Early intravenous immunoglobulin treatment in paraneoplastic neurological syndromes with onconeural antibodies
2018
Paraneoplastic neurological syndromes (PNS) are immune-mediated complications of cancer, characterised by relentless progression. The mainstay of PNS treatment is the achievement of tumour remission,1 while immunotherapy provides only little additional benefit.2 3 However, in historical series, immunotherapy was initiated over 6 months after neurological onset and, at that stage, neuronal loss is already extensive and irreversible.
Among available immunotherapies, intravenous immunoglobulin (IVIg) has been used in single cases4 and in one retrospective series,3 showing some efficacy when administered timely.4 Based on these findings, we designed a prospective study to assess the efficacy and safety of early IVIg treatment in patients with PNS.
### Study design
This prospective, multicentre, non-comparative, phase II clinical study was performed by the ‘Centre de Reference Francais des Syndromes Neurologiques Paraneoplasiques’. Written informed consent was obtained from all participants. This trial is registered at ClinicalTrials.gov (NCT02343211).
### Participants
Inclusion criteria were: (1) diagnosis of ‘definite’ PNS5; (2) anti-Hu, anti-Yo, or anti-CV2/CRMP5 antibodies in the serum and/or in the cerebrospinal fluid; (3) neurological symptom onset within 6 months; (4) modified Rankin Score (mRS) 2 or 3; (5) neurological deterioration over the last 3 weeks. Exclusion criteria were: (1) other concomitant immunotherapy; (2) absolute contraindications to IVIg (hypersensitivity to IVIg, selective IgA deficiency); (3) thrombophilia; (4) renal insufficiency (creatinine clearance <30 mL/min).
### Interventions
Enrolled patients received three cycles of IVIg (Privigen, 2 g/kg, every 4 weeks), followed by an interim evaluation. If the patient was stable or improved according to the primary outcome measure, three additional IVIg cycles were administered. If the patient deteriorated, IVIg was discontinued. Final evaluation was performed at 6 months.
The primary endpoint was improvement on the mRS at 3 months …
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