Managing Pulmonary Toxicities Associated with Immunotherapy: A Case Discussion.

Immunotherapy has changed the field of oncology around the world with the approval of immune checkpoint inhibitors for a number of tumor types over the last 5 years. However, immune-mediated adverse events can be challenging and difficult to treat, with one of the most dire consequences being immune-mediated pneumonitis. KEY POINTS: Rapid intervention and aggressive management for grade 3 or greater pneumonitisSlow taper of steroids and also recommend pneumocystis carinii pneumonia prophylaxisMonitor carefully for a pneumonitis flare with steroid taper, which can occur in the absence of resuming anti-programmed cell death protein 1 (PD-1) [1], and do not resume anti-PD-1 therapy until completely off steroids and no clinical or radiologic evidence of recurrenceConsider observation without anti-PD-1 resumption-in this case, durable response was maintained even without resuming anti-PD-1 therapy.

Cellular localization of ß-carotene 15,15' oxygenase-1 (BCO1) and ß-carotene 9',10' oxygenase-2 (BCO2) in rat liver and intestine.

The intestine and liver are crucial organs for vitamin A uptake and storage. Liver accounts for 70% of total body retinoid stores. Vitamin A deficiency (VAD) is a major micronutrient deficiency around the world. The provitamin A carotenoid, ß-carotene, is a significant source of vitamin A in the diet. ß-Carotene 15,15' oxygenase-1 (BCO1) and ß-carotene 9',10' oxygenase-2 (BCO2) are the two known carotenoid cleavage enzymes in humans. BCO1 and BCO2 are highly expressed in liver and intestine. Hepatocytes and hepatic stellate cells are two main cell types involved in the hepatic metabolism of retinoids. Stellate-like cells in the intestine also show ability to store vitamin A. Liver is also known to accumulate carotenoids, however, their uptake, retention and metabolism in specific liver and intestinal cell types is still unknown. Hence, we studied the cellular and subcellular expression and localization of BCO1 and BCO2 proteins in rat liver and intestine. We demonstrate that both BCO1 and BCO2 proteins are localized in hepatocytes and mucosal epithelium. We also show that BCO1 is also highly expressed in hepatic stellate cells (HSC) and portal endothelial cells in liver. At the subcellular level in liver, BCO1 is found in cytosol, while BCO2 is found in mitochondria. In intestine, immunohistochemistry showed strong BCO1 immunoreactivity in the duodenum, particularly in Brunner's glands. Both BCO1 and BCO2 showed diffuse presence along epithelia with strong immunoreactivity in endothelial cells and in certain epithelial cells which warrant further investigation as possible intestinal retinoid storage cells.

Treatment Outcomes of Immune-Related Cutaneous Adverse Events.

PURPOSE: The aim of the current study was to report the efficacy of topical and systemic treatments for immune-related cutaneous adverse events (ircAEs) attributed to checkpoint inhibitors in an uncontrolled cohort of patients referred to oncodermatology clinics. METHODS: A retrospective analysis of patients with ircAEs evaluated by dermatologists from January 1, 2014, to December 31, 2017, at three tertiary care hospitals and cancer centers were identified through electronic medical records. Clinicopathologic characteristics, dermatologic therapy outcome, and laboratory data were analyzed. RESULTS: A total of 285 patients (median age, 65 years [range, 17 to 89 years]) with 427 ircAEs were included: pruritus (n = 138; 32%), maculopapular rash (n = 120; 28%), psoriasiform rash (n = 22; 5%), and others (n = 147; 34%). Immune checkpoint inhibitor class was associated with ircAE phenotype (P = .007), where maculopapular rash was predominant in patients who received combination therapy. Severity of ircAEs was significantly reduced (mean Common Terminology Criteria for Adverse Events grade: 1.74 v 0.71; P < .001) with dermatologic interventions, including topical corticosteroids, oral antipruritics, and systemic immunomodulators. A total of 88 ircAEs (20%) were managed with systemic immunomodulators. Of these, 22 (25%) of 88 persisted or worsened. In seven patients with corticosteroid-refractory ircAEs, improvement resulted from targeted biologic immunomodulatory therapies that included rituximab and dupilumab. Serum interleukin-6 (IL-6) was elevated in 34 (52%) of 65 patients; grade 3 or greater ircAEs were associated with increased absolute eosinophils (odds ratio, 4.1; 95% CI, 1.3 to 13.4) and IL-10 (odds ratio, 23.8; 95% CI, 2.1 to 262.5); mean immunoglobulin E serum levels were greater in higher-grade ircAEs: 1,093 kU/L (grade 3), 245 kU/L (grade 2), and 112 kU/L (grade 1; P = .043). CONCLUSION: Most ircAEs responded to symptom- and phenotype-directed dermatologic therapies, whereas biologic therapies were effective in patients with corticosteroid-refractory disease. Increased eosinophils, IL-6, IL-10, and immunoglobulin E were associated with ircAEs, and they may represent actionable therapeutic targets for immune-related skin toxicities.

Understanding and Managing Immune-Related Adverse Events Associated With Immune Checkpoint Inhibitors in Patients With Advanced Melanoma.

The immune checkpoint inhibitors ipilimumab, nivolumab, and pembrolizumab represent a substantial improvement in treating advanced melanoma but are associated with adverse events (AEs) likely related to general immunologic enhancement. To ensure that patients receive optimal benefit from these agents, prompt assessment and treatment of AEs are essential. We review the efficacy and safety profiles of these immune checkpoint inhibitors and describe guidelines for managing immune-related AEs. We also present case studies describing the management of toxicities in patients receiving immune checkpoint inhibitor therapy. These cases illustrate the importance of collecting a detailed medical history when administering immunotherapy, as this information is necessary to establish baseline, inform monitoring, and determine the etiology of symptoms. Advanced practice nurses and physician assistants are uniquely positioned to educate patients on the early recognition of AEs and have an important role in establishing appropriate monitoring and open dialogue among services.

Targeting immune checkpoints in melanoma: an update.

Different treatment modalities encompassed under the term 'immunotherapy' have led to major breakthroughs in the treatment of melanoma. Immune checkpoint-blocking antibodies targeting CTLA-4 and PD-1 result in significant activity and prolonged survival in patients with advanced melanoma and are currently available for clinical use. Studies addressing novel immune checkpoint blocking antibodies, combined approaches and predictive/prognostic biomarkers are expected to broaden the applicability and efficacy of this approach. In this article, we will review clinically meaningful aspects of immune checkpoint blockade, promising strategies under development and the challenges faced in a continuous search to improve the outcomes of patients affected by this disease.

{beta}-Apocarotenoids do not significantly activate retinoic acid receptors {alpha} or {beta}.

beta-Carotene oxygenase 2 cleaves beta-carotene asymmetrically at non-central double bonds of the polyene chain, yielding apocarotenal molecules. The hypothesis tested was that apocarotenoids are able to stimulate transcription by activating retinoic acid receptors (RARs). The effects of long- and short-chain apocarotenals and apocarotenoic acids on the activation of RARalpha and RARbeta transfected into monkey kidney fibroblast cells (CV-1) were investigated. We synthesized or purified beta-apo-8'-carotenoic acid (apo-8'-CA), beta-apo-14'-carotenoic acid (apo-14'-CA), beta-cyclocitral (BCL), beta-cyclogernanic acid (BCA), beta-ionone (BI), beta-ionylideneacetaldehyde (BIA) beta-ionylideneacetic acid (BIAA) and a C13 ketone, beta-apo-13-carotenone (C13). None of the apocarotenoids tested showed significant transactivation activity for the RARs when compared with all-trans retinoic acid (RA). The results suggest that biological effects of these apocarotenoids are through mechanisms other than activation of RARalpha and beta.