From the Guidelines
Transverse myelitis is a severe neurologic condition characterized by inflammation of the spinal cord, which can be a complication of immune checkpoint inhibitor therapy, with an incidence of 3.8% to 12.0% in patients receiving such therapy, as reported in a study published in the Journal of Clinical Oncology in 2018 1.
Definition and Incidence
Transverse myelitis (TM) is an inflammatory condition that affects the spinal cord, causing damage to the myelin sheath that protects nerve fibers. The incidence of TM as a neurologic immune-related adverse event (irAE) varies depending on the type of immune checkpoint inhibitor (ICPi) therapy used, with higher rates observed in patients receiving combination therapy 1.
Clinical Presentation and Diagnosis
The clinical presentation of TM can include a range of symptoms, such as sensory motor neuropathy, painful sensory neuropathy, and enteric neuropathy. Diagnosis involves ruling out other causes of neurologic symptoms, such as CNS progression of cancer, seizure activity, infection, and metabolic derangement. Consultation with a neurologist is advised for all neurologic irAEs grade 2 or higher to determine the type and severity of neurologic impairment and guide further management 1.
Management and Treatment
Management of TM typically involves holding or discontinuing ICPi therapy, depending on the severity of the symptoms. For grade 2 or higher neurologic symptoms, corticosteroid therapy with methylprednisolone 1 to 4 mg/kg may be initiated, and for more severe cases, pulse-dose methylprednisolone, IVIG, or plasma exchange may be considered 1.
Key Considerations
Early recognition and treatment of TM are crucial to prevent permanent nerve damage and myelin destruction. A multidisciplinary approach, including neurology and oncology expertise, is essential for optimal management of TM and other neurologic irAEs 1.
From the Research
Definition and Overview of Transverse Myelitis (TM)
- Transverse myelitis (TM) is a rare but serious neurological disorder characterized by inflammation of the spinal cord, which can result in devastating neurologic effects 2.
- It is caused by inflammation and can have various etiologies, including autoimmune, inflammatory, and infectious causes 3, 2.
- Symptoms of TM typically develop over hours or days and worsen over a matter of days to weeks, presenting with sensory alteration, weakness, and autonomic dysfunction, including bowel and bladder problems 2.
Clinical Presentation and Diagnosis
- Clinical presentation of TM includes some combination of motor weakness, sensory symptoms, and bowel and bladder dysfunction 3.
- Evaluation for compressive etiologies must be a priority, as compressive myelopathy and TM are often clinically indistinguishable, and emergent surgical intervention is indicated in such cases 2.
- Neuroimaging, CSF studies, and serological studies are essential in diagnosing TM and determining its etiology 2.
Treatment and Management
- Treatment options for TM include corticosteroids, plasma exchange, IV immunoglobulin, and chemotherapeutic agents such as cyclophosphamide 3.
- High-dose corticosteroids have been shown to be effective in treating TM, particularly in immunocompetent patients with acute cytomegalovirus-associated TM 4.
- However, the effectiveness of methylprednisolone in treating TM is still debated, with some studies suggesting no significant benefit 5.
- Prompt recognition and early therapeutic intervention are critical to reducing the harmful effects of inflammation and improving patient outcomes 3, 2.