While immunotherapies are changing the way oncologists treat their patients, these new therapies are not entirely without side effects. Chinazom Ibegbu, MD, Assistant Professor of Oncology and neuro-oncologist at Roswell Park Comprehensive Cancer Center, discusses the neurological effects of immunotherapy. What are the side effects? What therapies cause these symptoms? And what can be done to support your patients?
My name is China's um a big boo. I'm a staff neuro oncologist here at Roswell Park Comprehensive Cancer Center. There are a lot of different immuno therapies out there vaccines, uncle it viruses, cell mediated therapies, monoclonal antibodies. But the two immuno therapies that are new kids on the block include immune checkpoint inhibitors and car T cells starting with immune checkpoint inhibitors. The neurologic side effects can be quite varied. They can affect both the peripheral nervous system and the central nervous system that includes the neuromuscular junction that also includes muscles and so that can manifest as neuropathy that can manifest as something like myasthenia gravis that can manifest as something like midas itis. It can also involve the central nervous system which includes the brain and the spinal cord. When it involves the brain it can look like anything like encephalopathy, it can be seizures and when it involves the spinal cord can cause something like a transverse myelitis specifically regarding car T cell therapy. The neuro toxicity that we talk about has been dubbed icons, which answer for immune cell effect. Er associated neuro toxicity syndrome. It affects 60 to 80% of patients who end up getting car T cell therapy about seven or 10 days after they do receive it, but up to 30 days after they receive it nor toxicities are varied. It can cause something like mild confusion or tremor all the way to serious seizures. Diffuse cerebral oedema, sometimes leading to coma and on death if we don't properly manage it in time. So with regards to uh immune checkpoint inhibitors, when somebody develops a neurologic complications associated with the checkpoint inhibitors, the first thing that we should do is actually stop the immune checkpoint inhibitor. We want to rule out other potential diagnoses before just blaming it on the checkpoint inhibitor. And if that isn't enough to treat the syndrome then we also add cortical steroids and these corticosteroids can effectively suppress the immune system and often resolve the neurologic complication that we are dealing with. If things are more severe, sometimes we have to escalate treatment and used treatments like Ivy League or plasma exchange or even other therapies to try and mitigate it and and sometimes it's specific to the actual neurological complications that we're dealing with. For example, somebody is dealing with peripheral neuropathy that is the result of one of these checkpoint inhibitors. We also institute uh neuropathic pain medications to help deal with some of the symptoms of pain and tingling. So as a neuro oncologist who sees these patients who develop neurologic complications from immunotherapy is like car T cells and immune checkpoint inhibitors. Our duties are varied. We assist the primary oncology team with diagnosis when it's not clear whether the neurologic symptom is actually due to the immunotherapy or if it's due to something else. We also help deal with the management and treatment of the complications, and so specifically again regarding checkpoint inhibitors and somebody develop something like immune mediated myasthenia gravis. We help assist the primary oncology team with treatments such as steroids and also specific treatment for myasthenia gravis like Pareto stigma and other treatments. So our involvement for patients with regards to these neurologic complications can can vary all the way from diagnosis to treatment and to follow up.