Clinical aspects
Sicca/Sjögren's syndrome triggered by PD-1/PD-L1 checkpoint inhibitors. Data from the International ImmunoCancer Registry (ICIR)
M. Ramos-Casals1, A. Maria2, M.E. Suárez-Almazor3, O. Lambotte4, B.A. Fisher5, G. Hernández-Molina6, P. Guilpain7, X. Pundole8, A. Flores-Chávez9, C. Baldini10, C.O. Bingham Iii11, P. Brito-Zerón12, J.-E. Gottenberg13, M. Kostine14, T.R. Radstake15, T. Schaeverbeke16, H. Schulze-Koops17, L. Calabrese18, M.A. Khamashta19, X. Mariette20
- Department of Autoimmune Diseases, ICMiD, Barcelona; Sjögren Syndrome Research Group (AGAUR), Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Barcelona; and Department of Medicine, University of Barcelona, Hospital Clínic, Barcelona, Spain.
- Department of Internal Medicine Multi-Organic Diseases, Local Referral Center for Autoimmune Diseases, Saint Eloi Hospital, Montpellier University Hospital, France.
- Section of Rheumatology and Clinical Immunology, Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- APHP Médecine Interne/Immunologie Clinique, Hôpital Bicêtre, Paris, and Université Paris Sud - INSERM U1184 - CEA, Immunology of Viral Infections and Autoimmune Diseases, IDMIT Department, IBFJ, Fontenay-aux-Roses & Le Kremlin- Bicêtre, France.
- Institute of Inflammation and Ageing, University of Birmingham; and National Institute of Health Research Birmingham Biomedical Research Centre and Department of Rheumatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
- Immunology and Rheumatology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Subirán, México City, Mexico.
- Department of Internal Medicine Multi-Organic Diseases, Local Referral Center for Autoimmune Diseases, Saint Eloi Hospital, Montpellier University Hospital, France.
- Section of Rheumatology and Clinical Immunology, Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Department of Autoimmune Diseases, ICMiD, Barcelona, Spain.
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Italy.
- Department of Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Autoimmune Diseases, ICMiD, Barcelona, and Department of Internal Medicine, Hospital CIMA-Sanitas, Barcelona, Spain.
- Dept. of Rheumatology, Strasbourg University Hospital, National Centre For Rare Systemic Autoimmune Diseases, CNRS, Institut de Biologie Moléculaire et Cellulaire, Immunologie, Immunopathologie et Chimie Thérapeutique, University of Strasbourg, France.
- Department of Rheumatology, Centre Hospitalier Universitaire, Bordeaux, France.
- Department of Rheumatology/Clinical Immunology, University Medical Center Utrecht, The Netherlands.
- Department of Rheumatology, Centre Hospitalier Universitaire, Bordeaux, France.
- Department of Rheumatology/Clinical Immunology, Ludwig-Maximilians-University Munich, Germany.
- Department of Rheumatic/Immunologic Diseases, Cleveland Clinic University, Cleveland, OH, USA.
- Lupus Clinic, Rheumatology Department, Dubai Hospital, UAE.
- Center for Immunology of Viral Infections and Autoimmune Diseases, Assistance Publique – Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, Université Paris Sud, INSERM, Paris, France.
on behalf of the ICIR
CER12399
2019 Vol.37, N°3 ,Suppl.118
PI 0114, PF 0122
Clinical aspects
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PMID: 31464670 [PubMed]
Received: 06/05/2019
Accepted : 02/07/2019
In Press: 28/08/2019
Published: 28/08/2019
Abstract
OBJECTIVES:
To analyse the worldwide occurrence of sicca/Sjögren’s (SS) syndrome associated with the use of immune checkpoint inhibitors (ICI) in patients with cancer.
METHODS:
The ImmunoCancer International Registry (ICIR) is a Big Data-Sharing multidisciplinary network composed by 40 specialists in Rheumatology, Internal Medicine, Immunology and Oncology from 18 countries focused on the clinical and basic research of the immune-related adverse events (irAEs) related to cancer immunotherapies. For this study, patients who were investigated for a clinical suspicion of SS after being exposed to ICI were included.
RESULTS:
We identified 26 patients (11 women and 15 men, with a mean age at diagnosis of 63.57 years). Underlying cancer included lung (n=12), renal (n=7), melanoma (n=4), and other (n=3) neoplasia. Cancer immunotherapies consisted of monotherapy (77%) and combined regimens (23%). In those patients receiving monotherapy, all patients were treated with PD-1/PD-L1 inhibitors (nivolumab in 9, pembrolizumab in 7 and durvalumab in 4); no cases associated with CTLA-4 inhibitors were identified. The main SS-related features consisted of dry mouth in 25 (96%) patients, dry eye in 17 (65%), abnormal ocular tests in 10/16 (62%) and abnormal oral diagnostic tests in 12/14 (86%) patients. Minor salivary gland biopsy was carried out in 15 patients: histopathological findings consisted of mild chronic sialadenitis in 8 (53%) patients and focal lymphocytic sialadenitis in the remaining 7 (47%); a focus score was measured in 5 of the 6 patients (mean of 1.8, range 1–4). Immunological markers included positive ANA in 13/25 (52%), anti-Ro/ SS-A in 5/25 (20%), RF in 2/22 (9%), anti-La/SS-B in 2/25 (8%), low C3/C4 levels in 1/17 (6%) and positive cryoglobulins in 1/10 (10%). Classification criteria for SS were fulfilled by 10 (62%) out of 16 patients in whom the two key classificatory features were carried out. Among the 26 patients, there were only 3 (11%) who presented exclusively with sicca syndrome without organ-specific autoimmune manifestations. Therapeutic management included measures directed to treat sicca symptoms and therapies against autoimmune-mediated manifestations (glucocorticoids in 42%, second/third-line therapies in 31%); therapeutic response for systemic features was observed in 8/11 (73%). No patient died due to autoimmune involvement.
CONCLUSIONS:
Patients with Sjögren’s syndrome triggered by ICI display a very specific profile different from that reported in idiopathic primary SS, including more frequent occurrence in men, a higher mean age, a predominant immunonegative serological profile, and a notable development of organ-specific autoimmune involvement in spite of the poor immunological profile. The close association found between sicca/Sjögren’s syndrome and primarily PD-1 blockade requires further specific investigation.