Imaging in immune checkpoint inhibitor-induced polymyalgia rheumatica

Geest, Kornelis S M van der; Sandovici, Maria; Rutgers, Abraham; Hiltermann, T Jeroen N; Oosting, Sjoukje F.; Slart, Riemer; Brouwer, Elisabeth

doi:10.1136/annrheumdis-2020-217381

Cited by 13 publications

(14 citation statements)

References 7 publications

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“…A [18F]-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) scan was performed during prednisolone-free remission in two subjects (figure 1B). These follow-up scans showed markedly lower FDG uptake scores when compared with the previously reported scans obtained at the diagnosis of ICI-PMR 5. Thus, the FDG-PET/CT scan confirmed that the ICI-PMR had subsided in both patients.…”

supporting

confidence: 72%

“…Grading: 0, no uptake; 1, uptake lower than liver; 2, uptake equal to liver; 3, uptake higher than liver 7. For comparison, the previously reported FDG uptake scores at diagnosis of ICI-PMR are also shown 5. Dx, diagnosis; FDG, [18F]-fluorodeoxyglucose; ICI, immune checkpoint inhibitor; IFX, infliximab (for autoimmune colitis); INJ, injection of shoulder (for ICI-PMR); NSAID, nonsteroidal anti-inflammatory drug; PET, positron emission tomography; PMR, polymyalgia rheumatica; VED, vedolizumab (for autoimmune colitis).…”

mentioning

confidence: 98%

“…We evaluated the treatment requirements of six consecutive patients with ICI-PMR (online supplementary table 1), of whom the clinical and imaging findings were recently reported 5. ICI therapy led to complete cancer remission (n=1), partial remission (n=4) or stable disease (n=1).…”

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confidence: 99%

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Management of immune checkpoint inhibitor-induced polymyalgia rheumatica

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Management of immune checkpoint inhibitor-induced polymyalgia rheumatica

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“…Keeping in mind the costs and radiation burden of FDG-PET/CT, this imaging modality could be applied in selected cases: for instance, patients with atypical presentation, or patients with strong clinical suspicion but a negative US or MRI scan. Recently, it was suggested that FDG-PET/CT may also aid the diagnosis of the PMR-like syndrome developing upon immune checkpoint inhibitor therapy for cancer [ 31 ].…”

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confidence: 99%

Comparison and validation of FDG-PET/CT scores for polymyalgia rheumatica

et al. 2021

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Objectives To compare and validate the diagnostic accuracy of FDG-PET/CT scores for polymyalgia rheumatica (PMR); and to explore their relationship with clinical factors. Methods This retrospective study included 39 consecutive patients diagnosed with PMR and 19 PMR comparators. The final clinical diagnosis was established after 6 months follow-up. Patients underwent FDG-PET/CT prior to glucocorticoid treatment. Visual grading of FDG uptake was performed at 30 anatomic sites. Three FDG-PET/CT scores (one by Henckaerts, two by Sondag) and two algorithms (by Flaus and Owen) were investigated. Receiver operating characteristic (ROC) analysis with area under the curve (AUC) was performed. Diagnostic accuracy was assessed at predefined cut-off points. Results All three FDG-PET/CT scores showed high diagnostic accuracy for a clinical diagnosis of PMR in the ROC analysis (AUC 0.889 to 0.914). The Henckaerts Score provided a sensitivity of 89.7% and specificity of 84.2% at its predefined cut-off point. A simplified Henckaerts Score showed similar diagnostic accuracy as the original score. The Sondag Scores showed limited specificity at their predefined cut-off points (i.e. 47.4% and 63.2%), while ROC analysis suggested that substantially higher cut-off points are needed for these scores. The Owen and Flaus Algorithms demonstrated high sensitivity, but lower specificity (i.e. 78.9% and 42.1%, respectively) for PMR. Female sex and presence of large vessel vasculitis were associated with lower FDG-PET/CT scores in patients with PMR. Conclusion The Henckaerts Score showed the highest diagnostic utility for PMR. A modified, concise version of the Henckaerts Score provided similar diagnostic accuracy as the original score.

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“…Magnetic resonance imaging (MRI) may show synovitis, tenosynovitis, bone marrow edema, and erosions (31). In PMR, ultrasound may show subdeltoid and subacromial bursitis, trochanteric bursitis, or biceps tenosynovitis (32,33). Ultrasound and MRI may also suggest other diagnoses, such as crystalline arthritis, OA, and noninflammatory musculoskeletal conditions.…”

Section: Physical Examinationmentioning

confidence: 99%

Expert Perspective: Immune Checkpoint Inhibitors and Rheumatologic Complications

Cappelli

Bingham

2021

Arthritis & Rheumatology

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Rheumatologists increasingly receive consults for patients treated with immune checkpoint inhibitors (ICIs) for cancer. ICIs can cause inflammatory syndromes known as immune-related adverse events (IRAEs). Several rheumatic IRAEs have been reported, including inflammatory arthritis, polymyalgia rheumatica, and myositis. For patients who present with musculoskeletal symptoms while receiving ICI therapy, it is important to have an algorithm for evaluation. The differential diagnosis includes a range of musculoskeletal syndromes, such as crystalline arthritis, mechanical issues, and osteoarthritis, in addition to IRAEs. After diagnosing a rheumatic IRAE, rheumatologists must work with the patient and the oncologist to form a treatment plan. Treatment of IRAEs is guided by severity. Evidence for management is limited to observational studies. Inflammatory arthritis and polymyalgia rheumatica are treated with nonsteroidal antiinflammatory drugs in mild cases, glucocorticoids for moderate-to-severe cases, and sometimes require other disease-modifying antirheumatic drugs. Myositis due to ICIs can be accompanied by myocarditis or myasthenia gravis. Glucocorticoids and withholding the ICI are usually required to treat myositis; some patients with severe myositis require intravenous immunoglobulin or plasmapheresis. Further research is needed to optimize treatment of IRAEs that does not compromise the antitumor effect of ICIs. Clinical challenge You receive a consult from a local oncologist. A 65-yearold man with a history of knee osteoarthritis (OA) who had previously undergone total joint arthroplasty of the left knee and is being treated with nivolumab (anti-programmed death 1 [anti-PD-1] monoclonal antibody) for non-small cell lung cancer has new symptoms of severe aching in his arms and legs, with limited mobility. The oncologist does not localize symptoms to the joints and/or muscles but notes that the patient is having trouble doing chores around the house such as cleaning and cooking.

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Imaging in immune checkpoint inhibitor-induced polymyalgia rheumatica

Cited by 13 publications

References 7 publications

Management of immune checkpoint inhibitor-induced polymyalgia rheumatica

Management of immune checkpoint inhibitor-induced polymyalgia rheumatica

Comparison and validation of FDG-PET/CT scores for polymyalgia rheumatica

Expert Perspective: Immune Checkpoint Inhibitors and Rheumatologic Complications

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