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Imaging in immune checkpoint inhibitor-induced polymyalgia rheumatica
  1. Kornelis S M van der Geest1,
  2. Maria Sandovici1,
  3. Abraham Rutgers1,
  4. T Jeroen N Hiltermann2,
  5. Sjoukje F Oosting3,
  6. Riemer H J A Slart4,5,
  7. Elisabeth Brouwer1
  1. 1Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
  2. 2Pulmonology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
  3. 3Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
  4. 4Radiology and Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
  5. 5Biomedical Photonic Imaging, University of Twente, Enschede, Overijssel, Netherlands
  1. Correspondence to Dr. Kornelis S M van der Geest, Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, 9712 CP Groningen, Netherlands; k.s.m.van.der.geest{at}umcg.nl

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We read with great interest the article ‘Addressing immune-related adverse events of cancer immunotherapy: how prepared are rheumatologists?’ by Kostine et al.1 The introduction of immune checkpoint inhibitor (ICI) therapy has been a major breakthrough in the management of metastatic cancer. On the downside, ICI therapy may induce unwanted autoimmune effects, the so-called immune-related adverse effects (irAEs). Various irAEs have been described that resemble a regular rheumatic disease, including polymyalgia rheumatica (ICI-PMR).2 3 The authors report that rheumatologists may lack confidence in diagnosing irAEs. Therefore, recommendations for the diagnosis of rheumatic irAEs are needed. Based on our experience with ICI-PMR, we propose that imaging could be an important part of such recommendations.

We investigated six consecutive patients with ICI-PMR by ultrasonography, and five of these patients also by [18F]-fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) scan. Five patients fulfilled the provisional American College of Rheumatology/European League Against Rheumatism classification criteria for PMR.4 A normal C-reactive protein level in the absence of an erythrocyte sedimentation rate (ESR) test precluded PMR classification in one patient. However, this patient fulfilled both the clinical and ultrasound criteria for PMR,4 and showed findings suggestive of PMR on the FDG-PET/CT scan.5 The median age was 73 years (range 59–83; online supplementary table 1). Patients received anti-programmed cell death protein 1 (PD-1) treatment, that …

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