Neuromuscular Weakness Syndromes from Immune Checkpoint Inhibitors: A Case Series and Literature Review

Immune checkpoint inhibitors (CPIs) (anti-cytotoxic T-lymphocyte antigen-4, anti-programmed death 1, and anti-programmed death-ligand 1) have transformed the landscape of cancer therapy. However, their increasing use has unleashed immune-related adverse events in various organs, among which neurologic ones, while rare, are increasingly being recognized and remain incompletely characterized. Herein, we report five patients with nonmelanoma cancers who developed weakness after receiving CPIs. The etiology was attributed to radiculoneuritis (one patient), myositis (one patient), Miller Fisher/myasthenia gravis (MG) (one patient), neuropathy/myositis/MG (one patient), and myositis/MG (one patient). Weakness developed after a median of two doses (range: 1–3) and 4 weeks (range: 3–10) from initiation of therapy. Two patients had severe manifestations without improvement while the other three experienced partial improvement despite discontinuation of the CPI (s) and initiation of immunosuppressive therapy. A review of literature identified 62 similar cases. This report highlights the challenges in the diagnosis and management of neurologic adverse events related to the use of CPIs. It also addresses the crucial need for early recognition, proper workup, and better biomarkers to help improve the outcomes of these adverse events

Neuro-ophthalmological Side Effect of Immune Checkpoint Inhibitors at a Tertiary Cancer Center

Immune checkpoint inhibitors (ICIs) are increasingly becoming the standard of care in cancer therapy. Despite their promising outcome from an oncological perspective, these treatments are associated with a variety of immune-related adverse events (irAEs). Neuro-ophthalmological irAEs such as myasthenia gravis (MG), myositis, Guillain-Barré syndrome (GBS), and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) associated with anti-PD-1, anti-PD-L1, and anti-CTLA-4 can be devastating. The aim of our study is to report the frequency, characteristics, treatment, and prognosis of side effects related to each class of ICI

Opinions and practices regarding electronic cigarette use among Romanian high school students

Objective: The study assessed awareness, opinions, practices regarding electronic cigarettes (e-cigarettes) and factors associated with their use among Romanian high school students. Methods: A cross-sectional study was conducted in 2013 in two major Romanian cities, distributing anonymous questionnaires to 342 high school students aged 16–18. Results: 52.3% of the smokers, 29.2% of the ex-smokers and 7% of the never-smokers had tried e-cigarettes at least once in their life; 7.8% of the smokers and 4.6% of the ex-smokers had used e-cigarettes in the last month. Among smokers, e-cigarette use was associated with lower participation in school health education regarding e-cigarettes and with having parents using e-cigarettes.. Among ex-smokers and never-smokers, e-cigarette use was associated with intention to use e-cigarettes in the next year and with having friends who use e-cigarettes. Conclusion: Health education programmes and regulatory interventions addressing e-cigarettes are needed in Romania. More research is necessary on how to develop effective public health messages

Posterior reversible encephalopathy syndrome in cancer patients: a single institution retrospective study

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiologic entity. Its management and outcome in the oncology population is limited because it is still difficult to identify despite an increasingly recognized occurrence. This is the largest retrospective study of PRES in cancer patients reported from a single institution. We explore the clinical manifestations and radiologic features to comprehensively assess PRES in order to prevent permanent neurologic deficits and mortality. We retrospectively identified 69 patients with cancer who developed PRES at MDACC between 01/2006 to 06/2012. Clinical and radiographic data were abstracted from their records and reviewed for our analysis. Mean age at PRES onset was 52 ± 17.8 years. Fifty-two (75 %; p < 0.001) patients were women. Most common diagnoses were leukemia (30 %) and lymphoma (12 %). Forty-eight (70 %) patients were treated with chemotherapy, 21 (30 %) bone marrow transplant and 14 (20 %) tacrolimus. Most common clinical presentation was seizures (67 %). PRES was associated with hypertension in 62 (90 %) patients. On brain MRI, 33 (44 %) patients had some evidence of hemorrhage, 22 (73 %) of these were thrombocytopenic. Thirty-five (51 %) patients fully recovered and 19 (28 %) had permanent neurological deficits. Morbidity and mortality were associated with continuation with offending agent, thrombocytopenia, variations in mean arterial pressure ≥20 mmHg, electrographic seizures at onset, atypical MRI pattern and delay in diagnostic imaging (7.4 ± 4.8 days vs. 1.9 ± 1.8 days; p = 0.031) as half of them did not receive a prompt intervention. Special attention should be given to patients who present with high-risk factors in order to prevent development of PRES or decrease patient morbidity and mortality. Management of PRES should be guided by the radiographic findings. Overall, early recognition, discontinuation of the offending agents, correction of thrombocytopenia and blood pressure control are still the main strategies to manage PRES

Erratum: Randomized double-blind placebo-controlled trial of bevacizumab therapy for radiation necrosis of the central nervous system (International Journal of Radiation Oncology Biology Physics (2011) 79:5 (1487-95) DOI: 10.1016/j.ijrobp.2009.12.061)

Dr. Jai Grewal should be included as an author for the article “Randomized Double-Blind Placebo-Controlled Trial of Bevacizumab Therapy for Radiation Necrosis of the Central Nervous System” (2011: 79(5):1487-95)