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Qu W, Wang F, Qin S, Sun Y, Huang C. Reactive cutaneous capillary endothelial proliferation following camrelizumab monotherapy or combination therapy for multi-cancers: a large-scale pooled analysis of 10 studies in China. Ther Adv Med Oncol 2024; 16:17588359241242607. [PMID: 38606164 PMCID: PMC11008344 DOI: 10.1177/17588359241242607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 03/12/2024] [Indexed: 04/13/2024] Open
Abstract
Background Skin toxicities are the most common adverse events related to immunotherapy, such as reactive cutaneous capillary endothelial proliferation (RCCEP) following treatment with the anti-programmed cell death-1 antibody camrelizumab. Objective This study aimed to comprehensively analyze the clinical features and prognostic value of RCCEP in patients with malignancies who received camrelizumab alone (Camre) or in combination with the angiogenesis-targeted agent apatinib (Camre-Apa) or chemotherapy (Camre-Chemo). Design A large-scale pooled analysis. Methods Individual patient-level data were derived from 10 clinical trials of camrelizumab monotherapy, camrelizumab plus apatinib, or camrelizumab plus chemotherapy (n = 1305). Results RCCEP occurred in 77.0% (516/670) of patients with Camre, 23.6% (70/296) with Camre-Apa, and 67.8% (230/339) with Camre-Chemo. Most RCCEP lesions were grade 1 or 2 in severity. The median time to onset was 0.8 months [interquartile range (IQR), 0.6-1.2] with Camre, 5.0 months (IQR, 2.7-8.0) with Camre-Apa, and 1.6 months (IQR, 1.0-4.2) with Camre-Chemo; and the median duration was 4.8 months (IQR, 2.6-8.8), 4.4 months (IQR, 1.7-8.9), and 7.2 months (IQR, 4.1-14.3), respectively. In all the three groups, patients with RCCEP showed significantly better clinical outcomes compared with those without [objective response rate: 23.8% versus 1.9% with Camre, 48.6% versus 21.2% with Camre-Apa, and 78.7% versus 54.1% with Camre-Chemo; median progression-free survival: 3.2 versus 1.7 months (hazard ratio (HR) = 0.36), 10.2 versus 4.5 months (HR = 0.39), and 12.7 versus 7.3 months (HR = 0.38); median overall survival: 13.3 versus 3.8 months (HR = 0.34), 29.2 versus 13.5 months (HR = 0.46), and not reached versus 12.8 months (HR = 0.19); all p < 0.0001]. Conclusion Although RCCEP occurred frequently with camrelizumab, most lesions were mild and self-limiting. The occurrence of RCCEP was strongly associated with the antitumor activity and survival of camrelizumab, both as monotherapy and in combination therapy.
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Affiliation(s)
- Wenshu Qu
- Department of Medical Oncology, Affiliated Jinling Hospital, Nanjing University of Chinese Medicine, Nanjing, China
| | - Feng Wang
- Department of Medical Oncology, Affiliated Jinling Hospital, Nanjing University of Chinese Medicine, Nanjing, China
| | - Shukui Qin
- Department of Medical Oncology, Affiliated Jinling Hospital, Nanjing University of Chinese Medicine, No. 34, 34 Biao, Yanggongjing Street, Nanjing 210002, China
| | - Yuqi Sun
- Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
| | - Chuanpei Huang
- Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
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Yang X, Yang B, Li D, Pan W, Tong Q, Wang L, Chen D, Fu C. Thromboembolic Events Associated with Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors: A Pharmacovigilance Analysis of the US FDA Adverse Event Reporting System (FAERS) Database. Clin Drug Investig 2024; 44:199-207. [PMID: 38376794 DOI: 10.1007/s40261-024-01346-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND AND OBJECTIVES Although thromboembolic events (TEEs) have been reported with the use of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs), their association remains largely unknown. In this study, we aimed to provide a comprehensive review of TEEs associated with EGFR-TKIs. METHODS We collected EGFR-TKIs (gefitinib, erlotinib, afatinib, and osimertinib) adverse reaction reports from 2015 Q1 to 2023 Q1 from the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database. Disproportionality analysis was conducted to identify thromboembolic adverse events associated with EGFR-TKIs by comparing them with the overall FAERS database according to the reporting odds ratio (ROR). Associated factors were explored using univariate logistic regression. RESULTS We identified 1068 reports of TEEs associated with EGFR-TKIs (1.24% accounts for all TEEs). Affected patients were females (49.72%) and those older than 65 years (41.20%). The reported TEE case fatality was 30.24%. The median time to onset (TTO) of all cases was 39 days [interquartile range (IQR) 11-161], and the median TTO of fatalities [31 days (IQR 10-116)] was significantly shorter than that of non-fatal cases [46 days (IQR 12-186)]. CONCLUSION This study yielded three key findings. Firstly, EGFR-TKIs seem to exhibit prothrombotic effects, elevating the risk of TEEs. Secondly, the clinical outcomes of TEEs associated with EGFR-TKIs were poor. Thirdly, most TEEs occurred within the initial 3 months, and fatal cases occurred earlier than non-fatal cases.
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Affiliation(s)
- Xiongwen Yang
- Department of Pharmacy, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China
- Institute of Pharmacy and Pharmacology, College of Basic Medical Science, Hengyang Medical School, University of South China, Hengyang, 421200, Hunan, People's Republic of China
| | - Bo Yang
- Department of Pharmacy, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China
- Institute of Pharmacy and Pharmacology, College of Basic Medical Science, Hengyang Medical School, University of South China, Hengyang, 421200, Hunan, People's Republic of China
| | - Dan Li
- Department of Pharmacy, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China
- Institute of Pharmacy and Pharmacology, College of Basic Medical Science, Hengyang Medical School, University of South China, Hengyang, 421200, Hunan, People's Republic of China
| | - Wei Pan
- Department of Pharmacy, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China
- Institute of Pharmacy and Pharmacology, College of Basic Medical Science, Hengyang Medical School, University of South China, Hengyang, 421200, Hunan, People's Republic of China
| | - Qin Tong
- Department of Oncology, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China
| | - Lili Wang
- Institute of Pharmacy and Pharmacology, College of Basic Medical Science, Hengyang Medical School, University of South China, Hengyang, 421200, Hunan, People's Republic of China
| | - Danjun Chen
- Department of Pharmacy, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China
- Institute of Pharmacy and Pharmacology, College of Basic Medical Science, Hengyang Medical School, University of South China, Hengyang, 421200, Hunan, People's Republic of China
| | - Chengxiao Fu
- Department of Pharmacy, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China.
- Institute of Pharmacy and Pharmacology, College of Basic Medical Science, Hengyang Medical School, University of South China, Hengyang, 421200, Hunan, People's Republic of China.
- Clinical Pharmacology Research Center, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China.
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Jungbauer F, Affolter A, Brochhausen C, Lammert A, Ludwig S, Merx K, Rotter N, Huber L. Risk factors for immune-related adverse effects during CPI therapy in patients with head and neck malignancies - a single center study. Front Oncol 2024; 14:1287178. [PMID: 38420014 PMCID: PMC10899674 DOI: 10.3389/fonc.2024.1287178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/30/2024] [Indexed: 03/02/2024] Open
Abstract
Introduction Checkpoint inhibitors, such as PD1 inhibitors, represent an important pillar in the therapy of advanced malignancies of the head and neck region. The most relevant complications are immune-related adverse effects (irAEs), which represent an immense burden for patients. Currently, no sufficient stratification measures are available to identify patients at increased risk of irAEs. The aim of this retrospective study was to examine whether demographic, histopathological, clinical, or laboratory values at the start of CPI therapy represent a risk factor for the later occurrence of autoimmune complications. Material and methods Data from 35 patients between 2018 and 2021 who received therapy with nivolumab or pembrolizumab for head and neck malignancy were analyzed and assessed for any associations with the subsequent occurrence of irAEs. Results IrAE developed in 37% of patients, with pneumonitis being the most common form (14%). Pneumonitis was found in patients with an average significantly lower T-stage of primary tumors. An increase in basophilic leukocytes was found in patients with dermatitis later in the course. When thyroiditis developed later, the patients had a higher CPS score and lower monocyte levels. Discussion Even though individual laboratory values at the beginning of therapy might show a statistical association with the later occurrence of irAEs, neither demographic, histopathological, nor laboratory chemistry values seem to be able to generate a sound and reliable risk profile for this type of complication. Therefore, patients need to be educated and sensitized to irAEs, and regular screening for irAEs should be carried out.
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Affiliation(s)
- Frederic Jungbauer
- Department of Otorhinolaryngology, Head- and Neck-Surgery, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Annette Affolter
- Department of Otorhinolaryngology, Head- and Neck-Surgery, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Brochhausen
- Department of Pathology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Anne Lammert
- Department of Otorhinolaryngology, Head- and Neck-Surgery, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Sonja Ludwig
- Department of Otorhinolaryngology, Head- and Neck-Surgery, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Kirsten Merx
- Department of Hematology and Oncology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Nicole Rotter
- Department of Otorhinolaryngology, Head- and Neck-Surgery, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Lena Huber
- Department of Otorhinolaryngology, Head- and Neck-Surgery, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
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4
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Identification of immune-related mechanisms of cetuximab induced skin toxicity in colorectal cancer patients. PLoS One 2022; 17:e0276497. [PMID: 36269747 PMCID: PMC9586384 DOI: 10.1371/journal.pone.0276497] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/08/2022] [Indexed: 11/07/2022] Open
Abstract
Skin rash is a well-known predictive marker of the response to cetuximab (Cmab) in metastatic colorectal cancer (mCRC). However, the mechanism of skin rash development is not well understood. Following exposure to EGFR-targeted therapies, changes in IL-8 levels have been reported. The aim of this study was to evaluate the association between skin rash and inflammatory cytokine levels, including IL-8. Between 2014 and 2017, we prospectively enrolled 38 mCRC patients who underwent chemotherapy with either Cmab or bevacizumab (Bmab) at two hospitals. We performed multiplex cytokine ELISA with 20 inflammatory cytokines including E-selectin, GM-CSF, IFN-alpha, IFN-γ, IL-1 alpha, IL-1 beta, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, IL-17A, IP-10, MCP-1, MIP-1 alpha, MIP-1 beta, P-selectin, sICAM-1, and TNF-alpha at baseline before cycle 1, 24 h after cycle 1, before cycle 2 (= 14 d), and before cycle 3 (= 28 d). Cytokine levels were compared using ANOVA after log-transformation. IL-8 genotypes in 30 patients treated with Cmab were determined using the polymerase chain reaction restriction fragment length polymorphism technique. Depending on the RAS mutational status, 30 and eight patients were treated with Cmab and Bmab-based chemotherapy, respectively. Skin rash developed in 23 (76.6%) of the 30 patients treated with Cmab plus FOLFIRI, after cycle 1. Only the mean log-transformed serum IL-8 level in patients with skin toxicity was statistically lower (2.83 ± 0.15) than in patients who did not experience skin toxicity (3.65 ± 0.27) and received Bmab (3.10 ± 0.26) (ANOVA test, p value = 0.0341). In addition, IL-8 polymorphism did not affect IL-8 levels, skin toxicity, or tumor response in Cmab treated patients. This study suggests that the inflammatory cytokine levels might be affected by Cmab exposure and are associated with the development of skin rash in mCRC patients. Further studies are warranted to evaluate this interaction in Cmab treated patients.
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5
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Sakumura M, Ando T, Ueda-Consolvo T, Motoo I, Mihara H, Kajiura S, Teramoto A, Nanjo S, Fujinami H, Yasuda I. Bilateral Serous Retinal Detachment Associated with a Mitogen-activated Protein KinaseKinase Inhibitor in a Patient with BRAF-mutant Colorectal Cancer. Intern Med 2022; 61:1707-1712. [PMID: 34707053 PMCID: PMC9259315 DOI: 10.2169/internalmedicine.8439-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein report a 73-year-old woman with BRAF V600E-mutated colon cancer treated with encorafenib plus cetuximab with binimetinib as standard salvage therapy for patients with advanced colorectal cancer. She developed bilateral serous retinal detachment the next day, and the regimen was discontinued, resulting in complete resolution by the third day. Doublet therapy without binimetinib was initiated along with a weekly ophthalmologic examination for 10 weeks without recurrence of retinal detachment. Thus, binimetinib was presumed to have been the cause of the retinal detachment. This clinical course suggests the need for close monitoring of patients for vision impairment and close collaboration with ophthalmologists.
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Affiliation(s)
- Miho Sakumura
- Third Department of Internal Medicine, Toyama University Hospital, Japan
| | - Takayuki Ando
- Third Department of Internal Medicine, Toyama University Hospital, Japan
| | - Tomoko Ueda-Consolvo
- Department of Ophthalmology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Iori Motoo
- Third Department of Internal Medicine, Toyama University Hospital, Japan
| | - Hiroshi Mihara
- Third Department of Internal Medicine, Toyama University Hospital, Japan
| | - Shinya Kajiura
- Third Department of Internal Medicine, Toyama University Hospital, Japan
| | - Akira Teramoto
- Third Department of Internal Medicine, Toyama University Hospital, Japan
| | - Sohachi Nanjo
- Third Department of Internal Medicine, Toyama University Hospital, Japan
| | - Haruka Fujinami
- Third Department of Internal Medicine, Toyama University Hospital, Japan
| | - Ichiro Yasuda
- Third Department of Internal Medicine, Toyama University Hospital, Japan
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6
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Haist C, Poschinski Z, Bister A, Hoffmann MJ, Grunewald CM, Hamacher A, Kassack M, Wiek C, Scheckenbach K, Hanenberg H. Engineering a single-chain variable fragment of cetuximab for CAR T-cell therapy against head and neck squamous cell carcinomas. Oral Oncol 2022; 129:105867. [DOI: 10.1016/j.oraloncology.2022.105867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 04/07/2022] [Accepted: 04/12/2022] [Indexed: 01/14/2023]
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7
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Koyama S, Fujiwara K, Morisaki T, Fujii T, Nakamura Y, Fukuhara T, Takeuchi H. Cetuximab and paclitaxel combination therapy for recurrent basaloid squamous cell carcinoma in the ethmoid sinus. Auris Nasus Larynx 2021; 48:1189-1192. [DOI: 10.1016/j.anl.2020.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/04/2020] [Accepted: 07/02/2020] [Indexed: 10/23/2022]
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8
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Siddiqui Z, Ahmed S, Vickers M. Epidermal Growth Factor Receptor Inhibitor-Induced Hypomagnesaemia: Is There a Best Replacement Strategy? EUROPEAN MEDICAL JOURNAL 2021. [DOI: 10.33590/emj/21-00083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Monoclonal antibodies targeting the epidermal growth factor receptor (EGFRI), such as cetuximab and panitumumab, are commonly used systemic therapies for advanced colorectal and head and neck cancers. Hypomagnesaemia is a common side effect of these therapies and occurs in up to 30% of patients. Interruption of EGFR signalling in the distal convoluted tubule leads to inactivation of the transcellular transporter transient receptor potential channel melastatin member 6 and increased renal magnesium excretion. This paper describes the incidence, risk factors, and the emerging management options for EGFRI-induced hypomagnesaemia.
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Affiliation(s)
- Zeba Siddiqui
- Department of Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Sumaiya Ahmed
- Department of Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Michael Vickers
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital, Ottawa, Canada
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9
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Muraro E, Fanetti G, Lupato V, Giacomarra V, Steffan A, Gobitti C, Vaccher E, Franchin G. Cetuximab in locally advanced head and neck squamous cell carcinoma: Biological mechanisms involved in efficacy, toxicity and resistance. Crit Rev Oncol Hematol 2021; 164:103424. [PMID: 34245856 DOI: 10.1016/j.critrevonc.2021.103424] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 06/02/2021] [Accepted: 07/04/2021] [Indexed: 12/17/2022] Open
Abstract
Since its introduction, the use of cetuximab in the treatment of head and neck squamous cell carcinoma (HNSCC) has experienced an evolution. Currently, cetuximab associated with radiotherapy is limited to the treatment of patients affected by a locally advanced malignancy and unfit for cisplatin. However, reliable biomarkers of cetuximab efficacy in this cancer setting are still lacking. This review focuses on the mechanisms of action of cetuximab, highlighting, in particular, the consequences of the binding to EGFR, and the pathways involved in the development of adverse events or acquired resistance. Indeed, adverse events, such as skin rash, have been associated with cetuximab efficacy in HNSCC several times. Acquired resistance is associated with microenvironment plasticity, which is, in turn, characterized by an increased immune infiltrate. The better definition of patients eligible for this kind of therapy could improve HNSCC management, possibly proposing a combined treatment with radiotherapy, cetuximab and immune checkpoint inhibitors as recently investigated.
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Affiliation(s)
- Elena Muraro
- Immunopathology and Cancer Biomarkers Unit, Department of Translational Research, CRO Aviano National Cancer Institute, Aviano, PN, Italy.
| | - Giuseppe Fanetti
- Department of Radiation Oncology, CRO Aviano National Cancer Institute, Aviano, PN, Italy
| | - Valentina Lupato
- Unit of Otolaryngology, General Hospital "S. Maria degli Angeli", Pordenone, Italy
| | - Vittorio Giacomarra
- Unit of Otolaryngology, General Hospital "S. Maria degli Angeli", Pordenone, Italy
| | - Agostino Steffan
- Immunopathology and Cancer Biomarkers Unit, Department of Translational Research, CRO Aviano National Cancer Institute, Aviano, PN, Italy
| | - Carlo Gobitti
- Department of Radiation Oncology, CRO Aviano National Cancer Institute, Aviano, PN, Italy
| | - Emanuela Vaccher
- Department of Medical Oncology, CRO Aviano National Cancer Institute, Aviano, PN, Italy
| | - Giovanni Franchin
- Department of Radiation Oncology, CRO Aviano National Cancer Institute, Aviano, PN, Italy
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Kähler KC, Gutzmer R, Meier F, Zimmer L, Heppt M, Gesierich A, Thoms KM, Utikal J, Hassel JC, Loquai C, Pföhler C, Heinzerling L, Kaatz M, Göppner D, Pflugfelder A, Bohne AS, Satzger I, Reinhardt L, Placke JM, Schadendorf D, Ugurel S. Early Exanthema Upon Vemurafenib Plus Cobimetinib Is Associated With a Favorable Treatment Outcome in Metastatic Melanoma: A Retrospective Multicenter DeCOG Study. Front Oncol 2021; 11:672172. [PMID: 34109122 PMCID: PMC8183381 DOI: 10.3389/fonc.2021.672172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background The combination of BRAF and MEK inhibitors has become standard of care in the treatment of metastatic BRAF V600-mutated melanoma. Clinical factors for an early prediction of tumor response are rare. The present study investigated the association between the development of an early exanthema induced by vemurafenib or vemurafenib plus cobimetinib and therapy outcome. Methods This multicenter retrospective study included patients with BRAF V600-mutated irresectable AJCC-v8 stage IIIC/D to IV metastatic melanoma who received treatment with vemurafenib (VEM) or vemurafenib plus cobimetinib (COBIVEM). The development of an early exanthema within six weeks after therapy start and its grading according to CTCAEv4.0 criteria was correlated to therapy outcome in terms of best overall response, progression-free (PFS), and overall survival (OS). Results A total of 422 patients from 16 centers were included (VEM, n=299; COBIVEM, n=123). 20.4% of VEM and 43.1% of COBIVEM patients developed an early exanthema. In the VEM cohort, objective responders (CR/PR) more frequently presented with an early exanthema than non-responders (SD/PD); 59.0% versus 38.7%; p=0.0027. However, median PFS and OS did not differ between VEM patients with or without an early exanthema (PFS, 6.9 versus 6.0 months, p=0.65; OS, 11.0 versus 12.4 months, p=0.69). In the COBIVEM cohort, 66.0% of objective responders had an early exanthema compared to 54.3% of non-responders (p=0.031). Median survival times were significantly longer for patients who developed an early exanthema compared to patients who did not (PFS, 9.7 versus 5.6 months, p=0.013; OS, not reached versus 11.6 months, p=0.0061). COBIVEM patients with a mild early exanthema (CTCAEv4.0 grade 1-2) had a superior survival outcome as compared to COBIVEM patients with a severe (CTCAEv4.0 grade 3-4) or non early exanthema, respectively (p=0.047). This might be caused by the fact that 23.6% of patients with severe exanthema underwent a dose reduction or discontinuation of COBIVEM compared to only 8.9% of patients with mild exanthema. Conclusions The development of an early exanthema within 6 weeks after treatment start indicates a favorable therapy outcome upon vemurafenib plus cobimetinib. Patients presenting with an early exanthema should therefore be treated with adequate supportive measures to provide that patients can stay on treatment.
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Affiliation(s)
- Katharina C Kähler
- Department of Dermatology, University Hospital Schleswig-Holstein (UKSH), Kiel, Germany
| | - Ralf Gutzmer
- Department of Dermatology, University Hospital Hannover, Hannover, Germany
| | - Friedegrund Meier
- Skin Cancer Center, National Center for Tumor Diseases, University Cancer Centre Dresden, Dresden, Germany.,Department of Dermatology, TU Dresden, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Lisa Zimmer
- Department of Dermatology, University Hospital Essen, German Cancer Consortium (DKTK), Essen, Germany
| | - Markus Heppt
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Anja Gesierich
- Department of Dermatology, University Hospital Würzburg, Würzburg, Germany
| | - Kai-Martin Thoms
- Department of Dermatology, University Medical Center Göttingen, Göttingen, Germany
| | - Jochen Utikal
- Skin Cancer Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Dermatology, Venereology and Allergology, University Medical Center Mannheim, Ruprecht-Karl University of Heidelberg, Mannheim, Germany
| | - Jessica C Hassel
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Carmen Loquai
- Department of Dermatology, University Hospital Mainz, Mainz, Germany
| | - Claudia Pföhler
- Department of Dermatology, University Hospital Homburg, Homburg, Germany
| | - Lucie Heinzerling
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany.,Department of Dermatology and Allergology, Ludwig-Maximilian University, München, Germany
| | - Martin Kaatz
- Department of Dermatology, SRH Waldklinikum, Gera, Germany
| | - Daniela Göppner
- Department of Dermatology, University Hospital Giessen, Gießen, Germany
| | | | - Ann-Sophie Bohne
- Department of Dermatology, University Hospital Schleswig-Holstein (UKSH), Kiel, Germany
| | - Imke Satzger
- Department of Dermatology, University Hospital Hannover, Hannover, Germany
| | - Lydia Reinhardt
- Skin Cancer Center, National Center for Tumor Diseases, University Cancer Centre Dresden, Dresden, Germany.,Department of Dermatology, TU Dresden, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jan-Malte Placke
- Department of Dermatology, University Hospital Essen, German Cancer Consortium (DKTK), Essen, Germany
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital Essen, German Cancer Consortium (DKTK), Essen, Germany
| | - Selma Ugurel
- Department of Dermatology, University Hospital Essen, German Cancer Consortium (DKTK), Essen, Germany
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11
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Kemski S, Molitor V, Steffens M, Nümm TJ, Herrmann N, Hornung T, Bieber T, Schumann C, Kächele V, Seufferlein T, Heinemann V, Scholl C, Stingl JC. Association between miRNA signatures in serum samples from epidermal growth factor inhibitor treated patients and skin toxicity. Oncotarget 2021; 12:982-995. [PMID: 34012511 PMCID: PMC8121613 DOI: 10.18632/oncotarget.27953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/19/2021] [Indexed: 11/25/2022] Open
Abstract
Objective: Epidermal growth factor receptor inhibitors (EGFRI) are used as targeted cancer therapy. On average 70% of patients treated with EGFRIs suffer from skin toxicity. Studies showed a correlation between overall survival and the appearance of a skin rash, which is used as a biomarker for therapy efficacy. Micro RNAs (miRNA) as tumor or resistance biomarkers for cancer therapy are also highly investigated. In our study, we searched for associations of miRNA expression profiles in serum, with the severity of skin rash, in order to identify tentative therapy predictive biomarkers. Materials and Methods: Five candidate miRNAs were selected, based on an earlier in vitro next-generation-sequencing-experiment and after literature search. MiR-21, miR-31, miR-17, miR-106b and miR-520e were investigated in serum samples from patients (n = 254) treated with EGFRI. The quantitative expression of miRNA was tested for association with the occurrence/severity of the rash. Results: In our cohort of patients treated with EGFR inhibiting monoclonal antibodies, miR-21 and miR-520e serum concentrations were negatively correlated with severity of skin rash (p-value 0.000582 and 1.53e-07 linear-trend-test) whereas for miR-31, a positive correlation was observed (p-value 9.01e-06 linear-trend-test). Conclusions: This suggests that miR-21, miR-31 and miR-520e expression might be a treatment dependent marker for EGFRI induced skin rash.
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Affiliation(s)
- Sarah Kemski
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany.,Department of Dermatology and Allergy, Christine Kühne Center for Allergy Research and Education (CK-CARE), University Hospital-Bonn, Bonn, Germany
| | - Vivien Molitor
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany
| | - Michael Steffens
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany
| | - Tim J Nümm
- Department of Dermatology and Allergy, Christine Kühne Center for Allergy Research and Education (CK-CARE), University Hospital-Bonn, Bonn, Germany
| | - Nadine Herrmann
- Department of Dermatology and Allergy, Christine Kühne Center for Allergy Research and Education (CK-CARE), University Hospital-Bonn, Bonn, Germany
| | - Thorsten Hornung
- Department of Dermatology and Allergy, Christine Kühne Center for Allergy Research and Education (CK-CARE), University Hospital-Bonn, Bonn, Germany
| | - Thomas Bieber
- Department of Dermatology and Allergy, Christine Kühne Center for Allergy Research and Education (CK-CARE), University Hospital-Bonn, Bonn, Germany
| | - Christian Schumann
- Department of Pulmonology, Thorax Oncology, Sleep and Respiration Medicine, Hospital Group Allgäu, Kempten, Germany
| | - Volker Kächele
- Medical Centre for Haematology and Oncology, Ulm, Germany
| | | | - Volker Heinemann
- Department of Internal Medicine III, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Catharina Scholl
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany
| | - Julia Carolin Stingl
- Institute of Clinical Pharmacology, University Hospital of the RWTH Aachen, Aachen, Germany
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12
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Buyse M, Saad ED, Peron J, Chiem JC, De Backer M, Cantagallo E, Ciani O. The Net Benefit of a treatment should take the correlation between benefits and harms into account. J Clin Epidemiol 2021; 137:148-158. [PMID: 33774140 DOI: 10.1016/j.jclinepi.2021.03.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/24/2021] [Accepted: 03/18/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The assessment of benefits and harms from experimental treatments often ignores the association between outcomes. In a randomized trial, generalized pairwise comparisons (GPC) can be used to assess a Net Benefit that takes this association into account. STUDY DESIGN AND SETTINGS We use GPC to analyze a fictitious trial of treatment versus control, with a binary efficacy outcome (response) and a binary toxicity outcome, as well as data from two actual randomized trials in oncology. In all cases, we compute the Net Benefit for scenarios with different orders of priority between response and toxicity, and a range of odds ratios (ORs) for the association between these outcomes. RESULTS The GPC Net Benefit was quite different from the benefit/harm computed using marginal treatment effects on response and toxicity. In the fictitious trial using response as first priority, treatment had an unfavorable Net Benefit if OR < 1, but favorable if OR > 1. With OR = 1, the Net Benefit was 0. Results changed drastically using toxicity as first priority. CONCLUSION Even in a simple situation, marginal treatment effects can be misleading. In contrast, GPC assesses the Net Benefit as a function of the treatment effects on each outcome, the association between outcomes, and individual patient priorities.
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Affiliation(s)
- Marc Buyse
- International Drug Development Institute, San Francisco, CA, USA; Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BioStat), Hasselt University, Diepenbeek, Belgium.
| | - Everardo D Saad
- International Drug Development Institute, Louvain-la-Neuve, Belgium
| | - Julien Peron
- Hospices Civils de Lyon, departments of Oncology and Biostatistics, Pierre-Benite, France; University of Lyon 1, CNRS UMR 5558, Biometry and Evolutive Biology Laboratory, Biostatistics-Health Team, Villeurbanne, France
| | | | - Mickaël De Backer
- Institut de statistique, biostatistique et sciences actuarielles, Université Catholique de Louvain, Louvain-la-Neuve, Belgium
| | - Eva Cantagallo
- European Organisation for Research and Treatment of Cancer (EORTC), Brussels, Belgium
| | - Oriana Ciani
- CERGAS - Università Commerciale L. Bocconi, Milan, Italy; University of Exeter Medical School, Evidence Synthesis & Modelling for Health Improvement, Exeter, UK
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13
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Jatoi A, Ou FS, Ahn DH, Zemla TJ, Le-Rademacher JG, Boland P, Ciombor KK, Jacobs NL, Pasche B, Cleary JM, McCune JS, Pedersen KS, Barzi A, Chiorean EG, Heying EN, Lenz HJ, Sloan JA, Grothey A, Lacouture ME, Bekaii-Saab T. Preemptive Versus Reactive Topical Clobetasol for Regorafenib-Induced Hand-Foot Reactions: A Preplanned Analysis of the ReDOS Trial. Oncologist 2021; 26:610-618. [PMID: 33604969 DOI: 10.1002/onco.13730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 02/04/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Hand-foot skin reaction (HFSR) is the most common regorafenib-induced adverse event and is in need of effective prevention and palliation. MATERIALS AND METHODS The Regorafenib Dose Optimization Study (ReDOS), a four-arm, previously published trial with a 1:1:1:1 randomization scheme, was analyzed in a manner in keeping with the original protocol to assess whether clobetasol 0.05% cream (a corticosteroid) applied to the palms and soles twice per day for 8 weeks was more effective when prescribed preemptively (before the development of HFSR) versus reactively (after the development of HFSR). Patients were assessed during the first two cycles of regorafenib. RESULTS Sixty-one patients received preemptive clobetasol, and 55 received reactive clobetasol. Groups were balanced on demographics. Over the first two cycles, no evidence of HFSR occurred in 30% with preemptive clobetasol versus 13% with reactive clobetasol (p = .03). During the first cycle, 54% and 45% of patients had no HFSR with preemptive and reactive clobetasol, respectively (p = .35). During the second cycle, 33% and 15% had no HFSR with preemptive and reactive clobetasol, respectively (p = .02). During the second cycle, rates of grade 1, 2, and 3 HFSR were 30%, 8%, and 3%, respectively, with preemptive clobetasol and 43%, 18%, and 7%, respectively, with reactive clobetasol (p = .12). Patient-reported outcomes showed HFSR compromised nearly all activities of daily living with worse quality of life in patients who received reactive versus preemptive clobetasol. No clobetasol-induced adverse events were reported. CONCLUSION Preemptive clobetasol might lessen regorafenib-induced hand-foot reactions compared with reactive therapy. Further confirmatory studies are needed in a larger patient cohort. IMPLICATIONS FOR PRACTICE Regorafenib causes hand-foot skin reactions. Preemptive clobetasol, a high-potency topical corticosteroid, appears to lessen the severity of this adverse event. Although further study is needed, the favorable adverse event profile of this intervention might prompt clinicians to discuss this option with their patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Nisha L Jacobs
- Minnesota Hematology Oncology, Coon Rapids, Minnesota, USA
| | - Boris Pasche
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - James M Cleary
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | | | | | | | | | - Heinz-Josef Lenz
- USC Norris Comprehensive Cancer Center, California, Los Angeles, USA
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14
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Statistical Considerations for Trials in Adjuvant Treatment of Colorectal Cancer. Cancers (Basel) 2020; 12:cancers12113442. [PMID: 33228149 PMCID: PMC7699469 DOI: 10.3390/cancers12113442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/29/2020] [Accepted: 11/17/2020] [Indexed: 12/26/2022] Open
Abstract
The design of the best possible clinical trials of adjuvant interventions in colorectal cancer will entail the use of both time-tested and novel methods that allow efficient, reliable and patient-relevant therapeutic development. The ultimate goal of this endeavor is to safely and expeditiously bring to clinical practice novel interventions that impact patient lives. In this paper, we discuss statistical aspects and provide suggestions to optimize trial design, data collection, study implementation, and the use of predictive biomarkers and endpoints in phase 3 trials of systemic adjuvant therapy. We also discuss the issues of collaboration and patient centricity, expecting that several novel agents with activity in the (neo)adjuvant therapy of colon and rectal cancers will become available in the near future.
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15
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Kilic O, Matos de Souza MR, Almotlak AA, Wang Y, Siegfried JM, Distefano MD, Wagner CR. Anti-EGFR Fibronectin Bispecific Chemically Self-Assembling Nanorings (CSANs) Induce Potent T Cell-Mediated Antitumor Responses and Downregulation of EGFR Signaling and PD-1/PD-L1 Expression. J Med Chem 2020; 63:10235-10245. [PMID: 32852209 DOI: 10.1021/acs.jmedchem.0c00489] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Overexpression of the epidermal growth factor receptor (EGFR) on various cancers makes it an important target for cancer immunotherapy. We recently demonstrated that single-chain variable fragment-based bispecific chemically self-assembled nanorings (CSANs) can successfully modify T cell surfaces and function as prosthetic antigen receptors (PARs) allowing selective targeting of tumor antigens while incorporating a dissociation mechanism of the rings. Here, we report the generation of anti-EGFR fibronectin (FN3)-based PARs with high yield, rapid protein production, predicted low immunogenicity, and increased protein stability. We demonstrated the cytotoxicity of FN3-PARs successfully while evaluating FN3 affinities, CSAN valencies, and antigen expression levels. Using an orthotopic breast cancer model, we showed that FN3-PARs can suppress tumor growth with no adverse effects and FN3-PARs reduced immunosuppressive programmed cell death ligand-1 (PD-L1) expression by downregulating EGFR signaling. These results demonstrate the potential of FN3-PARs to direct selective T cell-targeted tumor killing and to enhance antitumor T cell efficacy by modulating the tumor microenvironment.
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Affiliation(s)
| | - Marcos R Matos de Souza
- Department of Virology, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-902, Brazil
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16
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Favazza LA, Parseghian CM, Kaya C, Nikiforova MN, Roy S, Wald AI, Landau MS, Proksell SS, Dueker JM, Johnston ER, Brand RE, Bahary N, Gorantla VC, Rhee JC, Pingpank JF, Choudry HA, Lee K, Paniccia A, Ongchin MC, Zureikat AH, Bartlett DL, Singhi AD. KRAS amplification in metastatic colon cancer is associated with a history of inflammatory bowel disease and may confer resistance to anti-EGFR therapy. Mod Pathol 2020; 33:1832-1843. [PMID: 32376853 PMCID: PMC7483889 DOI: 10.1038/s41379-020-0560-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 04/24/2020] [Accepted: 04/24/2020] [Indexed: 12/13/2022]
Abstract
Mutations in RAS occur in 30-50% of metastatic colorectal carcinomas (mCRCs) and correlate with resistance to anti-EGFR therapy. Consequently, mCRC biomarker guidelines state RAS mutational testing should be performed when considering EGFR inhibitor treatment. However, a small subset of mCRCs are reported to harbor RAS amplification. In order to elucidate the clinicopathologic features and anti-EGFR treatment response associated with RAS amplification, we retrospectively reviewed a large cohort of mCRC patients that underwent targeted next-generation sequencing and copy number analysis for KRAS, NRAS, HRAS, BRAF, and PIK3CA. Molecular testing was performed on 1286 consecutive mCRC from 1271 patients as part of routine clinical care, and results were correlated with clinicopathologic findings, mismatch repair (MMR) status and follow-up. RAS amplification was detected in 22 (2%) mCRCs and included: KRAS, NRAS, and HRAS for 15, 5, and 2 cases, respectively (6-21 gene copies). Patients with a KRAS-amplified mCRC were more likely to report a history of inflammatory bowel disease (p < 0.001). In contrast, mutations in KRAS were associated with older patient age, right-sided colonic origin, low-grade differentiation, mucinous histology, and MMR proficiency (p ≤ 0.017). Four patients with a KRAS-amplified mCRC and no concomitant RAS/BRAF/PIK3CA mutations received EGFR inhibitor-based therapy, and none demonstrated a clinicoradiographic response. The therapeutic impact of RAS amplification was further evaluated using a separate, multi-institutional cohort of 23 patients. Eight of 23 patients with KRAS-amplified mCRC received anti-EGFR therapy and all 8 patients exhibited disease progression on treatment. Although the number of KRAS-amplified mCRCs is limited, our data suggest the clinicopathologic features associated with mCRC harboring a KRAS amplification are distinct from those associated with a KRAS mutation. However, both alterations seem to confer EGFR inhibitor resistance and, therefore, RAS testing to include copy number analyses may be of consideration in the treatment of mCRC.
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Affiliation(s)
- Laura A. Favazza
- Department of Pathology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
| | - Christine M. Parseghian
- Department of Gastrointestinal Medical Oncology, Division
of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX,
USA
| | - Cihan Kaya
- Department of Pathology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
| | - Marina N. Nikiforova
- Department of Pathology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
| | - Somak Roy
- Department of Pathology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
| | - Abigail I. Wald
- Department of Pathology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
| | - Michael S. Landau
- Department of Pathology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
| | - Siobhan S. Proksell
- Department of Medicine, Division of Gastroenterology,
Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA,
USA
| | - Jeffrey M. Dueker
- Department of Medicine, Division of Gastroenterology,
Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA,
USA
| | - Elyse R. Johnston
- Department of Medicine, Division of Gastroenterology,
Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA,
USA
| | - Randall E. Brand
- Department of Medicine, Division of Gastroenterology,
Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA,
USA
| | - Nathan Bahary
- Department of Medicine, Hillman Cancer Center, University
of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Vikram C. Gorantla
- Department of Medicine, Hillman Cancer Center, University
of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John C. Rhee
- Department of Medicine, Hillman Cancer Center, University
of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - James F. Pingpank
- Department of Surgery, Division of Hepatopancreatobiliary
Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Haroon A. Choudry
- Department of Surgery, Division of Gastrointestinal
Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA,
USA
| | - Kenneth Lee
- Department of Surgery, Division of Gastrointestinal
Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA,
USA
| | - Alessandro Paniccia
- Department of Surgery, Division of Gastrointestinal
Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA,
USA
| | - Melanie C. Ongchin
- Department of Surgery, Division of Gastrointestinal
Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA,
USA
| | - Amer H. Zureikat
- Department of Surgery, Division of Gastrointestinal
Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA,
USA
| | - David L. Bartlett
- Department of Surgery, Division of Gastrointestinal
Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA,
USA
| | - Aatur D. Singhi
- Department of Pathology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
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17
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Athauda A, Nankivell M, Langley RE, Alderson D, Allum W, Grabsch HI, Starling N, Chau I, Cunningham D. Impact of sex and age on chemotherapy efficacy, toxicity and survival in localised oesophagogastric cancer: A pooled analysis of 3265 individual patient data from four large randomised trials (OE02, OE05, MAGIC and ST03). Eur J Cancer 2020; 137:45-56. [PMID: 32745964 DOI: 10.1016/j.ejca.2020.06.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/27/2020] [Accepted: 06/07/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND There is a lack of large-scale randomised data evaluating the impact of sex and age in patients undergoing chemotherapy followed by potentially curative surgery for oesophagogastric cancer. PATIENTS AND METHODS Individual patient data from four prospective randomised controlled trials were pooled using a two-stage meta-analysis. For survival analysis, hazard ratios (HRs) were calculated for patients aged <70 and ≥ 70 years, as well as between males and females. Mandard tumour regression grade (TRG) and, ≥grade III toxicities were compared using logistic regression models to calculate odds ratios. All analyses were adjusted for the type of chemotherapy received. RESULTS 3265 patients were included for survival analysis (2668 [82%] male, 597 [18%] female; 2627 (80%) <70 years, 638 (20%) ≥70 years). A significant improvement in overall survival (OS) (HR: 0.78; p < 0.001) and disease-specific survival (DSS) (HR: 0.78; p < 0.001) was observed in females compared with males. No significant differences in OS (HR: 1.11; p = 0.045) or DSS (HR: 1.01; p = 0.821) were observed in older patients compared with younger patients. For patients who underwent resection, older patients (15% vs 10%; p = 0.03) and female patients (14% vs 10%, p = 0.10) were more likely to achieve favourable Mandard TRG scores. Females experienced significantly more ≥grade III nausea (10% vs 5%; p≤0.001), vomiting (10% vs 4%; p≤0.001) and diarrhoea (9% vs 4%; p≤0.001) than males. CONCLUSIONS In this large pooled analysis using prospective randomised trial data, females had significantly improved survival while experiencing more gastrointestinal toxicities. Older patients achieved comparable survival to younger patients and thus, dependent on fitness, should be offered the same treatment paradigm.
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Affiliation(s)
- Avani Athauda
- Gastrointestinal and Lymphoma Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 5PT, United Kingdom
| | - Matthew Nankivell
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn, Second Floor, London, WC1V 6LJ, United Kingdom
| | - Ruth E Langley
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn, Second Floor, London, WC1V 6LJ, United Kingdom
| | - Derek Alderson
- Department of Surgery, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, United Kingdom
| | - William Allum
- Gastrointestinal and Lymphoma Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 5PT, United Kingdom
| | - Heike I Grabsch
- Department of Pathology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands; Pathology and Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, LS9 7TF, United Kingdom
| | - Naureen Starling
- Gastrointestinal and Lymphoma Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 5PT, United Kingdom
| | - Ian Chau
- Gastrointestinal and Lymphoma Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 5PT, United Kingdom
| | - David Cunningham
- Gastrointestinal and Lymphoma Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 5PT, United Kingdom.
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18
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Williams LA, Ginex PK, Ebanks GL, Ganstwig K, Ciccolini K, Kwong BK, Robison J, Shelton G, Strelo J, Wiley K, Maloney C, Moriarty KA, Vrabel M, Morgan RL. ONS Guidelines™ for Cancer Treatment-Related Skin Toxicity. Oncol Nurs Forum 2020; 47:539-556. [PMID: 32830806 DOI: 10.1188/20.onf.539-556] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Management of cancer treatment-related skin toxicities can minimize treatment disruptions and improve patient well-being. OBJECTIVES This guideline aims to support patients and clinicians in decisions regarding management of cancer treatment-related skin toxicities. METHODS A panel developed a guideline for management of cancer treatment-related skin toxicities using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) for certainty of evidence and the National Academies of Sciences, Engineering, and Medicine criteria for trustworthy guidelines. The Cochrane risk-of-bias tool assessed risk of bias. A quantitative or narrative synthesis of the evidence was completed. RESULTS The panel issued seven conditional recommendations for epidermal growth factor receptor inhibitor rash, hand-foot skin reaction, hand-foot syndrome, and chemotherapy-induced alopecia. The panel suggested strategies for prevention and treatment for all toxicities except hand-foot syndrome, which only has a prevention recommendation. IMPLICATIONS FOR NURSING Cancer treatment-related skin toxicities can significantly affect quality of life. Incorporation of these interventions into clinical care can improve patient outcomes. SUPPLEMENTARY MATERIAL CAN BE FOUND AT&NBSP;HTTPS //onf.ons.org/supplementary-material-ons-guidelines-cancer-treatment-related-skin-toxicity.
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19
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Huang W, Li J, Qiu F, Wu X, Zhang J, Li X, Yao G, Zhu S. Therapeutic drug monitoring-based dose optimization for imatinib-associated serious cutaneous reactions in a patient with gastrointestinal stromal tumours: A case report. J Clin Pharm Ther 2020; 45:856-862. [PMID: 32479700 DOI: 10.1111/jcpt.13201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/24/2020] [Accepted: 05/14/2020] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Imatinib mesylate (IM) is the first-line therapy for unresectable or metastatic gastrointestinal stromal tumours (GISTs). Here, we report a case of successful progressive dose optimization by therapeutic drug monitoring (TDM) for a patient with GISTs who developed IM-associated serious cutaneous reactions. CASE DESCRIPTION A 72-year-old female patient received IM at a dose of 400 mg/day for GISTs. The patient developed serious eczematoid drug eruptions and desquamation, following which IM was discontinued. One year later, the GISTs recurred with metastasis, and IM was re-administered at a dose of 100 mg/day, and the dose was gradually increased on the basis of TDM. The final dose of IM was 200 mg/day, and the trough concentration (Ctrough ) of IM was 1457.76 ng/mL. The images obtained from follow-up computed tomography (CT) showed a marked anti-tumour response. IM was well tolerated and the patient developed tolerable IM-associated cutaneous reactions. WHAT IS NEW AND CONCLUSION The strategy of TDM-guided dose optimization makes it possible to achieve optimal clinical efficacy for patients with GISTs who develop IM-associated serious cutaneous reactions.
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Affiliation(s)
- Wanting Huang
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Juan Li
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Feng Qiu
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xingye Wu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xuemei Li
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Department of Pharmacy, Chongqing Health Center for Women and Children, Chongqing, China
| | - Gaoqiong Yao
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shenyin Zhu
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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20
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Bahl A, Bhatia K, Choudhary P, Singhla S, Shrivastava G, Bal J, Anand AK, Chaturvedi H, Dua B. Palliative chemotherapy with or without cetuximab in recurrent or metastatic squamous cell carcinoma of the head and neck: Indian tertiary care retrospective analysis. Head Neck 2020; 42:955-962. [DOI: 10.1002/hed.26070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 12/19/2019] [Accepted: 12/19/2019] [Indexed: 01/30/2023] Open
Affiliation(s)
- Ankur Bahl
- Department of Medical Oncology Max Superspeciality New Delhi India
| | - Komal Bhatia
- Department of Medical Oncology Max Superspeciality New Delhi India
| | | | - Suhas Singhla
- Department of Medical Oncology Max Superspeciality New Delhi India
| | | | - Jaspriya Bal
- Department of Nuclear Medicine Max Superspeciality Hospital New Delhi India
| | - Anil K. Anand
- Department of Radiation Oncology Max Superspeciality Hospital New Delhi India
| | - Harit Chaturvedi
- Department of Surgical Oncology Max Superspeciality Hospital New Delhi India
| | - Bharat Dua
- Department of Radiation Oncology Max Superspeciality Hospital New Delhi India
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21
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Bejan-Angoulvant T, Alexandre J. [Mechanism of action and adverse effects of monoclonal antibodies]. Med Sci (Paris) 2020; 35:1114-1120. [PMID: 31903925 DOI: 10.1051/medsci/2019208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Monoclonal antibodies are therapeutic monoclonal Ig that act by highly specific binding to their target antigen and by interacting with the immune system. Their side effects are mainly related to their mechanism of action. The most frequent adverse effects are infusion reactions. Post-marketing surveillance is essential for identifying adverse reactions and improving knowledge of their mechanism of action.
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Affiliation(s)
- Theodora Bejan-Angoulvant
- Service de Pharmacologie médicale, CHRU de Tours ; EA 7501, GICC, équipe PATCH, Université de Tours, 37000 Tours, France - LabEx MabImprove,
| | - Joachim Alexandre
- Service de Pharmacologie, CHU Caen ; EA4650, Normandie Université, Caen, 14000, France
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22
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Molecular Profiling of EGFR Status to Identify Skin Toxicity in Colorectal Cancer: A Clinicopathological Review. CURRENT HEALTH SCIENCES JOURNAL 2019; 45:127-133. [PMID: 31624638 PMCID: PMC6778291 DOI: 10.12865/chsj.45.02.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 06/20/2019] [Indexed: 11/24/2022]
Abstract
Colorectal cancer (CRC) represents an important health problem, being the third most common type of cancer. In Romania, the CRC incidence has doubled over the years. Both environmental factors and genetic susceptibility are very important for the pathogenesis of CRC. The epidermal growth factor receptor (EGFR) plays an extremely important role in CRC tumorigenesis. Overexpression or dysregulation of EGFR pathway molecules are frequently associated with tumor aggressiveness and patient response to treatment. Based on these considerations, EGFR became one of the first targets of molecular therapies used in CRC. At present, cetuximab and panitumumab are considered to be essential in the treatment of patients with metastatic colorectal cancer expressing the KRAS wild-type gene and EGFR. The main adverse effect for both cetuximab and panitumumab is skin toxicity, present in approximately 80% of patients. The risk of secondary infections, in particular of bacterial infections, is also increased. Cases of staphylococcal infection associated with skin peeling, cellulite, erysipelas, and even Staphylococcus sepsis, were reported. For a long time cutaneous toxicity has been a positive predictor in the efficacy of anti-EGFR treatment, but compliance with treatment and the quality of life of patients with metastatic CRC decreases in the presence of these skin reactions. That is why we emphasize the necessity and importance of using a modern method (molecular analysis of gene polymorphisms possibly supplemented by targeted confocal laser endomicroscopy) to identify a molecular diagnosis, in order to foresee and prevent the appearance of skin reactions and to manage skin toxicity.
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23
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Maher VE, Fernandes LL, Weinstock C, Tang S, Agarwal S, Brave M, Ning YM, Singh H, Suzman D, Xu J, Goldberg KB, Sridhara R, Ibrahim A, Theoret M, Beaver JA, Pazdur R. Analysis of the Association Between Adverse Events and Outcome in Patients Receiving a Programmed Death Protein 1 or Programmed Death Ligand 1 Antibody. J Clin Oncol 2019; 37:2730-2737. [PMID: 31116675 DOI: 10.1200/jco.19.00318] [Citation(s) in RCA: 206] [Impact Index Per Article: 41.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
PURPOSE To assess the relationship among tumor response rate, overall survival, and the development of related adverse events of special interest (AESIs) or related immune-mediated adverse events (imAEs) in patients with urothelial cancer treated with anti-programmed death protein 1 or ligand 1 (anti-PD-1/L1) antibodies. PATIENTS AND METHODS We examined seven trials in 1,747 patients with metastatic or locally advanced urothelial cancer that led to approval of an anti-PD-1/L1 antibody. Five trials enrolled patients who had received prior platinum-based therapy, and two enrolled patients who were cisplatin ineligible. The data sets were searched for AESIs, related AESIs, imAEs, and related imAEs. The relationship to study drug was determined by the investigator. ImAEs were defined as AESIs treated with topical or systemic corticosteroids. RESULTS In these exploratory analyses, a related AESI was reported in 64% of responding patients and in 34% of patients who did not respond to the anti-PD-1/L1 antibody, whereas a related imAE occurred in 28% and 12% of patients who did and did not respond to study drug, respectively. In a responder analysis, an increase in overall survival was seen in patients with related AESIs compared with those with no related AESIs (hazard ratio, 0.45; 95% CI, 0.39 to 0.52). Fifty-seven percent of responding patients with a related AESI reported the AESI before documentation of response. CONCLUSION Patients who responded to treatment with an anti-PD-1/L1 antibody were more likely to report a related AESI or related imAE. This relationship did not seem to be due to the increased duration of exposure in responding patients. Systemic corticosteroid use did not appear to affect the duration of response.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - James Xu
- US Food and Drug Administration, Silver Spring, MD
| | | | | | - Amna Ibrahim
- US Food and Drug Administration, Silver Spring, MD
| | - Marc Theoret
- US Food and Drug Administration, Silver Spring, MD
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24
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Taberna M, Oliva M, Mesía R. Cetuximab-Containing Combinations in Locally Advanced and Recurrent or Metastatic Head and Neck Squamous Cell Carcinoma. Front Oncol 2019; 9:383. [PMID: 31165040 PMCID: PMC6536039 DOI: 10.3389/fonc.2019.00383] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/24/2019] [Indexed: 12/29/2022] Open
Abstract
Cetuximab remains to date the only targeted therapy approved for the treatment of head and neck squamous cell carcinoma (HNSCC). The EGFR pathway plays a key role in the tumorigenesis and progression of this disease as well as in the resistance to radiotherapy (RT). While several anti-EGFR agents have been tested in HNSCC, cetuximab, an IgG1 subclass monoclonal antibody against EGFR, is the only drug with proven efficacy for the treatment of both locoregionally-advanced (LA) and recurrent/metastatic (R/M) disease. The addition of cetuximab to radiotherapy is a validated treatment option in LA-HNSCC. However, its use has been limited to patients who are considered unfit for standard of care chemoradiotherapy (CRT) with single agent cisplatin given the lack of direct comparison of these two regimens in randomized phase III trials and the inferiority suggested by metanalysis and phase II studies. The current use of cetuximab in HNSCC is about to change given the recent results from randomized prospective clinical trials in both the LA and R/M setting. Two phase III studies evaluating RT-cetuximab vs. CRT in Human Papillomavirus (HPV)-positive LA oropharyngeal squamous cell carcinoma (De-ESCALaTE and RTOG 1016) showed inferior overall survival and progression-free survival for RT-cetuximab combination, and therefore CRT with cisplatin remains the standard of care in this disease. In the R/M HNSCC, the EXTREME regimen has been the standard of care as first-line treatment for the past 10 years. However, the results from the KEYNOTE-048 study will likely position the anti-PD-1 agent pembrolizumab as the new first line treatment either alone or in combination with chemotherapy in this setting based on PD-L1 status. Interestingly, cetuximab-mediated immunogenicity through antibody dependent cell cytotoxicity (ADCC) has encouraged the evaluation of combined approaches with immune-checkpoint inhibitors in both LA and R/M-HNSCC settings. This article reviews the accumulated evidence on the role of cetuximab in HNSCC in the past decade, offering an overview of its current impact in the treatment of LA and R/M-HNSCC disease and its potential use in the era of immunotherapy.
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Affiliation(s)
- Miren Taberna
- Medical Oncology Department, Catalan Institute of Oncology, ONCOBELL, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Medicine Department, Barcelona University, Barcelona, Spain
| | - Marc Oliva
- Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Ricard Mesía
- B-ARGO Group, Medical Oncology Department, Catalan Institute of Oncology, Badalona, Spain
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25
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Hanck-Silva G, Fatori Trevizan LN, Petrilli R, de Lima FT, Eloy JO, Chorilli M. A Critical Review of Properties and Analytical/Bioanalytical Methods for Characterization of Cetuximab. Crit Rev Anal Chem 2019; 50:125-135. [DOI: 10.1080/10408347.2019.1581984] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Gilmar Hanck-Silva
- School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, São Paulo, Brazil
| | | | - Raquel Petrilli
- School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Felipe Tita de Lima
- School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, São Paulo, Brazil
| | - Josimar O. Eloy
- College of Pharmacy, Dentistry and Nursing, Federal University of Ceará (UFC), Fortaleza, Ceará, Brazil
| | - Marlus Chorilli
- School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, São Paulo, Brazil
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26
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Cetuximab as a Component of Multimodality Treatment of High-Risk Cutaneous Squamous Cell Carcinoma: A Retrospective Analysis From a Single Tertiary Academic Medical Center. Dermatol Surg 2019; 45:254-267. [DOI: 10.1097/dss.0000000000001755] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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27
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Abstract
Inflammatory skin diseases encompass a vast array of conditions. The field continues to expand and evolve with resurgence of conditions, through newly recognized medication adverse effects, and via more detailed descriptions of known dermatoses. The importance of clinicopathologic correlation and an up to date knowledge of dermatologic conditions cannot be overstated. This review focuses on an array of recent important developments in the histologic diagnosis of inflammatory conditions that affect the skin.
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28
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Lüftner D, Dell'Acqua V, Selle F, Khalil A, Leonardi MC, De La Torre Tomás A, Shenouda G, Romero Fernandez J, Orecchia R, Moyal D, Seité S. Evaluation of supportive and barrier-protective skin care products in the daily prevention and treatment of cutaneous toxicity during systemic chemotherapy. Onco Targets Ther 2018; 11:5865-5872. [PMID: 30271169 PMCID: PMC6149940 DOI: 10.2147/ott.s155438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction The purpose of this multicenter, prospective, observational, open-label study was to evaluate the use and tolerability of dermo-cosmetic products in preventing skin reactions associated with cancer treatments. Patients and methods A 12-product kit was supplied to patients before chemotherapy began and was to be used throughout the treatment phase. Cutaneous adverse events were evaluated at each treatment session. Physicians evaluated skin reactions (edema, erythema, dryness, desquamation, pigmentation disorders, and cracks) and gave their opinion on the skin benefit for patients at the end of the study. Patients also evaluated the product benefit using the Patient Benefit Index (PBI) questionnaire. Results were analyzed by subgroups of casual and regular users, based on number and frequency of products used. Results A total of 147 patients were enrolled in cancer services in Germany, France, Italy, Spain, and Canada. Mean age was 59 years with 71% being female. Product tolerance on whole body was rated good to excellent for at least 89% of the patients for each product. Aggravated skin reactions during the study were reported more frequently by casual users than regular users (39.5% versus 22%; p=0.029). Similarly, casual users reported more erythema aggravation (p=0.02) and desquamation (p=0.03) than regular users. PBI >1 was reported for 95.5% of patients and regular users had significantly higher scores than casual users (p=0.049). Discussion Overall, the 12-product kit was very well tolerated, with regular users reporting benefits more frequently than casual users. Results support international recommendations to use appropriate skin care products to minimize the impact of cutaneous reactions associated with chemotherapy.
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Affiliation(s)
- Diana Lüftner
- Department of Hematology, Oncology and Tumor Immunology, Charité University Hospital Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Veronica Dell'Acqua
- Department of Radiotherapy, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | | | | | | | | | | | - Roberto Orecchia
- Department of Radiotherapy, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Milan University, Milan, Italy
| | - Dominique Moyal
- La Roche-Posay Dermatological Laboratory, Levallois-Perret, France,
| | - Sophie Seité
- La Roche-Posay Dermatological Laboratory, Levallois-Perret, France,
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29
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Carbone ML, Lulli D, Passarelli F, Pastore S. Topical Plant Polyphenols Prevent Type I Interferon Signaling in the Skin and Suppress Contact Hypersensitivity. Int J Mol Sci 2018; 19:ijms19092652. [PMID: 30200670 PMCID: PMC6164211 DOI: 10.3390/ijms19092652] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 09/04/2018] [Indexed: 01/08/2023] Open
Abstract
Human keratinocytes were recently shown to respond to anti-EGFR (epidermal growth factor receptor) drugs with activation of an interferon-κ-driven autocrine loop, leading to enhanced expression of innate antiviral effectors and of the pro-inflammatory chemokines CXCL10 (C-X-C motif chemokine 10) and CCL2 (C-C motif ligand 2). Here we showed active type I interferon signaling in the skin lesions of cancer patients undergoing treatment with the anti-EGFR drug cetuximab. Strong nuclear positivity for Interferon Regulatory Factor 1 and phosphorylated Signal Transducer and Activator of Transcription 1, enhanced interferon-κ expression and CXCL10 was associated to the epidermal compartment. Notably, 50 micromolar resveratrol and quercetin fully suppressed the low constitutive levels of type I interferon signaling and prevented its activation by the anti-EGFR cetuximab or gefitinib in cultured keratinocytes. In sensitized mice undergoing DNFB (2,4-dinitro-1-fluorobenzene)-induced contact hypersensitivity, local administration of gefitinib prior to elicitation further amplified hapten-induced type I interferon activation, tissue edema, and infiltration by T cells, whereas resveratrol or quercetin suppressed this inflammatory cascade. Overall, these data suggest that topical application of resveratrol or quercetin could be potentially effective in preventing pathological conditions due to overactivation of type I IFN (interferon)-driven circuits in the skin, including the inflammatory manifestations of anti-EGFR drug-induced skin-targeted toxicity.
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Affiliation(s)
| | - Daniela Lulli
- Laboratory of Experimental Immunology, IDI-IRCCS, 00167 Rome, Italy.
| | | | - Saveria Pastore
- Laboratory of Experimental Immunology, IDI-IRCCS, 00167 Rome, Italy.
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30
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Takada S, Sagawa T, Fujikawa K, Tahatsu K, Fukai Y, Hashishita H, Takahashi Y, Endo M. Skin Disorders and Primary Tumor Location as Prognostic Factors in Patients with Metastatic Colorectal Cancer Treated with Cetuximab and Chemotherapy. Asian Pac J Cancer Prev 2018; 19:2325-2330. [PMID: 30141310 PMCID: PMC6171408 DOI: 10.22034/apjcp.2018.19.8.2325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background: Cetuximab-induced skin disorder is common in colorectal cancer (CRC), and is known to affect prolonged overall survival (OS). Patients with left-sided CRC survive longer than those with right-sided CRC, among those treated with combination cetuximab and chemotherapy. However, no study has evaluated patient prognosis in terms of OS and progression-free survival (PFS) in relation to both tumor location and skin disorder. This study aimed to determine the incidence of skin disorder according to tumor location and analyze the relationship of tumor location and skin disorder with OS. Methods: Patients with metastatic colorectal cancer (mCRC) treated with standard chemotherapy and cetuximab as first-line therapy were included. Differences in the incidence of skin disorders due to the location of the primary tumors were compared in the same patient. The OS and PFS in relation to the location of the primary tumors and presence or absence of skin disorder were also compared. Results: Total frequency of each skin disorder as rash acneiform, paronychia, and dry skin in patients with left- and right-sided mCRC was 70%, 70%, and 43% and 27%, 36%, and 27%, respectively. The median OS was 8.9 months for mCRC on the left-sided without skin disorder and 56.3 months for mCRC on the left-sided with skin disorder. In comparison, the median OS was 10.4 months for mCRC on the right-sided without skin disorder and 11.3 months for mCRC on the right-sided with skin disease (left-sided with skin disorder versus other three group; P<0.001). Conclusions: Primary tumor location and the presence of skin disorder are important factors in patients with mCRC who receive cetuximab. In particular, our results show the new fact that the left-sided and right-sided mCRC survival time were comparable if there is no skin disorder caused by cetuximab.
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Affiliation(s)
- Shinya Takada
- Department of Pharmacy, National Hospital Organization Hokkaido Cancer Center, Japan.
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31
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Guo X, Peters MDJ, Lu Z. Management of skin toxicity caused by epidermal growth factor receptor inhibitors: an evidence-based implementation project. ACTA ACUST UNITED AC 2018; 15:2815-2829. [PMID: 29135755 DOI: 10.11124/jbisrir-2017-003407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Epidermal growth factor receptor inhibitors (EGFRIs) bind to and inhibit epidermal growth factor receptors (EGFRs) in cancer cells, slowing/preventing tumor growth. As a type of "targeted therapy", they have demonstrated therapeutic effects on solid tumors including colorectal, lung, and head and neck cancers. While effective, various skin reactions are associated with EGFRI therapy which can lead to dose modification or discontinuation as well as discomfort, pain and reduced quality of life. With adequate knowledge and skills, EGFRI-induced skin toxicity can be effectively managed collaboratively by clinicians and people affected by cancer. OBJECTIVES This project aimed to improve management of skin toxicity caused by EGFRIs by implementing evidence-informed practice within a chemotherapy department. METHODS Evidence-informed recommendations for practice and corresponding audit criteria were developed based on a series of literature reviews. Current practice was reviewed against these criteria with 19 nurses and 21 patients within a chemotherapy department. Barriers to adherence to evidence-informed practice were identified and strategies to improve compliance were implemented with clinicians and patients. A follow-up audit against the criteria was used to measure changes in clinical practice. RESULTS Multiple strategies for getting research into practice appear to have been successful. The follow-up audit demonstrated large improvements in compliance across all audit criteria in comparison with baseline results with all but one criterion achieving 100% compliance. Low rates of suspected infection meant that clinical practice could not be measured for criterion 7. CONCLUSIONS Auditing current practice and implementation of strategies to improve compliance with evidence-informed practice were effective. Sustaining these improvements is vital to ensure clinical practice continues to support better patient outcomes.
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Affiliation(s)
- Xiaolu Guo
- 1Department of Nursing, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China 2The Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
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32
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Birch JC, Khatri G, Watumull LM, Arriaga YE, Leyendecker JR. Unintended Consequences of Systemic and Ablative Oncologic Therapy in the Abdomen and Pelvis. Radiographics 2018; 38:1158-1179. [PMID: 29995613 DOI: 10.1148/rg.2018170137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Human cancers are genetically complex and diverse. Although advances in oncologic therapy aim to define and target unique steps in carcinogenesis, oncologists often rely on less discriminate anticancer therapies that have consequences for normal tissues. Even many of the so-called targeted therapies currently employed can adversely affect normal cells, leading to complications that necessitate dose reductions or cessation of specific therapies. This article explores the unintended consequences of currently employed systemic and ablative anticancer therapies that might manifest at imaging examinations of the abdomen and pelvis, including cytotoxic, molecular targeted, and immunologic agents; ablation; and hematopoietic stem cell transplant. Each of these treatments can have both major and minor unintended effects in the targeted organ(s), in local or adjacent structures, or at distant sites. Timely detection and reporting of adverse consequences of anticancer therapies by the astute imager can result in critical treatment modifications and/or lifesaving interventions; therefore, knowledge of these unintended effects is paramount for radiologists interpreting the results of imaging examinations in cancer patients. ©RSNA, 2018.
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Affiliation(s)
- Julie C Birch
- From the Department of Radiology (J.C.B., G.K., L.M.W., J.R.L.) and Department of Internal Medicine, Division of Hematology/Oncology (Y.E.A.), University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Gaurav Khatri
- From the Department of Radiology (J.C.B., G.K., L.M.W., J.R.L.) and Department of Internal Medicine, Division of Hematology/Oncology (Y.E.A.), University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Lori M Watumull
- From the Department of Radiology (J.C.B., G.K., L.M.W., J.R.L.) and Department of Internal Medicine, Division of Hematology/Oncology (Y.E.A.), University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Yull E Arriaga
- From the Department of Radiology (J.C.B., G.K., L.M.W., J.R.L.) and Department of Internal Medicine, Division of Hematology/Oncology (Y.E.A.), University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - John R Leyendecker
- From the Department of Radiology (J.C.B., G.K., L.M.W., J.R.L.) and Department of Internal Medicine, Division of Hematology/Oncology (Y.E.A.), University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
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33
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Rzepecki AK, Cheng H, McLellan BN. Cutaneous toxicity as a predictive biomarker for clinical outcome in patients receiving anticancer therapy. J Am Acad Dermatol 2018; 79:545-555. [PMID: 29733938 DOI: 10.1016/j.jaad.2018.04.046] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 04/09/2018] [Accepted: 04/29/2018] [Indexed: 12/12/2022]
Abstract
The relationship between treatment outcome and cutaneous toxicity induced by anticancer therapy has gained attention in the past decade. In this article, we have provided an overview of the 3 main classes of anticancer agents-specifically, molecularly targeted kinase inhibitors, immune checkpoint inhibitors, and cytotoxic chemotherapeutics-and described the data evaluating the association between cutaneous toxicity induced by these agents and survival benefit. Although preliminary studies are promising with regard to the potential role of cutaneous toxicities as a surrogate biomarker of efficacy of treatment, larger prospective studies are needed to confirm this relationship. Dermatologists have a unique opportunity to collaborate with oncologists in the multidisciplinary treatment paradigm by helping to identify and manage these dermatologic events in patients with cancer. A heightened awareness of these toxicities is critical, as it can potentially allow recognition of the efficacy of anticancer therapy and may influence treatment decisions and patient outcomes.
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Affiliation(s)
- Alexandra K Rzepecki
- Department of Dermatology, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Haiying Cheng
- Department of Oncology, Montefiore Medical Center, Bronx, New York
| | - Beth N McLellan
- Division of Dermatology, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
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Ba-Sang DZ, Long ZW, Teng H, Zhao XP, Qiu J, Li MS. A network meta-analysis on the efficacy of sixteen targeted drugs in combination with chemotherapy for treatment of advanced/metastatic colorectal cancer. Oncotarget 2018; 7:84468-84479. [PMID: 27806321 PMCID: PMC5356673 DOI: 10.18632/oncotarget.12994] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 10/02/2016] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE A network meta-analysis was conducted comparing the short-term efficacies of 16 targeted drugs in combination with chemotherapy for treatment of advanced/metastatic colorectal cancer (CRC). RESULTS Twenty-seven RCTs were ultimately incorporated into this network meta-analysis. Compared with chemotherapy alone, bevacizumab + chemotherapy, panitumumab + chemotherapy and conatumumab + chemotherapy had higher PR rate. Bevacizumab + chemotherapy, cetuximab + chemotherapy, panitumumab + chemotherapy, trebananib + chemotherapy and conatumumab + chemotherapy had higher ORR rate in comparison to chemotherapy alone. Furthermore, bevacizumab + chemotherapy had higher DCR rate than chemotherapy alone. The results of our cluster analysis showed that chemotherapy combined with bevacizumab, cetuximab, panitumumab, conatumumab, ganitumab, or brivanib + cetuximab had better efficacies for the treatment of advanced/metastatic CRC in comparison to chemotherapy alone. MATERIALS AND METHODS Electronic databases were comprehensively searched for potential and related randomized controlled trials (RCTs). Direct and indirect evidence were incorporated for evaluation of stable disease (SD), progressive disease (PD), complete response (CR), partial response (PR), disease control rate (DCR) and overall response ratio (ORR) by calculating odds ratio (OR) and 95% confidence intervals (CI), and using the surface under the cumulative ranking curve (SUCRA). CONCLUSIONS These results indicated that bevacizumab + chemotherapy, panitumumab + chemotherapy, conatumumab + chemotherapy and brivanib + cetuximab + chemotherapy may have better efficacies for the treatment of advanced/metastatic CRC.
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Affiliation(s)
- Dan-Zeng Ba-Sang
- Department of Oncology, Shigatse People's Hospital, Shigatse 857000, Tibet, P. R. China
| | - Zi-Wen Long
- Department of Gastric Cancer and Soft-Tissue Sarcoma Surgery, Fudan university Shanghai Cancer Center, Shanghai 200032, P. R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P. R. China
| | - Hao Teng
- Department of Oncology, Shigatse People's Hospital, Shigatse 857000, Tibet, P. R. China
| | - Xu-Peng Zhao
- Department of Oncology, Shigatse People's Hospital, Shigatse 857000, Tibet, P. R. China
| | - Jian Qiu
- Department of Oncology, Shigatse People's Hospital, Shigatse 857000, Tibet, P. R. China
| | - Ming-Shan Li
- Department of Oncology, Shigatse People's Hospital, Shigatse 857000, Tibet, P. R. China
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35
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Wei F, Shin D, Cai X. Incidence, risk and prognostic role of anti-epidermal growth factor receptor-induced skin rash in biliary cancer: a meta-analysis. Int J Clin Oncol 2017; 23:443-451. [PMID: 29289981 DOI: 10.1007/s10147-017-1231-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 12/20/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anti-epidermal growth factor receptor (EGFR)-induced skin rash is a common adverse event and is considered a prognostic factor of various cancers. However, the role of rash is rarely known in biliary cancer, possibly owing to the low incidence of this frequently fatal malignancy. We thus performed a meta-analysis to investigate the incidence, risk and prognostic significance of skin rash related to anti-EGFR treatment for biliary cancer. METHODS Eligible studies were enrolled after a systematic search of electronic databases. A fixed-effects or random-effects model was utilized according to the heterogeneity. RESULTS Fourteen clinical trials published between 2006 and 2017 comprising 1,106 patients with advanced biliary cancer were included. The overall incidence of all-grade and high-grade (grade ≥3) rash was 78.2% [95% confidence interval (CI) 70.4-84.3] and 11.3% (7.6-16.5), respectively. Anti-EGFR treatment correlates with a significantly increased risk of all-grade [risk ratio (RR) 7.37, 95% CI 5.11-10.64, p < 0.0001] and high-grade (RR 6.94, 95% CI 1.89-25.45, p = 0.0035) rash compared with control medication. Higher grades of skin rash correlate with a higher objective response rate (RR 3.50, 95% CI 1.47-8.33, p = 0.0048), and a longer overall [hazard ratio (HR) 0.47, 95% CI 0.31-0.71, p = 0.0003) and progression-free survival (HR 0.51, 95% CI 0.36-0.72, p = 0.0001) compared with lower grades or no rash in patients who received anti-EGFR treatment. CONCLUSIONS Anti-EGFR treatment correlates with an increased risk of skin rash in advanced biliary cancer. Stratifying patients by the severity of rash may have major implications for survival benefit regarding anti-EGFR treatment for biliary cancer.
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Affiliation(s)
- Fangqiang Wei
- Department of General Surgery, Institute of Minimally Invasive Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, No. 3, Qingchun Road, Hangzhou, 310016, Zhejiang, China.,Department of Developmental Biology, Pittsburgh Liver Research Center, McGowan Institute for Regenerative Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, 15260, USA
| | - Donghun Shin
- Department of Developmental Biology, Pittsburgh Liver Research Center, McGowan Institute for Regenerative Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, 15260, USA
| | - Xiujun Cai
- Department of General Surgery, Institute of Minimally Invasive Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, No. 3, Qingchun Road, Hangzhou, 310016, Zhejiang, China.
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36
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Boudrias-Dalle E, Cloutier M, Harvey M, Leblanc G, Besner-Morin O, Adam JP. Durable complete remission following anti-EGFR antibodies in recurrent metastatic colorectal cancer. J Oncol Pharm Pract 2017; 25:239-243. [PMID: 28950807 DOI: 10.1177/1078155217730130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this case report, we describe a patient who remains in complete remission two years after the discontinuation of anti-EGFR monotherapy as a third-line treatment, accompanied by persistent severe hypomagnesemia. A 45-year-old Caucasian woman with mCRC started chemotherapy with weekly cetuximab. After ten months of treatment, the therapy was stopped because the patient had persistent grade III hypomagnesemia despite amiloride, oral, and intravenous magnesium. A month later, the patient was switched to panitumumab 6 mg/kg every two weeks for four additional months to avoid weekly visits to the clinic. Following discontinuation of panitumumab, PET scans remain negative to this day, two years after anti-EGFR therapy discontinuation. No factor has been identified to explain the complete and sustained response experienced by this patient. Hypomagnesemia is a common adverse effect of anti-EGFR therapy that can lead to treatment interruption and discontinuation if severe. This case highlights the importance of pursuing anti-EGFR therapy when a response is observed in spite of severe hypomagnesemia. It also provides preliminary information that anti-EGFR therapy could be stopped after a complete response is obtained.
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Affiliation(s)
| | - Magali Cloutier
- 1 Faculty of pharmacy, University of Montreal, Montréal, QC, Canada
| | - Marjorie Harvey
- 1 Faculty of pharmacy, University of Montreal, Montréal, QC, Canada
| | - Guy Leblanc
- 2 Department of Surgery, 60301 Maisonneuve-Rosemont Hospital , University of Montreal, Montreal, Canada
| | - Olivier Besner-Morin
- 3 Department of Pharmacy, 60301 Maisonneuve Rosemont Hospital , Montréal, QC, Canada
| | - Jean-Philippe Adam
- 4 Department of Pharmacy, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada.,5 Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
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Lemoine L, Sugarbaker P, Van der Speeten K. Drugs, doses, and durations of intraperitoneal chemotherapy: standardising HIPEC and EPIC for colorectal, appendiceal, gastric, ovarian peritoneal surface malignancies and peritoneal mesothelioma. Int J Hyperthermia 2017; 33:582-592. [DOI: 10.1080/02656736.2017.1291999] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Lieselotte Lemoine
- Department of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department of Surgical Oncology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Paul Sugarbaker
- Washington Cancer Institute, Washington Hospital Center, Washington DC, USA
| | - Kurt Van der Speeten
- Department of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department of Surgical Oncology, Ziekenhuis Oost-Limburg, Genk, Belgium
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De Tursi M, Zilli M, Carella C, Auriemma M, Lisco MN, Di Nicola M, Di Martino G, Natoli C, Amerio P. Skin toxicity evaluation in patients treated with cetuximab for metastatic colorectal cancer: a new tool for more accurate comprehension of quality of life impacts. Onco Targets Ther 2017; 10:3007-3015. [PMID: 28670133 PMCID: PMC5481280 DOI: 10.2147/ott.s127795] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objectives The effectiveness of evaluation of the severity of epidermal growth-factor receptor inhibitor (EGFRI)-associated dermatological toxicities remains a topic of debate. This study was designed to assess the correlation between quality of life (QoL) and severity of dermatological toxicity, evaluated using the National Cancer Institute’s Common Terminology Criteria for Adverse Events (NCI-CTCAE) and our novel scale, the Eruption Scoring System (ESS), in metastatic colorectal cancer (CRC) patients treated with first-line chemotherapy combined with cetuximab. Methods Cutaneous toxicity was evaluated, by oncologists and dermatologists, in patients (n=30) with histologically confirmed metastatic CRC who were scheduled to begin first-line chemotherapy combined with the EGFRI, cetuximab, using the NCI-CTCAE and ESS tools. Health-related QoL (HRQoL) was evaluated using the Skindex-29 and Skindex-17 dermatology-specific instruments. Correlations between QoL and skin toxicity severity were assessed using Spearman’s rank tests. Interclass correlation coefficients were used to assess interoperator agreement for ESS and NCI-CTCAE v4.0 scoring. Results A positive correlation was identified between dermatology HRQoL and the severity of dermatological toxicities assessed using the NCI-CTCAE v4.0 scale for cutaneous papulopustular acneiform rash; however, a stronger correlation was observed between HRQoL and toxicities evaluated using the ESS tool. Both NCI-CTCAE v4.0 and ESS tools demonstrated good interobserver agreement for grading of skin toxicity. Conclusion There is a strong correlation between the scores generated by the ESS and NCI-CTCAE tools to grade cutaneous toxicity related to treatment with the anti-EGFR monoclonal antibody, cetuximab. ESS can be considered a valid instrument for identification and grading of the severity of skin toxicity induced by cetuximab, with some advantages over the standard NCI-CTCAE scoring system.
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Affiliation(s)
- Michele De Tursi
- Department of Medical, Oral and Biotechnological Sciences, Medical Oncology Unit
| | - Marinella Zilli
- Department of Medical, Oral and Biotechnological Sciences, Medical Oncology Unit
| | - Consiglia Carella
- Department of Medical, Oral and Biotechnological Sciences, Medical Oncology Unit
| | | | | | - Marta Di Nicola
- Laboratory of Biostatistics, Department of Medical, Oral and Biotechnological Sciences
| | - Giuseppe Di Martino
- Department of Medicine and Aging Science, University degli Studi "G d'Annunzio" Chieti-Pescara, Chieti, Italy
| | - Clara Natoli
- Department of Medical, Oral and Biotechnological Sciences, Medical Oncology Unit
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Siano M, Molinari F, Martin V, Mach N, Früh M, Freguia S, Corradino I, Ghielmini M, Frattini M, Espeli V. Multicenter Phase II Study of Panitumumab in Platinum Pretreated, Advanced Head and Neck Squamous Cell Cancer. Oncologist 2017; 22:782-e70. [PMID: 28592616 PMCID: PMC5507653 DOI: 10.1634/theoncologist.2017-0069] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 04/04/2017] [Indexed: 11/20/2022] Open
Abstract
Lessons Learned. Panitumumab shows activity in terms of disease control rate and preventing disease progression but not for tumor shrinkage in head and neck squamous cell cancer for second‐line treatment. Epidermal growth factor receptor (EGFR) copy number gain, a property of tumor cells that theoretically could identify patients more likely to experience disease response, was common among patients having disease control. Our trial, given the lower toxicity with an every‐2‐week schedule, provides guidance for future trials, for example, in combinations of immune therapies and anti‐EGFR‐antibodies.
Background. The objective of this study was to investigate the efficacy and safety of panitumumab (anti‐epidermal growth factor receptor [EGFR] antibody) given as a single agent in platinum‐pretreated head and neck squamous cell cancer (HNSCC). Methods. Patients with advanced HNSCC previously treated with platinum‐containing therapy were included. Panitumumab was administered intravenously every 2 weeks at a dose of 6 mg/kg. Primary endpoint was overall response rate (ORR) according to Response Evaluation Criteria In Solid Tumors (RECIST) version 1.1; secondary endpoints were progression‐free survival (PFS) and safety. A Simon's two‐step design was chosen; 4 partial remissions (PR) in the first 32 patients were required for continuing to step two. An exploratory biomarker analysis was performed. Results. Thirty‐three patients were enrolled. Two patients obtained a PR for an ORR of 6%, and 15 (45%) showed stable disease (SD) for at least 2 months, resulting in a 51% disease control rate. Median PFS was 2.6 months (95% confidence interval [CI]: 1.7–3.7), while median OS was 9.7 months (95% CI: 6.3–17.2). The most frequent adverse drug reactions were cutaneous rash (64%) and hypomagnesemia (55%). Overall, 30% of patients experienced grade 3/4 adverse events. No infusion‐related reactions occurred. EGFR copy number gain (CNG) was more frequent in patients who benefitted from panitumumab. Two uncommon KRAS mutations (G48E, T50I) and 3 canonical PIK3CA mutations (all E545K) were detected. High‐risk HPV16 was found in 10 patients and EGFR CNG in 13 treated patients. EGFR CNG seems to be more frequent in individuals with at least SD compared with patients with progressive disease (59% vs. 30%). PFS for patients with EGFR CNG was 4.6 months (95% CI: 1.0–9.2 months) and 1.9 months (95% CI: 1.0–3.2 months) for patients without CNG (p = .02). Conclusion. Panitumumab monotherapy in pretreated HNSCC patients was well tolerated but moderately active. We observed a considerable disease control rate. Future strategies with this agent comprise right patient selection through the identification of reliable biomarkers and gene signatures predicting response and, considering good tolerability and convenience, combination strategies with novel agents and immune therapeutic agents.
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Affiliation(s)
- Marco Siano
- Department of Medical Oncology and Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Francesca Molinari
- Institute of Pathology, Laboratory of Molecular Pathology, Locarno, Switzerland
| | - Vittoria Martin
- Institute of Pathology, Laboratory of Molecular Pathology, Locarno, Switzerland
| | - Nicolas Mach
- Clinical Research Unit of the Dr. Henri Dubois-Ferrière, University Hospital, Geneva, Switzerland
| | - Martin Früh
- Department of Medical Oncology and Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Stefania Freguia
- Institute of Pathology, Laboratory of Molecular Pathology, Locarno, Switzerland
| | - Irene Corradino
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Michele Ghielmini
- Oncology Institute of Southern Switzerland, San Giovanni Hospital, Bellinzona, Switzerland
| | - Milo Frattini
- Institute of Pathology, Laboratory of Molecular Pathology, Locarno, Switzerland
| | - Vittoria Espeli
- Oncology Institute of Southern Switzerland, San Giovanni Hospital, Bellinzona, Switzerland
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Risk of Distinctive Hair Changes Associated With Pazopanib in Patients With Renal Cell Carcinoma (RCC) Versus Patients Without RCC: A Comparative Systematic Review and Meta-analysis. Clin Genitourin Cancer 2017; 15:e325-e335. [DOI: 10.1016/j.clgc.2016.12.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 12/05/2016] [Accepted: 12/10/2016] [Indexed: 11/23/2022]
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Granados-García M, Aguilar-Ponce JL, Maldonado-Magos F, De la Garza-Salazar JG. Advanced Squamous Cell Carcinoma of the Head and Neck: The Current Role of Cetuximab. ORL J Otorhinolaryngol Relat Spec 2017; 78:320-333. [PMID: 28125819 DOI: 10.1159/000455891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 01/06/2017] [Indexed: 11/19/2022]
Abstract
We review clinical trials of squamous cell carcinoma of the head and neck (SCCHN) to address the current and potential uses of cetuximab (CTX). PubMed was reviewed to identify papers published between 2010 and 2016. The search terms used were "cetuximab" and "head and neck cancer." A total of 634 articles were identified. Phase II or III studies with CTX in patients with advanced SCCHN without treatment or with recurrent/metastatic tumors were selected. Forty-six registries were obtained. Information was critically reviewed and relevant information presented. As definitive treatment of advanced squamous cells carcinomas and as palliative treatment of recurrent/metastatic disease, CTX alone or associated with chemotherapy and/or radiotherapy is an alternative to chemoradiotherapy because of its distinct and favorable toxicity profile.
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Affiliation(s)
- Martín Granados-García
- Head and Neck Cancer Department, Instituto Nacional de Cancerología, Mexico City, Mexico
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Bernad IP, Trufero JM, Urquizu LC, Pazo Cid RA, de Miguel AC, Agustin MJ, Lanzuela M, Antón A. Activity of weekly paclitaxel-cetuximab chemotherapy in unselected patients with recurrent/metastatic head and neck squamous cell carcinoma: prognostic factors. Clin Transl Oncol 2017; 19:769-776. [PMID: 28120324 DOI: 10.1007/s12094-016-1604-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 12/19/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Standard treatment for recurrent/metastatic head and neck squamous cell carcinoma (RM-SCCHN) is based in on platinum and cetuximab combination therapy. Unfortunately, not all patients are candidates to receive platinum-based treatment, because of different conditions as comorbidity and poor performance status. Weekly paclitaxel and cetuximab (WPC) is an active therapeutic alternative, based on a phase II study, with less toxicity. Our main objective is to confirm its activity in unselected patients, mostly unfit for aggressive therapies, analysing also some clinically relevant prognostic factors (PFs). METHODS Retrospective data was collected for RM-SCCHN patients, treated at our institution between January 2008 and July 2014 with weekly paclitaxel (80 mg/m2) and cetuximab (400/250 mg/m2). RESULTS 148 patients were treated. The objective response rate (OR) was as follows: 13 patients (8.78%) complete response (CR); 57 patients (38.51%) partial response (PR) and 30 patients (20.3%) stable disease (SD). Median overall survival (OS) was 10 months (95% CI 8.31-11.69) and median progression free survival (PFS) was 7 months (95% CI 5.88-8.12). Response to treatment showed independent prognosis relevance as PF in multivariate analysis for PFS and OS. Furthermore, decline in serum magnesium during the treatment was also an independent PF for OS. CONCLUSIONS WPC activity was confirmed as a useful therapy on real-life unselected RM-SCCHN patients, with similar benefit to that obtained in the phase II study, and comparable to platinum and cetuximab based treatment, confirming its value in unfit patients. In addition to treatment response, a change in serum magnesium values during treatment was proved as independent PF on OS.
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Affiliation(s)
- I Pajares Bernad
- Medical Oncology Department, Miguel Servet University Hospital, 1-3 Isabel la Catolica Avenue, 50009, Saragossa, Spain.
| | - J Martínez Trufero
- Medical Oncology Department, Miguel Servet University Hospital, 1-3 Isabel la Catolica Avenue, 50009, Saragossa, Spain
| | - L Calera Urquizu
- Medical Oncology Department, Miguel Servet University Hospital, 1-3 Isabel la Catolica Avenue, 50009, Saragossa, Spain
| | - R A Pazo Cid
- Medical Oncology Department, Miguel Servet University Hospital, 1-3 Isabel la Catolica Avenue, 50009, Saragossa, Spain
| | - A Cebollero de Miguel
- Medical Oncology Department, Miguel Servet University Hospital, 1-3 Isabel la Catolica Avenue, 50009, Saragossa, Spain
| | - M J Agustin
- Pharmacy Department, Miguel Servet University Hospital, Saragossa, Spain
| | - M Lanzuela
- Radiotherapy Department, Miguel Servet University Hospital, Saragossa, Spain
| | - A Antón
- Medical Oncology Department, Miguel Servet University Hospital, 1-3 Isabel la Catolica Avenue, 50009, Saragossa, Spain
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Aghevlian S, Boyle AJ, Reilly RM. Radioimmunotherapy of cancer with high linear energy transfer (LET) radiation delivered by radionuclides emitting α-particles or Auger electrons. Adv Drug Deliv Rev 2017; 109:102-118. [PMID: 26705852 DOI: 10.1016/j.addr.2015.12.003] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 11/26/2015] [Accepted: 12/06/2015] [Indexed: 12/31/2022]
Abstract
Radioimmunotherapy (RIT) aims to selectively deliver radionuclides emitting α-particles, β-particles or Auger electrons to tumors by conjugation to monoclonal antibodies (mAbs) that recognize tumor-associated antigens/receptors. The approach has been most successful for treatment of non-Hodgkin's B-cell lymphoma but challenges have been encountered in extending these promising results to the treatment of solid malignancies. These challenges include the low potency of β-particle emitters such as 131I, 177Lu or 90Y which have been commonly conjugated to the mAbs, due to their low linear energy transfer (LET=0.1-1.0keV/μm). Furthermore, since the β-particles have a 2-10mm range, there has been dose-limiting non-specific toxicity to hematopoietic stem cells in the bone marrow (BM) due to the cross-fire effect. Conjugation of mAbs to α-particle-emitters (e.g. 225Ac, 213Bi, 212Pb or 211At) or Auger electron-emitters (e.g. 111In, 67Ga, 123I or 125I) would increase the potency of RIT due to their high LET (50-230keV/μm and 4 to 26keV/μm, respectively). In addition, α-particles have a range in tissues of 28-100μm and Auger electrons are nanometer in range which greatly reduces or eliminates the cross-fire effect compared to β-particles, potentially reducing their non-specific toxicity to the BM. In this review, we describe the results of preclinical and clinical studies of RIT of cancer using radioimmunoconjugates emitting α-particles or Auger electrons, and discuss the potential of these high LET forms of radiation to improve the outcome of cancer patients.
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Affiliation(s)
- Sadaf Aghevlian
- Department of Pharmaceutical Sciences, University of Toronto, Toronto, ON, Canada
| | - Amanda J Boyle
- Department of Pharmaceutical Sciences, University of Toronto, Toronto, ON, Canada
| | - Raymond M Reilly
- Department of Pharmaceutical Sciences, University of Toronto, Toronto, ON, Canada; Department of Medical Imaging, University of Toronto, Toronto, ON, Canada; Toronto General Research Institute and Joint Department of Medical Imaging, University Health Network, Toronto, ON, Canada.
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Abdel-Rahman O, Lamarca A. Development of sorafenib-related side effects in patients diagnosed with advanced hepatocellular carcinoma treated with sorafenib: a systematic-review and meta-analysis of the impact on survival. Expert Rev Gastroenterol Hepatol 2017; 11:75-83. [PMID: 27882800 DOI: 10.1080/17474124.2017.1264874] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Clinical markers to predict the benefit from sorafenib in patients diagnosed with hepatocellular carcinoma (HCC) are lacking. A meta-analysis exploring the impact of development of sorafenib-related side effects on survival was conducted. Areas covered: Eligible studies included all clinical studies reporting on the survival/toxicity relationship in sorafenib-treated HCC patients. Data sources included Pub-Med, the Cochrane Controlled Trials Register, and Google scholar. After exclusion of ineligible studies, 16 studies were included in the analysis. Pooled hazard ratio (HR) for overall survival (OS) for patients developing diarrhoea vs. patients who did not was 0.42 (95% confidence interval (CI): 0.30-0.60; p < 0.00001); pooled HR for patients developing hypertension vs. those who did not was 0.46 (95% CI: 0.30-0.70; p = 0.0003); pooled HR for patients developing hand foot skin reaction vs. those who did not was 0.47 (95% CI: 0.35-0.62; p < 0.00001); pooled HR for OS for all types of skin toxicities was 0.51 (95% CI: 0.36-0.72; p = 0.0002); while pooled HR for OS for a combination of selected side effects (hypertension, HFS and diarrhoea) was 0.38 (95% CI: 0.30-0.48; p < 0.00001). No information was available regarding the impact of thyroid dysfunction or proteinuria. Expert commentary: This analysis of data demonstrated that the occurrence of sorafenib-related side effects (such as diarrhoea, hypertension and skin toxicities) is associated with a better OS in sorafenib-treated HCC patients.
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Affiliation(s)
- Omar Abdel-Rahman
- a Clinical Oncology Department, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Angela Lamarca
- b Medical Oncology Department , The Christie NHS Foundation Trust , Manchester , UK
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Kramkimel N, Thomas-Schoemann A, Sakji L, Golmard J, Noe G, Regnier-Rosencher E, Chapuis N, Maubec E, Vidal M, Avril M, Goldwasser F, Mortier L, Dupin N, Blanchet B. Vemurafenib pharmacokinetics and its correlation with efficacy and safety in outpatients with advanced BRAF-mutated melanoma. Target Oncol 2016. [PMID: 26208946 DOI: 10.1007/s11523-015-0375-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Vemurafenib is a BRAF kinase inhibitor approved for first-line treatment of metastatic BRAF (V600) -mutant melanoma. However, data on the pharmacokinetic/pharmacodynamic (PK/PD) relationship are lacking. The aim of this prospective, multicenter study was to explore the PK/PD relationship for vemurafenib in outpatients with advanced BRAF-mutated melanoma. Fifty-nine patients treated with single-agent vemurafenib were prospectively analyzed. Vemurafenib plasma concentration (n = 159) was measured at days 15, 30, 60, and 90 after treatment initiation. Clinical and biological determinants (including plasma vemurafenib concentration) for efficacy and safety were assessed using Cox's model and multivariate stepwise logistic regression. Median progression-free survival (PFS) and overall survival were 5.0 (95 % confidence interval [95 % CI] 2.0-6.0) and 11.0 (95% CI 7.0-16.0) months, respectively. Twenty-nine patients (49 %) experienced any grade ≥3 toxicity and the most frequent grade ≥2 toxicity was skin rash (37 %). Severe toxicities led to definitive discontinuation in seven patients (12 %). Grade ≥2 skin rash was not statistically associated with better objective response at day 60 (p = 0.06) and longer PFS (hazard ratio 0.47; 95 % CI 0.21-1.08; p = 0.075). Grade ≥2 skin rash was statistically increased in patients with ECOG ≥ 1 (odds ratio 4.67; 95 % CI 1.39-15.70; p = 0.012). Vemurafenib concentration below 40.4 mg/L at day 15 was significantly associated with a shorter PFS (1.5 [0.5-5.5] vs. 4.5 [2-undetermined] months, p = 0.029). Finally, vemurafenib concentration was significantly greater in patients developing grade ≥2 rash (61.7 ± 25.0 vs. 36.3 ± 17.9 mg/L, p < 0.0001). These results suggest that early plasma drug monitoring may help identify outpatients at high risk of non-response or grade ≥ 2 skin rash.
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Affiliation(s)
- N Kramkimel
- Assistance Publique Hôpitaux de Paris, Département de Dermatologie, Hôpital Cochin, Paris, France
| | - A Thomas-Schoemann
- Centre d'étude et de recours sur les inhibiteurs de l'angiogénèse (CERIA), Paris, France.,Assistance Publique Hôpitaux de Paris, Unité Fonctionnelle de Pharmacocinétique et Pharmacochimie, Hôpital Cochin, 27 rue du Faubourg Saint Jacques, 75014, Paris, France.,UMR8638 CNRS, UFR de Pharmacie, Université Paris Descartes, PRES Sorbonne Paris Cité, Paris, France
| | - L Sakji
- CHRU de Lille, Service de Dermatologie, Paris, France
| | - Jl Golmard
- Assistance Publique Hôpitaux de Paris, Département de Biostatistiques, Hôpital Pitié-Salpêtrière, Paris, France
| | - G Noe
- Assistance Publique Hôpitaux de Paris, Unité Fonctionnelle de Pharmacocinétique et Pharmacochimie, Hôpital Cochin, 27 rue du Faubourg Saint Jacques, 75014, Paris, France
| | - E Regnier-Rosencher
- Assistance Publique Hôpitaux de Paris, Département de Dermatologie, Hôpital Cochin, Paris, France
| | - N Chapuis
- Assistance Publique Hôpitaux de Paris, Service d'Hématologie biologique, Hôpital Cochin, Paris, France
| | - E Maubec
- Assistance Publique Hôpitaux de Paris, Département de Dermatologie, Hôpital Bichat, Paris, France
| | - M Vidal
- Centre d'étude et de recours sur les inhibiteurs de l'angiogénèse (CERIA), Paris, France.,Assistance Publique Hôpitaux de Paris, Unité Fonctionnelle de Pharmacocinétique et Pharmacochimie, Hôpital Cochin, 27 rue du Faubourg Saint Jacques, 75014, Paris, France.,UMR8638 CNRS, UFR de Pharmacie, Université Paris Descartes, PRES Sorbonne Paris Cité, Paris, France
| | - Mf Avril
- Assistance Publique Hôpitaux de Paris, Département de Dermatologie, Hôpital Cochin, Paris, France.,Institut Cochin, Institut National de la Sante et de la Recherche Médicale (INSERM) U1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Faculté de médecine, Université Paris Descartes, PRES Sorbonne Paris Cité, Paris, France
| | - F Goldwasser
- Centre d'étude et de recours sur les inhibiteurs de l'angiogénèse (CERIA), Paris, France.,Institut Cochin, Institut National de la Sante et de la Recherche Médicale (INSERM) U1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Faculté de médecine, Université Paris Descartes, PRES Sorbonne Paris Cité, Paris, France.,Assistance Publique Hôpitaux de Paris, Service de Cancérologie médicale, Hôpital Cochin, Paris, France
| | - L Mortier
- CHRU de Lille, Service de Dermatologie, Paris, France.,INSERM U 837, Faculté de Médecine, Université de Lille II, Lille, France
| | - N Dupin
- Assistance Publique Hôpitaux de Paris, Département de Dermatologie, Hôpital Cochin, Paris, France.,Institut Cochin, Institut National de la Sante et de la Recherche Médicale (INSERM) U1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Faculté de médecine, Université Paris Descartes, PRES Sorbonne Paris Cité, Paris, France
| | - B Blanchet
- Centre d'étude et de recours sur les inhibiteurs de l'angiogénèse (CERIA), Paris, France. .,Assistance Publique Hôpitaux de Paris, Unité Fonctionnelle de Pharmacocinétique et Pharmacochimie, Hôpital Cochin, 27 rue du Faubourg Saint Jacques, 75014, Paris, France.
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Venniyoor A, Al Bahrani B. Minocycline Improves the Efficacy of EGFR Inhibitor Therapy: A Hypothesis. Front Oncol 2016; 6:231. [PMID: 27833902 PMCID: PMC5081343 DOI: 10.3389/fonc.2016.00231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 10/13/2016] [Indexed: 11/13/2022] Open
Abstract
Skin rash is a side effect of drugs that inhibit epithelial growth factor receptor (EGFR) as a part of targeted therapy of cancer. Its appearance and severity correlates with survival. Minocycline, an oral tetracycline antibiotic, is recommended as treatment (and increasingly, for prevention) of the rash, though infection is seen in only one-third of the patients. Minocycline has additional anticancer properties such as poly(ADP-ribose) polymerase inhibition. It is proposed that such properties contribute to the efficacy of EGFR inhibitors and can also explain the positive correlation between grade of rash and survival as patients with higher grades of rash are more likely to receive minocycline. Early concurrent administration of minocycline is recommended in patients planned for EGFR therapy while awaiting trials proving this hypothesis.
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Affiliation(s)
- Ajit Venniyoor
- National Oncology Center, The Royal Hospital , Muscat , Oman
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48
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Hartmann S, Grandis JR. Treatment of head and neck cancer in the elderly. Expert Opin Pharmacother 2016; 17:1903-21. [DOI: 10.1080/14656566.2016.1220540] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Zheng J, Bai X, Hong C, Gao H, Li X. Meta-analysis of the incidence and risk of arterial and venous thromboembolic events associated with anti-EGFR agents in non-small-cell lung cancer patients. Expert Rev Clin Pharmacol 2016; 9:1389-1395. [PMID: 27494194 DOI: 10.1080/17512433.2016.1220830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND To determine the risk of arterial and venous thromboembolic events (ATEs and VETs) associated with anti-epidermal growth factor receptor (EGFR) agents in non-small-cell lung cancer (NSCLC) patients. METHODS Prospective randomized trials evaluating therapy with or without anti-EGFR agents in NSCLC patients. Data on VTEs and ATEs were extracted. RESULTS A total of 8,410 patients from 12 trials were included for analysis. Anti-EGFR agents significantly increased the risk of all-grade and high-grade VTEs (Peto OR 1.50, 95%CI 1.16-1.95, P = 0.002; Peto OR 1.73, 95%CI: 1.32-2.26, p < 0.001, respectively), but not for all-grade and high-grade ATEs. CONCLUSION The use of anti-EGFR agents significantly increased the risk of all-grade and high-grade VTEs but not for ATEs in NSCLC patients.
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Affiliation(s)
- Jian Zheng
- a Liaoning Cancer Hospital & Insititute, Third Department of Internal Medicine , Cancer Hospital of China Medical University , Shenyang , China
| | - Xiaoru Bai
- b Liaoning Cancer Hospital & Insititute, The department of medical imaging , Cancer Hospital of China Medical University , Shenyang , China
| | - Chengyu Hong
- a Liaoning Cancer Hospital & Insititute, Third Department of Internal Medicine , Cancer Hospital of China Medical University , Shenyang , China
| | - Hong Gao
- a Liaoning Cancer Hospital & Insititute, Third Department of Internal Medicine , Cancer Hospital of China Medical University , Shenyang , China
| | - Xiaoling Li
- a Liaoning Cancer Hospital & Insititute, Third Department of Internal Medicine , Cancer Hospital of China Medical University , Shenyang , China
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Sanguineti G, Licitra L. How Much of the Future Can Be Read Through the Skin? Int J Radiat Oncol Biol Phys 2016; 95:1355-1356. [DOI: 10.1016/j.ijrobp.2016.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 05/17/2016] [Indexed: 10/21/2022]
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