Frontiers in Immunology (Jan 2022)

Immune Checkpoint Inhibitor-Induced Cerebral Pseudoprogression: Patterns and Categorization

  • Hans Urban,
  • Hans Urban,
  • Hans Urban,
  • Hans Urban,
  • Eike Steidl,
  • Eike Steidl,
  • Eike Steidl,
  • Elke Hattingen,
  • Elke Hattingen,
  • Elke Hattingen,
  • Elke Hattingen,
  • Katharina Filipski,
  • Katharina Filipski,
  • Katharina Filipski,
  • Katharina Filipski,
  • Markus Meissner,
  • Martin Sebastian,
  • Agnes Koch,
  • Adam Strzelczyk,
  • Adam Strzelczyk,
  • Marie-Thérèse Forster,
  • Marie-Thérèse Forster,
  • Marie-Thérèse Forster,
  • Marie-Thérèse Forster,
  • Peter Baumgarten,
  • Peter Baumgarten,
  • Michael W. Ronellenfitsch,
  • Michael W. Ronellenfitsch,
  • Michael W. Ronellenfitsch,
  • Michael W. Ronellenfitsch,
  • Michael W. Ronellenfitsch,
  • Joachim P. Steinbach,
  • Joachim P. Steinbach,
  • Joachim P. Steinbach,
  • Joachim P. Steinbach,
  • Martin Voss,
  • Martin Voss,
  • Martin Voss,
  • Martin Voss

DOI
https://doi.org/10.3389/fimmu.2021.798811
Journal volume & issue
Vol. 12

Abstract

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BackgroundThe inclusion of immune checkpoint inhibitors (ICIs) in therapeutic algorithms has led to significant survival benefits in patients with various metastatic cancers. Concurrently, an increasing number of neurological immune related adverse events (IRAE) has been observed. In this retrospective analysis, we examine the ICI-induced incidence of cerebral pseudoprogression and propose a classification system.MethodsWe screened our hospital information system to identify patients with any in-house ICI treatment for any tumor disease during the years 2007-2019. All patients with cerebral MR imaging (cMRI) of sufficient diagnostic quality were included. cMRIs were retrospectively analyzed according to immunotherapy response assessment for neuro-oncology (iRANO) criteria.ResultsWe identified 12 cases of cerebral pseudoprogression in 123 patients treated with ICIs and sufficient MRI. These patients were receiving ICI therapy for lung cancer (n=5), malignant melanoma (n=4), glioblastoma (n=1), hepatocellular carcinoma (n=1) or lymphoma (n=1) when cerebral pseudoprogression was detected. Median time from the start of ICI treatment to pseudoprogression was 5 months. All but one patient developed neurological symptoms. Three different patterns of cerebral pseudoprogression could be distinguished: new or increasing contrast-enhancing lesions, new or increasing T2 predominant lesions and cerebral vasculitis type pattern.ConclusionCerebral pseudoprogression followed three distinct patterns and was detectable in 3.2% of all patients during ICI treatment and in 9.75% of the patients with sufficient brain imaging follow up. The fact that all but one of the affected patients developed neurological symptoms, which would be classified as progressive disease according to iRANO criteria, mandates vigilance in the diagnosis and treatment of ICI-induced cerebral lesions.

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