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Abstract
Objective To describe neural autoantibody profiles and outcomes in patients with neurologic autoimmunity associated with immune checkpoint inhibitor (ICI) cancer immunotherapy.
Methods In this retrospective descriptive study, 63 patients with ICI-related neurologic autoimmunity were included: 39 seen at the Mayo Clinic Neurology Department (clinical cohort) and 24 whose serum/CSF was referred to the Mayo Clinic Neuroimmunology Laboratory for autoantibody testing. Serum/CSF samples were tested for neural-specific autoantibodies. Predictors of unfavorable outcome (residual adverse event severity grade ≥3) were explored (logistic regression).
Results Median age at neurologic symptom onset was 65 years (range 31–86); 40% were female. Neurologic manifestations were CNS-restricted (n = 26), neuromuscular (n = 30), combined (n = 5), or isolated retinopathy (n = 2). Neural-specific autoantibodies were common in patients with CNS involvement (7/13 [54%] in the unbiased clinical cohort) and included known or unidentified neural-restricted specificities. Only 11/31 patients with CNS manifestations had neuroendocrine malignancies typically associated with paraneoplastic autoimmunity. Small-cell lung cancer (SCLC)–predictive antibodies were seen in 3 patients with non-neuroendocrine tumors (neuronal intermediate filament immunoglobulin G [IgG] and antineuronal nuclear antibody 1 with melanoma; amphiphysin IgG with non-SCLC). A median of 10 months from onset (range, 0.5–46), 14/39 in the clinical cohort (36%) had unfavorable outcomes; their characteristics were age ≥70 years, female, CNS involvement, lung cancer, higher initial severity grade, and lack of systemic autoimmunity. By multivariate analysis, only age remained independently associated with poor outcome (p = 0.01). Four of 5 patients with preexistent neurologic autoimmunity experienced irreversible worsening after ICI.
Conclusions Neural-specific autoantibodies are not uncommon in patients with ICI-related CNS neurologic autoimmunity. Outcomes mostly depend on the pre-ICI treatment characteristics and clinical phenotype.
Glossary
- AChR=
- acetylcholine receptor;
- ANNA=
- antineuronal nuclear antibody;
- BDUMP=
- bilateral diffuse uveal melanocytic proliferation;
- CRMP5=
- collapsin response-mediator protein 5;
- CTLA4=
- cytotoxic T-lymphocyte–associated antigen-4;
- GAD65=
- glutamic acid decarboxylase 65;
- GFAP=
- glial fibrillary acidic protein;
- HMGCR=
- β-hydroxy-β-methylglutaryl coenzyme-A reductase;
- ICI=
- immune checkpoint inhibitor;
- IgG=
- immunoglobulin G;
- IVIg=
- IV immunoglobulin;
- LGI1=
- leucine-rich glioma-inactivated 1;
- MG=
- myasthenia gravis;
- NIF=
- neuronal intermediate filament;
- NMDAR=
- NMDA receptor;
- PCA=
- Purkinje cell antibody;
- PD1=
- programmed death-1;
- PDL1=
- programmed death-1 ligand;
- PRES=
- posterior reversible encephalopathy syndrome;
- SCLC=
- small-cell lung carcinoma;
- SRP=
- signal recognition particle;
- STR=
- striational autoantibodies;
- UNA=
- autoantibodies as yet unidentified molecularly;
- VGCC=
- voltage-gated calcium channels;
- VGKC=
- voltage-gated potassium channel
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
- Received February 25, 2020.
- Accepted in final form May 27, 2020.
- © 2020 American Academy of Neurology
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