Effets cardiovasculaires graves des chimiothérapies, thérapies ciblées et des traitements immunosuppresseurs

Renin-Angiotensin-System Inhibitors for the Prevention of Chemotherapy-Induced Peripheral Neuropathy: OncoToxSRA, a Preliminary Cohort Study

Chemotherapy-induced peripheral neuropathy (CIPN) is a frequent and dose-limiting adverse side effect of treatment. CIPN affects the oncological prognosis of patients, as well as their quality of life. To date, no specific pharmacological therapy has demonstrated effectiveness in preventing CIPN. Accumulating preclinical evidence suggests that renin-angiotensin system (RAS) inhibitors may have neuroprotective effects. One hundred and twenty patients were included in this observational study and were followed from the beginning of their neurotoxic chemotherapy schedule until their final assessment, at least one month after its cessation. The National Cancer Institute's common toxicity criteria 4.0 (NCI-CTC 4.0) were used to grade the severity of adverse events. Follow-ups also included electrochemical skin conductance and scales for pain, quality of life and disability. Among patients receiving a platinum-based regimen, the mean grade of sensory neuropathy (NCI-CTC 4.0) was significantly lower in the RAS inhibitor group after the end of their anticancer treatment schedule. Because of the observational design of the study, patients in the RAS inhibitor group cumulated comorbidities at risk of developing CIPN. Randomized controlled trials in platinum-based regimens would be worth conducting in the future to confirm the neuroprotective potential of RAS inhibitors during chemotherapy.

Les avancées dans la prise en charge des cancers bronchopulmonaires : ce qui change pour le réanimateur

Le cancer bronchopulmonaire (CBP) est la première cause de mortalité par cancer en France et dans le monde, mais son pronostic tend à s’améliorer depuis une dizaine d’années grâce à de nouvelles classes de traitements : l’immunothérapie et les thérapies ciblées. L’immunothérapie stimule le système immunitaire afin d’engendrer une réponse antitumorale. Ces molécules peuvent être prescrites chez la plupart des patients avec un CBP non à petites cellules (CBNPC) métastatique et entraînent parfois des réponses tumorales majeures et durables pouvant dépasser les 24 mois. Toutefois, cette efficacité concerne entre 20 et 50 % des patients selon la ligne de traitement. Les thérapies ciblées sont des traitements oraux visant les cellules tumorales porteuses d’anomalies génétiques spécifiques (addictions oncogéniques) et intéressent moins de 15 % des patients avec CBNPC, majoritairement les non-fumeurs. Les deux principales sont les mutations du gène de l’epithelial growth factor receptor (EGFR) et les réarrangements d’anaplastic lymphoma kinase (ALK). Ces anomalies peuvent être diagnostiquées en quelques jours, parfois sur un prélèvement sanguin (biopsie liquide pour détecter les mutations EGFR). Les thérapies ciblées améliorent la survie globale des patients dont la médiane dépasse les 30 mois. Toutefois, ces deux classes de traitement entraînent des toxicités spécifiques, fréquentes mais souvent bénignes. Les hospitalisations en réanimation des patients porteurs de CBNPC sont croissantes. L’amélioration du pronostic de ces patients est à prendre en compte lors de la discussion d’admission en réanimation sans conduire à des prises en charge déraisonnables.

Management of Acute Complications of Targeted Therapy in Patients With Cancer: A Review of Cases Managed in ICU

INTRODUCTION

Targeted therapies, molecules in full expansion, are not free of side effects that can lead patients to intensive care. We performed an extensive review of the published evidence and propose a management strategy for acute complications of targeted therapy in critically ill patients with cancer.

METHODS

The literature search was performed in August 2017 using the Ovid Medline system by a scientific librarian and physicians. We made a review of cases admitted in intensive care unit (ICU) and a review of toxicities of grades greater or equal to 3.

RESULTS

Our search selected 59 articles. The main cardiovascular side effects requiring ICU are heart failure, which is generally reversible, severe hypertension, thrombotic and ischemic events, and rhythm disturbances. The main pulmonary side effects are interstitial lung disease essentially caused by crizotinib, respiratory infections, pneumothorax, and alveolar hemorrhage. The main gastrointestinal side effects are fulminant hepatitis that may be fatal, colitis that may be complicated by hemorrhage, and perforation. The main neurological side effect is posterior reversible encephalopathy syndrome essentially caused by bevacizumab. The main other side effects are Steven-Johnson syndrome, necrotizing fasciitis, and anaphylactic reactions.

CONCLUSIONS

The side effects induced by targeted therapies may be fatal but are generally potentially reversible. The main treatment includes stopping current therapy and symptomatic management. Treatment rechallenge should be discussed on a case-by-case basis.