Oncologic Emergencies: Immune-Based Cancer Therapies and Complications

Abstract

Cancer therapies have undergone several recent advancements. Current cancer treatments include immune-based therapies comprised of checkpoint inhibitors, and adoptive immunotherapy; each treatment has the potential for complications that differ from chemotherapy and radiation. This review evaluates immune-based therapies and their complications for emergency clinicians. Therapy complications include immune-related adverse events (irAE), cytokine release syndrome (CRS), autoimmune toxicity, and chimeric antigen receptor (CAR) T-cell-related encephalopathy syndrome (CRES). Immune-related adverse events are most commonly encountered with checkpoint inhibitors and include dermatologic complications, pneumonitis, colitis/diarrhea, hepatitis, and endocrinopathies. Less common irAEs include nephritis, myocardial injury, neurologic toxicity, ocular diseases, and musculoskeletal complications. CRS and CRES are more commonly associated with CAR T-cell therapy. CRS commonly presents with flu-like illness and symptoms resembling sepsis, but severe myocardial and pulmonary disease may occur. Critically ill patients require resuscitation, broad-spectrum antibiotics, and hematology/oncology consultation.

Figure 1

Checkpoint inhibitor mechanisms (CTLA-4 and PD-1). Modified from https://commons.wikimedia.org/wiki/File:11_Hegasy_CTLA4_PD1_Immuntherapie.png. Accessed April 7, 2019. CTLA4, cytotoxic T-lymphocyte antigen 4; PD-1, programmed cell death protein 1; PD-L1, programmed death-ligand 1; APC, antigen-presenting cell; TAA, tumor-associated antigen; TCR, t-cell receptor; CD, cluster of differentiation.

Figure 2

Chimeric antigen receptor (CAR) T-cell therapy process 1) T cells present in the blood are removed from the patient. 2) These T cells are incorporated with the gene-encoding specific antigen receptors. 3) This results in CAR receptors present on the surface of T cells. 4)These modified T cells are harvested and grown in a laboratory setting. 5) The engineered T cells are finally administered to the original patient. Modified from https://commons.wikimedia.org/wiki/File:CAR_T-cell_Therapy.svg. Accessed April 7, 2019.