Nivolumab-induced synovitis is characterized by florid T cell infiltration and rapid resolution with synovial biopsy-guided therapy
Background Immune checkpoint inhibitors (ICIs) are associated with rheumatic and musculoskeletal immune-related adverse events (irAEs) in 5%–20% of patients. Currently, patients refractory to corticosteroids and conventional disease-modifying antirheumatic drugs (cDMARD) are treated with biological...
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BMJ Publishing Group
2020-05-01
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| Series: | Journal for ImmunoTherapy of Cancer |
| Online Access: | https://jitc.bmj.com/content/8/1/e000281.full |
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| author | Susanna Proudman Sonja Klebe William Murray-Brown Tom D Wilsdon Helen Weedon Shawgi Sukumaran Jennifer G Walker Malcolm D Smith Mihir D Wechalekar |
| author_facet | Susanna Proudman Sonja Klebe William Murray-Brown Tom D Wilsdon Helen Weedon Shawgi Sukumaran Jennifer G Walker Malcolm D Smith Mihir D Wechalekar |
| author_sort | Susanna Proudman |
| collection | DOAJ |
| description | Background Immune checkpoint inhibitors (ICIs) are associated with rheumatic and musculoskeletal immune-related adverse events (irAEs) in 5%–20% of patients. Currently, patients refractory to corticosteroids and conventional disease-modifying antirheumatic drugs (cDMARD) are treated with biological DMARDs (bDMARDs) targeting tumor necrosis factor α (TNFα) and interleukin-6, although without a clear biological rationale. Synovial tissue (ST) biopsy presents a valuable opportunity to investigate irAE pathogenesis and appropriately stratify bDMARD use in refractory irAE patients.Case presentation We provide the first report of comparative, parallel ST and synovial fluid (SF) analyses of severe, cDMARD-refractory, seronegative polyarthritis, classified as a grade 3 irAE occurring in response to nivolumab treatment for metastatic squamous cell lung cancer, in comparison with ST and SF from patients with untreated rheumatoid arthritis (RA). We investigated immunohistochemical labeling of ST cytokine expression as a biological rationale for selecting therapy. Flow cytometric analysis of lymphocytes from ST, SF and blood collected before and after synovial biopsy-guided therapy, in comparison with RA, were evaluated for insights into the immunopathogenesis of irAE. Immunolabeling of ST demonstrated an excess of TNFα cytokine expression. Subsequent treatment with infliximab resulted in resolution of inflammatory symptoms and a significant reduction in C reactive protein levels. Flow cytometric analysis of synovial infiltrates indicated absence of programmed cell death protein-1 (PD-1) receptor positivity despite cessation of nivolumab approximately 200 days prior to the analyzes.Conclusions A deeper understanding of the immunopathogenetic basis of immune activation in irAEs is required in order to select therapy that is likely to be the most effective. This is the first report investigating parallel blood, ST and SF in ICI-induced severe rheumatic irAE. Use of a bDMARD directed by the dominant inflammatory cytokine achieved resolution of synovitis while maintaining cancer remission. |
| format | Article |
| id | doaj-art-3ff420a1c1334dfdbe3137f84bc8f0e1 |
| institution | Kabale University |
| issn | 2051-1426 |
| language | English |
| publishDate | 2020-05-01 |
| publisher | BMJ Publishing Group |
| record_format | Article |
| series | Journal for ImmunoTherapy of Cancer |
| spelling | doaj-art-3ff420a1c1334dfdbe3137f84bc8f0e12024-11-09T01:50:08ZengBMJ Publishing GroupJournal for ImmunoTherapy of Cancer2051-14262020-05-018110.1136/jitc-2019-000281Nivolumab-induced synovitis is characterized by florid T cell infiltration and rapid resolution with synovial biopsy-guided therapySusanna Proudman0Sonja Klebe1William Murray-Brown2Tom D Wilsdon3Helen Weedon4Shawgi Sukumaran5Jennifer G Walker6Malcolm D Smith7Mihir D Wechalekar82Royal Adelaide Hospital, Rheumatology Unit, Adelaide, Australia6 Department of Anatomical Pathology, Flinders Medical Centre, Bedford Park, South Australia, Australia1 College of Medicine & Public Health, Flinders University, Adelaide, South Australia, Australia2 Rheumatology Department, Flinders Medical Centre, Adelaide, South Australia, Australia1 College of Medicine & Public Health, Flinders University, Adelaide, South Australia, Australia4 Oncology Department, Flinders Medical Centre, Adelaide, South Australia, Australia1 College of Medicine & Public Health, Flinders University, Adelaide, South Australia, Australia1 College of Medicine & Public Health, Flinders University, Adelaide, South Australia, Australia1 College of Medicine & Public Health, Flinders University, Adelaide, South Australia, AustraliaBackground Immune checkpoint inhibitors (ICIs) are associated with rheumatic and musculoskeletal immune-related adverse events (irAEs) in 5%–20% of patients. Currently, patients refractory to corticosteroids and conventional disease-modifying antirheumatic drugs (cDMARD) are treated with biological DMARDs (bDMARDs) targeting tumor necrosis factor α (TNFα) and interleukin-6, although without a clear biological rationale. Synovial tissue (ST) biopsy presents a valuable opportunity to investigate irAE pathogenesis and appropriately stratify bDMARD use in refractory irAE patients.Case presentation We provide the first report of comparative, parallel ST and synovial fluid (SF) analyses of severe, cDMARD-refractory, seronegative polyarthritis, classified as a grade 3 irAE occurring in response to nivolumab treatment for metastatic squamous cell lung cancer, in comparison with ST and SF from patients with untreated rheumatoid arthritis (RA). We investigated immunohistochemical labeling of ST cytokine expression as a biological rationale for selecting therapy. Flow cytometric analysis of lymphocytes from ST, SF and blood collected before and after synovial biopsy-guided therapy, in comparison with RA, were evaluated for insights into the immunopathogenesis of irAE. Immunolabeling of ST demonstrated an excess of TNFα cytokine expression. Subsequent treatment with infliximab resulted in resolution of inflammatory symptoms and a significant reduction in C reactive protein levels. Flow cytometric analysis of synovial infiltrates indicated absence of programmed cell death protein-1 (PD-1) receptor positivity despite cessation of nivolumab approximately 200 days prior to the analyzes.Conclusions A deeper understanding of the immunopathogenetic basis of immune activation in irAEs is required in order to select therapy that is likely to be the most effective. This is the first report investigating parallel blood, ST and SF in ICI-induced severe rheumatic irAE. Use of a bDMARD directed by the dominant inflammatory cytokine achieved resolution of synovitis while maintaining cancer remission.https://jitc.bmj.com/content/8/1/e000281.full |
| spellingShingle | Susanna Proudman Sonja Klebe William Murray-Brown Tom D Wilsdon Helen Weedon Shawgi Sukumaran Jennifer G Walker Malcolm D Smith Mihir D Wechalekar Nivolumab-induced synovitis is characterized by florid T cell infiltration and rapid resolution with synovial biopsy-guided therapy Journal for ImmunoTherapy of Cancer |
| title | Nivolumab-induced synovitis is characterized by florid T cell infiltration and rapid resolution with synovial biopsy-guided therapy |
| title_full | Nivolumab-induced synovitis is characterized by florid T cell infiltration and rapid resolution with synovial biopsy-guided therapy |
| title_fullStr | Nivolumab-induced synovitis is characterized by florid T cell infiltration and rapid resolution with synovial biopsy-guided therapy |
| title_full_unstemmed | Nivolumab-induced synovitis is characterized by florid T cell infiltration and rapid resolution with synovial biopsy-guided therapy |
| title_short | Nivolumab-induced synovitis is characterized by florid T cell infiltration and rapid resolution with synovial biopsy-guided therapy |
| title_sort | nivolumab induced synovitis is characterized by florid t cell infiltration and rapid resolution with synovial biopsy guided therapy |
| url | https://jitc.bmj.com/content/8/1/e000281.full |
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