Lin Wei, Wang Wei, Hodi F Stephen, Min Le
Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou University Affiliated Provincial Hospital, FuZhou, Fujian, PR China.
EClinicalMedicine. 2024 Dec 6;79:102984. doi: 10.1016/j.eclinm.2024.102984. eCollection 2025 Jan.
Due to limited data on managing immunotherapy-induced secondary adrenal insufficiency (SAI) in melanoma survivors, this study investigated its management strategies and outcomes.
This retrospective cohort study analyzed melanoma patients treated with immune checkpoint inhibitors (ICIs) with SAI (Mel_SAI, n = 161), without SAI (Mel_CON, n = 168), and patients with pituitary adenoma-related SAI (Pit_SAI, n = 106) at our institution from January 2013 to November 2023. We compared glucocorticoid management patterns, quality of life using distress scores, and the impact of different glucocorticoid types on survival outcomes using Kaplan-Meier analysis.
Mel_SAI received significantly higher initial (median: 30 mg; IQR: 20-30 mg) and maintenance (median: 25 mg; IQR: 20-30 mg) hydrocortisone doses than Pit_SAI (initial: 20 mg; IQR: 15-30 mg; maintenance: 15 mg; IQR: 15-23 mg). Over half of Mel_SAI received prednisone as initial glucocorticoid replacement (n = 89, 55%), compared to 27% (n = 29) of Pit_SAI. Distress scores were significantly higher in Mel_SAI (median: 3; IQR: 2-5) than in Pit_SAI (median: 2; IQR: 1-3), but similar between Mel_CON. Prednisone use was associated with decreased survival in Mel_SAI (hazard ratio: 2.31; 95% CI: 1.14-4.46).
Higher glucocorticoid doses and prednisone use in melanoma patients with SAI may be due to higher distress scores rather than SAI itself. Given the negative impact on survival and potential side effects, we recommend hydrocortisone at standard doses as the preferred glucocorticoid replacement in melanoma patients with SAI.
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由于黑色素瘤幸存者中免疫治疗诱导的继发性肾上腺功能不全（SAI）管理的数据有限，本研究调查了其管理策略和结果。
这项回顾性队列研究分析了2013年1月至2023年11月在我们机构接受免疫检查点抑制剂（ICI）治疗的黑色素瘤患者，其中有SAI的患者（Mel_SAI，n = 161）、无SAI的患者（Mel_CON，n = 168）以及垂体腺瘤相关SAI的患者（Pit_SAI，n = 106）。我们比较了糖皮质激素管理模式、使用痛苦评分的生活质量，以及使用Kaplan-Meier分析不同类型糖皮质激素对生存结果的影响。
Mel_SAI接受的氢化可的松初始剂量（中位数：30 mg；四分位数间距：20 - 30 mg）和维持剂量（中位数：25 mg；四分位数间距：20 - 30 mg）显著高于Pit_SAI（初始剂量：20 mg；四分位数间距：15 - 30 mg；维持剂量：15 mg；四分位数间距：15 - 23 mg）。超过一半的Mel_SAI患者接受泼尼松作为初始糖皮质激素替代治疗（n = 89，55%），而Pit_SAI患者为27%（n = 29）。Mel_SAI患者的痛苦评分（中位数：3；四分位数间距：2 - 5）显著高于Pit_SAI患者（中位数：2；四分位数间距：1 - 3），但Mel_CON患者之间的痛苦评分相似。在Mel_SAI患者中，使用泼尼松与生存率降低相关（风险比：2.31；95%置信区间：1.14 - 4.46）。
黑色素瘤SAI患者中较高的糖皮质激素剂量和泼尼松的使用可能是由于较高的痛苦评分，而非SAI本身。鉴于对生存的负面影响和潜在的副作用，我们建议以标准剂量的氢化可的松作为黑色素瘤SAI患者首选的糖皮质激素替代治疗。
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