Tamponade during immune checkpoint inhibitors therapy in lung cancer: case-reports and systematic review of the literature

Introduction

Immune therapy is a new option that has revolutionized cancer therapy. Immune checkpoint inhibitors target mostly either PD-1 (Pembrolizumab, Nivolumab) or PD-L1 (Durvalumab). Immune-related cardiotoxic side effects, among them, tamponade, initially thought to be rare, seem to be increasingly cited in the literature. Moreover, tobacco smoking is linked to 80% of lung cancers. Smoking during cancer therapy may influence on radiotherapy and chemotherapy outcomes but little is known on immunotherapy.

Purpose

We aimed to review all the published cases of tamponade during immune therapy for lung cancer and to report all the cases that occurred in the University Hospital Ambroise Paré. We also wanted to highlight the possible impact of tobacco on immunotherapy.

Methods

We conducted a literature review in the PubMED database, from database inception up to 02/14/2020, with a combination of the following terms: “tamponade AND ((immune checkpoint inhibitors) OR (PD-1) OR (PD-L1))”. We also reported all the tamponade cases occurred in our hospital from the beginning of immune checkpoint inhibitors therapy existence up to 02/14/2020.

Results

Seventeen cases citing tamponade were identified in the literature to which we added 3 cases from our hospital. Mortality rate at 1 month was of 20%. Nivolumab was involved in 80%, Pembrolizumab in 10% and Durvalumab in 10%. In 75%, lung cancer was with a stage IV. Men accounted for 85% and mean age was of 62 years. Active smokers represented 85% and passive smokers existed in 5%, after diagnosis, smoking cessation was done in 10%. Tamponade occurred either shortly after the first administrations but also after several doses. Pericardial fluid cytology revealed malignant cells in half of the cases and microbiology was always negative. For all the cases, excepted for one who was directly considered as palliative, an evacuation of the pericardial fluid was done. In 45% a corticotherapy was initiated. Two cases quickly worsened after pericardial evacuation by unmasking a probable myocarditis with cardiogenic shock which needed the use of a veno-arterial extracorporeal membrane oxygenation.

Conclusions

Tamponade under immune checkpoint inhibitors therapy appears less rare than initially thought and mortality rate at one month was not negligible. The use of regular echocardiography during this immune therapy may be crucial in detecting early stages of the disease process and smoking cessation should also be advised for these patients. The prevalence of complications among all the patients both exposed to immune therapy and tobacco could not be calculated in this work (case-reports), but some recent studies may indicate survival gains of smoking cessation. Further research establishing more specific guidelines is naturally necessary in dealing with this potentially fatal effect but also in establishing the possibly additional role of smoking in the cardiotoxicity of immunotherapy.

Funding Acknowledgement

Type of funding source: None

[Five years' experience of cosmetic camouflage of disfiguring skin disorders: Patient satisfaction]

INTRODUCTION

Living with disfiguring disorders can impair the emotional well-being and relationships of patients as well as their social and professional life. Since 2010, courses in medical cosmetic correction for disfiguring diseases have been conducted at the dermatology department of the Timone University Hospital in Marseille and they form part of an educational program. The aim of this study was to assess the satisfaction of patients taking part in this program.

PATIENTS AND METHODS

This is a retrospective study of 55 patients taking part in make-up sessions from January 2010 to December 2014 and subsequently completing a questionnaire.

RESULTS

The median patient age was 46 years with most being women (n=49, 89 %). They presented pigmentary disorders (54.5 %), inflammatory diseases (27.3 %) and scars (18.2 %). 75 % of patients stated that they had improved their knowledge and 82 % remarked that the technique was personalized to their needs. The technique was considered as easy by 62 % and reproducible by 87 % of patients. 55 % of patients considered that cosmetic camouflage improved their quality of life and 56 % stated that it helped them accept the gaze of others.

CONCLUSION

In our study skin camouflage appears easy to use and meets patient expectations.

P1494Usefulness of longitudinal strain adjusted to regional thickness in hypertrophic cardiomyopathy

Background

In hypertrophic cardiomyopathy (HCM), longitudinal strain analysis allows to early detect left ventricular (LV) contraction abnormalities despite preserved LV ejection fraction. In current software, the width of the region of interest (ROI) is the same over the entire myocardial wall, and might analyze partially LV hypertrophic segments.

Purpose

The aim of this study is to evaluate a novel software for strain analysis with an adjustable ROI according to each segment thickness.

Methods

We included 110 patients: 55 patients with HCM (HCM group) and 55 healthy subjects (age- and sex-matched control group). All patients underwent echocardiography using a Vivid 9 GE system and measurements were performed using EchoPAC software. Global longitudinal strain (GLS) and regional strain for each of the 17 segments was calculated with standard software (for 2 groups) and with software adjusted to the myocardial wall thickness (for HCM group).

Results

GLS was significantly decreased in the HCM group as compared to the control group (−15.1±4.8% versus −20.5±4.3%, p<0.0001). In HCM group, GLS (standard method versus adjusted to thickness) were not significantly different (p=0.34). Interestingly, regional strain adjusted to thickness was significantly lower than standard strain in hypertrophic segments, especially in basal inferoseptal segment (p=0.0002), median inferoseptal segment (p<0.001) and median anteroseptal segment (p=0.02). Strain adjusted to thickness was still significantly lower in the most hypertrophic segments (≥20 mm) (−3.7±3%, versus −5.9±4.4%, p=0.049 in the basal inferoseptal segment and −5.7±3.5% versus −8.3±4.5%, p=0.0007 in the median inferoseptal segment). Analysis of strain adjusted to thickness had a better feasibility (97.5% versus 99%, p=0.01).

Conclusion

Analysis of longitudinal strain adjusted to regional thickness is feasible in HCM and allows a better evaluation of myocardial deformation, especially in the most LV hypertrophic segments.

Age-specific characteristics of neutrophilic dermatoses and neutrophilic diseases in children

BACKGROUND

Our suggested 'modern' concepts of 'neutrophilic dermatoses' (ND) and 'neutrophilic disease' were based on observations in adult patients and have not been studied in paediatric patients. Only a minority of ND occurs in children, and little is known about age-specific characteristics.

OBJECTIVES

To describe age-specific characteristics of ND in children and to study whether our suggested 'modern' classification of ND may be applied to children.

METHODS

We conducted a retrospective multicentre study in a French cohort of 27 paediatric patients diagnosed with pyoderma gangrenosum (PG) or Sweet's syndrome (SS).

RESULTS

Demographics and distribution of typical/atypical forms were similar in patients diagnosed with PG and SS. Atypical ND were more frequent in infants (90%), when compared to young children (60%) and adolescents (33%). Neutrophilic disease was observed in 17/27 patients and was most frequent in infants. Neutrophilic disease of the upper respiratory tract, as well as cardiac neutrophilic disease, was only observed in infants, whereas other locations were similarly found in infants, young children and adolescents. In infants and young children, ND were associated with a large spectrum of general diseases, whereas in adolescents associations were limited to inflammatory bowel disease and Behçet's disease.

CONCLUSIONS

Our study describes the concept of ND in paediatric patients and shows that they have some characteristics different from ND occurring in adults. ND occurring in infants can be associated with a large spectrum of general diseases. Occurrence of neutrophilic disease is frequent in children. Thus, ND occurring in young paediatric patients should incite clinicians to schedule complementary explorations in order to search for involvement of other organs and to rule out monogenetic autoinflammatory syndromes.

Dermatological manifestations in Noonan syndrome: a prospective multicentric study of 129 patients positive for mutation

BACKGROUND

Data on dermatological manifestations of Noonan syndrome (NS) remain heterogeneous and are based on limited dermatological expertise.

OBJECTIVES

To describe the dermatological manifestations of NS, compare them with the literature findings, and test for dermatological phenotype-genotype correlations with or without the presence of PTPN11 mutations.

METHODS

We performed a large 4-year, prospective, multicentric, collaborative dermatological and genetic study.

RESULTS

Overall, 129 patients with NS were enrolled, including 65 patients with PTPN11-NS, 34 patients with PTPN11-NS with multiple lentigines (NSML), and 30 patients with NS who had a mutation other than PTPN11. Easy bruising was the most frequent dermatological finding in PTPN11-NS, present in 53·8% of patients. Multiple lentigines and café-au-lait macules (n ≥ 3) were present in 94% and 80% of cases of NSML linked to specific mutations of PTPN11, respectively. Atypical forms of NSML could be associated with NS with RAF1 or NRAS mutations. In univariate analysis, patients without a PTPN11 mutation showed (i) a significantly higher frequency of keratinization disorders (P = 0·001), including keratosis pilaris (P = 0·005), ulerythema ophryogenes (P = 0·0001) and palmar and/or plantar hyperkeratosis (P = 0·06, trend association), and (ii) a significantly higher frequency of scarce scalp hair (P = 0·035) and scarce or absent eyelashes (P = 0·06, trend association) than those with PTPN11 mutations.

CONCLUSIONS

The cutaneous phenotype of NS with a PTPN11 mutation is generally mild and nonspecific, whereas the absence of a PTPN11 mutation is associated with a high frequency of keratinization disorders and hair abnormalities.

Dermatological manifestations in cardiofaciocutaneous syndrome: a prospective multicentric study of 45 mutation-positive patients

BACKGROUND

Data on dermatological manifestations of cardiofaciocutaneous syndrome (CFCS) remain heterogeneous and almost without expert dermatological classification.

OBJECTIVES

To describe the dermatological manifestations of CFCS; to compare them with the literature findings; to assess those discriminating CFCS from other RASopathies, including Noonan syndrome (NS) and Costello syndrome (CS); and to test for dermatological phenotype-genotype correlations.

METHODS

We performed a 4-year, large, prospective, multicentric, collaborative dermatological and genetic study.

RESULTS

Forty-five patients were enrolled. Hair abnormalities were ubiquitous, including scarcity or absence of eyebrows and wavy or curly hair in 73% and 69% of patients, respectively. Keratosis pilaris (KP), ulerythema ophryogenes (UO), palmoplantar hyperkeratosis (PPHK) and multiple melanocytic naevi (MMN; over 50 naevi) were noted in 82%, 44%, 27% and 29% of patients, respectively. Scarcity or absence of eyebrows, association of UO and PPHK, diffuse KP and MMN best differentiated CFCS from NS and CS. Oral acitretin may be highly beneficial for therapeutic management of PPHK, whereas treatment of UO by topical sirolimus 1% failed. No significant dermatological phenotype-genotype correlation was determined.

CONCLUSIONS

A thorough knowledge of CFCS skin manifestations would help in making a positive diagnosis and differentiating CFCS from CS and NS.