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Le Gall-Ianotto C, Verdet R, Nowak E, Le Roux L, Gasse A, Fiedler A, Carlhant-Kowalski D, Marcorelles P, Misery L, Ianotto JC. Rationale and design of the multicentric, double-blind, double-placebo, randomized trial APrepitant versus HYdroxyzine in association with cytoreductive treatments for patients with myeloproliferative neoplasia suffering from Persistent Aquagenic Pruritus. Trial acronym: APHYPAP. Trials 2021; 22:938. [PMID: 34923994 PMCID: PMC8686668 DOI: 10.1186/s13063-021-05864-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 11/23/2021] [Indexed: 12/04/2022] Open
Abstract
Background Aquagenic pruritus (AP), an intense sensation of scratching induced after water contact, is the most troublesome aspect of BCR-ABL1-negative myeloproliferative neoplasms (MPNs). Mostly described in polycythemia vera (PV, ~ 40%), it is also present in essential thrombocythemia (ET) and primary myelofibrosis (PMF) (10%). Even if this symptom can decrease or disappear under cytoreductive treatments, 30% of treated MPN patients still persist with a real impact on the quality of life (QoL). Because its pathophysiology is poorly understood, efficient symptomatic treatments of AP are missing. The neuropeptide substance P (SP) plays a crucial role in the induction of pruritus. Several studies showed the efficacy of aprepitant, an antagonist of SP receptor (NK-1R), in the treatment of chronic pruritus but never evaluated in AP. The objectives of APHYPAP are twofold: a clinical aim with the evaluation of the efficacy of two drugs in the treatment of a persistent AP for MPN patients and a biological aim to find clues to elucidate AP pathophysiology. Methods/design A multicentric, double-blind, double-placebo, randomized study will include 80 patients with MPN (PV or ET or PMF) treated since at least 6 months for their hemopathy but suffering from a persistent AP (VAS intensity ≥6/10). Patients will be randomized between aprepitant (80 mg daily) + placebo to match to hydroxyzine OR hydroxyzine (25 mg daily) + placebo to match to aprepitant for 14 days. At D0, baseline information will be collected and drugs dispense. Outcome measures will be assessed at D15, D30, D45, and D60. The primary study endpoint will be the reduction of pruritus intensity below (or equal) at 3/10 on VAS at D15. Secondary outcome measures will include the number of patients with a reduction or cessation of AP at D15 or D60; evaluation of QoL and AP characteristics at D0, D15, D30, D45, and D60 with MPN-SAF and AP questionnaires, respectively; modification of plasmatic concentrations of cytokines and neuropeptides at D0, D15, D30, and D60; and modification of epidermal innervation density and pruriceptor expression at D0 and D15. Discussion The APHYPAP trial will examine the efficacy of aprepitant vs hydroxyzine (reference treatment for AP) to treat persistent AP in MPN patients. The primary objective is to demonstrate the superiority of aprepitant vs hydroxyzine to treat persistent AP of MPN patients. The treatment received will be considered efficient if the AP intensity will be reduced at 3/10 or below on VAS after 14 days of treatment. The results of this study may provide a new treatment option for this troublesome symptom and also give us more insights in the pathophysiology understanding of AP. Trial registration APHYPAP. NCT03808805, first posted: January 18, 2019; last update posted: June 10, 2021. EudraCT 2018-090426-66
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Neurokinin 1 Receptor Antagonists for Pruritus. Drugs 2021; 81:621-634. [PMID: 33675531 PMCID: PMC8102458 DOI: 10.1007/s40265-021-01478-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2021] [Indexed: 11/25/2022]
Abstract
Pruritus, commonly known as itch, is a very common symptom in numerous dermatological disorders and systemic diseases. It can manifest as acute, or when lasting longer than 6 weeks, it is considered chronic and can lead to significant distress and reduced quality-of-life of those suffering. Current therapeutics are limited and are lacking in efficacy, and the development of more effective treatments is needed. The neurokinin 1 receptor (NK1R) antagonists are a novel class of drugs that possess several properties such as antidepressant, anxiolytic and antiemetic activities. Recently, several studies have described the antipruritic activity of NK1R antagonists for treating chronic pruritus. In this review we outline the pathogenesis of chronic pruritus, the mechanism by which the neuropeptide substance P (SP) and its receptor NK1R may be targeted to inhibit pruritic activity, and the efficacy and tolerability of NK1R antagonists, which have been, or are currently being investigated for treating conditions where chronic pruritus is a major symptom. Increasing evidence from ongoing and completed studies demonstrates the importance of SP and NK1R signalling in mediating pruritic activity. Several NK1R antagonists have shown significant antipruritic activity and thus targeting the SP-NK1R pathway may provide a therapeutic option for treating chronic pruritus of certain origin/s in the foreseeable future.
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Pulido‐Perez A, Carretero‐Lopez F, Bergon‐Sendin M, Nieto‐Benito L, Romero‐Jimenez R, Dorado‐Herrero N, Bastos‐Oreiro M, Suárez‐Fernández R. Aprepitant in refractory pruritus of systemic lymphoproliferative disorders. J Eur Acad Dermatol Venereol 2020; 34:e422-e424. [DOI: 10.1111/jdv.16370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- A. Pulido‐Perez
- Department of Dermatology Hospital General Universitario Gregorio Marañón Madrid Spain
| | - F. Carretero‐Lopez
- Department of Radiology Hospital General Universitario Gregorio Marañón Madrid Spain
| | - M. Bergon‐Sendin
- Department of Dermatology Hospital General Universitario Gregorio Marañón Madrid Spain
| | - L.M. Nieto‐Benito
- Department of Dermatology Hospital General Universitario Gregorio Marañón Madrid Spain
| | - R. Romero‐Jimenez
- Department of Pharmacy Hospital General Universitario Gregorio Marañón Madrid Spain
| | - N. Dorado‐Herrero
- Department of Hematology Hospital General Universitario Gregorio Marañón Madrid Spain
| | - M.B. Bastos‐Oreiro
- Department of Hematology Hospital General Universitario Gregorio Marañón Madrid Spain
| | - R. Suárez‐Fernández
- Department of Dermatology Hospital General Universitario Gregorio Marañón Madrid Spain
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Vincenzi B, Trower M, Duggal A, Guglielmini P, Harris P, Jackson D, Lacouture ME, Ratti E, Tonini G, Wood A, Ständer S. Neurokinin-1 antagonist orvepitant for EGFRI-induced pruritus in patients with cancer: a randomised, placebo-controlled phase II trial. BMJ Open 2020; 10:e030114. [PMID: 32034016 PMCID: PMC7045265 DOI: 10.1136/bmjopen-2019-030114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of orvepitant (10 or 30 mg given once daily, orally for 4 weeks), a neurokinin-1 receptor antagonist, compared with placebo in reducing the intensity of epidermal growth factor receptor inhibitor (EGFRI)-induced intense pruritus. DESIGN Randomised, double-blind, placebo-controlled clinical trial. SETTING 15 hospitals in Italy and five hospitals in the UK. PARTICIPANTS 44 patients aged ≥18 years receiving an EGFRI for a histologically confirmed malignant solid tumour and experiencing moderate or intense pruritus after EGFRI treatment. INTERVENTION 30 or 10 mg orvepitant or placebo tablets once daily for 4 weeks (randomised 1:1:1). PRIMARY AND SECONDARY OUTCOME MEASURES The primary endpoint was change from baseline in mean patient-recorded numerical rating scale (NRS) score (over the last three recordings) at week 4. Secondary outcome measures were NRS score, verbal rating scale score, Skindex-16 and Leeds Sleep Evaluation Questionnaire at each study visit (baseline, weeks 1, 4, 8); rescue medication use; EGFRI dose reduction; and study withdrawal because of intense uncontrolled pruritus. RESULTS The trial was terminated early because of recruitment challenges; only 44 of the planned 90 patients were randomised. All patients were analysed for efficacy and safety. Mean NRS score change from baseline to week 4 was -2.78 (SD: 2.64) points in the 30 mg group, -3.04 (SD: 3.06) points in the 10 mg group and -3.21 (SD: 1.77) points in the placebo group; the difference between orvepitant and placebo was not statistically significant. No safety signal was detected. Adverse events related to orvepitant (asthenia, dizziness, dry mouth, hyperhidrosis) were all of mild or moderate severity. CONCLUSIONS Orvepitant was safe and well tolerated. No difference in NRS score between the orvepitant and placebo groups was observed at the week 4 primary endpoint. A number of explanations for this outcome are possible. TRIAL REGISTRATION NUMBER EudraCT2013-002763-25.
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Affiliation(s)
- Bruno Vincenzi
- Medical Oncology, Universita Campus Bio-Medico di Roma Facolta di Medicina e Chirurgia, Roma, Italy
| | | | - Ajay Duggal
- Adnovate Clinical Development Strategies, East Sussex, UK
| | | | | | | | - Mario E Lacouture
- Department of Dermatology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Giuseppe Tonini
- Medical Oncology, Universita Campus Bio-Medico di Roma Facolta di Medicina e Chirurgia, Roma, Italy
| | | | - Sonja Ständer
- Center for Chronic Pruritus, University Hospital Münster, Münster, Germany
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Pojawa-Gołąb M, Jaworecka K, Reich A. NK-1 Receptor Antagonists and Pruritus: Review of Current Literature. Dermatol Ther (Heidelb) 2019; 9:391-405. [PMID: 31190215 PMCID: PMC6704190 DOI: 10.1007/s13555-019-0305-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Indexed: 12/13/2022] Open
Abstract
The discovery of the first neurokinin 1 (NK-1) receptor antagonist was a turning point in the prevention of chemotherapy-induced nausea and vomiting. The NK-1 antagonists are a novel class of drugs that possess antidepressant, anxiolytic, and antiemetic properties. Recently, clinicians have also described an anti-itch activity of NK-1 antagonists. We present herein results from currently available data on use of NK-1R antagonists in dermatology. For this purpose, a systemic electronic literature search of the PubMed and CINAHL databases, Cochrane Library, and clinicaltrials.gov website was performed. Based on currently available data, it can be concluded that NK-1 inhibitors show significant antipruritic potential for treatment of chronic pruritus in different dermatological conditions, but further studies are needed to establish the best indications and dosage of these drugs.
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Affiliation(s)
| | - Kamila Jaworecka
- Department of Dermatology, University of Rzeszów, Rzeszów, Poland
| | - Adam Reich
- Department of Dermatology, University of Rzeszów, Rzeszów, Poland.
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Abstract
Itch treatment is a major challenge in the dermatologist’s practice. We encounter patients suffering from pruritus on a regular basis, and often lack diverse treatment options to adequately respond to the patients’ needs. In the last 20 years, novel pathways have been investigated that were beyond the scope of histamine. Although most did not result in a molecule available on the Canadian market, it is interesting and important as health care providers to stay up to date with new neuronal pathways involved in itch transmission and potential new therapeutic options. In this review, we will discuss pathways targeted in new topical treatments such as antagonist of proteinase-activated receptor-2, the endocannabinoid system, neurotrophins and tropomyosin-related kinase A receptor, the transient receptor potential-vanilloid or transient receptor potential-melastatine ion channels. New systemic therapies are now focusing on antagonizing the neurokinin receptor, modulating the opioidergic system, or targeting itch cytokines such as interleukin-31.
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Affiliation(s)
| | - Laurent Misery
- Department of Dermatology, University Hospital Brest, France
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Seki N, Ochiai R, Haruyama T, Ishihara M, Natsume M, Fukasawa Y, Sakamoto T, Tanzawa S, Usui R, Honda T, Ota S, Ichikawa Y, Watanabe K. Need for Flexible Adjustment of the Treatment Schedule for Aprepitant Administration against Erlotinib-Induced Refractory Pruritus and Skin Rush. Case Rep Oncol 2019; 12:84-90. [PMID: 30792647 PMCID: PMC6381921 DOI: 10.1159/000493256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 11/19/2022] Open
Abstract
Common dermatological side-effects associated with erlotinib, epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI), include pruritus and skin rash, which are mediated by substance P, leading to the occasional discontinuation of cancer treatment. Aprepitant is an antagonist of neurokinin-1 receptor, through which substance P activates the pruritogens. Thus, aprepitant is expected to offer a promising option for the treatment of erlotinib-induced pruritus. However, the appropriate treatment schedule for aprepitant administration is under consideration. Here, we discuss the need for flexible adjustment of the treatment schedule for aprepitant administration against erlotinib-induced refractory pruritus and skin rush. A 71-year-old female smoker presented with stage IV EGFR-mutated lung adenocarcinoma. She was started on erlotinib at 150 mg/day. However, by 28 days, severe pruritus and acneiform skin rush resistant to standard therapies occurred, resulting in the interruption of erlotinib therapy. After recovery, she was restarted on erlotinib at 100 mg/day. However, severe pruritus and skin rush developed again within 2 weeks. Then, we started the first 3-day dose of aprepitant (125 mg on day 1, 80 mg on day 3, and 80 mg on day 5) based on the results of the previous prospective study, which showed the success rate of 100% with at least the second dose of aprepitant. However, the pruritus and skin rush exacerbated again within 4 weeks. Therefore, we started the second 3-day dose of aprepitant, but in vain. At this point, as the patient-centered medicine, bi-weekly schedule of the 3-day dose of aprepitant was considered and, then, adopted. As the results, the pruritus and skin rush remained well-controlled throughout the subsequent treatment with erlotinib.
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Affiliation(s)
- Nobuhiko Seki
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Ryosuke Ochiai
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Terunobu Haruyama
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Masashi Ishihara
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Maika Natsume
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yoko Fukasawa
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Takahiko Sakamoto
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Shigeru Tanzawa
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Ryo Usui
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Takeshi Honda
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Shuji Ota
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasuko Ichikawa
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Kiyotaka Watanabe
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
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Zic JA, Straka BT, McGirt LY, Nian H, Yu C, Brown NJ. Aprepitant for the Treatment of Pruritus in Sézary Syndrome: A Randomized Crossover Clinical Trial. JAMA Dermatol 2018; 154:1221-1222. [PMID: 30140912 PMCID: PMC6233739 DOI: 10.1001/jamadermatol.2018.2510] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- John A. Zic
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brittany T. Straka
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee,now in private practice, Westerville, Ohio
| | - Laura Y. McGirt
- Division of Dermatology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee,now with Department of Hematology/Oncology, Levine Cancer Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Hui Nian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nancy J. Brown
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Shevchenko A, Valdes-Rodriguez R, Yosipovitch G. Causes, pathophysiology, and treatment of pruritus in the mature patient. Clin Dermatol 2017; 36:140-151. [PMID: 29566918 DOI: 10.1016/j.clindermatol.2017.10.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Chronic itch is a common and debilitating health condition in the elderly. There are several common causes of itch in the mature population, such as skin xerosis, immunosenescence, and neuropathic changes. In addition, skin diseases, such as seborrheic dermatitis and stasis dermatitis, systemic conditions (end-stage renal disease and diabetes), or psychogenic derailments, such as depression, anxiety, and dementia, can all serve as triggers of pruritus. Polypharmacy, a common occurrence among the elderly population, may also serve as a cause of itch that may or may not be accompanied by dermatitis. Such medications as μ opioids and calcium channel blockers have been found to have a connection with pruritus in the advanced aging population. Determining the exact trigger for pruritus in the elderly may be especially challenging, because itch can be idiopathic in many cases. The role of treatments should not only take into account elimination of various underlying cutaneous, systemic, or psychogenic conditions associated with itch but also focus on the skin changes that are characteristic of the aging process. Development of such treatment options can be guided by elucidation of the mechanisms underlying the pathophysiology of itch in the geriatric population.
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Affiliation(s)
- Alina Shevchenko
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Rodrigo Valdes-Rodriguez
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Gil Yosipovitch
- Department of Dermatology & Miami Itch Center at the University of Miami, Leonard M. Miller School of Medicine, Miami, FL, USA.
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Tabrizi MA, Mckeown J, Siew K. Management of persistent pruritus in carcinoma erysipeloides associated with oesophageal cancer. Intern Med J 2017; 47:829-831. [DOI: 10.1111/imj.13476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 03/08/2017] [Accepted: 03/09/2017] [Indexed: 11/29/2022]
Affiliation(s)
| | - Joanne Mckeown
- Department of Palliative Care; Royal Perth Hospital; Perth Western Australia Australia
| | - Kelvin Siew
- Department of Oncology; Joondaloop Health Campus; Perth Western Australia Australia
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Aprepitant for refractory nivolumab-induced pruritus. Lung Cancer 2017; 109:58-61. [PMID: 28577951 DOI: 10.1016/j.lungcan.2017.04.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 04/11/2017] [Accepted: 04/26/2017] [Indexed: 12/26/2022]
Abstract
Although substantial progress has been made in the treatment of non-small-cell lung cancer (NSCLC) patients with immune checkpoint inhibitors (ICIs), severe immune-related adverse events (irAEs) sometimes occur. Here, we report a case of severe refractory pruritus after Stevens-Johnson syndrome (SJS) in a patient with NSCLC treated with nivolumab. The patient was a 76-year-old Japanese woman with advanced NSCLC treated with nivolumab. After the second dose, she experienced severe rash with mucous involvement. We diagnosed SJS and started 50mg of oral prednisolone (1mg/kg). The rash completely resolved after prednisolone was started, but we could not manage the severe pruritus with emollients, antihistamines, and steroids. Finally, we administered aprepitant, an oral neurokinin-1 receptor antagonist, for her refractory pruritus. Her symptoms improved within 5days. Severe refractory pruritus can arise from ICIs, and aprepitant may be a useful treatment.
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Song JS, Tawa M, Chau NG, Kupper TS, LeBoeuf NR. Aprepitant for refractory cutaneous T-cell lymphoma-associated pruritus: 4 cases and a review of the literature. BMC Cancer 2017; 17:200. [PMID: 28302100 PMCID: PMC5356405 DOI: 10.1186/s12885-017-3194-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 03/11/2017] [Indexed: 11/28/2022] Open
Abstract
Background Aprepitant is an FDA-approved medication for chemotherapy-induced nausea and vomiting. It blocks substance P binding to neurokinin-1; substance P has been implicated in itch pathways both as a local and global mediator. Case presentations We report a series of four patients, diagnosed with cutaneous T-cell lymphoma, who experienced full body pruritus recalcitrant to standard therapies. All patients experienced rapid symptom improvement (within days) following aprepitant treatment. Conclusion Aprepitant has been shown in small studies to be efficacious for treating chronic and malignancy-associated pruritus. Prior studies have shown no change in clinical efficacy of chemotherapeutics with concurrent aprepitant administration. These cases further demonstrate that aprepitant can be considered as a therapeutic option in malignancy-associated pruritus and further support the need for larger clinical trials.
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Affiliation(s)
- Johanna S Song
- Department of Dermatology, Brigham and Women's Hospital, 221 Longwood Ave., Boston, MA, 02115, USA.,Center for Head and Neck Cancer, Dana-Farber Cancer Institute, 450 Brookline Ave., Boston, MA, 02215, USA.,Harvard Medical School, 25 Shattuck St., Boston, MA, 02115, USA
| | - Marianne Tawa
- Center for Cutaneous Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave., Boston, MA, 02215, USA
| | - Nicole G Chau
- Center for Head and Neck Cancer, Dana-Farber Cancer Institute, 450 Brookline Ave., Boston, MA, 02215, USA
| | - Thomas S Kupper
- Department of Dermatology, Brigham and Women's Hospital, 221 Longwood Ave., Boston, MA, 02115, USA.,Center for Cutaneous Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave., Boston, MA, 02215, USA.,Harvard Medical School, 25 Shattuck St., Boston, MA, 02115, USA
| | - Nicole R LeBoeuf
- Department of Dermatology, Brigham and Women's Hospital, 221 Longwood Ave., Boston, MA, 02115, USA. .,Center for Cutaneous Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave., Boston, MA, 02215, USA. .,Harvard Medical School, 25 Shattuck St., Boston, MA, 02115, USA.
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