Anomalies pigmentaires induites par les traitements anticancéreux. Deuxième partie : les thérapies ciblées

Blue-grey hyperpigmentation in acne after vandetanib therapy and doxycycline use: A case report

Vandetanib is an oral tyrosine kinase inhibitor with cutaneous adverse effects that include the development of acne. We present a patient who underwent vandetanib therapy for stage IV medullary thyroid cancer in conjunction with the use of doxycycline for acne that developed. After vandetanib use, blue-grey pigmentation developed in the acne on his face, chest, back, and arms, which darkened after the use of doxycycline. We review the literature to report that this blue-grey hyperpigmentation was likely vandetanib-induced but may have been the result of both drugs being used in combination.

Nail Changes With Chemotherapeutic Agents and Targeted Therapies

Patients on Cancer chemotherapeutic agents often develop nail changes most of which are only cosmetic concern and disappear on drug withdrawal. But some nail changes can be painful and disabling thereby affecting quality of life substantially. Different components of the nail unit include the nail matrix, nail bed, nail plate, the hyponychium, lunula, the proximal and lateral nail folds. In this article we review the nail changes induced by chemotherapeutics and targeted anticancer drugs, preventive measures and treatment options available.

Bluish-gray fingernail discoloration due to the use of nivolumab

INTRODUCTION

Immune checkpoint inhibitors have improved clinical outcomes in a wide range of cancers. While skin toxicity is not uncommon with immune checkpoint inhibitors, generalized nail discoloration has not been reported with their use in oncology.

CASE REPORT

Herein, we report a unique case of bluish-gray fingernail discoloration due to nivolumab therapy for relapsed melanoma.Management and outcome: This condition reversed completely 10 weeks after nivolumab discontinuation. Naranjo nomogram assessment renders the causality relationship between nivolumab and nail discoloration probable.

DISCUSSION

To our knowledge, this is the first case report of an unusual bluish-gray nail discoloration due to therapy with nivolumab. The mechanism by which nivolumab causes this side effect remains to be elucidated.

Vitiligo-like lesions in a patient treated with nivolumab for renal cell carcinoma

RATIONALE

The introduction of immune check-point inhibitors (ICIs) in the treatment of solid neoplasms is associated with the need to know and manage a new type of side effects that are commonly defined immune-mediated adverse events. Dermatologic immune-mediated adverse events are relatively common. Vitiligo-like lesions, defined as hypopigmented skin lesions, have already been associated with the use of ICIs in particular in patients with malignant melanoma, probably due to a common autoimmune mechanism against both melanoma cells and normal melanocytes. The onset of vitiligo-like lesions is very rare in non-melanoma patients and nowadays only few cases are described in the literature.

PATIENT CONCERNS

We described the case of a heavily pre-treated woman affected by renal cell carcinoma that has been treated with nivolumab for 2 years obtaining a stabilization of disease after an initial mild progression. After 9 months from the beginning of nivolumab, when the disease has reached its maximum stabilization, the patient developed vitiligo-like lesions of the back win halo nevi.

DIAGNOSES

Vitiligo like lesion of the back not pre-existing before nivolumab treatment. The etiology was assumed to be nivolumab related as a result of an autoimmune activation against normal melanocytes.

INTERVENTIONS

The patient was followed with dermatological evaluations without changes in nivolumab dose and schedule OUTCOMES:: No variations of the described lesions were recorded after the first description. The patients underwent a durable stabilization of her tumor.

LESSONS

This case on the one hand is the first case of vitiligo-like lesions associated with ICIs in patients affected by renal cell carcinoma, and on the other hand it seems to confirm that the onset of immumomediate adverse reactions, but in particular vitiligo lesions, can probably be considered a sign of response to immunological treatments probably as a consequence of activation of the immune response.

Clinical management of cutaneous adverse events in patients on targeted anticancer therapies and immunotherapies: a national consensus statement by the Spanish Academy of Dermatology and Venereology and the Spanish Society of Medical Oncology

Progress in the understanding of many tumors has enabled the development of new therapies, such as those targeted at specific molecules involved in cell growth (targeted therapies) or intended to modulate the immune system (immunotherapy). However, along with the clinical benefit provided by these new treatments, new adverse effects have also appeared. Dermatological toxicities such as papulopustular eruptions, xerosis, and pruritus are common with EGFR inhibitors. Other adverse effects have also been described with PDGFR, BCR-ABL, and MAPK tyrosine kinase inhibitors, antiangiogenic drugs, and inhibitors at immune checkpoints such as CTLA-4 and PD-1/PD-L1. Onset of these adverse effects often causes dose reductions and/or delays in administering the prescribed therapy, which can affect patient survival and quality of life. It is, therefore, important to prevent the occurrence of these adverse effects, or to treat unavoidable ones as soon as possible. This requires cooperation between medical oncologists and dermatologists. This article reviews the various dermatological toxicities associated with targeted therapies and immunotherapies, along with their diagnosis and therapeutic management.

Vitiligo in a patient with lung adenocarcinoma treated with nivolumab: A case report

Nivolumab, an anti-programmed cell death-1 protein monoclonal antibody, is effective for treating patients with late-stage non-small-cell lung cancer. Immune checkpoint inhibitors such as nivolumab induce various kinds of immune-related adverse events, including vitiligo. Vitiligo has been reported in patients with melanoma but not lung cancer. We describe a 75-year-old man with lung adenocarcinoma, stage 4 with pleural and pericardial effusion, that progressed after first-line chemotherapy. Subsequently, he was treated with nivolumab as second-line therapy. After 6days of administering nivolumab, he developed vitiligo suddenly on the trunk of his body. Except for vitiligo, his physical examination was normal, and treatment with nivolumab was well tolerated. Therefore, this treatment was continued without further development or expansion of vitiligo. A computed tomography scan showed a reduction in the size of the lung nodule and stabilization of the pleural and pericardial effusion. This is the first case of vitiligo associated with the use of nivolumab in a patient with lung adenocarcinoma.

[Pigmentations of the oral cavity]

Buccal mucosa color is explained by hemoglobin in the vessels and melanin in the epithelium. Abnormal presence of melanin pigments (hypermelaninosis, hypermelanocytosis), hematic pigments (hemoglobin, hemosiderin, iron) but also some exogenous circonstancies explain pigmented lesions (figure 1). These lesions could be localized (single lesions), multifocal (multiple lesions) or diffused. In case of a localized pigmentation with melanic appearance, melanoma must be systematically eliminated with a biopsy. In the case of a more diffused lesion, systemic disease must be evoked. A drug etiology is also possible. A blood pigment excess could be a vascular malformation (flat lesions) or a tumoral process (nodular or swollen lesions). In both cases, Kaposi's disease should be systematically eliminated. Pigmentations near dental restorations (amalgams, prosthetic crowns) could be explained by an exogenous factor but a biopsy should be performed in case of a doubt with melanoma.

Development of Photoonycholysis with Vandetanib Therapy

Vandetanib therapy is a novel once-daily oral multitargeted tyrosine kinase inhibitor, which is currently used in advanced or metastatic medullary thyroid cancer. Skin toxicities are among the most prevalent adverse events reported with this targeted therapy (e.g. acne-like rash, hand-foot skin reaction, hair changes, and paronychia). In addition, photosensitivity reactions may affect more than one third of treated patients. We report here 2 patients developing photosensitivity reactions with vandetanib therapy, including photoonycholysis. Our patients presented a wide range of phototoxic reactions with exaggerated sunburn reactions solely located to photoexposed areas or hyperpigmentation with visible blue dots. More importantly, both patients concomitantly developed nail changes consistent with type 1 photoonycholysis, which had never been reported so far neither with vandetanib therapy nor with other anticancer-targeted therapies. In addition, histopathologic findings and reflectance confocal microscopy imaging performed in one patient suffering from photodistributed skin hyperpigmentation both strengthen the likelihood of a postinflammatory mechanism. Clinicians should be aware of these underestimated but very characteristic photoinduced adverse events, which can lead to treatment interruption and require very strict photoprotective measures in treated patients.

Persistently curly hair phenotype with the use of nivolumab for squamous cell lung cancer

Increasing use of programmed cell death protein 1/programmed cell death protein 1 ligand inhibition for the treatment of patients with various malignancies such as advanced lung cancer, kidney cancer, and melanoma has resulted in valuable clinical responses, along with the occurrence of new and often puzzling side effects. Known cutaneous effects of CTLA4 and programmed cell death protein 1/programmed cell death protein 1 ligand inhibitors include generalized pruritus, vitiligo, maculopapular lesions, and lichenoid skin eruptions. Alopecia has been the only hair effect previously associated with this class of agents. We describe herein the first case of a persistent curly hair phenotype with the use of nivolumab in a patient with metastatic squamous cell lung cancer.

Selective use of vandetanib in the treatment of thyroid cancer

Vandetanib is a once-daily orally available tyrosine kinase inhibitor that works by blocking RET (REarranged during Transfection), vascular endothelial growth factor receptor (VEGFR-2, VEGFR-3), and epidermal growth factor receptor and to a lesser extent VEGFR-1, which are important targets in thyroid cancer (TC). It is emerging as a potentially effective option in the treatment of advanced medullary thyroid cancer (MTC) and in dedifferentiated papillary thyroid cancer not responsive to radioiodine. The most important effect of vandetanib in aggressive MTC is a prolongation of progression-free survival and a stabilization of the disease. Significant side effects have been observed with the vandetanib therapy (as fatigue, hypertension, QTc prolongation, cutaneous rash, hand-and-foot syndrome, diarrhea, etc), and severe side effects can require the suspension of the drug. Several studies are currently under way to evaluate the long-term efficacy and tolerability of vandetanib in MTC and in dedifferentiated papillary TC. The efficacy of vandetanib in patients with MTC in long-term treatments could be overcome by the resistance to the drug. However, the effectiveness of the treatment could be ameliorated by the molecular characterization of the tumor and by the possibility to test the sensitivity of primary TC cells from each subject to different tyrosine kinase inhibitor. Association studies are evaluating the effect of the association of vandetanib with other antineoplastic agents (such as irinotecan, bortezomib, etc). Further research is needed to determine the ideal therapy to obtain the best response in terms of survival and quality of life.

Nail toxicities induced by systemic anticancer treatments

Patients treated with systemic anticancer drugs often show changes to their nails, which are usually well tolerated and disappear on cessation of treatment. However, some nail toxicities can cause pain and functional impairment and thus substantially affect a patient's quality of life, especially if they are given taxanes or EGFR inhibitors. These nail toxicities can affect both the nail plate and bed, and might present as melanonychia, leukonychia, onycholysis, onychomadesis, Beau's lines, or onychorrhexis, as frequently noted with conventional chemotherapies. Additionally, the periungual area (perionychium) of the nail might be affected by paronychia or pyogenic granuloma, especially in patients treated with drugs targeting EGFR or MEK. We review the nail changes induced by conventional chemotherapies and those associated with the use of targeted anticancer drugs and discuss preventive or curative options.

Non-rash dermatologic adverse events related to targeted therapies

OBJECTIVES

To provide background information and management strategies for non-rash dermatological adverse events.

DATA SOURCES

Peer-reviewed journal articles, professional manuals, online sources.

CONCLUSION

During the last decade, many dermatological adverse events of targeted therapy have been reported, including xerosis, skin fissures, pruritus, photosensitivity, pigmentation changes, hair and nail changes, hand-foot skin reaction, squamoproliferative lesions, Stevens-Johnsons syndrome, and toxic epidermal necrolysis. Although evidenced-based treatment options are scarce, many recommendations have been described in the literature that should be considered to apply in daily practice.

IMPLICATIONS FOR NURSING PRACTICE

Nursing practice will be enhanced by education, assessment, and management recommendations.