based biomarkers are of particular interest because of their straightforward implementation in routine clinical care. We sought to identify markers for dendritic cell (DC) vaccine-based immunotherapy against metastatic melanoma through gene expression analysis of peripheral blood mononuclear cells. A large-scale microarray analysis of 74 samples from two treatment centers, taken directly after the first round of DC vaccination, was performed. We found that phosphatidylethanolamine binding protein 1 (PEBP1)/Raf Kinase inhibitory protein (RKIP) expression can be used to identify a significant proportion of patients who performed poorly after DC vaccination. This result was validated by q-PCR analysis on blood samples from a second cohort of 95 patients treated with DC vaccination in four different centers. We conclude that low PEBP1 expression correlates with poor overall survival after DC vaccination. Intriguingly, this was only the case for expression of PEBP1 after, but not prior to, DC vaccination. Moreover, the change in PEBP1 expression upon vaccination correlated well with survival. Further analyses revealed that PEBP1 expression positively correlated with genes involved in T cell responses but inversely correlated with genes associated with myeloid cells and aberrant inflammation including STAT3, NOTCH1, and MAPK1. Concordantly, PEBP1 inversely correlated with the myeloid/lymphoid-ratio and was suppressed in patients suffering from chronic inflammatory disease.
Collapse
Affiliation(s)
- Sonja I Buschow
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Gastroenterology and Hepatology, Erasmus University Medical Center (Erasmus MC), Rotterdam, The Netherlands
| | - Matteo Ramazzotti
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Inge M J Reinieren-Beeren
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lucie M Heinzerling
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Harm Westdorp
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Irene Stefanini
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Luca Beltrame
- Department of Oncology, Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Stanleyson V Hato
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eva Ellebaek
- CCIT, Center for Cancer Immune Therapy, Department of Hematology and Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - Stefanie Gross
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Van Anh Nguyen
- Department of Dermatology, Venereology and Allergology, Medical University of Innsbruck, Innsbruck, Austria
| | - Georg Weinlich
- Department of Dermatology, Venereology and Allergology, Medical University of Innsbruck, Innsbruck, Austria
| | - Jiannis Ragoussis
- Genomics Group, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK.,Current address: McGill University and Genome Quebec Innovation Centre, McGill University, Quebec, Canada
| | - Dilair Baban
- Genomics Group, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Beatrice Schuler-Thurner
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Inge M Svane
- CCIT, Center for Cancer Immune Therapy, Department of Hematology and Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - Nikolaus Romani
- Department of Dermatology, Venereology and Allergology, Medical University of Innsbruck, Innsbruck, Austria
| | - Jonathan M Austyn
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - I Jolanda M De Vries
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gerold Schuler
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | | | - Carl G Figdor
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
17
|
Abstract
A range of AIDS prevention programmes suggested that cooperation between traditional healers and the biomedical primary health-care system would benefit patients. To assess the knowledge and attitudes of traditional healers in Cameroon towards Western medicine and evaluate their willingness to cooperate with the district health-care system, a qualitative study was undertaken. In this study, 16 randomly chosen traditional healers in Kumba, Cameroon, were interviewed. Western medicine was well accepted for certain indications and referral of patients to health-care centres was frequently practised. All healers stated that they wished to cooperate more extensively with the district primary health-care system and to obtain more biomedical knowledge. Closer cooperation between traditional healers and the district primary health-care system is possible. The frequent occurrence of illiteracy must be considered when designing health education for traditional healers.
Collapse
Affiliation(s)
- Lucie M Heinzerling
- Department of Dermatology and Allergy, Charité-Universitätsmedizin, Berlin, Germany.
| |
Collapse
|
18
|
Hofmann L, Forschner A, Loquai C, Goldinger SM, Zimmer L, Ugurel S, Schmidgen MI, Gutzmer R, Utikal JS, Göppner D, Hassel JC, Meier F, Tietze JK, Thomas I, Weishaupt C, Leverkus M, Wahl R, Dietrich U, Garbe C, Kirchberger MC, Eigentler T, Berking C, Gesierich A, Krackhardt AM, Schadendorf D, Schuler G, Dummer R, Heinzerling LM. Cutaneous, gastrointestinal, hepatic, endocrine, and renal side-effects of anti-PD-1 therapy. Eur J Cancer 2016; 60:190-209. [PMID: 27085692 DOI: 10.1016/j.ejca.2016.02.025] [Citation(s) in RCA: 446] [Impact Index Per Article: 55.8] [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: 02/22/2016] [Accepted: 02/25/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anti-programmed cell death receptor-1 (PD-1) antibodies represent an effective treatment option for metastatic melanoma as well as for other cancer entities. They act via blockade of the PD-1 receptor, an inhibitor of the T-cell effector mechanisms that limit immune responses against tumours. As reported for ipilimumab, the anti-PD-1 antibodies pembrolizumab and nivolumab can induce immune-related adverse events (irAEs). These side-effects affect skin, gastrointestinal tract, liver, endocrine system and other organ systems. Since life-threatening and fatal irAEs have been reported, adequate diagnosis and management are essential. METHODS AND FINDINGS In total, 496 patients with metastatic melanoma from 15 skin cancer centers were treated with pembrolizumab or nivolumab; 242 side-effects were described in 138 patients. In 116 of the 138 patients, side-effects affected the skin, gastrointestinal tract, liver, endocrine, and renal system. Rare side-effects included diabetes mellitus, lichen planus, and pancreas insufficiency due to pancreatitis. CONCLUSION Anti-PD1 antibodies can induce a plethora of irAEs. The knowledge of them will allow prompt diagnosis and improve the management resulting in decreased morbidity.
Collapse
Affiliation(s)
- Lars Hofmann
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Germany
| | - Andrea Forschner
- Department of Dermatology, University Hospital Tübingen, Germany
| | - Carmen Loquai
- Department of Dermatology, University Hospital Mainz, Germany
| | | | - Lisa Zimmer
- Department of Dermatology, University Hospital, University Duisburg-Essen, Germany
| | - Selma Ugurel
- Department of Dermatology, University Hospital, University Duisburg-Essen, Germany
| | | | - Ralf Gutzmer
- Department of Dermatology and Allergy, Skin Cancer Center Hannover, Hannover Medical School, Germany
| | - Jochen S Utikal
- Skin Cancer Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Dermatology, Venereology and Allergology, University Medical Center Mannheim, Ruprecht-Karl University of Heidelberg, Mannheim, Germany
| | - Daniela Göppner
- Department of Dermatology, University Hospital Magdeburg, Germany
| | - Jessica C Hassel
- Department of Dermatology, University Hospital Heidelberg, Germany
| | | | - Julia K Tietze
- Department of Dermatology and Allergology, Ludwig-Maximilian-University (LMU) Munich, Germany
| | - Ioannis Thomas
- Department of Dermatology, University Hospital Tübingen, Germany
| | - Carsten Weishaupt
- Department of Dermatology, University Hospital Münster, Münster, Germany
| | - Martin Leverkus
- Department of Dermatology, University Hospital RWTH Aachen, Germany
| | - Renate Wahl
- Department of Dermatology, University Hospital RWTH Aachen, Germany
| | - Ursula Dietrich
- Department of Dermatology, University Hospital Dresden, Germany
| | - Claus Garbe
- Department of Dermatology, University Hospital Tübingen, Germany
| | - Michael C Kirchberger
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Germany
| | - Thomas Eigentler
- Department of Dermatology, University Hospital Tübingen, Germany
| | - Carola Berking
- Department of Dermatology and Allergology, Ludwig-Maximilian-University (LMU) Munich, Germany
| | - Anja Gesierich
- Department of Dermatology, University Hospital Würzburg, Germany
| | - Angela M Krackhardt
- III. Medical Department, Technische Universität München (TUM), Munich, Germany
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital, University Duisburg-Essen, Germany
| | - Gerold Schuler
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Germany
| | - Reinhard Dummer
- Department of Dermatology, University Hospital Zurich, Switzerland
| | - Lucie M Heinzerling
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Germany.
| |
Collapse
|
19
|
Zimmer L, Goldinger SM, Hofmann L, Loquai C, Ugurel S, Thomas I, Schmidgen MI, Gutzmer R, Utikal JS, Göppner D, Hassel JC, Meier F, Tietze JK, Forschner A, Weishaupt C, Leverkus M, Wahl R, Dietrich U, Garbe C, Kirchberger MC, Eigentler T, Berking C, Gesierich A, Krackhardt AM, Schadendorf D, Schuler G, Dummer R, Heinzerling LM. Neurological, respiratory, musculoskeletal, cardiac and ocular side-effects of anti-PD-1 therapy. Eur J Cancer 2016; 60:210-25. [PMID: 27084345 DOI: 10.1016/j.ejca.2016.02.024] [Citation(s) in RCA: 408] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 02/25/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anti-programmed cell death 1 (PD-1) antibodies represent an effective treatment option for metastatic melanoma and other cancer entities. They act via blockade of the PD-1 receptor, an inhibitor of the T-cell effector mechanisms that limit immune responses against tumours. As reported for ipilimumab, the anti-PD-1 antibodies pembrolizumab and nivolumab can induce immune-related adverse events (irAEs). These side-effects can involve skin, gastrointestinal tract, liver, the endocrine system and other organ systems. Since life-threatening and fatal irAEs have been reported, adequate diagnosis and management are essential. METHODS AND FINDINGS In total, 496 patients with metastatic melanoma from 15 skin cancer centres were treated with pembrolizumab or nivolumab. Two hundred forty two side-effects in 138 patients have been analysed. In 77 of the 138 patients side-effects affected the nervous system, respiratory tract, musculoskeletal system, heart, blood and eyes. Not yet reported side-effects such as meningo-(radiculitis), polyradiculitis, cardiac arrhythmia, asystolia, and paresis have been observed. Rare and difficult to manage side-effects such as myasthenia gravis are described in detail. CONCLUSION Anti-PD-1 antibodies can induce a plethora of irAEs. The knowledge of them will allow prompt diagnosis and improve the management resulting in decreased morbidity.
Collapse
Affiliation(s)
- Lisa Zimmer
- Department of Dermatology, University Hospital, University Duisburg-Essen, Germany
| | | | - Lars Hofmann
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Germany
| | - Carmen Loquai
- Department of Dermatology, University Hospital Mainz, Germany
| | - Selma Ugurel
- Department of Dermatology, University Hospital, University Duisburg-Essen, Germany
| | - Ioannis Thomas
- Department of Dermatology, University Hospital Tübingen, Germany
| | | | - Ralf Gutzmer
- Department of Dermatology and Allergy, Skin Cancer Center Hannover, Hannover Medical School, Germany
| | - Jochen S Utikal
- Skin Cancer Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Dermatology, Venereology and Allergology, University Medical Center Mannheim, Ruprecht-Karl University of Heidelberg, Mannheim, Germany
| | - Daniela Göppner
- Department of Dermatology, University Hospital Magdeburg, Germany
| | - Jessica C Hassel
- Department of Dermatology, University Hospital Heidelberg, Germany
| | | | - Julia K Tietze
- Department of Dermatology and Allergology, University Hospital Munich (LMU), Germany
| | - Andrea Forschner
- Department of Dermatology, University Hospital Tübingen, Germany
| | | | - Martin Leverkus
- Department of Dermatology, University Hospital RWTH Aachen, Germany
| | - Renate Wahl
- Department of Dermatology, University Hospital RWTH Aachen, Germany
| | - Ursula Dietrich
- Department of Dermatology, University Hospital Dresden, Germany
| | - Claus Garbe
- Department of Dermatology, University Hospital Tübingen, Germany
| | - Michael C Kirchberger
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Germany
| | - Thomas Eigentler
- Department of Dermatology, University Hospital Tübingen, Germany
| | - Carola Berking
- Department of Dermatology and Allergology, University Hospital Munich (LMU), Germany
| | - Anja Gesierich
- Department of Dermatology, University Hospital Würzburg, Germany
| | - Angela M Krackhardt
- III. Medical Department, Technische Universität München (TUM) Munich, Germany
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital, University Duisburg-Essen, Germany
| | - Gerold Schuler
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Germany
| | - Reinhard Dummer
- Department of Dermatology, University Hospital Zurich, Switzerland
| | - Lucie M Heinzerling
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Germany.
| |
Collapse
|
20
|
Haahtela T, Burbach GJ, Bachert C, Bindslev-Jensen C, Bonini S, Bousquet J, Bousquet-Rouanet L, Bousquet PJ, Bresciani M, Bruno A, Canonica GW, Darsow U, Demoly P, Durham SR, Fokkens WJ, Giavi S, Gjomarkaj M, Gramiccioni C, Kowalski ML, Losonczy G, Orosz M, Papadopoulos NG, Stingl G, Todo-Bom A, von Mutius E, Köhli A, Wöhrl S, Järvenpää S, Kautiainen H, Petman L, Selroos O, Zuberbier T, Heinzerling LM. Clinical relevance is associated with allergen-specific wheal size in skin prick testing. Clin Exp Allergy 2014; 44:407-16. [PMID: 24283409 PMCID: PMC4215109 DOI: 10.1111/cea.12240] [Citation(s) in RCA: 53] [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: 05/21/2013] [Revised: 10/29/2013] [Accepted: 10/31/2013] [Indexed: 11/30/2022]
Abstract
Background Within a large prospective study, the Global Asthma and Allergy European Network (GA2LEN) has collected skin prick test (SPT) data throughout Europe to make recommendations for SPT in clinical settings. Objective To improve clinical interpretation of SPT results for inhalant allergens by providing quantitative decision points. Methods The GA2LEN SPT study with 3068 valid data sets was used to investigate the relationship between SPT results and patient-reported clinical relevance for each of the 18 inhalant allergens as well as SPT wheal size and physician-diagnosed allergy (rhinitis, asthma, atopic dermatitis, food allergy). The effects of age, gender, and geographical area on SPT results were assessed. For each allergen, the wheal size in mm with an 80% positive predictive value (PPV) for being clinically relevant was calculated. Results Depending on the allergen, from 40% (blatella) to 87–89% (grass, mites) of the positive SPT reactions (wheal size ≥ 3 mm) were associated with patient-reported clinical symptoms when exposed to the respective allergen. The risk of allergic symptoms increased significantly with larger wheal sizes for 17 of the 18 allergens tested. Children with positive SPT reactions had a smaller risk of sensitizations being clinically relevant compared with adults. The 80% PPV varied from 3 to 10 mm depending on the allergen. Conclusion These ‘reading keys’ for 18 inhalant allergens can help interpret SPT results with respect to their clinical significance. A SPT form with the standard allergens including mm decision points for each allergen is offered for clinical use.
Collapse
Affiliation(s)
- T Haahtela
- Skin and Allergy Hospital, Helsinki University Hospital, Helsinki, Finland
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Voskens CJ, Goldinger SM, Loquai C, Robert C, Kaehler KC, Berking C, Bergmann T, Bockmeyer CL, Eigentler T, Fluck M, Garbe C, Gutzmer R, Grabbe S, Hauschild A, Hein R, Hundorfean G, Justich A, Keller U, Klein C, Mateus C, Mohr P, Paetzold S, Satzger I, Schadendorf D, Schlaeppi M, Schuler G, Schuler-Thurner B, Trefzer U, Ulrich J, Vaubel J, von Moos R, Weder P, Wilhelm T, Göppner D, Dummer R, Heinzerling LM. The price of tumor control: an analysis of rare side effects of anti-CTLA-4 therapy in metastatic melanoma from the ipilimumab network. PLoS One 2013; 8:e53745. [PMID: 23341990 PMCID: PMC3544906 DOI: 10.1371/journal.pone.0053745] [Citation(s) in RCA: 358] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 12/03/2012] [Indexed: 01/17/2023] Open
Abstract
Background Ipilimumab, a cytotoxic T-lymphocyte antigen-4 (CTLA-4) blocking antibody, has been approved for the treatment of metastatic melanoma and induces adverse events (AE) in up to 64% of patients. Treatment algorithms for the management of common ipilimumab-induced AEs have lead to a reduction of morbidity, e.g. due to bowel perforations. However, the spectrum of less common AEs is expanding as ipilimumab is increasingly applied. Stringent recognition and management of AEs will reduce drug-induced morbidity and costs, and thus, positively impact the cost-benefit ratio of the drug. To facilitate timely identification and adequate management data on rare AEs were analyzed at 19 skin cancer centers. Methods and Findings Patient files (n = 752) were screened for rare ipilimumab-associated AEs. A total of 120 AEs, some of which were life-threatening or even fatal, were reported and summarized by organ system describing the most instructive cases in detail. Previously unreported AEs like drug rash with eosinophilia and systemic symptoms (DRESS), granulomatous inflammation of the central nervous system, and aseptic meningitis, were documented. Obstacles included patientś delay in reporting symptoms and the differentiation of steroid-induced from ipilimumab-induced AEs under steroid treatment. Importantly, response rate was high in this patient population with tumor regression in 30.9% and a tumor control rate of 61.8% in stage IV melanoma patients despite the fact that some patients received only two of four recommended ipilimumab infusions. This suggests that ipilimumab-induced antitumor responses can have an early onset and that severe autoimmune reactions may reflect overtreatment. Conclusion The wide spectrum of ipilimumab-induced AEs demands doctor and patient awareness to reduce morbidity and treatment costs and true ipilimumab success is dictated by both objective tumor responses and controlling severe side effects.
Collapse
Affiliation(s)
| | | | - Carmen Loquai
- Department of Dermatology, University Hospital Mainz, Mainz, Germany
| | - Caroline Robert
- Institute Gustave Roussy, Department of Dermatology, Villejuif, France
| | | | - Carola Berking
- Department of Dermatology and Allergology, University of Munich LMU, Munich, Germany
| | - Tanja Bergmann
- Department of Internal Medicine (Gastroenterology, Endocrinology, and Pneumology), University Hospital Erlangen, Erlangen, Germany
| | - Clemens L. Bockmeyer
- Department of Dermatology and Allergy/Department of Pathology, Skin Cancer Center Hannover/Hannover Medical School, Hannover, Germany
| | - Thomas Eigentler
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Michael Fluck
- Department of Dermatology, Hospital Hornheide, Münster, Germany
| | - Claus Garbe
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Ralf Gutzmer
- Department of Dermatology and Allergy/Department of Pathology, Skin Cancer Center Hannover/Hannover Medical School, Hannover, Germany
| | - Stephan Grabbe
- Department of Dermatology, University Hospital Mainz, Mainz, Germany
| | - Axel Hauschild
- Department of Dermatology, University Hospital Kiel, Kiel, Germany
| | - Rüdiger Hein
- Department of Dermatology/III. Medical Department, Technische Universität München, München, Germany
| | - Gheorghe Hundorfean
- Department of Internal Medicine (Gastroenterology, Endocrinology, and Pneumology), University Hospital Erlangen, Erlangen, Germany
| | - Armin Justich
- Department of Dermatology, University Hospital Graz, Graz, Austria
| | - Ullrich Keller
- Department of Dermatology/III. Medical Department, Technische Universität München, München, Germany
| | - Christina Klein
- Department of Dermatology, University Hospital Mainz, Mainz, Germany
| | - Christine Mateus
- Institute Gustave Roussy, Department of Dermatology, Villejuif, France
| | - Peter Mohr
- Department of Dermatology, Elbe Kliniken Buxtehude, Buxtehude, Germany
| | - Sylvie Paetzold
- Department of Dermatology, University Hospital Frankfurt, Frankfurt, Germany
| | - Imke Satzger
- Department of Dermatology and Allergy/Department of Pathology, Skin Cancer Center Hannover/Hannover Medical School, Hannover, Germany
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital Essen, Essen, Germany
| | - Marc Schlaeppi
- Department of Oncology/Hematology and Dermatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Gerold Schuler
- Department of Dermatology, University Hospital Erlangen, Erlangen, Germany
| | | | - Uwe Trefzer
- Department of Dermatology, University Hospital Charité Berlin, Berlin, Germany
| | - Jens Ulrich
- Department of Dermatology, Hospital Quedlinburg, Quedlinburg, Germany
| | - Julia Vaubel
- Department of Dermatology, University Hospital Essen, Essen, Germany
| | - Roger von Moos
- Department of Dermatology, Cantonal Hospital Graubünden, Chur, Switzerland
| | - Patrik Weder
- Department of Oncology/Hematology and Dermatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Tabea Wilhelm
- Department of Dermatology, University Hospital Charité Berlin, Berlin, Germany
| | - Daniela Göppner
- Department of Dermatology, University Hospital Magdeburg, Magdeburg, Germany
| | - Reinhard Dummer
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - Lucie M. Heinzerling
- Department of Dermatology, University Hospital Erlangen, Erlangen, Germany
- Department of Oncology/Hematology and Dermatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- * E-mail:
| |
Collapse
|
22
|
Abstract
BACKGROUND Rashes are a frequent conundrum in clinical practice as they may be reactive, drug induced or disease specific. Identification of the culprit drug is important as re-exposure may be harmful or even life-threatening and unnecessary avoidance of 'innocent' drugs leads to limitations of treatment options. OBJECTIVE To objectify the cause of suspected cutaneous drug reactions in a large patient population. METHOD Over 5years (2006-10), 612 patients with suspected cutaneous drug reactions were evaluated. Histology was assessed. About 200 patients were invited for complete work-up with skin tests (prick/intracutaneous testing and scratch/patch as indicated) and, if necessary, lymphocyte transformation tests (LTT). In special cases, drug provocation tests were conducted. RESULTS A total number of 141 cases with suspected drug reaction underwent full work-up (age 6-86years; 75% female, 25% male). In 107 cases (76%) a drug was identified whereas 34 (24%) were reactive rashes or had other causes. Mostly, cutaneous drug reactions were maculopapular rashes, urticaria/angio-oedema; less frequently, acute generalized exanthematous pustulosis, drug reaction with eosinophilia and systemic symptoms, systemic drug-related intertriginous and flexural exanthema, toxic epidermal necrolysis and fixed drug eruptions were present. Of all the cutaneous drug reactions investigated, 39·8% were caused by antibiotics, 21·2% by anti-inflammatories, 7·6% by contrast media and 31·4% by others (oral antidiabetics, antimycotics, antipsychotics, antiepileptics and others). CONCLUSION Clinical assessment overestimates the role of drug allergies in cutaneous reactions. Assessment of suspected drug reactions can be greatly improved by thorough evaluation including dermatological and allergological work-up with skin testing and assays such as LTT.
Collapse
Affiliation(s)
- L M Heinzerling
- Department of Dermatology and Allergies, Cantonal Hospital, St Gallen, Switzerland Department of Dermatology, University Hospital Erlangen, 91054 Erlangen, Germany.
| | | | | |
Collapse
|
23
|
|
24
|
Bousquet PJ, Burbach G, Heinzerling LM, Edenharter G, Bachert C, Bindslev-Jensen C, Bonini S, Bousquet-Rouanet L, Demoly P, Bresciani M, Bruno A, Gjomarkaj M, Canonica GW, Darsow U, Durham S, Fokkens WJ, Giavi S, Gramiccioni C, Papadopoulos NG, Haahtela T, Kowalski ML, Magyar P, Muraközi G, Orosz M, Röhnelt C, Stingl G, Todo-Bom A, von Mutius E, Wiesner A, Wöhrl S, Bousquet J, Zuberbier T. GA2LEN skin test study III: minimum battery of test inhalent allergens needed in epidemiological studies in patients. Allergy 2009; 64:1656-62. [PMID: 19824887 DOI: 10.1111/j.1398-9995.2009.02169.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The number of allergens to be tested in order to identify sensitized patients is important in order to have the most cost-effective approach in epidemiological studies. OBJECTIVE To define the minimal number and the type of skin prick test (SPT) allergens required to identify a patient as sensitized using results of the new Pan-European GA(2)LEN skin prick test study. METHOD In a large Pan-European multicenter (17 centers in 14 countries) patient based study, a standardized panel of 18 allergens has been prick tested using a standardized procedure. Conditional approach allowed to determine the allergens selection. RESULT Among the 3034 patients involved, 1996 (68.2%) were sensitized to at least one allergen. Overall, eight allergens (grass pollen, Dermatophagoides pteronyssinus, birch pollen, cat dander, Artemisia, olive pollen, Blatella and Alternaria) allowed to identified more than 95% of sensitized subjects. However, differences were observed between countries, two allergens being sufficient for Switzerland (grass pollen and cat dander) as opposed to nine for France (grass pollen, Dermatophagoides pteronyssinus, olive pollen, cat dander, Blatella, cypress, dog dander, alder and [Artemisia or Alternaria]). According to country, up to 13 allergens were needed to identify all sensitized subjects. CONCLUSION Eight to ten allergens allowed the identification of the majority of sensitized subjects. For clinical care of individual patients, the whole battery of 18 allergens is needed to appropriately assess sensitization across Europe.
Collapse
Affiliation(s)
- P-J Bousquet
- Département de Biostatistique, Epidémiologie Clinique, Santé Publique et Information Médicale, Groupe Hospitalo-Universtaire Carémeau, Nîmes, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Burbach GJ, Heinzerling LM, Röhnelt C, Bergmann KC, Behrendt H, Zuberbier T. Ragweed sensitization in Europe - GA(2)LEN study suggests increasing prevalence. Allergy 2009; 64:664-5. [PMID: 19210367 DOI: 10.1111/j.1398-9995.2009.01975.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Ambrosia has now reached threshold for high prevalence allergen in Europe.
Collapse
|
26
|
Heinzerling LM, Kempf W, Kamarashev J, Hafner J, Nestle FO. Treatment of verrucous carcinoma with imiquimod and CO2 laser ablation. Dermatology 2003; 207:119-22. [PMID: 12835572 DOI: 10.1159/000070963] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2002] [Accepted: 12/31/2002] [Indexed: 11/19/2022] Open
Abstract
An 82-year-old female patient presented with a large perianal hyperkeratotic tumor extending into the anal canal. Staging did not reveal any metastatic spread. Diagnosis of verrucous carcinoma or Buschke-Löwenstein tumor, respectively, was based on typical clinical and histologic features. Moreover, human papillomavirus 6b DNA sequences could be detected by PCR. Surgical excision could not be performed due to the general health status of the patient; thus, alternative therapy methods were necessary. Treatment with imiquimod cream 5% (Aldara), a topical immune response modifier applied once a day and left for 12 h, led to significant partial tumor regression and clear demarcation of the tumor. The remaining tumor, now feasible for treatment with CO2 laser, was removed in two sessions in local anesthesia. In a third session, tumor parts in the anal canal were vaporized. This case demonstrates that the combination of imiquimod and CO2 laser ablation is an effective treatment option for verrucous carcinoma.
Collapse
|
27
|
Abstract
BACKGROUND The melanoma incidence has increased over recent decades. Educational campaigns aim to encourage protection from the sun and early detection of melanoma. METHODS During a campaign in Switzerland, information on risk factors, sun protection and melanoma prevention was distributed. 10987 people completed a questionnaire regarding risk factors, and 2746 people were examined by a dermatologist. RESULTS Men had a higher risk as assessed by skin type, ultraviolet exposure, family history, number of moles and sunburns during childhood. Changes in moles were reported significantly more often by people with: (1). a positive family history (p < 0.0001); (2). multiple moles (p < 0.0001), and (3). sunburns during childhood (p < 0.0001). A precancerous or cancerous condition was suspected in 16% of individuals examined. CONCLUSION Early detection of melanoma can be achieved by this type of campaign. Primary prevention is a long-term approach and educational efforts targeting risk groups must be continued.
Collapse
Affiliation(s)
- L M Heinzerling
- Department of Dermatology, University Hospital of Zürich, Switzerland
| | | | | | | | | | | |
Collapse
|
28
|
Heinzerling LM, Feige K, Rieder S, Akens MK, Dummer R, Stranzinger G, Moelling K. Tumor regression induced by intratumoral injection of DNA coding for human interleukin 12 into melanoma metastases in gray horses. J Mol Med (Berl) 2002; 78:692-702. [PMID: 11434722 DOI: 10.1007/s001090000165] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Preclinical studies investigating new therapeutic principles against melanoma are presently being carried out in mouse models; however, these are not optimal. Here we describe a novel animal model using gray horses. These animals spontaneously develop metastatic melanoma that resembles human disease and is thus highly relevant for preclinical studies testing new immunotherapy protocols. We found that injection of plasmid DNA coding for the human cytokine interleukin 12 into established metastases induced significant regression in all 12 treated lesions in a total of 7 horses. Complete disappearance was observed in one treated lesion, with no recurrence after 6 months. No adverse events have been observed in any of the animals during and after treatment. These results demonstrate the effectiveness and safety of interleukin 12 encoding plasmid DNA therapy against established metastatic disease in a large animal model and serve as a basis for a clinical trial.
Collapse
Affiliation(s)
- L M Heinzerling
- Institute of Medical Virology, University of Zurich, Switzerland
| | | | | | | | | | | | | |
Collapse
|
29
|
Heinzerling LM, Urbanek M, Funk JO, Peker S, Bleck O, Neuber K, Burg G, von den Driesch P, Dummer R. Reduction of tumor burden and stabilization of disease by systemic therapy with anti-CD20 antibody (rituximab) in patients with primary cutaneous B-cell lymphoma. Cancer 2000. [DOI: 10.1002/1097-0142(20001015)89:8<1835::aid-cncr26>3.0.co;2-h] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
30
|
Heinzerling LM, Urbanek M, Funk JO, Peker S, Bleck O, Neuber K, Burg G, von Den Driesch P, Dummer R. Reduction of tumor burden and stabilization of disease by systemic therapy with anti-CD20 antibody (rituximab) in patients with primary cutaneous B-cell lymphoma. Cancer 2000; 89:1835-44. [PMID: 11042581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
BACKGROUND Primary cutaneous B-cell lymphoma (CBCL) is characterized by restriction to the skin, a high incidence of recurrence after various treatment modalities, and a variable but mostly favorable prognosis. METHODS Ten patients with long standing primary CBCL (3 with follicular CBCL, 5 with cutaneous, large B-cell lymphoma, 1 with diffuse large cell lymphoma, and 1 with extranodal large cell lymphoma) were treated by intravenous application of a chimeric antibody against the CD20 transmembrane antigen that is present on malignant and normal B-cells. In 6 of 10 patients, several treatment attempts either had failed or could not be used due to severe side effects or underlying disease. RESULTS The treatment regimen resulted in two complete regressions, five partial responses, and one mixed response, and two patients did not respond to the treatment. No severe side effects occurred, except for slight pain in the nodules after infusion and an urticarial reaction at the tumor sites. A prolonged, complete disappearance of B-cells from the peripheral blood was observed. The immunoglobulin serum levels and inflammatory markers were unchanged. Histologic examination of biopsies from two regressing tumor nodes showed necrotic tumor cells and infiltration with CD8 positive cells. CONCLUSIONS Intravenous therapy with the anti-CD20 antibody rituximab is a nontoxic and effective treatment for patients with primary cutaneous B-cell lymphoma.
Collapse
MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/therapeutic use
- Female
- Humans
- Infusions, Intravenous
- Lymphoma, B-Cell/drug therapy
- Lymphoma, B-Cell/pathology
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/pathology
- Male
- Middle Aged
- Rituximab
- Skin Neoplasms/drug therapy
- Skin Neoplasms/pathology
- Treatment Outcome
Collapse
Affiliation(s)
- L M Heinzerling
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | | | | | | | | | | | | | | | | |
Collapse
|