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He CX, Guo L, Qu T, Jin HZ. Tumor necrosis factor inhibitors enhance corticosteroid therapy for Stevens-Johnson syndrome and toxic epidermal necrolysis linked to immune checkpoint inhibitors: a prospective study. Front Immunol 2024; 15:1421684. [PMID: 39170619 PMCID: PMC11335491 DOI: 10.3389/fimmu.2024.1421684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 07/22/2024] [Indexed: 08/23/2024] Open
Abstract
Introduction Immune-related epidermal necrolysis (irEN), including Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN), represents a potentially lethal reaction to immune checkpoint inhibitors. An optimal treatment strategy remains undefined. This study evaluates the effectiveness and safety of combination therapy with corticosteroids and tumor necrosis factor inhibitors (TNFi) in treating irEN patients. Methods In this single-center, prospective, observational study, patients with irEN received either corticosteroid monotherapy or a combination therapy of corticosteroids and TNFi (etanercept for SJS, infliximab for TEN). The primary endpoint was re-epithelization time, with secondary endpoints including corticosteroid exposure, major adverse event incidence, acute mortality rates, and biomarkers indicating disease activity and prognosis. The study was registered at the Chinese Clinical Trial Registry (ChiCTR2100051052). Results Thirty-two patients were enrolled (21 SJS, 11 TEN); 14 received combination therapy and 18 received corticosteroid monotherapy. IrEN typically occurred after 1 cycle of ICI administration, with a median latency of 16 days. Despite higher SCORTEN scores in the combination group (3 vs. 2, p = 0.008), these patients experienced faster re-epithelization (14 vs. 21 days; p < 0.001), shorter corticosteroid treatment duration (22 vs. 32 days; p = 0.005), and lower prednisone cumulative dose (1177 mg vs. 1594 mg; p = 0.073). Major adverse event rates were similar between groups. Three deaths occurred due to lung infection or disseminated intravascular coagulation, with mortality rates for both groups lower than predicted. Potential risk factors for increased mortality included continuous reduction in lymphocyte subset counts (CD4+ T cells, CD8+ T cells, natural killer cells) and consistent rises in inflammatory markers (serum ferritin, interleukin-6, TNF-α). Re-epithelization time negatively correlated with body mass index and positively correlated with epidermal detachment area and serum levels of interleukin-6 and TNF-α. Conclusions Corticosteroids combined with TNFi markedly promote re-epithelization, reduce corticosteroid use, and decrease acute mortality in irEN patients without increasing major adverse events, offering a superior alternative to corticosteroid monotherapy. Inflammatory markers and lymphocyte subsets are valuable for assessing disease activity and prognosis.
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Affiliation(s)
| | | | | | - Hong-Zhong Jin
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
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2
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Bray ER, Lin RR, Li JN, Elgart GW, Elman SA, Maderal AD. Immune checkpoint inhibitor associated epidermal necrosis, beyond SJS and TEN: a review of 98 cases. Arch Dermatol Res 2024; 316:233. [PMID: 38795205 DOI: 10.1007/s00403-024-03061-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/14/2024] [Accepted: 04/26/2024] [Indexed: 05/27/2024]
Abstract
Immune checkpoint inhibitor (ICI) therapies carry the risk of major immune-related adverse events (irAEs). Among the most severe irAEs is epidermal necrosis that may clinically mimic Stevens-Johnson syndrome (SJS) and toxic epidermal necrosis (TEN). The aim of this study was to provide a summary of the clinical and histological features of ICI-associated epidermal necrosis, with a special focus on factors associated with fatal outcomes in cases of extensive disease. A total of 98 cases, 2 new cases and 96 reported on PubMed and in the literature, of ICI-associated epidermal necrosis were assessed. Development of epidermal necrosis occurred between 1 day and 3 years after starting ICI therapy, with an average onset of 13.8 weeks for patients with limited (< 30% BSA) and 11.3 weeks for those with extensive (≥ 30% BSA) involvement, and a median onset of 5.8 weeks and 4 weeks respectively. A preceding rash was seen in 52 cases and was more common in extensive cases. Mucosal involvement was only reported in 65% of extensive cases but was significantly associated with fatal reactions. Co-administration of cytotoxic chemotherapy was associated with more extensive disease. Recovery was observed in 96% and 65% of those with limited and extensive involvement respectively and no specific therapy was associated with improved survival. Young age was significantly associated with poor outcomes in extensive disease, the average age of surviving patients was 64.5 years old versus 55.1 years old for deceased patients, p < 0.01. Both superficial perivascular and interface/lichenoid inflammatory infiltrates were commonly seen. These findings suggest that ICI-associated epidermal necrosis should be considered a distinct clinical entity from drug-induced SJS/TEN.
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Affiliation(s)
- Eric R Bray
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1600 N.W. 10th Avenue, RMSB, Room 2023-A Miami, Miami, FL, 33136, USA.
- Jackson Memorial Hospital, 1611 NW 12th Ave, Miami, FL, 33136, USA.
| | - Rachel R Lin
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1600 N.W. 10th Avenue, RMSB, Room 2023-A Miami, Miami, FL, 33136, USA
| | - Jeffrey N Li
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1600 N.W. 10th Avenue, RMSB, Room 2023-A Miami, Miami, FL, 33136, USA
- Jackson Memorial Hospital, 1611 NW 12th Ave, Miami, FL, 33136, USA
| | - George W Elgart
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1600 N.W. 10th Avenue, RMSB, Room 2023-A Miami, Miami, FL, 33136, USA
- Jackson Memorial Hospital, 1611 NW 12th Ave, Miami, FL, 33136, USA
| | - Scott A Elman
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1600 N.W. 10th Avenue, RMSB, Room 2023-A Miami, Miami, FL, 33136, USA
- Jackson Memorial Hospital, 1611 NW 12th Ave, Miami, FL, 33136, USA
| | - Andrea D Maderal
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1600 N.W. 10th Avenue, RMSB, Room 2023-A Miami, Miami, FL, 33136, USA
- Jackson Memorial Hospital, 1611 NW 12th Ave, Miami, FL, 33136, USA
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3
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Satoh TK, Neulinger MM, Stadler PC, Aoki R, French LE. Immune checkpoint inhibitor-induced epidermal necrolysis: A narrative review evaluating demographics, clinical features, and culprit medications. J Dermatol 2024; 51:3-11. [PMID: 38031902 DOI: 10.1111/1346-8138.17039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/09/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have transformed cancer treatment but can cause immune-related adverse events (irAEs). Severe cutaneous irAEs, including epidermal necrolysis, are rare but potentially life-threatening. There is limited understanding of the clinical features and management of ICI-induced Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN), so we aimed to analyze 95 cases of ICI-induced SJS/TEN (35 cases of SJS, 26 cases of TEN, two cases of SJS/TEN overlap, and 32 cases of unspecified) to increase knowledge of this condition among oncologists and dermatologists. We conducted a comprehensive search of PubMed for all relevant case reports published until the end of December 2022, and collected data on patient demographics, cancer type, ICI regimen, time to onset of SJS/TEN, clinical presentation, management strategies, and outcomes. PD-1 inhibitors were the most common ICIs associated with SJS/TEN (58.9%), followed by the combination of PD-1 and CTLA-4 inhibitors (11.6%), and PD-L1 inhibitors (6.3%). Lung cancer and melanoma were the most frequent malignancies treated (35.8% and 25.4%, respectively). SJS/TEN occurred most frequently within the first 4 weeks (51.7%), and corticosteroid monotherapy was the most commonly chosen systemic treatment (56.4%). The overall mortality rate of ICI-induced SJS/TEN was 30.8%. Our findings highlight the frequency and severity of ICI-induced SJS/TEN and the urgent need for predictive molecular biomarkers aimed at preventive measures and early intervention.
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Affiliation(s)
- Takashi K Satoh
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | | | - Pia-Charlotte Stadler
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Rui Aoki
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Lars E French
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida, USA
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4
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Shi CR, Shaughnessy M, Sehgal K, Clark JR, Reynolds KL, Toyohara J, Chen ST. Successful rechallenge with pembrolizumab after case of progressive immunotherapy-related mucocutaneous eruption (PIRME), a Stevens-Johnson syndrome-like reaction. Int J Dermatol 2023; 62:1292-1294. [PMID: 36628976 DOI: 10.1111/ijd.16572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 12/19/2022] [Indexed: 01/12/2023]
Affiliation(s)
- Connie R Shi
- Department of Dermatology, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Kartik Sehgal
- Department of Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - John R Clark
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kerry L Reynolds
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Steven T Chen
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
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5
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Ubukata N, Nakatani E, Hashizume H, Sasaki H, Miyachi Y. Risk factors and drugs that trigger the onset of Stevens-Johnson syndrome and toxic epidermal necrolysis: A population-based cohort study using the Shizuoka Kokuho database. JAAD Int 2022; 11:24-32. [PMID: 36818677 PMCID: PMC9932121 DOI: 10.1016/j.jdin.2022.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2022] [Indexed: 12/25/2022] Open
Abstract
Background Evidence of factors associated with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) from population-based studies is scarce. Objective We aimed to identify the incidence, risk factors, and drugs that trigger the development of SJS/TEN in the general population. Methods A regional, population-based, longitudinal cohort with 2,398,393 Japanese individuals was analyzed using the Shizuoka Kokuho Database from 2012 to 2020. Results Among 1,909,570 individuals, 223 (0.01%, 2.3 cases/100,000 person-years) patients were diagnosed with SJS/TEN during the observational period of a maximum of 7.5 years. In a multivariable analysis, the risks of SJS/TEN were an older age, and the presence of type 2 diabetes, peripheral vascular disease, and systemic autoimmune diseases. The administration of drugs, such as immune checkpoint inhibitors, insulin, and type 2 diabetes agents, triggered the onset of SJS/TEN. Limitations The results may apply only to the Japanese population. Conclusion In this cohort population from a database representing the general population, the risks of developing SJS/TEN were old age and a history of type 2 diabetes, peripheral vascular disease, and systemic autoimmune disease. Furthermore, in addition to previously reported drugs, the administration of immune checkpoint inhibitors, insulin, and type 2 diabetes agents, may trigger the development of SJS/TEN.
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Affiliation(s)
- Nanako Ubukata
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Shizuoka-shi, Shizuoka, Japan
| | - Eiji Nakatani
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Shizuoka-shi, Shizuoka, Japan
| | - Hideo Hashizume
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Shizuoka-shi, Shizuoka, Japan,Department of Dermatology, Iwata City Hospital, Iwata, Japan,Correspondence to: Hideo Hashizume, MD, PhD, Department of Dermatology, Iwata City Hospital, 512-3, Ohkubo, Iwata, Shizuoka, 438–8550, Japan.
| | - Hatoko Sasaki
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Shizuoka-shi, Shizuoka, Japan
| | - Yoshiki Miyachi
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Shizuoka-shi, Shizuoka, Japan
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Yang Y, Li J, Till BG, Wang J, Zhang B, Wang H, Huang H, Li T, Gao Q, Li H, Wang Z. Toxic Epidermal Necrolysis-Like Reaction Following Combination Therapy With Camrelizumab and Apatinib for Advanced Gallbladder Carcinoma. Front Oncol 2021; 11:728253. [PMID: 34778042 PMCID: PMC8586206 DOI: 10.3389/fonc.2021.728253] [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: 06/21/2021] [Accepted: 10/06/2021] [Indexed: 12/18/2022] Open
Abstract
Recently, combination regimens based on programmed cell death-1 (PD-1) blockade have become increasingly common in clinical practice for the treatment of cancer. Such combinations significantly improve efficacy, but treatment-related adverse events have also become more complex and severe. Here, we report an acute toxic epidermal necrolysis (TEN)-like reaction in a patient with gallbladder cancer who received camrelizumab (an anti-PD-1 antibody) in combination with apatinib. Interestingly, distinct clinical and pathological characteristics were observed that differed from those of the reported cases of severe cutaneous reactions induced by anti-PD-1 antibodies alone; thus, we speculate that it was induced by the combination of camrelizumab and apatinib. It is worth noting that the TEN-like reaction showed resistance to methylprednisolone initially, which was gradually resolved after the addition of intravenous immunoglobulin (IVIg). Immunohistochemical staining revealed that the skin lesion was infiltrated by moderate numbers of CD4+ T cells and large numbers of CD8+ T cells during the progression of the TEN-like reaction, and mass cytometry by time-of-flight showed a significant reduction in the CD4+ and CD8+ T cell proportions in the peripheral blood after the rash improved. All these findings highlight the essential role of CD4+ T cells and CD8+ T cells in the TEN-like reaction induced by camrelizumab plus apatinib treatment, and we speculate that T cells, especially CD8+ T cells, attack keratinocytes. In conclusion, the TEN-like reaction induced by camrelizumab and apatinib deserves clinical attention, and further work is needed to elucidate the exact pathophysiologic mechanism as well as the optimal management strategy.
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Affiliation(s)
- Yonghao Yang
- Department of Immunotherapy, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Jun Li
- Department of Molecular Pathology, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Brian G Till
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Jun Wang
- Department of Oncology, First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Lung Cancer Institute, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Jinan, China
| | - Bicheng Zhang
- Cancer Center, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hanping Wang
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Hao Huang
- Department of Immunotherapy, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Tiepeng Li
- Department of Immunotherapy, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Quanli Gao
- Department of Immunotherapy, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Hongle Li
- Department of Immunotherapy, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Zibing Wang
- Department of Immunotherapy, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
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Choi ECE, Heng YK, Lim YL. Immune checkpoint inhibitor-related Stevens-Johnson syndrome/toxic epidermal necrolysis-like reactions. J Am Acad Dermatol 2021; 85:e109. [PMID: 33878411 DOI: 10.1016/j.jaad.2021.03.122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/04/2021] [Indexed: 12/13/2022]
Affiliation(s)
| | | | - Yen Loo Lim
- Dermatology, National Skin Centre, Singapore
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8
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Molina GE, Otto TS, Yu Z, Foreman RK, Reynolds KL, Chen ST. Response to: "Immune checkpoint inhibitor-related Stevens-Johnson syndrome/toxic epidermal necrolysis-like reactions". J Am Acad Dermatol 2021; 85:e111-e112. [PMID: 33878410 DOI: 10.1016/j.jaad.2021.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Gabriel E Molina
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Tracey S Otto
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Zizi Yu
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Ruth K Foreman
- Harvard Medical School, Boston, Massachusetts; Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kerry L Reynolds
- Harvard Medical School, Boston, Massachusetts; Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Steven T Chen
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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