Immune Checkpoint Inhibitor-Associated Myositis: A Characteristic Phenotype with a Poor Outcome Related to Concomitant Myocarditis

Celine Anquetil^1,2, Joe-Elie Salem^3,4, Benedicte Lebrun-Vignes⁵, Douglas B Johnson⁶, Andrew Mammen^7,8, Werner Stenzel⁹, Sarah Leonard-louis¹⁰, Olivier Benveniste^11,12, Javid J Moslehi³ and Yves Allenbach^2,13, ¹Internal Medicine and Clinical Immunlogy, Assistance Public - Hopitaux de Paris, Pitié-Salpêtrière University Hospital, PARIS, France, ²CDR en myologie UMR974,, Institut National de la Santé et de la Recherche Médicale, Association Institut de Myologie, PARIS, France, ³Division of Cardiovascular Medicine and Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nasheville, TN, ⁴Department of Pharmacology, Regional Center of Pharmacovigilance, INSERM, CIC-1421, Paris, France, ⁵Department of Pharmacology, Regional Center of Pharmacovigilance, INSERM, CIC-1421, PARIS, France, ⁶Division of Oncology, Department of Medicine, Vanderbilt University Medical Center, Nasheville, TN, ⁷National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, ⁸Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, ⁹Charité - Universitätsmedizin, Department of Neuropathology, Berlin, Germany, Berlin, Germany, ¹⁰Département de Neuropathologie, Centre de Référence des Maladies Neuro-Musculaires Paris Est, Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Universitaire Pitié-Salpêtrière, Paris, France, ¹¹Department of Internal Medicine and Clinical Immunology and Inflammation-Immunopathology-Biotherapy Department (I2B), Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, East Paris Neuromuscular Diseases Reference Center, Paris, France, ¹²Centre de Recherche en Myologie, UMRS974, Institut National de la Santé et de la Recherche Médicale, Association Institut de Myologie, Paris, France, ¹³Internal Medicine and Clinical Immunology, Sorbonne University - Assistance Public - Hopitaux de Paris, Pitié-Salpêtrière University Hospital, Paris, France

Meeting: 2018 ACR/ARHP Annual Meeting

Keywords: Adverse events, Immunotherapy, Myocardial involvement and myositis

Session Information

Date: Wednesday, October 24, 2018

Session Title: 6W022 ACR Abstract: Muscle Biology, Myositis & Myopathies II: Clinical & Misc Topics (2976–2981)

Session Type: ACR Concurrent Abstract Session

Session Time: 11:00AM-12:30PM

Background/Purpose:

Immune checkpoint inhibitors (ICI) are a major breakthrough in cancer treatment providing frequent durable responses and improving overall survival. Blocking immune checkpoints (Programmed cell Death 1 (PD-1)/PD-ligand 1 or Cytotoxic T Lymphocyte-Associated Protein 4 (CTLA-4)) to restore antitumor immune response may also induce immune-related adverse events (irAEs) targeting a large spectrum of organs including cardiac and skeletal muscle tissue. The overall mortality related to irAE is less than 2% with myocarditis being fatal in ~40-50% of cases. Myocarditis is associated with myositis in at least 25% of cases.

To date, only few cases of myositis have been reported. With the increased rate of ICI use, improvement in recognition, description, and management of muscular irAEs are required.

Methods: Data were collected from the VigiBase (http://www.vigiaccess.org/), the World Health Organization database of individual safety case reports (Uppsala, Sweden). Cases were identified using the High Level Term “Muscle infections and inflammations” of the Medical Dictionary for Regulatory Activities terms and at least one of seven following ICIs (Nivolumab, Pembrolizumab, Ipilimumab, Tremelimumab, Avelumab, Durvalumab, and Atezolizumab).

Results: Through March 2018, 180 myositis patients were identified (71 years [29-90]). They had most often been treated for melanoma (31.1%) or pulmonary cancer (30.6%) and 85% had received monotherapy, usually anti-PD1. The median time of myositis onset was 26 days [18-39] after the initial exposure to ICIs (data available in 61 patients). Amongst all myositis patients, 16.1% (n=29) also presented with myocarditis, 15.6% (n=28) with myasthenia gravis-like symptoms (oculomotor disorders and/or ptosis), 3.3% (n=6) with both and 13.9% with other concurrent irAEs including hepatitis (n=14), colitis (n=3), thyroiditis (n=3), nephritis (n=3), and hypophysitis (n=2). ICI-associated myositis caused significant morbidity and mortality, with fatalities occurring in 21.2% of patients. Moreover, 49.4% of patients with myositis had severe complications such as prolonged hospitalization, a life-threatening event, or a disabling effect. The mortality rate was significantly associated with combination therapy compared to monotherapy (38.5% vs. 18.1% p=0.02) and was higher in patients with concomitant myocarditis (51.7%) compared to those without myocarditis (14.9%, p<0.0001).

Conclusion:

ICI-associated myositis occurs early during therapy and is most often reported with combination regimens. ICI-associated myositis has a unique clinical presentation including ocular signs and concomitant myocarditis. Systematic screening for myocarditis might be crucial in patients with ICI-associated myositis, due to the frequent overlap between these conditions and the high mortality of ICI-myocarditis.

Disclosure: C. Anquetil, None; J. E. Salem, None; B. Lebrun-Vignes, None; D. B. Johnson, None; A. Mammen, None; W. Stenzel, None; S. Leonard-louis, None; O. Benveniste, None; J. J. Moslehi, None; Y. Allenbach, None.

To cite this abstract in AMA style:

Anquetil C, Salem JE, Lebrun-Vignes B, Johnson DB, Mammen A, Stenzel W, Leonard-louis S, Benveniste O, Moslehi JJ, Allenbach Y. Immune Checkpoint Inhibitor-Associated Myositis: A Characteristic Phenotype with a Poor Outcome Related to Concomitant Myocarditis [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 10). https://acrabstracts.org/abstract/immune-checkpoint-inhibitor-associated-myositis-a-characteristic-phenotype-with-a-poor-outcome-related-to-concomitant-myocarditis/. Accessed May 19, 2019.

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