Antiangiogenetische Therapie beim Nierenzellkarzinom

[Side effect management of tyrosine kinase inhibitors in urology : Gastrointestinal side effects]

For approximately one decade, tyrosinkinase inhibitors (TKIs, smart drugs) have dramatically changed and improved the treatment of patients suffering from metastasized renal cell carcinoma. However, the different drugs have substantial side effects. Especially gastrointestinal symptoms may be problematic for patients. These side effects represent a challenge for the physician. On the one hand, dosage modifications and treatment interruption should be avoided to minimize the risk for progression. On the other hand, only mild side effects are tolerable for the patient. Based on a literature review, a clear overview of the incidence of possible side effects for the drugs axitinib, cabozantinib, pazopanib, sorafenib, and sunitinib is provided. Furthermore, we give a practical guide on how to prevent and treat the different gastrointestinal side effects. Finally, it is pointed out when dosage modifications or interruption of treatment are necessary and how to expeditiously re-escalate the treatment after mitigation of side effects.

[Hypertension and palmar plantar erythroderma. Management of adverse events of angiogenetic inhibitors in the treatment of renal cell carcinoma]

The introduction of angiogenesis inhibitors has altered the systemic therapy of metastatic renal cell carcinoma. Being a"permanent" medication, the management of side effects has special importance, for adverse events may limit therapy. Hypertension (up to 34% of cases) and palmar plantar erythroderma (6-30% of cases) are common side effects.Blood pressure should be monitored during therapy, and arterial hypertension should be treated with a standard medication. If a hypertensive emergency still occurs, a dose reduction or discontinuation of treatment might be indicated.Prophylaxis may prevent or extenuate palmar plantar erythroderma in many cases, enabling regular chemotherapy as planned. In cases with severe clinical symptoms a reduction or interruption of the dose will be necessary. In most cases local therapy is sufficient.

[New tyrosine kinase and EGFR inhibitors in cancer therapy. Cardiac and skin toxicity as relevant side effects. Part B: Skin]

Recently, inhibitors of the epidermal growth factor receptor (EGFR) and multikinase inhibitors have been successfully established in the therapy of various solid tumors. EGFR inhibitors and multikinase inhibitors are specific and selective agents that intervene with the dysfunctional regulatory processes of malignant cells. This results in a favorable safety profile and range of side effects, especially in comparison to conventional chemotherapy. The various cutaneous adverse drug reactions are considered substance class effects and are the most frequent side effects of these targeted therapies. Therapy with EGFR inhibitors is associated with acneiform rash, painful paronychia, xerosis cutis, acral fissures, hair changes, and pruritus. Treatment with tyrosin kinase inhibitors may cause hand-foot syndrome, various types of drug rash, hair loss, xerosis cutis, and pruritus. These side effects may be stigmatizing and place a huge burden on the patient's quality of life. Treatment is a challenge and best performed in interdisciplinary cooperation of dermatologists and oncologists.

[Cutaneous side effects of the multikinase inhibitors sorafenib and sunitinib]

Molecular targeted therapy with monoclonal antibodies and low molecular weight inhibitors is gaining increasing importance particularly in the treatment of malignant tumors. These drugs are specific and highly selective agents that intervene in the dysfunctional regulatory processes of malignant cells in order to influence cell proliferation, cell differentiation, or angiogenesis. The multikinase inhibitors sorafenib and sunitinib exhibit a favorable tolerability profile and spectrum of side effects, especially in comparison to conventional chemotherapeutic agents. However, they induce specific cutaneous side effects that can in turn be indicators of antitumor activity. This review article compares the cutaneous side effects of the two multikinase inhibitors sorafenib and sunitinib and discusses the therapeutic options for the individual cutaneous reaction patterns.

Simultaneous anti-angiogenic therapy and single-fraction radiosurgery in clinically relevant metastases from renal cell carcinoma

OBJECTIVE

• To analyse the safety and efficacy of simultaneous standard anti-angiogenic therapy and stereotactic radiosurgery (SRS) in patients with spinal and cerebral metastases from renal cell carcinoma.

PATIENTS AND METHODS

• In all, 106 patients with spinal (n= 55) or cerebral (n= 51) metastatic lesions and an Eastern Cooperative Oncology Group status of 0 or 1 were treated with sorafenib or sunitinib and simultaneous SRS. • The primary endpoint was local control. • Secondary endpoints were toxicity and overall survival.

RESULTS

• Median follow up was 14.7 months (range 1-42 months). Forty-five patients were treated with sunitinb and 61 patients with sorafenib. Two patients had asymptomatic tumour haemorrhage after SRS. • No skin toxicity, neurotoxicity or myelopathy occurred after SRS, and SRS did not alter the adverse effects of anti-angiogenic therapy. • Local tumour control 15 months after SRS was 98% (95% confidence interval 89-99%). The median pain score before SRS was 5 (range 1-8) and was lowered to 0 (range 0-2, P < 0.01) after SRS. There were no treatment-related deaths or late complications after SRS. • Overall survival was 17.4 months in patients with spinal lesions and 11.1 month in patients with cerebral lesions (P= 0.038).

CONCLUSIONS

• Simultaneous systemic anti-angiogenic therapy and SRS for selected patients with renal cell carcinoma who have spinal and cerebral metastases is safe and effective. • Single-fraction delivery allows for efficacious integration of focal radiation treatment into oncological treatment concepts without additional toxicity. • Further studies are needed to determine the limits of SRS for renal cell carcinoma metastases outside the brain and spine.

Search for evidence-based approaches for the prevention and palliation of hand-foot skin reaction (HFSR) caused by the multikinase inhibitors (MKIs)

BACKGROUND

The anticancer multikinase inhibitors (MKIs) are associated with cutaneous adverse events, including hand-foot skin reaction (HFSR), a condition affecting 20%-40% of patients. Symptoms are usually mild, but can evolve into a painful condition that limits function and impacts quality of life (QoL), resulting in shortened cancer treatment duration or intensity. The goal of this study was to systematically review the literature on the prevention and palliation of MKI-associated HFSR, to identify areas for further clinical study, and to provide a foundation for evidence-based guidelines for HFSR management.

METHODS

Systematic searches of the National Library of Medicine's PubMed database, Cochrane Reviews, BIOSIS, CancerLit, and the American Society of Clinical Oncology website were conducted using search terms for cutaneous toxicities associated with chemotherapeutic agents. Articles were categorized (C) based on type of agent and cutaneous reaction as: C1 (MKI and HFSR); C2 (MKI and other cutaneous toxicity); C3 (other antineoplastic agents and HFSR); and C4, other.

RESULTS

Of the 2,069 abstracts screened, 350 (17%) met the criteria for C1-C4, with 56 (16%) coded as C1 with details of HFSR histology, pathogenesis, clinical outcome, QoL impact, and/or prevention and treatment approaches in MKI-treated patients. No randomized, controlled trials (RCTs) on prevention/palliation of HFSR were identified. Anecdotal evidence or expert opinion advocated protective measures, preventive and therapeutic skin care, systemic analgesics for pain, vitamin B(6), and MKI dose modification.

CONCLUSION

No articles containing evidence from RCTs on preventive/palliative approaches to MKI-associated HFSR have been published. Systematic study of optimal treatment strategies for HFSR is needed to advance development of evidence-based treatment guidelines.