- Email: [email protected]
Acute fatal myocarditis after a single dose of anti-PD-1 immunotherapy, autopsy findings: a case report
Journal Pre-proof Acute fatal myocarditis after a single dose of anti-pd-1 immunotherapy, autopsy findings: a case report Tanner Hardy, MD, Ming Yin, MD, Jesus A. Chavez, MD, Iouri Ivanov, MD, Wei Chen, MD, Tibor Nadasdy, MD, Sergey V. Brodsky, MD, PhD PII:
S1054-8807(20)30006-5
DOI:
https://doi.org/10.1016/j.carpath.2020.107202
Reference:
CVP 107202
To appear in:
Cardiovascular Pathology
Received Date: 24 October 2019 Revised Date:
10 December 2019
Accepted Date: 9 January 2020
Please cite this article as: Hardy T, Yin M, Chavez JA, Ivanov I, Chen W, Nadasdy T, Brodsky SV, Acute fatal myocarditis after a single dose of anti-pd-1 immunotherapy, autopsy findings: a case report, Cardiovascular Pathology, https://doi.org/10.1016/j.carpath.2020.107202. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Elsevier Inc. All rights reserved.
ACUTE FATAL MYOCARDITIS AFTER A SINGLE DOSE OF ANTI-PD-1 IMMUNOTHERAPY, AUTOPSY FINDINGS: A CASE REPORT.
Tanner Hardy, MD1, Ming Yin, MD2, Jesus A Chavez, MD1, Iouri Ivanov, MD1, Wei Chen, MD1, Tibor Nadasdy, MD1, Sergey V Brodsky, MD, PhD1 Departments of 1Pathology and 2Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
Corresponding author: Sergey V Brodsky, MD, PhD Associate Professor Dept of Pathology The Ohio State University 333 W 10th Ave Graves Hall, B078 Columbus, OH 43210 Phone: 614-688-5831 e-mail: [email protected]
Highlights: ● PD-1 immunotherapy is associated with complications, including myocarditis. ● Myocarditis is often fatal, accounting up to 22% of death associated with PD-1 immunotherapy complications ● Inflammation in the myocardium composes of T cells and macrophages with rare B cells ● C4d staining is negative in the interstitial capillaries
Abstract Nivolumab (PD-1 inhibitor) and Ipilimumab (CTLA-34 inhibitor) are both commonly used immune checkpoint inhibitor therapies for various cancers. Various adverse events are associated with these therapies including hepatitis, nephritis, dermatitis, and myocarditis. It is believed these adverse events occur in part because modified cellular receptors lead to enhanced CD4 and CD8 lymphoproliferation. These events usually occur after several months and rounds of treatment. Here we present a case of an 81-year-old male with recurrent renal cell carcinoma (RCC) who experienced myocarditis after only a single dose of combination therapy with Nivolumab and Ipilimumab. He presented with elevated troponins and a 3rd degree heart block; three days after admission he died. Histologic examination revealed a predominance of CD3 T cells (CD4 > CD8) and CD68 macrophages, with occasional CD20 B cells. C4d staining was negative in the interstitial capillaries, suggesting that antibody-mediated injury of endothelial cells did not play a significant role in the pathogenesis of this myocarditis. Additional studies ruled out an infectious etiology. Immune checkpoint inhibitors are increasingly more common,
and it is important clinicians are aware patients can present with myocarditis early in the course of treatment.
Keywords: PD-1 immunotherapy, myocarditis, autopsy
1.1 Introduction Immunotherapy using checkpoint inhibitor medications is an increasingly common treatment modality to battle cancer, which targets foci of cancer with neoantigens that can be recognized and attacked by the immune system. In general, these medications work by blocking the T-cell inhibitory pathways; therefore allowing activation of T cell-mediated immune response including tumor immunity [1, 2]. Two commonly used medications are Nivolumab, an anti-PD-1 (anti-programmed cell death 1) antibody, and Ipilimumab, an anti-CTLA-4 (anti-cytotoxic T-lymphocyte associated antigen 4) antibody. Both individually work to enhance an anti-tumor response, and when used in conjunction, have a synergistic effect on the immune system, leading to a higher treatment response and increased survival in patients with different malignancies [3, 4]. However, over 90% of patients on a combination of Nivolumab and Ipilimumab developed treatment-related toxicities; nearly half (46%) were severe (grade 3 or 4) [5] likely due to disturbed immunologic homeostasis from unsuppressed T cell activities. Various adverse effects have been reported after initiation of immune checkpoint inhibitor therapy, such as: myocarditis, nephritis, hepatitis, dermatitis, pneumonitis, and many others [6-9].
With the increased commonality and use of these novel medications, the associated adverse events are becoming more common [8, 10]. Specifically, myocarditis is an adverse event with low incidence but extremely high mortality which deserves immediate recognition. Cases of PD-1 associated myocarditis have been previously reported [11-17], and it usually develops after weeks or months of the immunotherapy. The rate of myocarditis among fatalities associated with immunotherapy complications is quite high, reaching 22% [18]. Herein we report a case of a fatal myocarditis that developed after a single dose of Nivolumab and Ipilimumab treatment for recurrent renal cell carcinoma.
2.1 Case Report 2.1.1. Clinical history The patient was an 81-year-old male with surgically resected renal cell carcinoma (RCC), stage T3N0 (clear cell with sarcomatoid component) who later developed metastasis to the bladder and right ureter. His other significant medical problems included typical carcinoid tumor (T1aN0) of the lung, which was removed by lobectomy, but he did not have any known autoimmune diseases. He subsequently underwent right ureterectomy for the metastatic lesions and remained in remission for nearly 17 months until development of recurrent pelvic RCC metastasis. Immunotherapy was selected due to his advanced age and better treatment tolerance. The patient received his first infusions of Nivolumab (3 mg/kg in sodium 0.9%) and Ipilimumab (1 mg/kg in sodium 0.9%) with a treatment plan of every 3 weeks for the metastatic RCC. After this treatment he experienced fatigue, decreased appetite and weight loss. Three weeks later, laboratory data showed elevated alanine transaminase (ALT) (241 U/L; normal 1052 U/L) and aspartate aminotransferase (AST) (417 U/L; normal 14-40 U/L). The second dose of
immunotherapy was cancelled and the patient was admitted to the hospital for possible immunotherapy-associated hepatitis. Further workup showed elevated troponins (74.96 ng/mL; normal <0.11 ng/mL), creatinine kinase (2964 U/L; normal 30-220 U/L), potassium (5.3 mmol/L; normal 3.5-5.0 mmol/L), and low sodium (129 mmol/L; normal 133-143 mmol/L); electrocardiogram showed concerns for a complete heart block. He was started on intravenous methylprednisolone (1 mg/kg) daily for the immune-related hepatitis, and aspirin (324 mg) for the elevated troponins. Cardiology consultant confirmed complete 3rd degree heart block and suspected a non-ST segment elevation myocardial infarction, given the EKG and troponin findings. He was taken to the cardiac catheterization laboratory for placement of a temporary pacing wire and cardiac angiogram; however, no obstructive coronary artery disease was found. Hence, he was diagnosed of checkpoint inhibitor induced myocarditis and started on 500mg methylprednisolone i.v. daily on day 2 of admission. Laboratory data at that time showed improved ALT (223 U/L;), AST (294 U/L) but continuously elevated troponins (48.50 ng/mL), creatinine kinase (1905 U/L), and potassium (5.3 mmol/L). An echocardiogram demonstrated a normal left ventricular ejection fraction of 60-65%. Autoimmune workup was positive for anti-striated muscle and Asialo-GM1 antibodies and negative for acetylcholine receptor, antiganglioside antibodies, including GM1, GM2, GD1a, GD1b, and GQ1b. The following day laboratory data still showed elevated troponins (60.03 ng/mL), creatinine kinase (723 U/L), and potassium (5.5 mmol/L). The patient began to experience weakness and shortness of breath. Plasmapheresis was initiated due to a lack of improvement on steroids and a concern for multisystem inflammatory response. The patient’s cardiac rhythm
continued to persist in 3rd degree heart block. Despite the maximal medical interventions, he was pronounced dead, and an autopsy was performed. 2.1.2 Autopsy findings. Grossly, the heart weight was 438 gm (reference range for gender and body weight 278484 gm[19]) with a thickened left ventricular wall (1.5 cm; reference range for gender and body weight 1.05-1.25 cm [19]) and interventricular septum (1.8 cm, reference range for gender and body weight 1.20-1.60 cm [19]), and dilated tricuspid (13.7 cm, reference range for gender and body weight 11.4-11.8 cm [19]) and mitral (11 cm, reference range for gender and body weight 9.2-9.8 cm [19]) valves; additionally, there was calcified atherosclerosis of the coronary arteries. Microscopically, there was cardiomyocyte hypertrophy with lipofuscin deposits and mild and focal interstitial and replacement fibrosis. Diffuse active appearing inflammatory cell infiltrates were seen, and these infiltrates were associated with acute cardiomyocyte injury (Fig 1, A, B). To
characterize
the
cell
populations
of
the
inflammatory
cell
infiltrates,
immunoperoxidase stainings with antibodies to CD3, CD4, CD8, CD20 and CD68 were performed. There was a predominance of CD3-positive T cells with occasional CD20-positive B and numerous CD68-positive macrophages (Fig 2, A-C); a pattern consistent with acute myocarditis. There were more CD4-positive cells as compared to CD8-positive cells (Fig 2, D, E). Staining with antibodies to PD-1 and PD-L1 showed numerous PD-1 positive inflammatory cells (Fig 3, A) and positive sarcolemmal staining for PD-L1 in the cardiomyocytes, in the areas of inflammation, but not in uninvolved myocardium (Fig 3, B). Staining for CD4 was negative in the interstitial capillaries but showed non-specific positive staining in the cardiomyocytes in the areas of inflammation (Fig 3, D). Stainings for viral infections (adenovirus, cytomegalovirus, and herpes simplex virus) were negative. As an incidental finding, there were focal deposits of
amorphous hypoeosinophilic material that stained positive by Congo red stain and showed bright apple-green birefringence under the polarized light (Fig 4, A, B). Further workup suggested that these
amyloid
deposits
represent
a
transthyretin
type
of
amyloid
(negative
immunohistochemistry staining with kappa and lambda light chains and amyloid A antibodies and positive staining with prealbumin antibodies). No amyloid deposits were seen in the liver and kidneys, but there were small focal amyloid deposits in the vascular wall in the lungs. Histology of the liver did not show features of hepatitis.
3.1 Discussion Herein we describe pathologic findings in a patient with acute myocarditis as an early complication of immunotherapy after a single dose. We characterized the inflammatory cell infiltrates in the myocardium and investigated the role of antibody-mediated endothelial cell injury in the pathogenesis of this myocarditis. Myocarditis is an uncommon adverse event associated with the use of Nivolumab and Ipilimumab checkpoint inhibitor therapy. These myocarditises mostly were observed after multiple rounds of treatment, ranging from months to years after the first dose [11-17]. Yamaguchi et al described autopsy findings in a patient with fulminant
myocarditis
that
developed
after
thirteen
doses
of
Nivolumab
[17].
Immunohistochemical findings in that case showed numerous CD4 and CD8 positive cells with occasional CD20 positive cells and positive staining for PD-L1 in the areas of inflammation [17]. PD-1 positive cells were seen in the areas of inflammation, which corresponds with our previous observations in the kidney, when we found PD-1 positive T cells in the areas of inflammation in patients with PD-1 immunotherapy associated interstitial nephritis [9]. When comparing our case with that of Yamaguchi et al, we observed similar histological findings; both cases showed
positive CD4, CD8, PD-L1 staining and negative viral titers. However, our case showed a predominance of CD4 cells, whereas the case described by Yamaguchi showed numerous CD8positive cells [17]. Furthermore, the onset and catastrophic consequence was imminent in our case (after a single dose, within 3 weeks), whereas the clinical presentation was after 13 treatment doses and more than one year after initiation of immunotherapy in the case described by Yamaguchi. Atallah et al [16] observed that in a review of 42 cases of myocarditis, 33% of patients developed clinical symptoms after a single dose. However, there was no histologic evidence of myocarditis in these patients. Clinical course of the myocarditises varies. About a half of the patients have spontaneous remission, about 25% develop persistent cardiac dysfunction, and up to 25% may have fatal outcome or rapidly progress to end-stage cardiac dysfunction that requires a heart transplantation [20]. Pradhan et al reported that among 50 patients who developed a PD1 immunotherapy associated myocarditis, 27 died (21 were cardiac death related to the myocarditis and other death were attributed to other causes, including tumor progression) [21]. Treatments included steroids, other immunosuppressive drugs, IVIG and plasmapheresis [21]. The mechanisms underlying immunotherapy-related myocarditis have been explored in the past. Tajiri et al [20] suggested that there is a common antigen in the heart and the tumor that is targeted by T-cells. Another possible mechanism is that peripheral immune tolerance to the heart could be compromised by treatment with anti-CTLA-4 antibody that interferes with CTLA4-B7 interaction. This may result in lowering the threshold for T-cell activation and increase cardiac-reactive T-cell activity [16]. In a murine model of autoimmune myocarditis, PD-1 deficiency increases CD8-cell mediated myocardial inflammation and injury, resulting in elevated intracardiac inflammatory response and cytokine production [22]. Matson et al [15]
demonstrated that in a case of acute myocarditis that developed after two treatments with Nivolumab, the T-cell population in the myocardium was clonally identical to the T cells in the patient’s lung tumor, suggesting that this myocarditis is associated with autoimmune reaction rather to other causes, such as viral. In their study, Matson et al found parvovirus B19 DNA in the myocardium, but not virus by immunohistochemistry [15]. In our case, we did not identify evidence of adenovirus, cytomegalovirus, and herpes simplex virus by immunohistochemistry either. Studies illustrate when cells are completely void of PD-L1 and CTLA-4 T cell receptors, this can actually enhance lymphoproliferation and induce lymphocytic myocarditis with CD4 and CD8 T cells [20, 22]. This recently identified data may contribute to the myocarditis seen in patients taking immune checkpoint inhibitors, especially when using combination therapy. When observing the effect of CTLA-4 and PD-1 inhibitors in the setting of colitis, Coutzac et al [23] found that in patients with CTLA-4-induced colitis, there were increased mucosal CD4 T cells, and in those with PD-1-induced colitis, there were increased mucosal and intraepithelial CD8 T cells. Similarly, in the cases of myocarditis associated with PD-1 immunotherapy, there were predominancy of CD8-positive T cells [15, 17, 21]. Interestingly, in our case, there was predominantly CD4-positive T cells as compared to CD8-positive T cells, suggesting that mechanisms of immune response in early and late PD-1 associated myocarditises could be different. To characterize the role of antibody-mediated endothelial injury in the PD-1 immunotherapy associated myocarditis, we performed immunohistochemistry with the antibody to C4d. There was no relevant staining in the interstitial capillaries, suggesting that antibodymediated process did not play a significant role in the development of this myocarditis.
In conclusion, we describe a case of fatal acute myocarditis that developed after a single dose of PD-1 and CTLA-4 blockade treatment. This observation should alert treating physicians to monitor early onset of myocarditis for patients on PD-1/PD-L1 or CTLA-4 blockade therapy. 4.1 Figure legends: Figure 1. Light microscopy findings in the heart. A – Diffuse patchy interstitial inflammation was seen in the myocardium, Hematoxylin/Eosin (H&E), magnification 40x. B – Acute cardiomyocyte injury as was evident by contraction band necrosis (arrow) was seen in the areas of inflammation, H&E, 200x.
Figure 2. Characterization of inflammatory cells in the heart. A – immunohistochemical staining with an antibody to CD3 highlighted numerous T cells, magnification 200x. B - immunohistochemical staining with an antibody to CD20 highlighted occasional B cells, magnification 200x. C - immunohistochemical staining with an antibody to CD68 highlighted numerous macrophages, magnification 200x. D - immunohistochemical staining with an antibody to CD4 highlighted CD4-positive T cells, magnification 200x. E - immunohistochemical staining with an antibody to CD8 highlighted CD8-positive T cells, magnification 200x.
Figure 3. PD-1 and PD-L1 expression in the areas of inflammation, the role of complement in the PD-1 associated myocardial injury. A - immunohistochemical staining with an antibody to PD-1 highlighted PD-1 positive cells in the areas of inflammation, magnification 200x. B - immunohistochemical staining with an antibody to PD-L1 was negative in the intact myocardium, but there was positive sarcolemmal staining in the cardiomyocytes in the areas of inflammation, magnification 200x. C - immunohistochemical staining with an antibody to C4d was negative in the interstitial capillaries, occasional cardiomyocytes in the areas of inflammation were positive, magnification 200x.
Figure 4. Amyloidosis in the heart. A – foci of hypoeosinophilic material were noted in the myocardium, H&E, magnification 200x. B – this material was positive by Congo Red and showed apple-green birefringence under the polarized light, Congo Red, polarized, magnification 200x.
5.1 Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
6.1 References:
[1] Alissafi T, Hatzioannou A, Legaki AI, Varveri A, Verginis P. Balancing cancer immunotherapy and immune-related adverse events: The emerging role of regulatory T cells. Journal of autoimmunity. 2019:102310. [2] Sosa A, Lopez Cadena E, Simon Olive C, Karachaliou N, Rosell R. Clinical assessment of immune-related
adverse
events.
Therapeutic
advances
in
medical
oncology.
2018;10:1758835918764628. [3] Wolchok JD, Chiarion-Sileni V, Gonzalez R, Rutkowski P, Grob JJ, Cowey CL, et al. Overall Survival with Combined Nivolumab and Ipilimumab in Advanced Melanoma. New England Journal of Medicine. 2017;377:1345-56. [4] Hodi FS, Postow MA, Chesney J, Pavlik AC, Robert C, Grossman K, et al. Clinical Response, Progression-Free Survival (Pfs) and Safety in Patients (Pts) with Advanced Melanoma (Mel) Receiving Nivolumab (Nivo) Combined with Ipilimumab (Ipi) Versus Ipi Monotherapy in Checkmate 069 Study. Asia-Pac J Clin Onco. 2015;11:109-. [5] Motzer RJ, Tannir NM, McDermott DF, Aren Frontera O, Melichar B, Choueiri TK, et al. Nivolumab plus Ipilimumab versus Sunitinib in Advanced Renal-Cell Carcinoma. The New England journal of medicine. 2018;378:1277-90.
[6] Weber JS, Kahler KC, Hauschild A. Management of immune-related adverse events and kinetics of response with ipilimumab. J Clin Oncol. 2012;30:2691-7. [7] Nishino M, Sholl LM, Hodi FS, Hatabu H, Ramaiya NH. Anti-PD-1-Related Pneumonitis during Cancer Immunotherapy. The New England journal of medicine. 2015;373:288-90. [8] Chen TW, Razak AR, Bedard PL, Siu LL, Hansen AR. A systematic review of immunerelated adverse event reporting in clinical trials of immune checkpoint inhibitors. Ann Oncol. 2015;26:1824-9. [9] Cassol C, Satoskar A, Lozanski G, Rovin B, Hebert L, Nadasdy T, et al. Anti - PD-1 Immunotherapy May Induce Interstitial Nephritis With Increased Tubular Epithelial Expression of PD-L1. Kidney Int Rep. 2019;4:1152-60. [10] Arnaud-Coffin P, Maillet D, Gan HK, Stelmes JJ, You B, Dalle S, et al. A systematic review of adverse events in randomized trials assessing immune checkpoint inhibitors. International journal of cancer. 2019;145:639-48. [11] Johnson DB, Balko JM, Compton ML, Chalkias S, Gorham J, Xu Y, et al. Fulminant Myocarditis with Combination Immune Checkpoint Blockade. The New England journal of medicine. 2016;375:1749-55. [12] Tadokoro T, Keshino E, Makiyama A, Sasaguri T, Ohshima K, Katano H, et al. Acute Lymphocytic Myocarditis With Anti-PD-1 Antibody Nivolumab. Circulation Heart failure. 2016;9. [13] Agrawal N, Khunger A, Vachhani P, Colvin TA, Hattoum A, Spangenthal E, et al. Cardiac Toxicity Associated with Immune Checkpoint Inhibitors: Case Series and Review of the Literature. Case reports in oncology. 2019;12:260-76.
[14] Semper H, Muehlberg F, Schulz-Menger J, Allewelt M, Grohe C. Drug-induced myocarditis after nivolumab treatment in a patient with PDL1- negative squamous cell carcinoma of the lung. Lung cancer. 2016;99:117-9. [15] Matson DR, Accola MA, Rehrauer WM, Corliss RF. Fatal Myocarditis Following Treatment with the PD-1 Inhibitor Nivolumab. Journal of forensic sciences. 2018;63:954-7. [16] Atallah-Yunes SA, Kadado AJ, Kaufman GP, Hernandez-Montfort J. Immune checkpoint inhibitor therapy and myocarditis: a systematic review of reported cases. Journal of cancer research and clinical oncology. 2019;145:1527-57. [17] Yamaguchi S, Morimoto R, Okumura T, Yamashita Y, Haga T, Kuwayama T, et al. LateOnset Fulminant Myocarditis With Immune Checkpoint Inhibitor Nivolumab. The Canadian journal of cardiology. 2018;34:812 e1- e3. [18] Wang DY, Salem JE, Cohen JV, Chandra S, Menzer C, Ye F, et al. Fatal Toxic Effects Associated With Immune Checkpoint Inhibitors: A Systematic Review and Meta-analysis. JAMA Oncol. 2018;4:1721-8. [19] Ludwig J, Ludwig J. Handbook of autopsy practice. Totowa, N.J.: Humana Press; 2002. [20] Tajiri K, Aonuma K, Sekine I. Immune checkpoint inhibitor-related myocarditis. Japanese journal of clinical oncology. 2018;48:7-12. [21] Pradhan R, Nautiyal A, Singh S. Diagnosis of immune checkpoint inhibitor-associated myocarditis: A systematic review. International journal of cardiology. 2019;296:113-21. [22] Tarrio ML, Grabie N, Bu DX, Sharpe AH, Lichtman AH. PD-1 protects against inflammation and myocyte damage in T cell-mediated myocarditis. J Immunol. 2012;188:487684.
[23] Coutzac C, Adam J, Soularue E, Collins M, Racine A, Mussini C, et al. Colon ImmuneRelated
Adverse
Events:
Anti-CTLA-4
and
Anti-PD-1
Blockade
Immunopathological Entities. Journal of Crohn's & colitis. 2017;11:1238-46.
A
Figure 1
B
Induce
Distinct
A
B
C
D
E
Figure 2
A
C
Figure 3
B
A
Figure 4
B
Highlights: ● PD-1 immunotherapy is associated with complications, including myocarditis. ● Myocarditis is often fatal, accounting up to 22% of death associated with PD-1 immunotherapy complications ● Inflammation in the myocardium composes of T cells and macrophages with rare B cells ● C4d staining is negative in the interstitial capillaries
Conflict of interest.
All authors declare no conflict of interest. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
S1054-8807(20)30006-5
DOI:
https://doi.org/10.1016/j.carpath.2020.107202
Reference:
CVP 107202
To appear in:
Cardiovascular Pathology
Received Date: 24 October 2019 Revised Date:
10 December 2019
Accepted Date: 9 January 2020
Please cite this article as: Hardy T, Yin M, Chavez JA, Ivanov I, Chen W, Nadasdy T, Brodsky SV, Acute fatal myocarditis after a single dose of anti-pd-1 immunotherapy, autopsy findings: a case report, Cardiovascular Pathology, https://doi.org/10.1016/j.carpath.2020.107202. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Elsevier Inc. All rights reserved.
ACUTE FATAL MYOCARDITIS AFTER A SINGLE DOSE OF ANTI-PD-1 IMMUNOTHERAPY, AUTOPSY FINDINGS: A CASE REPORT.
Tanner Hardy, MD1, Ming Yin, MD2, Jesus A Chavez, MD1, Iouri Ivanov, MD1, Wei Chen, MD1, Tibor Nadasdy, MD1, Sergey V Brodsky, MD, PhD1 Departments of 1Pathology and 2Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
Corresponding author: Sergey V Brodsky, MD, PhD Associate Professor Dept of Pathology The Ohio State University 333 W 10th Ave Graves Hall, B078 Columbus, OH 43210 Phone: 614-688-5831 e-mail: [email protected]
Highlights: ● PD-1 immunotherapy is associated with complications, including myocarditis. ● Myocarditis is often fatal, accounting up to 22% of death associated with PD-1 immunotherapy complications ● Inflammation in the myocardium composes of T cells and macrophages with rare B cells ● C4d staining is negative in the interstitial capillaries
Abstract Nivolumab (PD-1 inhibitor) and Ipilimumab (CTLA-34 inhibitor) are both commonly used immune checkpoint inhibitor therapies for various cancers. Various adverse events are associated with these therapies including hepatitis, nephritis, dermatitis, and myocarditis. It is believed these adverse events occur in part because modified cellular receptors lead to enhanced CD4 and CD8 lymphoproliferation. These events usually occur after several months and rounds of treatment. Here we present a case of an 81-year-old male with recurrent renal cell carcinoma (RCC) who experienced myocarditis after only a single dose of combination therapy with Nivolumab and Ipilimumab. He presented with elevated troponins and a 3rd degree heart block; three days after admission he died. Histologic examination revealed a predominance of CD3 T cells (CD4 > CD8) and CD68 macrophages, with occasional CD20 B cells. C4d staining was negative in the interstitial capillaries, suggesting that antibody-mediated injury of endothelial cells did not play a significant role in the pathogenesis of this myocarditis. Additional studies ruled out an infectious etiology. Immune checkpoint inhibitors are increasingly more common,
and it is important clinicians are aware patients can present with myocarditis early in the course of treatment.
Keywords: PD-1 immunotherapy, myocarditis, autopsy
1.1 Introduction Immunotherapy using checkpoint inhibitor medications is an increasingly common treatment modality to battle cancer, which targets foci of cancer with neoantigens that can be recognized and attacked by the immune system. In general, these medications work by blocking the T-cell inhibitory pathways; therefore allowing activation of T cell-mediated immune response including tumor immunity [1, 2]. Two commonly used medications are Nivolumab, an anti-PD-1 (anti-programmed cell death 1) antibody, and Ipilimumab, an anti-CTLA-4 (anti-cytotoxic T-lymphocyte associated antigen 4) antibody. Both individually work to enhance an anti-tumor response, and when used in conjunction, have a synergistic effect on the immune system, leading to a higher treatment response and increased survival in patients with different malignancies [3, 4]. However, over 90% of patients on a combination of Nivolumab and Ipilimumab developed treatment-related toxicities; nearly half (46%) were severe (grade 3 or 4) [5] likely due to disturbed immunologic homeostasis from unsuppressed T cell activities. Various adverse effects have been reported after initiation of immune checkpoint inhibitor therapy, such as: myocarditis, nephritis, hepatitis, dermatitis, pneumonitis, and many others [6-9].
With the increased commonality and use of these novel medications, the associated adverse events are becoming more common [8, 10]. Specifically, myocarditis is an adverse event with low incidence but extremely high mortality which deserves immediate recognition. Cases of PD-1 associated myocarditis have been previously reported [11-17], and it usually develops after weeks or months of the immunotherapy. The rate of myocarditis among fatalities associated with immunotherapy complications is quite high, reaching 22% [18]. Herein we report a case of a fatal myocarditis that developed after a single dose of Nivolumab and Ipilimumab treatment for recurrent renal cell carcinoma.
2.1 Case Report 2.1.1. Clinical history The patient was an 81-year-old male with surgically resected renal cell carcinoma (RCC), stage T3N0 (clear cell with sarcomatoid component) who later developed metastasis to the bladder and right ureter. His other significant medical problems included typical carcinoid tumor (T1aN0) of the lung, which was removed by lobectomy, but he did not have any known autoimmune diseases. He subsequently underwent right ureterectomy for the metastatic lesions and remained in remission for nearly 17 months until development of recurrent pelvic RCC metastasis. Immunotherapy was selected due to his advanced age and better treatment tolerance. The patient received his first infusions of Nivolumab (3 mg/kg in sodium 0.9%) and Ipilimumab (1 mg/kg in sodium 0.9%) with a treatment plan of every 3 weeks for the metastatic RCC. After this treatment he experienced fatigue, decreased appetite and weight loss. Three weeks later, laboratory data showed elevated alanine transaminase (ALT) (241 U/L; normal 1052 U/L) and aspartate aminotransferase (AST) (417 U/L; normal 14-40 U/L). The second dose of
immunotherapy was cancelled and the patient was admitted to the hospital for possible immunotherapy-associated hepatitis. Further workup showed elevated troponins (74.96 ng/mL; normal <0.11 ng/mL), creatinine kinase (2964 U/L; normal 30-220 U/L), potassium (5.3 mmol/L; normal 3.5-5.0 mmol/L), and low sodium (129 mmol/L; normal 133-143 mmol/L); electrocardiogram showed concerns for a complete heart block. He was started on intravenous methylprednisolone (1 mg/kg) daily for the immune-related hepatitis, and aspirin (324 mg) for the elevated troponins. Cardiology consultant confirmed complete 3rd degree heart block and suspected a non-ST segment elevation myocardial infarction, given the EKG and troponin findings. He was taken to the cardiac catheterization laboratory for placement of a temporary pacing wire and cardiac angiogram; however, no obstructive coronary artery disease was found. Hence, he was diagnosed of checkpoint inhibitor induced myocarditis and started on 500mg methylprednisolone i.v. daily on day 2 of admission. Laboratory data at that time showed improved ALT (223 U/L;), AST (294 U/L) but continuously elevated troponins (48.50 ng/mL), creatinine kinase (1905 U/L), and potassium (5.3 mmol/L). An echocardiogram demonstrated a normal left ventricular ejection fraction of 60-65%. Autoimmune workup was positive for anti-striated muscle and Asialo-GM1 antibodies and negative for acetylcholine receptor, antiganglioside antibodies, including GM1, GM2, GD1a, GD1b, and GQ1b. The following day laboratory data still showed elevated troponins (60.03 ng/mL), creatinine kinase (723 U/L), and potassium (5.5 mmol/L). The patient began to experience weakness and shortness of breath. Plasmapheresis was initiated due to a lack of improvement on steroids and a concern for multisystem inflammatory response. The patient’s cardiac rhythm
continued to persist in 3rd degree heart block. Despite the maximal medical interventions, he was pronounced dead, and an autopsy was performed. 2.1.2 Autopsy findings. Grossly, the heart weight was 438 gm (reference range for gender and body weight 278484 gm[19]) with a thickened left ventricular wall (1.5 cm; reference range for gender and body weight 1.05-1.25 cm [19]) and interventricular septum (1.8 cm, reference range for gender and body weight 1.20-1.60 cm [19]), and dilated tricuspid (13.7 cm, reference range for gender and body weight 11.4-11.8 cm [19]) and mitral (11 cm, reference range for gender and body weight 9.2-9.8 cm [19]) valves; additionally, there was calcified atherosclerosis of the coronary arteries. Microscopically, there was cardiomyocyte hypertrophy with lipofuscin deposits and mild and focal interstitial and replacement fibrosis. Diffuse active appearing inflammatory cell infiltrates were seen, and these infiltrates were associated with acute cardiomyocyte injury (Fig 1, A, B). To
characterize
the
cell
populations
of
the
inflammatory
cell
infiltrates,
immunoperoxidase stainings with antibodies to CD3, CD4, CD8, CD20 and CD68 were performed. There was a predominance of CD3-positive T cells with occasional CD20-positive B and numerous CD68-positive macrophages (Fig 2, A-C); a pattern consistent with acute myocarditis. There were more CD4-positive cells as compared to CD8-positive cells (Fig 2, D, E). Staining with antibodies to PD-1 and PD-L1 showed numerous PD-1 positive inflammatory cells (Fig 3, A) and positive sarcolemmal staining for PD-L1 in the cardiomyocytes, in the areas of inflammation, but not in uninvolved myocardium (Fig 3, B). Staining for CD4 was negative in the interstitial capillaries but showed non-specific positive staining in the cardiomyocytes in the areas of inflammation (Fig 3, D). Stainings for viral infections (adenovirus, cytomegalovirus, and herpes simplex virus) were negative. As an incidental finding, there were focal deposits of
amorphous hypoeosinophilic material that stained positive by Congo red stain and showed bright apple-green birefringence under the polarized light (Fig 4, A, B). Further workup suggested that these
amyloid
deposits
represent
a
transthyretin
type
of
amyloid
(negative
immunohistochemistry staining with kappa and lambda light chains and amyloid A antibodies and positive staining with prealbumin antibodies). No amyloid deposits were seen in the liver and kidneys, but there were small focal amyloid deposits in the vascular wall in the lungs. Histology of the liver did not show features of hepatitis.
3.1 Discussion Herein we describe pathologic findings in a patient with acute myocarditis as an early complication of immunotherapy after a single dose. We characterized the inflammatory cell infiltrates in the myocardium and investigated the role of antibody-mediated endothelial cell injury in the pathogenesis of this myocarditis. Myocarditis is an uncommon adverse event associated with the use of Nivolumab and Ipilimumab checkpoint inhibitor therapy. These myocarditises mostly were observed after multiple rounds of treatment, ranging from months to years after the first dose [11-17]. Yamaguchi et al described autopsy findings in a patient with fulminant
myocarditis
that
developed
after
thirteen
doses
of
Nivolumab
[17].
Immunohistochemical findings in that case showed numerous CD4 and CD8 positive cells with occasional CD20 positive cells and positive staining for PD-L1 in the areas of inflammation [17]. PD-1 positive cells were seen in the areas of inflammation, which corresponds with our previous observations in the kidney, when we found PD-1 positive T cells in the areas of inflammation in patients with PD-1 immunotherapy associated interstitial nephritis [9]. When comparing our case with that of Yamaguchi et al, we observed similar histological findings; both cases showed
positive CD4, CD8, PD-L1 staining and negative viral titers. However, our case showed a predominance of CD4 cells, whereas the case described by Yamaguchi showed numerous CD8positive cells [17]. Furthermore, the onset and catastrophic consequence was imminent in our case (after a single dose, within 3 weeks), whereas the clinical presentation was after 13 treatment doses and more than one year after initiation of immunotherapy in the case described by Yamaguchi. Atallah et al [16] observed that in a review of 42 cases of myocarditis, 33% of patients developed clinical symptoms after a single dose. However, there was no histologic evidence of myocarditis in these patients. Clinical course of the myocarditises varies. About a half of the patients have spontaneous remission, about 25% develop persistent cardiac dysfunction, and up to 25% may have fatal outcome or rapidly progress to end-stage cardiac dysfunction that requires a heart transplantation [20]. Pradhan et al reported that among 50 patients who developed a PD1 immunotherapy associated myocarditis, 27 died (21 were cardiac death related to the myocarditis and other death were attributed to other causes, including tumor progression) [21]. Treatments included steroids, other immunosuppressive drugs, IVIG and plasmapheresis [21]. The mechanisms underlying immunotherapy-related myocarditis have been explored in the past. Tajiri et al [20] suggested that there is a common antigen in the heart and the tumor that is targeted by T-cells. Another possible mechanism is that peripheral immune tolerance to the heart could be compromised by treatment with anti-CTLA-4 antibody that interferes with CTLA4-B7 interaction. This may result in lowering the threshold for T-cell activation and increase cardiac-reactive T-cell activity [16]. In a murine model of autoimmune myocarditis, PD-1 deficiency increases CD8-cell mediated myocardial inflammation and injury, resulting in elevated intracardiac inflammatory response and cytokine production [22]. Matson et al [15]
demonstrated that in a case of acute myocarditis that developed after two treatments with Nivolumab, the T-cell population in the myocardium was clonally identical to the T cells in the patient’s lung tumor, suggesting that this myocarditis is associated with autoimmune reaction rather to other causes, such as viral. In their study, Matson et al found parvovirus B19 DNA in the myocardium, but not virus by immunohistochemistry [15]. In our case, we did not identify evidence of adenovirus, cytomegalovirus, and herpes simplex virus by immunohistochemistry either. Studies illustrate when cells are completely void of PD-L1 and CTLA-4 T cell receptors, this can actually enhance lymphoproliferation and induce lymphocytic myocarditis with CD4 and CD8 T cells [20, 22]. This recently identified data may contribute to the myocarditis seen in patients taking immune checkpoint inhibitors, especially when using combination therapy. When observing the effect of CTLA-4 and PD-1 inhibitors in the setting of colitis, Coutzac et al [23] found that in patients with CTLA-4-induced colitis, there were increased mucosal CD4 T cells, and in those with PD-1-induced colitis, there were increased mucosal and intraepithelial CD8 T cells. Similarly, in the cases of myocarditis associated with PD-1 immunotherapy, there were predominancy of CD8-positive T cells [15, 17, 21]. Interestingly, in our case, there was predominantly CD4-positive T cells as compared to CD8-positive T cells, suggesting that mechanisms of immune response in early and late PD-1 associated myocarditises could be different. To characterize the role of antibody-mediated endothelial injury in the PD-1 immunotherapy associated myocarditis, we performed immunohistochemistry with the antibody to C4d. There was no relevant staining in the interstitial capillaries, suggesting that antibodymediated process did not play a significant role in the development of this myocarditis.
In conclusion, we describe a case of fatal acute myocarditis that developed after a single dose of PD-1 and CTLA-4 blockade treatment. This observation should alert treating physicians to monitor early onset of myocarditis for patients on PD-1/PD-L1 or CTLA-4 blockade therapy. 4.1 Figure legends: Figure 1. Light microscopy findings in the heart. A – Diffuse patchy interstitial inflammation was seen in the myocardium, Hematoxylin/Eosin (H&E), magnification 40x. B – Acute cardiomyocyte injury as was evident by contraction band necrosis (arrow) was seen in the areas of inflammation, H&E, 200x.
Figure 2. Characterization of inflammatory cells in the heart. A – immunohistochemical staining with an antibody to CD3 highlighted numerous T cells, magnification 200x. B - immunohistochemical staining with an antibody to CD20 highlighted occasional B cells, magnification 200x. C - immunohistochemical staining with an antibody to CD68 highlighted numerous macrophages, magnification 200x. D - immunohistochemical staining with an antibody to CD4 highlighted CD4-positive T cells, magnification 200x. E - immunohistochemical staining with an antibody to CD8 highlighted CD8-positive T cells, magnification 200x.
Figure 3. PD-1 and PD-L1 expression in the areas of inflammation, the role of complement in the PD-1 associated myocardial injury. A - immunohistochemical staining with an antibody to PD-1 highlighted PD-1 positive cells in the areas of inflammation, magnification 200x. B - immunohistochemical staining with an antibody to PD-L1 was negative in the intact myocardium, but there was positive sarcolemmal staining in the cardiomyocytes in the areas of inflammation, magnification 200x. C - immunohistochemical staining with an antibody to C4d was negative in the interstitial capillaries, occasional cardiomyocytes in the areas of inflammation were positive, magnification 200x.
Figure 4. Amyloidosis in the heart. A – foci of hypoeosinophilic material were noted in the myocardium, H&E, magnification 200x. B – this material was positive by Congo Red and showed apple-green birefringence under the polarized light, Congo Red, polarized, magnification 200x.
5.1 Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
6.1 References:
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[23] Coutzac C, Adam J, Soularue E, Collins M, Racine A, Mussini C, et al. Colon ImmuneRelated
Adverse
Events:
Anti-CTLA-4
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Immunopathological Entities. Journal of Crohn's & colitis. 2017;11:1238-46.
A
Figure 1
B
Induce
Distinct
A
B
C
D
E
Figure 2
A
C
Figure 3
B
A
Figure 4
B
Highlights: ● PD-1 immunotherapy is associated with complications, including myocarditis. ● Myocarditis is often fatal, accounting up to 22% of death associated with PD-1 immunotherapy complications ● Inflammation in the myocardium composes of T cells and macrophages with rare B cells ● C4d staining is negative in the interstitial capillaries
Conflict of interest.
All authors declare no conflict of interest. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.