Dermatomyositis associated with capecitabine in the setting of malignancy

Causes and Clinical Presentation of Drug-Induced Dermatomyositis: A Systematic Review

Importance

While several medications are known to induce dermatomyositis (DM), most existing studies are case reports or small case series from a single institution. There is also limited information on DM induced by immune checkpoint inhibitors, which are increasingly used in oncologic therapy.

Objective

To characterize causes and clinical presentation of drug-induced DM based on the current literature.

Evidence Review

A systematic review was performed in PubMed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines, from inception to August 22, 2022. Articles meeting preestablished inclusion criteria (written in English and classified as original articles, case reports, literature reviews, and observation letters) were selected and data abstracted. Articles that met the scope of the review were also added from reference lists. When possible, study results were quantitatively combined.

Findings

In 134 studies (114 from the literature search and 20 additional studies pulled from reference lists) describing 165 cases, 88 patients (53.3%) were female, and the median (IQR) age was 61 (49-69) years. Among the cases of drug-induced DM, the most common associated medications were hydroxyurea (50 [30.3%]), immune checkpoint inhibitors (27 [16.4%]), statins (22 [13.3%]), penicillamine (10 [6.1%]), and tumor necrosis factor inhibitors (10 [6.1%]). Histopathologic testing, when undertaken, helped establish the diagnosis. There was a median (IQR) of 60 (21-288) days between drug initiation and drug-induced DM onset. History of cancer was reported in 85 cases (51.6%).

Conclusions and Relevance

In this systematic review, drug-induced DM was associated with multiple types of medications, including chemotherapies and immunotherapies. It is essential that dermatologists promptly recognize and diagnose drug-induced DM so that they can guide management to minimize interruption of therapy when possible.

Management of Cancer-Associated Myositis

Purpose of the Review

Cancer-associated myositis (CAM) is defined as when cancer appears within 3 years of myositis onset. Dermatomyositis and seronegative immune–mediated necrotizing myopathy are the phenotypes mostly related to cancer. In general, treatment principles in myositis patients with and without CAM are similar. However, some aspects of myositis management are particular to CAM, including (a) the need for a multidisciplinary approach and a close relationship with the oncologist, (b) the presence of immunosuppressive and antineoplastic drug interactions, and (c) the role of the long-term immunosuppressive therapy as a risk factor for cancer relapse or development of a second neoplasm. In this review, we will also discuss immunotherapy in patients treated with checkpoint inhibitors as a treatment for their cancer.

Recent Findings

Studies on cancer risk in patients treated with long-term immunosuppressive drugs, in autoimmune diseases such as systemic lupus erythematosus or rheumatoid arthritis, and in solid organ transplant recipients have shed some light on this topic. Immunotherapy, which has been a great advance for the treatment of some types of malignancy, may be also of interest in CAM, given the special relationship between both disorders.

Summary

Management of CAM is a challenge. In this complex scenario, therapeutic decisions must consider both diseases simultaneously.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40674-022-00197-2.

Acute worsening of dermatomyositis after initiation of PARP inhibitor therapy in two women with advanced ovarian malignancy

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Chemotherapy initiation and subsequent tumor lysis can release immunogenic antigens.

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Advanced staged ovarian cancer associated with dermatomyositis.

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PARP Inhibitor initiation can worsen paraneoplastic syndromes like dermatomyositis.

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Signs and symptoms of dermatomyositis can be confused with chemotherapy side-effects.

A case of capecitabine-induced dermatomyositis

Dermatomyositis (DM) is an idiopathic, inflammatory connective tissue disorder characterized by symmetrical proximal myopathy and characteristic skin involvement. The pathogenesis of DM is widely debated; however, it is postulated to be an end result of immune-mediated cascade, triggered by multiple environmental factors in a genetically predisposed individual. In addition to underlying malignancies, many drugs have been reported to be associated with DM. Capecitabine is a chemotherapeutic agent, approved by the United States-Food and Drug Administration for the management of colonic, metastatic colonic, and metastatic breast carcinoma. It is converted into 5-fluorouracil after oral intake. Common dose-limiting toxicities associated with the usage of the capecitabine include increased bilirubin levels, diarrhea, and hand-foot syndrome. DM-induced by capecitabine has rarely been reported. Herein, we describe a patient of metastatic carcinoma breast, who developed DM after capecitabine intake. The patient had accidental re-challenge with capecitabine resulting in the reappearance of the cutaneous and musculoskeletal system, thereby confirming our diagnosis of drug-induced DM in the setting of underlying malignancy.

Occurrence of Dermatomyositis Immediately after Mastectomy Subsequent to Severe Chemotherapeutic Drug Eruption

We herein report a patient with breast cancer who developed dermatomyositis (DM) immediately after mastectomy. She had a history of severe drug eruption during neoadjuvant chemotherapy six months previously. Within a month after the operation, myalgia and rash, including Gottron's papules, developed, and skeletal-muscle enzymes elevated, so she was diagnosed with probable DM according to the Bohan and Peter criteria. In many neoplastic DM cases, the course of the disease parallels the course of the malignancy. Possible mechanisms were suggested to explain the development of DM in the present case and offer new insight into autoimmune diseases.

Severe myositis of the hip flexors after pre-operative chemoradiation therapy for locally advanced rectal cancer: case report

BACKGROUND

The use of neoadjuvant radiation therapy and chemotherapy in the treatment of locally advanced rectal adenocarcinoma has been shown to reduce disease recurrence when combined with surgery and adjuvant chemotherapy. We report a case of a patient who developed a debilitating bilateral myopathy of the hip flexors after successful treatment for rectal cancer. To the best of our knowledge, this is the first such complication from radiation therapy reported in a patient with colorectal cancer. The disproportionate severity of our patient's myopathy relative to the dose of radiation used also makes this case unique among reports of neuromuscular complications from radiation therapy.

CASE PRESENTATION

The patient is a 65-year-old male with node negative, high-grade adenocarcinoma of the rectum penetrating through the distal rectal wall. He underwent neoadjuvant concurrent pelvic radiation therapy and capecitabine-based chemotherapy, followed by abdominoperineal resection and post-operative FOLFOX chemotherapy. Five months post-completion of pelvic radiotherapy and 2 months after the completion of adjuvant chemotherapy, he presented with bilateral weakness of the iliopsoas muscles and severe pain radiating to the groin. The patient improved with 40 mg/d of prednisone, which was gradually tapered to 2 mg/d over 6 months, with substantial recovery of muscle strength and elimination of pain.

CONCLUSIONS

The timing, presentation and response of our patient's symptoms to corticosteroids are most consistent with a radiation recall reaction. Radiation recall is a phenomenon whereby previously irradiated tissue becomes vulnerable to toxicity by subsequent systemic therapy and is rarely associated with myopathies. Radiation recall should be considered a potential complication of neoadjuvant radiation therapy for rectal cancer, and for ongoing research into the optimization of treatment for these patients. Severe myopathies caused by radiation recall may be fully reversible with corticosteroid treatment.