# Guillain-Barré Syndrome-Like Polyneuropathy Associated with Immune Checkpoint Inhibitors: A Systematic Review of 33 Cases

Authors: Yan Li; Xiuchun Zhang; Chuansheng Zhao
Journal: BioMed Research International
 (2021)

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## Abstract

Immune checkpoint inhibitors (ICIs) have been increasingly used in the treatment of various types of tumors with favorable results. But these treatments also led to a variety of immune-related adverse events (irAEs). Neurological irAEs such as Guillain-Barré Syndrome are rare and may have serious consequences once they occur. A systematic literature search was performed in PubMed and Embase for all case reports of GBS associated with ICIs published in English reporting on human beings from 1990 up to date. A total of 30 case reports (totalpatients=33) were used for final analysis. The included cases were from 11 countries, covering 10 tumor types, with melanoma accounting for the largest number. The mean age was 62.2±11.1 years old, and males were dominant (male: 26 and female: 7). The median time of initial symptoms was 8.2 weeks after the 1st dose of ICIs. The most common manifestations of GBS associated with ICIs were weakness, hyporeflexia or areflexia, and paresthesia in order. The GBS subtypes suggested by electrophysiological results were acute inflammatory demyelinating polyneuropathy (AIDP), acute motor axonal neuropathy (AMAN), and Miller Fisher syndrome (MFS). The protein level of CSF in patients with GBS related to ICIs was 180.68±152.51 mg/dl. Immediate termination of ICIs followed by intravenous immunoglobulin was the preferred treatment option. 72.7% of patients recovered or had residual mild dysfunction after treatment. Elderly male patients with melanoma were most likely to develop ICI-related GBS. The specific neurological symptoms, CSF analysis, and electrophysiological examination were important means of diagnosis.


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## 1. Introduction

In the last decade, with a better understanding of the factors that promote or inhibit T cell response, great progress has been made on tumor immunotherapy. Immune checkpoint inhibitors (ICIs) have become a powerful clinical strategy for treating cancer, including an antibody targeting cytotoxic T lymphocyte-associated antigen-4 (CTLA-4, e.g., ipilimumab), antibodies directed against programmed cell death protein-1 (PD-1, e.g., nivolumab, pembrolizumab, and cemiplimab), and anti-PD-1 ligand (PD-L1, e.g., atezolizumab, durvalumab, and avelumab) [1]. These drugs can be used alone or in combination with other immunotherapy [2] or chemotherapy [3] to improve the survival of cancer patients. Currently, it has been used for the treatment of tumors of lung, kidney, liver, bladder and breast cancer, melanoma, and lymphomas [4–6]. ICIs improve the prognosis and quality of life of patients, whereas the increase of use also brings various immune-related adverse events (irAEs). The dermatologic, gastrointestinal, pulmonary, hepatic, and endocrine systems were most frequently involved.Cases of neurological irAEs are rare, accounting for less than 3% [7]. So far, the best-characterized central nervous system irAEs are encephalitis and meningitis. And neurologic irAEs known to be most relevant to the peripheral nervous system are peripheral neuropathies, GBS, myasthenia gravis, and myositis [8]. Once they occur, such as encephalitis, Guillain-Barré syndrome, or myasthenia gravis, they can develop into serious consequences or even death.Epidemiology shows that nearly two-thirds of patients with GBS have a recent history of infection before the illness [9]. GBS with potentially life-threatening consequences occurs in approximately 0.1-0.2% of patients treated with ICIs [10]. To date, information on the incidence, characteristics, and outcomes of GBS associated to ICIs treatment is very limited. And the available information varies widely in diagnosis and treatment. Multidisciplinary treatment of tumors urgently requires neurologists and oncologists to accurately understand the clinical manifestations and treatment of ICI-related GBS.This review summarized the published data on GBS or GBS-like disease occurring in patients after treatment with ICIs from 1990 up to date and analyzed their time patterns of occurrence, clinical presentation, diagnosis, treatment, and prognosis.


## 2. Methods

A systematic literature search was performed in PubMed and Embase for all case reports of GBS associated with ICIs published in English reporting on human beings from 1990 up to date. For the case reports search, the keywords used were as follows: [“Guillain-Barré Syndrome” OR “acute inflammatory demyelinating polyradiculoneuropathy” OR “Miller Fisher Syndrome” OR “acute motor axonal neuropathy” OR “acute motor-sensory axonal neuropathy”] AND [“Immune Checkpoint Inhibitors” OR “Immune Checkpoint Blockers” OR “PD-L1 Inhibitors” OR “Programmed Death-Ligand 1 Inhibitors” OR “CTLA-4 Inhibitors” OR “Cytotoxic T-Lymphocyte-Associated Protein 4 Inhibitors” OR “PD-1 Inhibitors” OR “Programmed Cell Death Protein 1 Inhibitor”]. Abstracts of medical conference were excluded. For each case, we extracted data on demographics and clinical manifestations and adjuvant examinations (imaging, cerebrospinal fluid, and electrophysiology). If gender, age, GBS clinical variation [11], electrophysiological subtype [12], or results of the relevant examination were not explicitly reported in the article, this case could not be considered for analysis. The search was conducted by Yan Li and Xiuchun Zhang. The selection of the articles should be agreed upon by the above two persons.GraphPad Prism 8 was used for statistical analysis, and continuous data were expressed in the form ofmean±standarddeviation or median. P<0.05 was considered statistically significant. Since the proportion of males and females in the included cases was significantly different, unpaired t-test was used to analyze the ages of males and females.Because the patient’s personal information was provided in the original case report, authorization from the Ethics Committee was not required for this study.


## 3. Results

Using the search terminology, 38 case reports were identified from our database search, covering the period from January 2008 to February 2021. Three patients were excluded due to lack of age and CSF protein concentration, respectively. One case report was excluded because it was written in Japanese. Two case reports were not included because the diagnosis of GBS was ambiguous due to a disease progression similar to acute-onset CIDP. In addition, two patients with a history of GBS had no serious toxicities or deterioration of the previous autoimmune disorders after ICI therapy. The two patients were also excluded. A total of 30 case reports (totalpatients=33) were used for final analysis [13–42]. According to the diagnostic criteria of GBS in NINDS, all the above 33 cases were consistent with the features of GBS. The clinical data and diagnostic details of all included patients were summarized in Tables 1–3.Table 1
Main characteristics and diagnostic details of included cases.
CaseArticleCountryAgeSexTumor typeICIsTime of GBS onset after the initiation treatment (week)Time to neurological plateau (days)GBS diagnosis1Muralikrishnan, S et al. [14]USA65FemaleMelanomaPembrolizumab4 weeks44Clinical+CSF+electrophysiology2Han, C et al. [15]China55MaleRCCPembrolizumab16 weeksNo mentionClinical+CSF+electrophysiology3Arora, A et al. [16]USA70MaleMelanoma and prostate cancerPembrolizumab12 weeks16Clinical+CSF+electrophysiology4Yuen, C et al. [17]USA66MaleMelanomaNivolumab12 days (1.7 weeks)34Clinical+CSF+electrophysiology5Pomerantz, M et al. [18]Italy58MaleSCLCA combination of nivolumab and pembrolizumab59 days (8.4 weeks)No mentionClinical+CSF+electrophysiology6Pierrard, J et al. [19]Belgium70MaleUrothelial carcinomaNivolumab59 weeks14Clinical+CSF+electrophysiology7McNeill, C. J et al. [20]UK68MaleRCCNivolumab8 weeks13Clinical+CSF+electrophysiology8Kyriazoglou, A et al. [22]Greece74MaleBladder cancerNivolumab8 weeks15Clinical+CSF+electrophysiology9Mazzaschi, G et al. [21]Italy80MaleLung adenocarcinomaNivolumab12 days(1.7 weeks)22Clinical+CSF+electrophysiology10Gravbrot, N et al. [23]USA71MaleMelanomaIpilimumab10 weeksSeveral daysClinical+CSF+electrophysiology11Wilson, R et al. [24]UK52MaleMelanomaNivolumabIpilimumab4 weeks7Clinical+CSF+electrophysiology12Thapa, B et al. [25]USA60MaleLung adenocarcinomaNivolumab14 weeksNo mentionClinical+CSF+electrophysiology13Ong, S et al. [26]UK66MaleLung adenocarcinomaPembrolizumab6.5 weeks16Clinical+electrophysiology14Nukui, T et al. [27]Japan45MaleNasal cancerNivolumab10 weeks14Clinical+CSF+electrophysiology15Manam, R et al. [28]USA73MaleLung adenocarcinomaPembrolizumab3 weeksNo mentionClinical+CSF16Manam, R et al. [28]USA81MaleMelanomaPembrolizumab10 weeksNo mentionClinical+CSF+electrophysiology17Garcia, C. A et al. [29]USA55MaleMelanomaIpilimumab6 weeksNo mentionClinical+CSF+electrophysiology18Fukumoto, Y et al. [30]Japan66MaleNSCLCNivolumab3 weeks16Clinical+CSF+electrophysiology19Cafuir, L et al. [31]USA42MaleMelanomaIpilimumab10 weeks13Clinical + CSF + electrophysiology20Baird-Gunning, J. J. D et al. [31]Australia58FemaleMelanomaNivolumabIpilimumab10 days (1.4 weeks)12Clinical+CSF+electrophysiology21Supakornnumporn, S et al. [33]USA77MaleMelanomaNivolumabIpilimumab10 weeks14Clinical+CSF+electrophysiology22Schneiderbauer, R et al. [34]German51MaleMelanomaNivolumab20 weeksNo mentionClinical+CSF+electrophysiology23Patel, R. J et al. [35]USA71MaleMelanomaIpilimumab10 weeks10Clinical+electrophysiology24Kelly Wu, W et al. [36]USA37FemaleMelanoma and papillary thyroid cancerIpilimumabNo mention9Clinical+CSF+electrophysiology25Gu, Y et al. [37]Australia49FemaleMelanomaIpilimumab Nivolumab5 days (0.7 weeks)11Clinical+CSF+electrophysiology26Jacob, A et al. [38]USA68FemaleLung squamous and cell carcinomaNivolumab12 weeks14Clinical+CSF+electrophysiology27Gaudy-Marqueste, C et al. [40]France65MaleMelanomaIpilimumab6 weeks11Clinical+CSF28Bot, I et al. [41]Netherlands63MaleMelanomaIpilimumab12 weeksA few daysClinical+CSF+electrophysiology29Wilgenhof, S et al. [42]Belgium57FemaleMelanomaIpilimumab8 weeksNo mentionClinical + CSF + electrophysiology30de Maleissye, M.F. et al. [39]France45FemaleMelanomaPembrolizumab9 weeks21Clinical+CSF+electrophysiology31Janssen, J.B.E. et al. [42]Netherlands74MaleProstate cancerPembrolizumab6 weeks21Clinical+CSF+electrophysiology32Janssen, J.B.E. et al. [13]Netherlands67MaleMelanomaNivolumab3 weeks7Clinical+CSF33Janssen, J.B.E. et al. [13]Netherlands55MaleMelanomaPembrolizumab16 weeks15Clinical+CSFLEs: lower extremities; UEs: upper extremities; NSCLC: non-small-cell lung cancer; SCLC: small-cell lung cancer; RCC: renal cell carcinoma. Time to Nadir: days between the onset of neurological symptoms and the development of the worst clinical symptoms (no progression).Table 2
The clinical data and diagnostic details of all included patients.
CaseGBS clinical pictureHughes scaleOnsetMotorSensoryReflexAutonomic disturbancesRespiratory involvement1LEs ascending numbness bilaterallyMuscle weakness in lower limbs and left handLeft tongue numbness and diminished facial sensation.Generalized areflexiaNoneNo22Weakness and numbness of the extremitiesA mild decrease in muscle strength of the limbsParesthesia of the four extremitiesAbsence of tendon reflex of the limbs. No pathological reflex.NoneNo13Progressive bilateral LE weaknessDecreased strength in lower extremitiesSlight impairment of touch and pinprick sensation, worsening back pain and painful burning in feet bilaterallyBilaterally absent patellar and ankle reflexesNoneNo64Bilateral finger and toe paresthesia followed by weakness of the lower and then upper limbsAbsent pinprick sensation and vibratory sensationGeneralized areflexiaTachycardia hypotensionRespiratory distress65Bilateral LE paresthesias, painBilateral LE weakness and progressively worsened to a complete inability to ambulateDiminished sensory perception in LEs, pinprick over all distal extremities, marked decrease in vibration sensation and absent proprioception in LEsGeneralized areflexiaNoneNo46Rapidly progressing weakness of LEsRapidly progressing upper limb weakness over 2 weeksNoneNormalNoneNo37Progressive weakness and sensory disturbance in face and limbsGeneral weakness. slurred speech, double vision, difficulty swallowing, within 72 hours, rapidly worsening bulbar symptomsParesthesia of his hands and feet, an unsteady gaitNormal tone, power and deep tendon reflexesNoneShortness of breath58Muscle weakness and fatigueSevere proximodistal weakness in the UEs and LEsImpairment of position sense, vibration, stereognosisn, and graphesthesiaAreflexia of the 4 limbs and absent pathologic reflexesNoneNo39Paresthesia and burning pain arose in LEs, followed by a progressive bilateral weaknessSymmetric distal dominant weakness and dramatically worsened. Loss of fine motor control on distal UEsPain and sever numbness.Hypoareflexia and decreased deep tendon reflexesNoneNo410Severe, progressive, symmetric ascending weaknessThe paralysis progressed to inability to stand and arm weaknessMild dysphagiaWithout sensory lossUnobtainable deep tendon reflexesNoneShortness of breath411Headache and generalized tirednessBilateral facial weakness, distal limb weaknessProgressive hand and feet numbnessReduced deep tendon reflexesNoneNo312Severe weakness of all extremitiesMild to moderate decrease in motor strength in all 4 extremities, LEs worse than UEsSensory loss of vibration/proprioception in bilateral LEsDiminished reflexes in bilateral LEs but normal reflexes in bilateral UEsNoneNo413LE pain, paresthesia and weaknessUE weakness and a lower motor neuron pattern of right-sided facial weaknessBilateral, predominantly distal LE weaknessReduced sensationGeneralized areflexiaNoneNo214Diplopia, muscle weakness, and numbness of extremitiesBed-boundRight external ophthalmoplegia, left facial nerve palsy and bulbar palsy, severe muscle weaknessBilateral facial dysesthesiaAbsent deep-tendon reflexesNoneNo415Generalized weaknessProgressive weakness in the bilateral LEs greater than the UEsWithout sensory lossAbsent deep tendon reflexes in the bilateral UEs and LEsNoneNo316Progressive weakness in the bilateral LEs and then spreading to the bilateral UEsA strength of 2/5 in the bilateral UEs and 0/5 in the bilateral LEs and no bulbar muscle weaknessWithout sensory lossAreflexiaNoneRequiring mechanical ventilation417Paresthesias in distal LEs bilaterallyAscending weaknessAscending paresthesiasLoss of deep tendon reflexesNoneNo218Muscle weakness of the LEsWeakness rapidly progressed and became bed-boundParesthesias of the distal limbsAbsence of deep tendon reflexes of the four extremitiesNoneNo419Bilateral thigh weakness and paresthesia of the soles of his feetLEs weakness, worsened rapidlyPain and numbness.Vibration in the toes impairedTendon reflexes in the LEs were absent.NoneNo320Bilateral ptosis and external ophthalmoplegiaProximal upper and lower limb weakness, neck flexion weaknessMarked truncal and limb ataxia were evident accompanied by impaired proprioception.AreflexiaNoneNo221Rapidly progressive numbness and tingling sensation in both hands and feet, generalized muscle weakness with multiple fallsSevere distal and proximal muscle weakness in both upper and lower extremitiesLoss of all sensory modalities in distal upper and lower extremitiesGeneralized areflexiaNoneNo422Muscular weakness in both legs and peripheral paresthesiasMuscular weakness in both legsFormication in both hands, bilateral hypoesthesia of the legs up to the upper thighAbsent tendon reflexes in both legsNoneNo123Progressive LE weaknessProgressive and ascending muscle weaknessWithout sensory lossAbsent deep tendon reflexesNoneNo424Tonically dilated pupil, gastrointestinal dysmotility, urinary retention, and profound orthostatic hypotensionWorsening dysarthria, generalized weaknessAscending paresthesias, absent proprioceptionAbsent deep tendon reflexesNoneNo525Painful paresthesia in the extremitiesProximal loss of antigravity power and loss of independent mobilitySensory lossAbsent reflexesNausea, postural hypotension constipationNo426Fatigue and bilateral LE weaknessProfound weakness in lower extremities, progressive loss of motor functionTingling sensation in feet, progressive loss of sensory functionLoss of deep tendon reflexes in all extremities associated with complete lack of strengthNoneRespiratory muscle paralysis527Pruritus, abdominal meteorism, and natiseaSymmetrical weakness in the 4 limbsMild bilateral hypoesthesia in the extremitiesDisappearance of deep tendon reflexesAbdominal meteorism and natiseaWorsening of the respiratory function628Paresthesias of the feet and fingertips and unsteady gaitA mild tetraparesisSensory loss in both hands and feetGeneralized areflexiaNoneNo529Dysesthesia (numbness and tingling) at the hands and feetRapidly ascending loss of motor functionRapidly ascending loss of sensory functionLoss of the deep tendon reflexesNoneRespiratory insufficiency530Paresthesia and hypoesthesia of all limbsRapidly followed by symmetrical motor weakness in legsPeripheral facial paralysisParesthesia and hypoesthesiaAreflexia in the legsNoneNo631Painful fingers and loss of tasteWeakness in all extremitiesSensory loss in all extremitiesAreflexia in both legsNoneRespiratory function was affected632Muscular pains in his arms and legs without paralysisLoss of motor functions in the hands and LEsLoss of sensor functions in the hands and LEsAreflexia of LEsNoneThe respiratory function preserved433Ascending weakness, paresthesia, and sensory loss progressiveWeakness of the legsSensory disturbances of the lower extremitiesAreflexiaNoneThe respiratory function preserved3LEs: lower extremities; UEs: upper extremities.Table 3
Electrophysiology, CSF, imaging, treatment, and clinical outcomes.
CaseNCS findingCSFImagingTreatmentOutcomeProtein(15-45 mg/dl)Cell (<5/μl)14 weeks after ICIs: not suggestive of neuropathy78 OL (+)17IVIG over 5 days for the first timeSignificant improvement in muscle weakness. 18 days after discharge, the disease developed an ascending paralysis of the extremities.44 days later: acute and chronic demyelinating polyneuropathy175 OL (-)3PLEX for 7 days and solumedrol for 5 days instead of IVIG for reoccurrenceMelanoma progression occurred about 1 year after the last dose of pembrolizumab. Rechallenging with ipilimumab. Only ongoing bilateral leg tingling and diarrhea2Acute motor and sensory axonal neuropathy58.338MRI of the brain and spinal cord was normal.Oral treatment with dexamethasone and then switched to IVIG along with prednisoneSymptoms improved during 1 week of treatment. After 1 month, walking and standing was normal.No recurrence of tumor3AIDP4054Spinal MRI: abnormal thickening and enhanced posterior nerve roots (L4-L5, L5-S1), no features of metastatic diseaseDexamethasone for 6 days and IVIG for 5 daysHydrocephalus, ventricular enlargement and bed-boundDied after withdraw from life support4Dysautonomia secondary to AIDP910IVIG+prednisone+PLEXLife-sustaining therapiesRespiratory distress, tachycardia, and hypotensionDied after withdrew life-sustain5AIDP12441Brain as well as the lumbar and thoracic spine MRI: no clear cord or cauda equina involvement despite spine metastasesIVIG for 5 daysRehabilitationNo other potential agents were given and alive 6 months after the use of last immunotherapies.6AIDP1058Spine MRI: severe stenosis of lumbar spinal canalIVIG for 5 days and methylprednisolone during 7 daysA rapid clinical improvement was observed within the first 3 days. Methylprednisone was tapered progressively over 10 weeks. Completely recovered. 6 months later, cancer remains stable.7MFS1755Brain and cervical spine MRI: normalIVIG and intravenous methylprednisone followed by oral prednisoloneSevere global limb weakness and respiratory decompensation developed after 3 days of IVIG.Respiratory function and motor weakness improved after 9 days of corticosteroid treatment.Rehabilitation after 3 months of treatment8AIDP1402Brain and cord MRI: nonspecific cerebral white-matter lesionsIVIG for 5 days along with prednisone for 1 monthImprovement.Disease progressed with increased number and size of lung metastases. Died from sepsis9AIDP882Brain and spinal MRI: no evidence of metastases or ischaemic and/or hemorrhagic lesionsMethylprednisoloneIVIG for 5 daysPrednisoneWithout clinical benefitLeg weakness, numbness in patient’s fingers, and paresthesia dramatically improved.A further improvement was obtained after 2 weeks of prednisolone.10Acute sensorimotor polyradiculoneuropathy with mixed axonal/demyelinating<45<5Spinal CT: normalIVIG for 5 days and prednisone 30 mg daily at the same time3 weeks later, improved rapidly and transition to pembrolizumab with no evidence of GBS11AIDP2300Spinal MRI: normalIVIGGood recovery12AMAN37 mg/dl but elevated IgG levels2PrednisoneIVIGSymptoms continued to worsen.Minimally improved but prevented further progression13AIDPNo lumbar puncture was performed.Spinal MRI: degenerative changes with no evidence of cord compressionMethylprednisone andIVIGPrednisone19 days after admission, weakness and numbness mostly resolved.1 month later, neurological recovery except for mild residual paresthesias of the feet14Multiple cranial neuropathy and AIDP3507Lumbar spine MRI: a reduction of gadolinium enhancement of nerve roots and cauda equinaIVIGSteroid pulse therapyMultiple cranial neuropathies were moderately improved after 4 weeks of treatment.Muscle weakness remarkably improved after the 3 courses of therapy.15AIDP680<5Methylprednisolone along with IVIGPLEXStrength diminished to 2/5 in the bilateral UEs and LEs.Respiratory status worsened.Respiratory status improved, and motor function gradually recovered.16AIDP560<5Brain CT: a hemorrhage within one of his metastatic lesions and associated vasogenic edemaMethylprednisolone along with IVIG for 5 daysPLEXAcute hypoxic respiratory failure, requiring mechanical ventilation. After five days of treatment without any clinical improvement.A hemorrhage within one of metastatic lesions and associated vasogenic edema. Died after the withdrawn of care17AIDP175Lymphocytic pleocytosisBrain and spinal MRI: abnormal enhancement involving the bilateral 5th, 7th and 8th cranial nerves, cauda equina nerve roots as well as the conus surface and peripheral nerves at the thoracolumbar junctionMethylprednisoloneMotor symptoms in hands and lower extremities improved rapidly after 2 days and gradually recovered over a 12-week period.Weakness resolved completely, residual minimal paresthesias18AIDP3394Prednisone (60 mg/day)IVIG (0.4 g/kg) for 5 daysSymptoms worsenedGradually improved3 months later, he was able to walk with a cane.19Asymmetric, subacute to early chronic and ongoing lumbar polyradiculoneuropathy with axonal involvement and demyelinating>3001Spinal MRI: diffuse enhancement surrounding the entire conus and all of the nerve rootsDexamethasonePartial response systemically and neurologic improvement6.5 months later, melanoma progressed.20MFS and demyelinating sensorimotor polyneuropathy1250IVIG 2 g/kg for 5 days and methylprednisolone followed by a weaning dose of oral prednisolonePLEXModest clinical improvementSignificant functional improvement and complete recovered at last. But melanoma had progressed.21AIDP860IVIG over 5 daysPrednisone 90 mg/dayDysphagia requiring nasogastric tube for feedingAfter 6 months, neurological condition improved significantly and the dysphagia completely was resolved. Numbness was still present but improved.22AIDP73<5IVIG for 5 daysMethylprednisoloneDid not lead to any clinical improvementClinical recovery started 48 h later and was nearly complete after 6 weeks.23Acute sensorimotor polyradiculopathy with mixed axonal/demyelinating features39<5Thoracic spine and lumbar spine CT: degenerative changesIVIGMarked improvement on treatment day 524GBS presenting as dysautonomia, a length-dependent, sensorimotor polyneuropathy with axonal and demyelinating propertiesNo lumbar puncture was performed.IVIGDysautonomia and weakness persisted, and cardiovascular and respiratory status improved by 2 months.Persistent urinary retention, oropharyngeal dysphagia, and generalized weakness25AMSAN with autonomic symptoms11515Spinal MRI: normalIVIG (0.4 g/kg/d) for 5 daysMethylprednisolone (1 g/d for 5 days, then 500 mg/d for 3 days) followed by tapering oral prednisone (1 mg/kg/d)PLEX (5 changes over 2 weeks, followed by weekly exchanges)Symptoms stabilized with mild improvement, yet one month later, it developed worsening weakness and ongoing painful paresthesia. Persistent nausea coupled with postural hypotensin and constipation6 weeks later (12 weeks after initial treatment), the patient had only mild weakness.9 months later, melanoma progressed.26GBS850Spine MRI: normalIVIG+PLEXWithin 2 hours, respiratory muscle paralyzed, and ventilator support was applied.She was extubated after 11 days and expired within a few hours.27Acute, generalized, symmetrical, and sensorimotor neuropathy, impossible to distinguish axonal or demyelinating disorder because of severe limb edema1600MethylprednisolonePLEXClinical status did not improve.Died of multivisceral failure within a few days28AMSAN890Cervical spine MRI: normalIVIGThe muscle strength of all limbs slightly increased. But 3 days later, died from respiratory insufficiency29AIDP167<2Brain and spinal MRI: normalMethylprednisoloneRecovery30AIDP56NormalPrednisoloneIVIGThe neurologic symptoms reached the peak within 3 weeks and decreased over the next 2 months.31MFS81 OL (+)NormalCentral nervous system imaging showed no cerebral or vertebral pathology.PrednisoloneIVIGPLEXA slight improvement with these treatments2 months later, died from pneumonia32GBS107.561PrednisoloneIVIGThe pain was greatly diminished.8 months later, the motor and sensor function of extremities were still slowly recovering.33GBS204.6 OL (+)NormalPrednisoloneIVIGMethylprednisoloneThe mild persistent weakness of his feet extensors and mild sensory loss and ataxiaAIDP: acute inflammatory demyelinating polyradiculoneuropathy; MFS: Miller Fisher syndrome; IVIG: intravenous immunoglobulin; PLEX: plasma exchange; AMAN: acute motor axonal neuropathy; AMSAN: acute motor and sensory axonal neuropathy; OL: oligoclonal bands.


### 3.1. Demographic Characteristics

GBS cases (n=33) were from the United State (n=13), United Kingdom (n=3), Japan (n=2), Italy (n=2), Belgium (n=2), Australia (n=2), China (n=1), Greece (n=1), Netherlands (n=4), France (n=2), and German (n=1) (Table 1). Of the 33 cases, twenty-six of these cases were male and seven were female, with an average of 62.2±11.1 years (median: 65 years and range: 37-81 years). There was a male preponderance in 33 ICI-associated GBS patients we collected, with 3.7 times as many cases as female (26 vs. 7 cases: 78.8% vs. 21.2%). There was a significant difference between male and female ages at onset (mean: 64.4±10.3 vs. 54.1±11.1 years, P=0.0278). The reports of comorbidities were variable, and no epidemics of specific diseases had been observed, so we did not analyze the comorbidities.


### 3.2. Immune Checkpoint Inhibitors and Tumor Type

Of ICI-associated GBS patients, sixteen patients exposed to nivolumab, eleven patients were investigated with ipilimumab, and seven patients were treated with pembrolizumab. Of these, four patients received nivolumab in combination with ipilimumab, and one patient received nivolumab in combination with pembrolizumab. In the above cases, the types of tumor the patients suffered from were melanoma (n=20) [13, 14, 16, 17, 23, 24, 28, 29, 31–37, 39–42], lung tumor (n=7) [18, 21, 25, 26, 28, 30, 38], urinary tumor (n=5) [13, 15, 19, 20, 22], and nasal cancer (n=1) [27]. The details were summarized in Tables 4 and 5.Table 4
Tumor type and immune checkpoint inhibitors.
Tumor typeMonotherapyCombination therapyPembrolizumabNivolumabIpilimumabNivolumab and ipilimumabPembrolizumab and nivolumabMelanoma (20)(M:F=14:6)6374Lung cancer (7)(M:F=6:1)NSCLS (1)1SCLS (1)1Adenocarcinoma (4)22Squamous cell carcinoma (1)1Urinary tumor (5)M: 5RCC (2)11Urothelial carcinoma (1)1Bladder cancer (1)Prostate cancer (1)11Nasal cancer (1)M: 11NSCLS: non-small-cell lung cancer; SCLS: small-cell lung cancer; RCC: renal cell carcinoma.Table 5
Treatment and prognosis of ICIs-GBS.
Treatment (n=33)ProgressionRecoveryResidual dysfunctionDeathIVIG (n=3)21IVIG+steroid (n=16)862IVIG+PLEX (n=1)1IVIG+steroid+PLEX (n=7)223Steroid (n=5)131Steroid+PLEX (n=1)1Total13119IVIG: intravenous immunoglobulin; PLEX: plasma exchange.


### 3.3. Clinical Features of GBS Spectrum

The onset time of symptoms in 32 patients was analyzed, and the results suggested that the median time was 8.2 weeks after the initiation of ICI treatments. The minimum was 0.7 weeks (5 days) [37], and the maximum was 59 weeks [19]. As shown in Table 1, the time to neurological plateau was mentioned in 23 cases, with an average of 16.0±8.4 days (range 7-44 days). The most common manifestations of GBS associated with ICIs were weakness (93.9%, 31/33), hyporeflexia or areflexia (90.9%, 30/33), and paresthesia (81.8%, 27/33). Among them, sensory symptoms and paraparesis or tetraparesis cooccurred in 45.5% (15/33) of cases. Other less common symptoms included cranial nerve involvement (20.7%, 7/33), dysphagia or dysarthria (18.2%, 6/33), respiratory symptoms (21.2%, 6/33), and ataxia (9.1%, 3/33). There were also 2 rare cases of GBS patients with dysautonomia as the onset symptoms [17, 36]. The Hughes Functional Grading Scale (HFGS) [43] was used to evaluate the clinical severity, and higher numbers indicated more severe disability. The average was 3.85±1.42, with a high score of 6 and a low score of 1 (Table 2).


### 3.4. Electrophysiological, CSF, and Imaging Results

Twenty-seven patients underwent electrophysiological examination, and 18 cases had detailed electrophysiological reports. In the remaining cases, only the GBS subtype was mentioned. 54.5% (18/33) of cases were consistent with AIDP [16–19, 21, 22, 24, 26–30, 33, 34, 39, 42] and axonal damage accounted for 12.1% (4/33, AMSAN: 3 and AMAN: 1) [15, 23, 25, 27]. The subtypes in four cases were equivocal because they showed mixed features of axonal injury and demyelination [23, 31, 35, 36]. There were also three cases, two with MFS [13, 20] and the other with MFS-GBS overlap [32]. Regrettably, there were two cases of GBS diagnosis with no mention of subtypes [13, 38, 40].CSF analysis was performed in 31 out of the 33 cases. The average protein level of CSF in patients with GBS related to ICIs was180.68±152.51 mg/dl (range: 37-680 mg/dl). 63.6% of the cases (21/33) presented with typical albuminocytological dissociation (cells≤5/μl and CSFprotein>45 mg/dl) [14, 16, 20–22, 24, 28, 30–34, 38, 40–42]. The median value of CSF protein was 124.5 mg/dl (range: 73-680 mg/dl). Slight pleocytosis (i.e., cellcount>5/μl) was detected in 4/33 cases (12.1%) with a maximum cell count of 15/μl and a median CSF protein of 115 mg/dl [15, 19, 27, 37]. CSF protein values and cell counts were normal in three cases [23, 25, 35], and there was elevated CSF immunoglobulin G levels in one case [25].MRI was performed in 54.5% (18/33) of cases, of which both brain and spinal cord were examined in 8 cases and only spinal cord was 10 cases. MRI results showed nerve root involvement in 4 cases [16, 27, 29, 31], severe spinal stenosis in 1 case [19], cranial nerve involvement in 1 case, and normal or no metastatic signs in the rest [29].


### 3.5. Treatment and Prognosis of GBS

Twenty-seven cases (81.8%) were treated with intravenous immunoglobulin (IVIG), sixteen of the 27 patients with a combination of steroid therapy and one with PLEX. Seven of the 27 patients were treated with all three treatments. Five cases were treated with steroid therapy alone, and one case was treated with steroid combined with PLEX. No patients were treated with PLEX alone.After treatment, 24 cases (72.7%) recovered or had only mild residual dysfunction, with two of them rechallenged ipilimumab [14] or pembrolizumab [21], and 5 cases had residual mild paresthesia [13, 14, 26, 29, 33]. Among the 33 ICIS-related GBS patients, 5 patients developed tumor progression after discontinuation of ICIS treatment, including 4 patients with melanoma [14, 31, 32, 37] and 1 patient with bladder cancer [22]. Of the eight deaths, three died of the respiratory muscle paralysis caused by GBS [17, 38, 41], 2 died of infection [13, 39], and three were due to progression of the tumor caused by ICI discontinuation [16, 28, 40].


## 3.1. Demographic Characteristics

GBS cases (n=33) were from the United State (n=13), United Kingdom (n=3), Japan (n=2), Italy (n=2), Belgium (n=2), Australia (n=2), China (n=1), Greece (n=1), Netherlands (n=4), France (n=2), and German (n=1) (Table 1). Of the 33 cases, twenty-six of these cases were male and seven were female, with an average of 62.2±11.1 years (median: 65 years and range: 37-81 years). There was a male preponderance in 33 ICI-associated GBS patients we collected, with 3.7 times as many cases as female (26 vs. 7 cases: 78.8% vs. 21.2%). There was a significant difference between male and female ages at onset (mean: 64.4±10.3 vs. 54.1±11.1 years, P=0.0278). The reports of comorbidities were variable, and no epidemics of specific diseases had been observed, so we did not analyze the comorbidities.


## 3.2. Immune Checkpoint Inhibitors and Tumor Type

Of ICI-associated GBS patients, sixteen patients exposed to nivolumab, eleven patients were investigated with ipilimumab, and seven patients were treated with pembrolizumab. Of these, four patients received nivolumab in combination with ipilimumab, and one patient received nivolumab in combination with pembrolizumab. In the above cases, the types of tumor the patients suffered from were melanoma (n=20) [13, 14, 16, 17, 23, 24, 28, 29, 31–37, 39–42], lung tumor (n=7) [18, 21, 25, 26, 28, 30, 38], urinary tumor (n=5) [13, 15, 19, 20, 22], and nasal cancer (n=1) [27]. The details were summarized in Tables 4 and 5.Table 4
Tumor type and immune checkpoint inhibitors.
Tumor typeMonotherapyCombination therapyPembrolizumabNivolumabIpilimumabNivolumab and ipilimumabPembrolizumab and nivolumabMelanoma (20)(M:F=14:6)6374Lung cancer (7)(M:F=6:1)NSCLS (1)1SCLS (1)1Adenocarcinoma (4)22Squamous cell carcinoma (1)1Urinary tumor (5)M: 5RCC (2)11Urothelial carcinoma (1)1Bladder cancer (1)Prostate cancer (1)11Nasal cancer (1)M: 11NSCLS: non-small-cell lung cancer; SCLS: small-cell lung cancer; RCC: renal cell carcinoma.Table 5
Treatment and prognosis of ICIs-GBS.
Treatment (n=33)ProgressionRecoveryResidual dysfunctionDeathIVIG (n=3)21IVIG+steroid (n=16)862IVIG+PLEX (n=1)1IVIG+steroid+PLEX (n=7)223Steroid (n=5)131Steroid+PLEX (n=1)1Total13119IVIG: intravenous immunoglobulin; PLEX: plasma exchange.


## 3.3. Clinical Features of GBS Spectrum

The onset time of symptoms in 32 patients was analyzed, and the results suggested that the median time was 8.2 weeks after the initiation of ICI treatments. The minimum was 0.7 weeks (5 days) [37], and the maximum was 59 weeks [19]. As shown in Table 1, the time to neurological plateau was mentioned in 23 cases, with an average of 16.0±8.4 days (range 7-44 days). The most common manifestations of GBS associated with ICIs were weakness (93.9%, 31/33), hyporeflexia or areflexia (90.9%, 30/33), and paresthesia (81.8%, 27/33). Among them, sensory symptoms and paraparesis or tetraparesis cooccurred in 45.5% (15/33) of cases. Other less common symptoms included cranial nerve involvement (20.7%, 7/33), dysphagia or dysarthria (18.2%, 6/33), respiratory symptoms (21.2%, 6/33), and ataxia (9.1%, 3/33). There were also 2 rare cases of GBS patients with dysautonomia as the onset symptoms [17, 36]. The Hughes Functional Grading Scale (HFGS) [43] was used to evaluate the clinical severity, and higher numbers indicated more severe disability. The average was 3.85±1.42, with a high score of 6 and a low score of 1 (Table 2).


## 3.4. Electrophysiological, CSF, and Imaging Results

Twenty-seven patients underwent electrophysiological examination, and 18 cases had detailed electrophysiological reports. In the remaining cases, only the GBS subtype was mentioned. 54.5% (18/33) of cases were consistent with AIDP [16–19, 21, 22, 24, 26–30, 33, 34, 39, 42] and axonal damage accounted for 12.1% (4/33, AMSAN: 3 and AMAN: 1) [15, 23, 25, 27]. The subtypes in four cases were equivocal because they showed mixed features of axonal injury and demyelination [23, 31, 35, 36]. There were also three cases, two with MFS [13, 20] and the other with MFS-GBS overlap [32]. Regrettably, there were two cases of GBS diagnosis with no mention of subtypes [13, 38, 40].CSF analysis was performed in 31 out of the 33 cases. The average protein level of CSF in patients with GBS related to ICIs was180.68±152.51 mg/dl (range: 37-680 mg/dl). 63.6% of the cases (21/33) presented with typical albuminocytological dissociation (cells≤5/μl and CSFprotein>45 mg/dl) [14, 16, 20–22, 24, 28, 30–34, 38, 40–42]. The median value of CSF protein was 124.5 mg/dl (range: 73-680 mg/dl). Slight pleocytosis (i.e., cellcount>5/μl) was detected in 4/33 cases (12.1%) with a maximum cell count of 15/μl and a median CSF protein of 115 mg/dl [15, 19, 27, 37]. CSF protein values and cell counts were normal in three cases [23, 25, 35], and there was elevated CSF immunoglobulin G levels in one case [25].MRI was performed in 54.5% (18/33) of cases, of which both brain and spinal cord were examined in 8 cases and only spinal cord was 10 cases. MRI results showed nerve root involvement in 4 cases [16, 27, 29, 31], severe spinal stenosis in 1 case [19], cranial nerve involvement in 1 case, and normal or no metastatic signs in the rest [29].


## 3.5. Treatment and Prognosis of GBS

Twenty-seven cases (81.8%) were treated with intravenous immunoglobulin (IVIG), sixteen of the 27 patients with a combination of steroid therapy and one with PLEX. Seven of the 27 patients were treated with all three treatments. Five cases were treated with steroid therapy alone, and one case was treated with steroid combined with PLEX. No patients were treated with PLEX alone.After treatment, 24 cases (72.7%) recovered or had only mild residual dysfunction, with two of them rechallenged ipilimumab [14] or pembrolizumab [21], and 5 cases had residual mild paresthesia [13, 14, 26, 29, 33]. Among the 33 ICIS-related GBS patients, 5 patients developed tumor progression after discontinuation of ICIS treatment, including 4 patients with melanoma [14, 31, 32, 37] and 1 patient with bladder cancer [22]. Of the eight deaths, three died of the respiratory muscle paralysis caused by GBS [17, 38, 41], 2 died of infection [13, 39], and three were due to progression of the tumor caused by ICI discontinuation [16, 28, 40].


## 4. Discussion

The effects of checkpoint inhibition affect a wide range of system and trigger a wide range of autoimmune toxicity. The exact mechanism of neurological irAEs in ICI-treated patients is unknown [44]. The existence of shared antigens between the tumor and itself may be one possible mechanism, such as gangliosides found in both melanoma and Schwann cells [45]. ICI-related GBS is rare as a type of neurological irAEs, but it can develop into life-threatening consequence once occurred. Diagnosis of ICI-related GBS should be made in the shortest possible time so as not to delay the administration of immune-regulation therapy.There was a male preponderance in 33 ICI-related GBS patients we collected, with 3.71 times as many cases as female (male 26 and female 7). However, among GBS triggered by infection, males were affected only 1.5 times more frequently than females [11]. An epidemiological study on the risk factors of melanoma showed that the incidence of melanoma of men was almost three times that of by women by the age of 75 [12]. The incidence of lung tumor in men has historically been higher than in women, although the incidence of lung tumor in women has risen since the 1960s, especially in younger women [46–48]. Perhaps the higher incidence of cancer in men, resulting in more opportunities for men to use ICIs, was one of the reasons for the higher incidence of ICI-related GBS. Besides, ICIs were more effective for male cancer patients than female patients [49]. And the development of irAEs was related to the beneficial effects of immunotherapy in malignant tumors, especially in advanced-stage melanoma, advanced and metastatic NSCLC, and advanced renal cell carcinoma (RCC) [50]. The high effectiveness of ICI treatment in male patients may be also responsible for the male preponderance in ICI-related GBS.In this study, melanoma had the largest number of tumor type that caused GBS after ICI treatment. Neurological irAEs were rare, with an incidence of less than 3% [8], whereas the overall incidence of severe nerve injury in melanoma patients treated with nivolumab with or without ipilimumab reached 0.93% [7], nearly one-third of the total neurological irAEs. Well know, GBS is a multifactorial autoimmune disorder, cell-mediated immunity plays an important role in immunopathology of all types of GBS. The activation of T cell caused by bacterial and virus leads to the production of cytokines and the release of free radicals, thus resulting in segmental demyelination [51]. And the cross-reaction between B-cell autoantibodies and axon gangliosides leads to axonal degradation [51]. Melanocytes and Schwann cells originate from the neural crest and have many common epitopes in humoral and cellular immune responses [52]. T cells regulate the degree of initial response of T cells by upregulating CTLA-4, while PD-1 inhibits the response of T cells in peripheral tissues and plays an important role in immune self-tolerance [53]. Due to the cross-reaction of molecular mimicry, T cell-mediated autoimmunity against melanoma cell antigens may also have an effect on the myelin antigens on Schwann cell membranes. In addition, the response rate of melanoma to ICIs was higher than other tumors [54]. A FAERS database-based clinical study also showed that patients with melanoma or non-small-cell lung cancer maybe at higher risk of fatal neurologic AEs [55]. Therefore, the author speculated that melanoma patients were more likely to develop GBS after ICI treatment than other types of tumors.Existing reports suggested that the overall incidence of neurological adverse events (nAEs) at all levels was 3.8% for anti-CTLA-4 and 6.1% for anti-PD-1/PD-L1 [56]. CTLA-4 and its ligands are only expressed on immune cells, while PD-1 and PD-L1 (ligands of PD-1) are expressed on both immune and nonimmune cells in peripheral tissues [57]. The difference in spatial distribution between the CTLA-4 and PD-1 pathways may explain the high incidence of GBS in patients treated with nivolumab.Many literatures had reported the timing of irAEs onset after the initiation of ICI treatments. The skin manifestations appeared at 2-3 weeks, and immune-mediated colitis, hepatitis, pneumonitis, and nephritis appeared approximately 5-10 weeks, 12-16 weeks, 8-14 weeks, and 14-42 weeks, respectively. Endocrine dysfunctions appeared from 9 weeks [58]. At present, there is no literature on the time to onset of neurologic symptom related to GBS caused by ICIs. The initial time of symptoms in 33 patients in this article was analyzed, and the results suggested that the median time was 8.2 weeks after the initiation of ICI treatments. Compared with GBS caused by infectious triggers, neurologic symptom appeared much later. This conclusion was expected to be helpful for the rapid diagnosis of ICIs-GBS.Of the 33 GBS related to ICI patients we collected, the initial symptoms were very similar to infection-triggered GBS. Lumbar puncture was performed, and CSF analysis revealed elevated protein levels and albuminocytologic dissociation. A study of 962 patients with infection-induced GBS showed that the average protein level was113.8±11.8 mg/dl (range: 18–450 mg/dl) [59]. In this study, the average protein level of CSF in patients with GBS related to ICIs was 180.68±152.51 mg/dl (range: 37-680 mg/dl). From a numerical point of view, the levels of CSF protein level of ICI-related GBS seemed to be higher than those of GBS induced by infection. Although it was not possible to distinguish infection-induced GBS from ICI-induced GBS based on CSF protein levels, lumbar puncture and protein-cell-separation were valuable in differentiating a variety of diseases such as spinal cord compression, metabolic diseases, side effects of drugs, vasculitis, and chronic inflammatory demyelinating polyneuropathy. In addition to elevated protein levels, lymphocytosis may also occur [37]. A similar pattern was observed in this study, with 4 patients showing a mild lymphocytosis in the CSF. However, multiple cases had been reported of lymphocytosis in the CSF of patients with infection-induced GBS [60–63]. Obviously, lymphocytosis in the CSF was not a characteristic of ICI-related GBS.The electrophysiological results detailed in this study indicated that ICI-related GBS was a generalized, sensorimotor polyneuropathy characterized by mixed axonal/demyelination. An electrophysiological study of ICI-related peripheral neuropathy showed that immune-mediated neuropathy mainly manifested as demyelination of motor nerves, followed by length dependent axonal loss in sensory nerve [60]. The results of this study were in part consistent with the above conclusions. No matter what kind of electrophysiological changes were closely related to the autoimmune response of ICIs against peripheral nerve tissue, the onset of symptoms of neuropathy was closely related to ICI treatment, and corticosteroid or immune-regulatory therapy had good results.In the treatment of all 33 patients, the immediate discontinuation of ICIs was an uncontroversial decision. Most patients received IVIG after discontinuation, with 16 patients receiving both IVIG and steroid therapy. Despite steroids were generally not recommended for treatment in infection-induced GBS, in ICI-related GBS, both American Society of Clinical Oncology (ASCO) Clinical Practice Guideline and National Comprehensive Cancer Network (NCCN) guidelines stated that trial of (methyl) prednisolone 1-2 mg/Kg was reasonable [64, 65], especially when CSF pleocytosis was higher than being anticipated for GBS [10]. And if the symptoms deteriorated, plasma exchange or IVIG treatment could be considered [66].Among the 33 ICI-related GBS patients, 5 patients developed tumor progression after discontinuation of ICI treatment. One of the four patients with progressed melanoma rechallenged different class of immunotherapy, with significant and sustained response nearly 1 year later and no recurrence of GBS-like neuropathy. Whether or not to retreat with ICIs and whether to retreat with the same or different ICIs are challenges for oncologists. There is also limited data on the clinical efficacy and safety of retreatment. The current guidelines suggested that corticoid therapy and temporary or permanent discontinuing ICIs were required forgrade≥2 irAEs and permanently discontinuing ICI treatment for grade 4 irAEs [65, 67]. A study had shown that the recurrence rate of the same irAEs resulting in discontinuation of ICI treatment in cancer patients who rechallenged the same ICI was 28.6% (anti-PD-1 or anti-PD-L1 monotherapy), 47.4% (anti-CTLA-4 monotherapy), and 43.5% (combination therapy), respectively [66]. The recurrence rate of irAEs varied depending on the organ involved in the initial irAEs, with gastrointestinal irAEs having the highest recurrence rate [68]. And the variables associated with a higher recurrence rate of irAEs were anti-CTLA-4 regimen, age, colitis, hepatitis, and pneumonia, in order [68]. In addition, the duration from ICI discontinuation to rechallenge, and the severity of the initial irAEs did not predict whether irAEs would reappear after rechallenge of ICIs [69]. However, no relevant literature has been reported on whether discontinuation due to ICI-related GBS can rechallenge the same or different ICIs again.In addition, paraneoplastic peripheral neuropathy should be excluded in the diagnosis of ICI-related GBS. Paraneoplastic peripheral neuropathy is a remote effect of the malignancy mediated by the immune system. It develops prior or during a cancer and is independent of tumor infiltration or cancer therapy [70]. Paraneoplastic sensory neuropathy is the most frequent in this group of disorders, and motor, autonomic, or central nervous systems are also involved [71]. Date on the treatment of paraneoplastic peripheral neuropathy is limited, and the combination of malignancy therapy with immunomodulatory therapies such as corticosteroids, IV immunoglobulin, or immunosuppressants may be effective [72]. However, ICI-related GBS occurred in malignant tumors after ICI treatment, and the immunomodulatory therapeutic effect was obvious. This is the most obvious difference between the two.Here are also several limitations in this study. First, the number of the included cases was small which limited us to perform subgroup analysis. Second, patients with various cancers were included, which might have bias in the incidence of some adverse effects.


## 5. Conclusion

Elderly male patients with melanoma were most likely to develop ICI-related GBS. And the median duration was 8.2 weeks after the initial ICI treatment. In order to make a final diagnosis, physicians need to collect specific neurological symptoms and signs and combine them with CSF analysis and electrophysiological examination. In addition, imaging is required to exclude tumor metastasis. Immediate termination of ICIs followed by IVIG in combination with high-dose steroids therapy or PLEX and supportive treatment could lead to a better prognosis.



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