Immune checkpoint inhibitor-related dermatologic adverse events

A Narrative Review of Pemphigoid Diseases: Bridging Associations, Comorbidities, and Management

Pemphigoid diseases are a group of rare, chronic autoimmune blistering disorders (AIBD) characterized by subepidermal blister formation due to autoantibody-mediated targeting of structural components of the basement membrane zone (BMZ). This narrative review provides an updated overview of four key subtypes: bullous pemphigoid (BP), mucous membrane pemphigoid (MMP), linear IgA bullous dermatosis (LABD), and epidermolysis bullosa acquisita (EBA) with specific emphasis on disease associations that dermatologists should be aware of for comprehensive patient care. BP, the most common subepidermal blistering disorder, is frequently associated with neurological and cardiovascular comorbidities, while MMP primarily affects mucosal surfaces, often leading to significant scarring and functional impairment and can be associated with malignancy in certain subtypes. LABD and EBA are less common but can be linked with systemic autoimmune conditions such as inflammatory bowel disease (IBD). Shared challenges across these subtypes include difficulties in diagnosis due to overlapping clinical and histopathologic features, treatment-related complications from prolonged corticosteroid use, and the substantial impact on patients' quality of life. Advances in therapeutic strategies, including biologic agents such as rituximab and dupilumab, offer promising alternatives to traditional treatments, yet access to new targeted therapies remains a significant barrier. This review emphasizes the need for large-scale studies to better understand disease associations, the identification of biomarkers for personalized therapy, improved treatment options, and the implementation of multidisciplinary care approaches.

Autoimmune-related adverse events induced by immune checkpoint inhibitors

Targeted immunotherapies, particularly immune checkpoint inhibitors (ICIs), have transformed cancer treatment by significantly improving patient response and survival rates. However, ICIs could disrupt self-tolerance, inducing the development of immune-related adverse events (irAEs). Most irAEs are classified as autoimmune conditions mediated by ICI-activated CD8+ cytotoxic T cells or activated B cells producing pathogenic autoantibodies. These irAEs phenotypically resemble spontaneous autoimmune disease and lead to considerable morbidity, health care costs, and compromised treatment efficacy. With the widespread use and new emergence of ICIs, the spectrum of ICI-induced irAEs has become increasingly extensive and complex. Concurrently, research in this field is advancing rapidly, a review summarizing the latest progress on irAEs is timely and essential. In this review, we highlight numerous recent research advances, covering the epidemiology, immune mechanisms, and diverse manifestations of irAEs, with a particular focus on organ-specific autoimmunity. We also discuss current strategies, challenges, and future directions for the prevention and therapeutic management of these adverse events.

Vitiligo-like rash in a patient with lung cancer caused by sintilimab: A case report

BACKGROUND

This article discusses a case involving a 63-year-old man with non-small cell lung cancer, who was treated with a combination of chemotherapy and immunotherapy. The patient was treated with five cycles of chemotherapy (pemetrexed and carboplatin) combined with sintilimab, a programmed death 1 inhibitor.

CASE SUMMARY

After the fifth cycle of treatment, the patient developed skin itching and a vitiligo-like rash, which are known side effects of immunotherapy. Despite dermatological consultation and treatment with topical corticosteroids, the rash worsened while the itching subsided. The patient continued with the treatment, and after 15 cycles, the tumor showed a response with a reduction in size. The vitiligo-like rash increased, but the antitumor treatment remained effective.

CONCLUSION

The case highlights the use of immunotherapy in patients with non-small cell lung cancer and the potential side effect of vitiligo-like rash. The patient's tumor responded well to the treatment, and despite the skin reaction, the treatment was not discontinued due to its effectiveness. The article suggests that further studies are needed to understand the mechanism behind vitiligo in patients with lung cancer receiving immune checkpoint inhibitors and whether the development of vitiligo-like rash after immune checkpoint inhibitor therapy is associated with improved prognosis. The case also underscores the importance of managing immune-related adverse events in the context of effective antitumor treatment.

Development and validation of a risk model for effective immune and stromal related signature predicting prognosis of patients with ovarian cancer

The tumor microenvironment (TME) plays a critical role in ovarian cancer (OC) progression, yet the relationship between immune and stromal scores within the TME and prognostic outcomes remains poorly understood. Immune and stromal cell scores were computed using the "estimate" R package, which enabled the assessment of immune and stromal components in OC samples. We then performed univariate and multivariate Cox regression analyses to identify prognostic factors associated with these scores using data from The Cancer Genome Atlas (TCGA). Additionally, LASSO Cox regression were employed to identify key prognostic genes linked to immune infiltration. Our analysis of OC expression data identified 1,667 differentially expressed genes (DEGs) associated with immune and stromal scores. From these, we developed a 6-gene risk model, consisting of ALOX5AP, FCGR1C, GBP2, IL21R, KLRB1, and PIK3CG, which effectively stratified OC patients into high-risk and low-risk groups. Survival analysis and area under the curve (AUC) assessment confirmed the model's strong predictive accuracy. Furthermore, drug sensitivity predictions indicated that sorafenib was particularly effective in high-risk patients, with this finding validated through in vitro experiments. The 6-gene TME-related risk model offers robust prognostic capabilities for OC and could serve as a valuable tool for clinical stratification and personalized treatment approaches.

Cutaneous T cell immunity

The skin is the primary barrier against environmental insults, safeguarding the body from mechanical, chemical and pathogenic threats. The frequent exposure of the skin to environmental challenges requires an immune response that incorporates a sophisticated combination of defenses. Tissue-resident lymphocytes are pivotal for skin immunity, working in tandem with commensal bacteria to maintain immune surveillance and homeostasis, as well as participating in the pathogenesis of several skin diseases. Indeed, it has been estimated that the human skin harbors nearly twice as many T cells as found in the circulation. Effective treatment of skin diseases and new therapy development require a thorough understanding of the complex interactions among skin tissue, immune cells and the microbiota, which together regulate the skin's immune balance. This Review explores the latest developments and understanding of this critical barrier organ, with a specific focus on the role of skin-resident T cells.

Treatment-Related Adverse Events in Extended Stage Small Cell Lung Cancer Patients Receiving First-Line Chemoimmunotherapy Versus Chemotherapy Alone: A Systematic Review and Meta-Analysis

Introduction: Nowadays the prognosis of extended stage (ES) small cell lung cancer (SCLC) patients is poor. However, a high response rate to first-line chemotherapy (CT) and the addition of immune checkpoint inhibitors (ICIs) have notably ameliorated the outcome of these patients. The aim of our study is to compare treatment-related adverse events (TRAEs) between ES- SCLC patients receiving first-line ICIs adding CT and those receiving only CT. Methods: All phase III clinical trials published between 15 June 2008, and 30 June 2024, likenessing ICIs adding systemic CT and only CT in treatment-naïve ES-SCLC patients were retrieved. Results: Twenty-six types of adverse events were included, grouped into ten categories, for a total of 43,391 observations (observations in immune group n = 22,643 and in placebo group n = 20,748) and 9831 events. Our analysis suggested a statistically significant increase in hematological events in patients receiving ICIs plus CT compared with CT alone. Conversely, blood pressure alterations such as hypertension were more frequent in patients treated with CT alone. Conclusions: Despite our analysis confirming the manageable safety profile of chemoimmunotherapy, this remains an issue to be further investigated.

Association between reactive cutaneous capillary endothelial proliferation and the efficacy of camrelizumab in esophageal cancer: a retrospective cohort study

Background

Reactive cutaneous capillary endothelial proliferation (RCCEP) is a common immune-related adverse event (irAE) related to camrelizumab. This study sought to investigate the relationship between RCCEP and the treatment efficacy of camrelizumab in esophageal cancer (EC), and to explore the risk factors for RCCEP.

Methods

This retrospective study collected the data of patients with EC who were treated with camrelizumab between November 2019 and November 2023. The patients were divided into RCCEP-negative groups and RCCEP-positive groups based on the occurrence of RCCEP. Subsequently, the Chi-squared test was applied to analyze the differences in objective response rate (ORR) and disease control rate (DCR) between the two groups. The association between progression-free survival (PFS) or overall survival (OS), and RCCEP was analyzed by the log-rank test. The factors associated with RCCEP were analyzed using univariable and multivariable Logistic regression analyses. Data cutoff was on February 2, 2024.

Results

In total, 397 patients were included in this study, of whom 128 (32.24%) suffered from RCCEP. There were no significant differences in the baseline characteristics of the patients in the RCCEP-negative and RCCEP-positive groups. Among the patients with RCCEP, seven had grade 3 RCCEP, and none had grade 4 or 5 RCCEP. Compared with the patients without RCCEP, those with RCCEP had a significantly higher ORR (71.09% vs. 43.87%, P<0.001) and DCR (94.53% vs. 72.49%, P<0.001). In the multivariate Cox analysis, RCCEP was found to be independently associated with longer PFS (P<0.001) and OS (P<0.001). In the univariate Cox analysis of patients with RCCEP, neither RCCEP time nor grade was associated with prolonged PFS and OS. The multivariable logistic regression analysis revealed that more camrelizumab treatment cycles was significantly associated with a higher risk of RCCEP [odds ratio (OR) =1.24; 95% confidence interval (CI): 1.16-1.31] and camrelizumab combined with antiangiogenic therapy was significantly associated with a lower risk of RCCEP (OR =0.24; 95% CI: 0.07-0.86).

Conclusions

In the EC patients treated with camrelizumab, those with RCCEP had significantly better outcomes in terms of the ORR, DCR, PFS, and OS than those without RCCEP. The emergence of RCCEP may serve as a potential predictor for the therapeutic efficacy of camrelizumab in the treatment of EC. More camrelizumab treatment cycles and not receiving combined anti-angiogenic therapy were independent risk factors for RCCEP.

Emerging role of regulatory T cells in the immunopathogenesis of vitiligo and implications for treatment

Vitiligo is an autoimmune skin disease that targets pigment-producing melanocytes and results in depigmentation. This disfiguring condition frequently affects visible areas of the body and therefore causes a heavy psychological burden and a decreased quality of life. Although it remains intractable, the ever-growing understanding of its immunopathogenesis has dramatically shaped the treatment paradigm for vitiligo. With the impact of autoreactive cytotoxic T cells explained extensively, accumulating evidence suggests the unique role of regulatory T cells (Tregs) in the immune microenvironment of vitiligo. We systematically reviewed Treg deficiency, instability, reduced vitality and dysfunction in people with vitiligo, combined with novel findings regarding Treg function modulation in autoimmune backgrounds, including metabolic alteration, post-translational modifications and interaction with other immune cells. We further summarized classic and advanced Treg-targeted therapeutics in vitiligo practice and research. Herein, we share up-to-date knowledge of Tregs in vitiligo, providing insights into novel Treg-based therapeutic strategies.

Cutaneous Adverse Events Following Nemolizumab Administration: A Review

Atopic dermatitis (AD) is a chronic inflammatory skin disease characterized by epidermal barrier dysfunction and immune dysregulation, with interleukin (IL)-4, IL-13, and IL-31 recognized as key mediators. Prurigo nodularis (PN) is another chronic inflammatory disorder driven by T helper type 2-mediated inflammation and neural dysregulation, leading to severe pruritus. Nemolizumab, a humanized monoclonal antibody targeting IL-31 receptor A, has been approved for use in the treatment of AD and PN. Clinical trials have demonstrated significant reductions in pruritus and cutaneous symptoms associated with its use. In clinical practice, acute eczema and edematous erythema frequently occur, occasionally necessitating the discontinuation of treatment. Despite these observations, no comprehensive review has examined nemolizumab-associated cutaneous adverse events. This review aimed to examine various cutaneous reactions associated with nemolizumab therapy, including psoriasiform eruptions, AD exacerbation, bullous pemphigoid, drug-induced eruptions, and fungal infections. Potential mechanisms underlying these reactions include T-cell activation due to drug sensitization, immune responses triggered by nemolizumab acting as a hapten, and a relative increase in IL-4 and IL-13 levels following IL-31 inhibition. However, the precise pathophysiological mechanism and risk factors remain unclear, and standardized clinical management guidelines are lacking. Further accumulation of clinical data and immunological research are essential for developing evidence-based strategies to manage these adverse events, ensuring treatment continuity and optimizing patient outcomes.

Nanomaterials-driven in situ vaccination: a novel frontier in tumor immunotherapy

In situ vaccination (ISV) has emerged as a promising strategy in cancer immunotherapy, offering a targeted approach that uses the tumor microenvironment (TME) to stimulate an immune response directly at the tumor site. This method minimizes systemic exposure while maintaining therapeutic efficacy and enhancing safety. Recent advances in nanotechnology have enabled new approaches to ISV by utilizing nanomaterials with unique properties, including enhanced permeability, retention, and controlled drug release. ISV employing nanomaterials can induce immunogenic cell death and reverse the immunosuppressive and hypoxic TME, thereby converting a "cold" tumor into a "hot" tumor and facilitating a more robust immune response. This review examines the mechanisms through which nanomaterials-based ISV enhances anti-tumor immunity, summarizes clinical applications of these strategies, and evaluates its capacity to serve as a neoadjuvant therapy for eliminating micrometastases in early-stage cancer patients. Challenges associated with the clinical translation of nanomaterials-based ISV, including nanomaterial metabolism, optimization of treatment protocols, and integration with other therapies such as radiotherapy, chemotherapy, and photothermal therapy, are also discussed. Advances in nanotechnology and immunotherapy continue to expand the possible applications of ISV, potentially leading to improved outcomes across a broad range of cancer types.

Using Cancer-Associated Fibroblasts as a Shear-Wave Elastography Imaging Biomarker to Predict Anti-PD-1 Efficacy of Triple-Negative Breast Cancer

In the clinical setting, the efficacy of single-agent immune checkpoint inhibitors (ICIs) in triple-negative breast cancer (TNBC) remains suboptimal. Therefore, there is a pressing need to develop predictive biomarkers to identify non-responders. Considering that cancer-associated fibroblasts (CAFs) represent an integral component of the tumor microenvironment that affects the stiffness of solid tumors on shear-wave elastography (SWE) imaging, wound healing CAFs (WH CAFs) were identified in highly heterogeneous TNBC. This subtype highly expressed vitronectin (VTN) and constituted the majority of CAFs. Moreover, WH CAFs were negatively correlated with CD8+ T cell infiltration levels and influenced tumor proliferation in the Eo771 mouse model. Furthermore, multi-omics analysis validated its role in immunosuppression. In order to non-invasively classify patients as responders or non-responders to ICI monotherapy, a deep learning model was constructed to classify the level of WH CAFs based on SWE imaging. As anticipated, this model effectively distinguished the level of WH CAFs in tumors. Based on the classification of the level of WH CAFs, while tumors with a high level of WH CAFs were found to exhibit a poor response to anti programmed cell death protein 1 (PD-1) monotherapy, they were responsive to the combination of anti-PD-1 and erdafitinib, a selective fibroblast growth factor receptor (FGFR) inhibitor. Overall, these findings establish a reference for a novel non-invasive method for predicting ICI efficacy to guide the selection of TNBC patients for precision treatment in clinical settings.

Remote presentation of nivolumab-induced bullous pemphigoid in hepatocellular carcinoma

A man in his 70s with a history of unresectable hepatocellular carcinoma (HCC) treated with nivolumab presented with a blistering rash 14 months after nivolumab initiation. Biopsies and direct immunofluorescence confirmed the diagnosis of bullous pemphigoid (BP). BP is an autoimmune skin disorder in which autoantibodies bind to the dermal-epidermal junction. It is a rare sequela of programmed cell death protein-1 (PD-1) inhibitors that can develop after treatment initiation and typically resolve soon after discontinuation. Most cases are reported in melanoma and non-small cell lung cancers, and rarely in HCC irrespective of the timing of onset. We describe a rare presentation of remote BP with PD-1 inhibitor use in HCC. PD-1 inhibitor-induced BP is a rare cutaneous immune-related adverse event, and this case highlights the variability in onset and chronicity.

Adverse drug reaction assessment of pembrolizumab in cervical cancer treatment: a real-world pharmacovigilance study using the FAERS database

Objective

Advanced cervical cancer remains associated with high mortality rates. While pembrolizumab has improved clinical outcomes in cervical cancer, the therapeutic efficacy in advanced stages is often compromised by immune-related adverse events (irAEs). This study aimed to systematically analyze pembrolizumab-associated adverse events (AEs) in cervical cancer using the FDA Adverse Event Reporting System (FAERS) database, providing new insights for optimizing clinical practice.

Methods

AE reports related to pembrolizumab in cervical cancer were extracted from the FAERS database (Q1 2016 to Q4 2024). Disproportionality analyses were performed using multiple algorithms, including the reporting odds ratio (ROR), proportional reporting ratio (PRR), Bayesian confidence propagation neural network (BCPNN), and multi-item gamma Poisson shrinker (MGPS). AEs were classified by system organ class (SOC) and preferred term (PT) based on the Medical Dictionary for Regulatory Activities (MedDRA), then ranked by frequency and signal strength.

Results

A total of 646 pembrolizumab-related AE reports in cervical cancer were identified. Age distribution peaked at 45-65 years cohort (32.75%), followed by 18-44 years (12.85%), 66-75 years (11.76%), and >75 years (4.64%). Among 270 AE reports with documented onset timelines, events predominantly occurred 3-6 months after pembrolizumab initiation (n=114, 41.36%). Clinical outcomes were categorized as other (52.80%), hospitalization (27.00%), death (10.25%), unknown (6.06%), life-threatening (2.77%), and disability (1.12%). Predominant AEs involved hematologic, endocrine, dermatologic, neurologic, gastrointestinal, urinary, and reproductive systems.

Conclusion

This real-world pharmacovigilance study systematically characterizes pembrolizumab-associated AEs in cervical cancer, identifying high-signal events such as hematologic disorders, endocrine dysfunction, and dermatologic toxicities. These findings provide critical evidence for risk stratification and safety monitoring in clinical practice, emphasizing the need for organ-specific vigilance during the 3-6 months treatment window.

CRISPR/Cas9-Mediated Knockout and Overexpression Studies Unveil the Role of PD-L1 in Immune Modulation in a Psoriasis-like Mouse Model

The role of programmed death-ligand 1 (PD-L1), an essential immune checkpoint protein, has garnered considerable interest in recent years due to its influence on immune responses, particularly inhibiting immature Th cells into Th17 cells. This study aims to examine the effect of PD-L1 on psoriasis progress, which is the condition characterized by an immune response dominated by Th17 cells. We constructed the PD-L1 knockout (PD-L1KO) and overexpression (PD-L1OE) mice through CRISPR/Cas9 technology to assess the impact of PD-L1 in an imiquimod (IMQ)-induced psoriasis-like mouse model. In comparison to IMQ, the ear thickness exhibited a reduction, the PASI score decreased, and HE sections revealed a thinning of the epidermal spines in PD-L1OE mice. PD-L1KO mice, however, showed opposite results. Moreover, immunohistochemical assessments of the skin lesion tissues demonstrated heightened epidermal proliferation and inflammatory infiltration in the PD-L1KO group, accompanied by elevated tissue expression of proliferating cell nuclear antigen (PCNA), Nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) p50, and F4/80 in comparison to IMQ-treated and WT mice. The absence of PD-L1 in IMQ-induced mice was found to intensify the immune response, as evidenced by heightened expression of phosphorylated signal transducers and activators of transcription 3 (pSTAT3) and CD3 in the affected tissues compared to both IMQ-treated and WT mice. According to our findings, PD-L1 plays important roles in inhibiting inflammation, proliferation, and regulating immune responses. Targeting PD-L1 may present a promising therapeutic strategy for the management of psoriasis.

Lichen Sclerosus in Cancer Patients

OBJECTIVE

To characterize the association between cancer therapies and the development of lichen sclerosus (LS) in a case series of patients.

METHODS

A retrospective chart review was performed to screen for patients who were diagnosed with LS while undergoing cancer therapy at Memorial Sloan Kettering Cancer Center between 2003 and 2019. Patients were excluded if they had been diagnosed with LS prior to starting cancer therapy. Clinical and treatment characteristics were analyzed.

RESULTS

The final study sample included 29 female patients who developed LS in the setting of systemic cancer therapy. Median time to LS onset after cancer therapy initiation was 420 days. Primary tumor types included breast (10, 34.5%), gynecologic (8, 27.6%), gastrointestinal (5, 17.2%), cutaneous (2, 6.9%), lung (2, 6.9%), and hematologic (2, 6.9%). Cancer therapy regimens included hormonal therapy (10, 34.5%), chemoradiation (7, 24.1%), cytotoxic chemotherapy (7, 24.1%), PD-1/PD-L1 inhibitors (3, 10.3%), local radiation (1, 3.4%), and allogeneic stem cell transplant (1, 3.4%). Across all patients, the mean number of treatments for LS was 2.8. Twenty-three (79.3%) patients received the first-line therapy of ultrapotent topical steroids, but 16 (69.6%) required additional topical and systemic treatment. Limitations include retrospective design and referral bias.

CONCLUSIONS

Breast cancer was the most common primary tumor among patients in this study. The most common cancer therapy regimen was hormonal therapy. Most patients required an escalation in therapy to manage their LS. For patients undergoing cancer treatment, concomitant LS management can present unique challenges due to the biological mechanism of some anticancer therapies and the pathophysiology of LS. There is limited data to guide treatment of LS for this population. Some of the patients included in this analysis had progression of LS and recurrence of cancer while undergoing management of both conditions, necessitating close follow-up.

Research in practice: Immune checkpoint inhibitor related autoimmune bullous dermatosis

Immune checkpoint receptors and ligands such as cytotoxic T lymphocyte antigen-4 (CTLA-4), programmed death-1 (PD-1) and ligand-1 (PD-L1) are widely expressed on immune and non-immune cells and fine tune the activation level of immune cells, thus, enabling, preventing, or terminating immune responses. Blockade of CTLA-4, PD-1 or PD-L1 by checkpoint inhibitors (CIs), unleashing immune responses, has become a mainstay in the treatment of diverse types of cancer. The induction of autoinflammatory, yet unspecific tissue damage in diverse organs is called an immune related adverse event (irAE), a class side-effect of CIs and may require the discontinuation of immunotherapy. Among frequent skin rashes, CIs targeting the PD-L1/PD-1 axis can elicit the IgG autoantibody- and granulocyte-driven bullous pemphigoid (BP) in about 0.3% to 0.6% of treated patients. Pathogenesis of BP requires a complex cellular inflammatory response after anti-BP180 autoantibody binding to the dermal epidermal junction. The prevalence of autoantibodies against BP180 in healthy blood donors of approximately 0.52% equals the prevalence of irBP among treated cancer patients, underlining the potential relevance of the PD-1 mediated regulation of tissue inflammation for spontaneous BP. If skin rashes appear during CI therapy, biopsies should be taken and examined by histopathological and direct immunofluorescence microscopy.

Case Report: Subacute cutaneous lupus erythematosus induced by the anti-PD-1 antibody camrelizumab combined with chemotherapy

The use of immune checkpoint inhibitors (ICI) can lead to immune-related adverse events (irAE), of which skin irAE is common, affecting up to 50% of ICI-treated patients. Although only a few cases of subacute cutaneous lupus erythematosus (SCLE) have been reported in patients receiving anti-programmed death-1(anti-PD-1) immunotherapy, it is important to identify ICI-induced SCLE because it may cause delayed and/or prolonged skin reactions even after treatment discontinuation. To date, no cases of cutaneous lupus associated with Camrelizumab treatment have been reported.

Case report

We report a case of a patient with advanced non-small cell lung cancer (NSCLC) who gradually developed erythematous rashes on sun-exposed skin with pruritus after one course of anti-PD-1 antibody Camrelizumab combined with chemotherapy. The rashes were initially considered as eczema, but did not improve after symptomatic treatment. The rashes continued to worsen after the third course of treatment, and the pruritus was unbearable. After antibody testing, the patient was found to have positive anti-SS-A/Ro antibody, and the histological changes were consistent with subacute cutaneous lupus erythematosus. SCLE was controlled with local and systemic glucocorticoids, hydroxychloroquine, and discontinuation of anti-PD-1 therapy.

Conclusion

Camrelizumab treatment may be associated with the appearance of subacute cutaneous lupus erythematosus in sun-exposed skin regions, which can be rapidly relieved by local and systemic glucocorticoids and hydroxychloroquine. It is recommended to perform early antibody testing and skin biopsy for diagnosis and treatment. Unlike classic drug-related SCLE, patients may develop multiple autoimmune diseases, and caution should be taken when using immune checkpoint inhibitors for subsequent treatment.

Epigenetic regulators combined with tumour immunotherapy: current status and perspectives

Immunotherapy, particularly immune checkpoint inhibitor therapy, has demonstrated clinical benefits in solid tumours. Despite its satisfactory clinical efficacy, it still faces several issues, such as limited eligibility, low response rates and cytotoxicity. Cancer epigenetics implies that tumour cells exhibit unique phenotypes because of their unique characteristics, thus reprogramming of the epigenome holds promise for cancer therapy. Epigenetic regulation plays an important role in regulating gene expression during tumour development and maintenance. Epigenetic regulators induce cancer cell cycle arrest, apoptosis and differentiation of cancer cells, thereby exerting anti-tumour effects. Recent studies have revealed a significant correlation between epigenetic regulatory factors and immune checkpoint therapy. Epigenetics can modulate various aspects of the tumour immune microenvironment and immune response to enhance the sensitivity of immunotherapy, such as lowering the concentration required and mitigating cytotoxicity. This review primarily discusses DNA methyltransferase inhibitors, histone deacetylase inhibitors, enhancer of zeste homolog 2 inhibitors and lysine-specific demethylase 1 inhibitors, which are associated with transcriptional repression. This repression alters the expression of genes involved in the immune checkpoint, thereby enhancing the effectiveness of immunotherapy. We also discuss the potential and challenges of tumour immunotherapy and highlight its advantages, application challenges and clinical research on integrating epigenetic regulatory factors with tumour immunotherapy.

Characterizing Chronic Cutaneous Immune-Related Adverse Events Following Immune Checkpoint Inhibitors

This cohort study describes the morphologic classification, histopathologic characteristics, treatments, and outcomes of chronic cutaneous immune-related adverse events occurring in adjuvant or metastatic setting.

Appearance-related needs and challenges among cancer patients undergoing systemic therapy: a comprehensive survey study

PURPOSE

Recent improvements in cancer prognosis have highlighted the need for patients to balance social interactions with their therapeutic regimens. Central to this balance is managing the physical changes induced by cancer treatments. This study aimed to examine patients' reactions to these changes and to identify their needs related to appearance care.

METHODS

We conducted a survey among 800 patients undergoing systemic therapy to investigate the actual impact of changes and to determine the specific care needs across 45 appearance-related items. The survey using the original questionnaire was an online self-reported.

RESULTS

Of the surveyed patients, 202 responded. The median age was 58 years (ranging from 30 to 81), comprising 144 women and 58 men. Hair loss was experienced by 157 (78%) patients, with 109 (70%) of them purchasing wigs. The demand for information and consultation was highest for alopecia, reported by over 60% of respondents, followed by needs related to skin care and wigs. In addition, 26 items had unmet needs affecting more than 50% of the participants, with 24 of these items pursued by fewer than half of the patients. In female patients who experienced hair loss, patients with breast cancer more frequently sought information and consultation and had higher levels of unmet needs compared with those with non-breast cancer.

CONCLUSIONS

The findings underscore the substantial and diverse appearance-related needs among cancer patients, with many experiencing significant unmet needs. These results suggest that comprehensive support systems are essential to address the varied and individualized needs of patients undergoing contemporary cancer treatments.

Population pharmacokinetics and exposure-response relationships of dostarlimab in primary advanced or recurrent endometrial cancer in part 1 of RUBY

AIMS

Dostarlimab-gxly is a humanized monoclonal antibody of the IgG4 isotype that binds to the programmed cell death protein-1 (PD-1) receptor and blocks its ligands. RUBY (NCT03981796) is a two-part multicentre study in patients with recurrent or primary advanced endometrial cancer. The overall aims were to characterise the population pharmacokinetics (PopPK) from Part 1 of this study, identify relevant covariates of interest, and assess exposure-efficacy/safety (ER) relationships.

METHODS

A PopPK model developed using GARNET (NCT02715284) study data for dostarlimab monotherapy was externally validated with RUBY Part 1 study data. Subsequently, the model was updated with data across the two studies. Exposure-safety analyses for adverse events related to dostarlimab alone or in combination with standard of care (SOC) were modelled using logistic regression. Exposure-efficacy analysis included Cox proportional hazards analysis of the primary efficacy endpoint of progression-free survival (PFS).

RESULTS

For the model update, 7957 pharmacokinetics observations from 868 patients pooled from both RUBY and GARNET studies were available. The model was consistent with the previous model. Dostarlimab clearance was estimated to be 7.79% lower when dostarlimab was given as SOC combination therapy. However, no significant covariates were clinically relevant. Hepatic or renal impairment did not affect pharmacokinetics. Among the safety endpoints, only rash showed a small yet statistically significant effect (P < .05) in all subjects; however, this was not not deemed clinically relevant. There were no other clinically significant exposure-safety or exposure-PFS relationships.

CONCLUSIONS

The addition of chemotherapy to dostarlimab had limited effect on dostarlimab PopPK, with no clinically significant covariates or clinically relevant exposure-safety or exposure-PFS relationships.

Sintilimab-induced photodistributed bullous pemphigoid: A case report

RATIONALE

Immune-checkpoint inhibitors have emerged as a frontline treatment for a growing list of malignancies. Immunotherapy-induced bullous pemphigoid (BP) is a rare dermatological immune-related adverse event of immune-checkpoint inhibitor therapy immune-checkpoint inhibitor therapy. We report a case of immunotherapy-associated BP, with lesions presenting in a photodistribution. This case report aims to emphasize the early recognition of rare clinical manifestations induced by immunotherapy to improve patient prognosis.

PATIENT CONCERNS

The patient was a 77-year-old man with a history of right upper lung squamous cell carcinoma on sintilimab (anti-programmed cell death protein-1 [PD-1]) for over a year. After 12 months of initiation of PD-1 inhibitors, nonspecific cutaneous eruption appeared on his head, face, and extremities, mostly pruritic eczematous dermatitis with papules and plaques. The time to development of bullae after medication initiation was 16 months.

DIAGNOSES

Sintilimab-induced BP.

INTERVENTION

Oral prednisone was gradually tapered to discontinuation following intravenous methylprednisolone; the skin lesions have basically recovered.

OUTCOMES

Follow-up for 19 months showed no recurrence of the skin lesions.

LESSONS

This case report emphasizes that the clinical manifestations of BP induced by PD-1/programmed death ligand-1 inhibitors can be diverse. Dermatologists need to increase their awareness of BP caused by PD-1/programmed death ligand-1 inhibitors.

Management of immune checkpoint inhibitor-associated toxicities in older adults with cancer: recommendations from the International Society of Geriatric Oncology (SIOG)

Immune checkpoint inhibitors (ICIs) have substantially advanced the treatment landscape for a wide variety of malignancies. Older adults represent a large and rapidly growing demographic, among whom ICIs are widely prescribed. Management of ICI-associated toxicity among older adults, particularly in the presence of frailty and comorbidity, poses unique challenges. In this Policy Review, developed by the International Society of Geriatric Oncology (SIOG), we offer an evidence-based framework for health-care providers, caregivers, and policy makers for treating older adults with ICIs, focusing on unique considerations for this population that are not adequately addressed by existing guidelines, and expanding them to encompass geriatric oncology principles.

Immune checkpoint inhibitor-associated bullous pemphigoid: A retrospective and real-world study based on the United States Food and Drug Administration adverse event reporting system

This study aimed to describe bullous pemphigoid (BP) associated with immune checkpoint inhibitors (ICIs) reported in the United States Food and Drug Administration adverse event reporting system (FAERS). We obtained reports of ICI-associated BP from the first quarter of 2011 to the first quarter of 2024 in the FAERS database. The reporting odds ratio (ROR) method of the disproportionality analysis was performed to assess the potential risk for ICI-associated BP. We also described the clinical characteristics of ICI-associated BP and evaluated the time to onset (TTO) of BP developed after treatment with ICIs. Eight hundred and six cases of ICI-associated BP were gathered, in which 56.58% of the patients were aged 65 years or older. The majority of patients were male, accounting for 68.49% of all cases. The prevalent potential cancer type was skin cancer (31.64%). The results of the disproportionality analysis showed that males (ROR = 2.10 [1.78-2.49]), patients aged 65 or older (ROR = 2.13 [1.79-2.55]), and patients with skin cancer (ROR = 2.08 [1.80-2.43]) were more likely to develop ICI-associated BP. In comparison to cytotoxic T-lymphocyte-associated antigen 4 inhibitor and programmed cell death ligand 1 inhibitor, programmed cell death 1 inhibitor-associated BP has a higher risk of development (ROR = 24.45 [22.52-26.56]). ICI-associated BP had a median TTO of 204 days (interquartile range 57-426 days). ICI-associated BP is a rare but important immune-related adverse event. Our study provided helpful information to help medical professionals further understand ICI-associated BP.

Toxic epidermal necrolysis induced by axitinib in a patient with advanced lung adenocarcinoma

Patients taking oral EGFR inhibitors should be alert to the risk of TEN if they suddenly develop widespread rash.

Immune-related adverse events with PD-1/PD-L1 inhibitors: insights from a real-world cohort of 2523 patients

Purpose

Immune checkpoint inhibitors (ICIs) have significantly changed cancer therapy, improving patient survival rates and clinical outcomes. Nevertheless, the use of PD-1/PD-L1 inhibitors can result in immune-related adverse events (irAEs). This study aims to investigate the prevalence and associated risk factors of irAEs in a real-world setting, as well as to assess their effects on optimal therapeutic outcomes.

Methods

A retrospective analysis involved 2523 patients with cancer who received inpatient PD-1/PD-L1 inhibitors treatment between January 2018 and December 2022. We documented patients' demographic and clinical characteristics, PD-1 or PD-L1 inhibitors, treatment modalities, incidences, timing, and severity of irAEs, and efficacy outcomes by reviewing inpatient records. Patients were categorized into an irAEs group and a non-irAEs group, with the former further subdivided into a multiple irAEs group and a single irAE group. Chi-square tests were employed to evaluate differences in baseline characteristics and efficacy outcomes between the irAEs and non-irAEs groups, as well as between the multiple and single irAE groups. Additionally, logistic regression analysis was utilized to identify risk factors linked to irAEs.

Results

Among 2523 eligible patients, 1096 reported 1802 irAEs, with an incidence incidence of 43.4%. Among 1096 individuals, 92.1% were classified as grade 1-2, while 7.9% were grade 3 or higher. IrAEs affected various organ systems, with endocrine toxicity (17.7%), hepatic toxicity (17.2%), and hematologic toxicity (11.4%) being the most common. 20.5% patients experienced multi-system irAEs. The average time for patients to develop irAEs was within four treatment cycles. Significant differences in patient gender, age, Eastern Cooperative Oncology Group (ECOG) Performance Status (PS), comorbidities, PD-1 or PD-L1 inhibitors, and treatment modalities were observed between the irAEs and non-irAEs groups, but not between the multiple irAEs and single irAE groups. Compared to the non-irAEs group, the irAEs group exhibited a higher objective response rate (ORR) and disease control rate (DCR), and the multiple irAEs group also showed a higher ORR than the single irAE group.

Conclusion

This real-world study indicated that the occurrence of irAEs is related to patient gender, age, ECOG PS, comorbidities, PD-1/PD-L1 inhibitors, and treatment modalities. The occurrence of irAEs may be associated with better treatment benefits.

Caerin 1.1/1.9-mediated antitumor immunity depends on IFNAR-Stat1 signalling of tumour infiltrating macrophage by autocrine IFNα and is enhanced by CD47 blockade

Previously, we demonstrated that natural host-defence peptide caerin 1.1/caerin 1.9 (F1/F3) increases the efficacy of anti-PD-1 and therapeutic vaccine, in a HPV16 + TC-1 tumour model, but the anti-tumor mechanism of F1/F3 is still unclear. In this study, we explored the impact of F1/F3 on the tumor microenvironment in a transplanted B16 melanoma model, and further investigated the mechanism of action of F1/F3 using monoclonal antibodies to deplete relevant cells, gene knockout mice and flow cytometry. We show that F1/F3 is able to inhibit the growth of melanoma B16 tumour cells both in vitro and in vivo. Depletion of macrophages, blockade of IFNα receptor, and Stat1 inhibition each abolishes F1/F3-mediated antitumor responses. Subsequent analysis reveals that F1/F3 increases the tumour infiltration of inflammatory macrophages, upregulates the level of IFNα receptor, and promotes the secretion of IFNα by macrophages. Interestingly, F1/F3 upregulates CD47 level on tumour cells; and blocking CD47 increases F1/F3-mediated antitumor responses. Furthermore, F1/F3 intratumor injection, CD47 blockade, and therapeutic vaccination significantly increases the survival time of B16 tumour-bearing mice. These results indicate that F1/F3 may be effective to improve the efficacy of ICB and therapeutic vaccine-based immunotherapy for human epithelial cancers and warrants consideration for clinical trials.

The implementation and side effect management of immune checkpoint inhibitors in gynecologic oncology: a JAGO/NOGGO survey

BACKGROUND

The integration of immune checkpoint inhibitors (ICIs) into routine gynecologic cancer treatment requires a thorough understanding of how to manage immune-related adverse events (irAEs) to ensure patient safety. However, reports on real-world clinical experience in the management of ICIs in gynecologic oncology are very limited. The aim of this survey was to provide a real-world overview of the experiences and the current state of irAE management of ICIs in Germany, Switzerland, and Austria.

METHODS

We designed a questionnaire consisting of 34 items focused on physicans' clinical experiences with ICIs and their management of irAEs. The survey was distributed between October 2022 and May 2023 to medical professionals with experience in the field of gynecologic oncology.

RESULTS

A total of 221 gynecologists participated in the study. Most respondents (n = 130, 59.1%) were primarily engaged in gynecologic oncology at the time of the survey, with an average of ten years of clinical experience. Individual experiences with regard to irAEs varied significantly. When asked which irAEs they had observed "frequently" or "very frequently", respondents most commonly reported thyroiditis (37.2%), followed by skin reactions (23.6%), and pneumonitis (10.6%). A total of n = 16 (7.4%) reported at least one death of a patient due to irAEs. Feeling "unconfident" or "very unconfident" about managing irAEs was reported by 35.6% (n = 78). With regard to clinical management of adverse events after discontinuation of treatment, 32.4% (n = 68) ceased to inquire about irAEs after six months.

CONCLUSION

The results of this survey provide valuable insights into physicians' real-world experiences with irAEs associated with ICI treatment. Dealing with serious immune-related and potentially life-threatening side effects has become a routine aspect of clinical practice. Many physicians, however, express a lack of sufficient familiarity with irAEs and their management. Therefore, it is essential to improve medical education, specialized oncological training, and close interdisciplinary collaboration to improve patient care.

Diagnosis and Management of Skin Toxicities in Systemic Treatment of Genitourinary Cancers

The landscape of available therapeutic options for treatment of genitourinary (GU) cancers is expanding dramatically. Many of these treatments have distinct, sometimes severe, skin toxicities including morbilliform, bullous, pustular, lichenoid, eczematous, psoriasiform, and palmoplantar eruptions. Pruritus and skin pigmentation changes have also been noted. This review aims to synthesize dermatologic events observed with antibody drug conjugates, poly (ADP-ribose) polymerase (PARP) inhibitors, androgen receptor pathway inhibitors, tyrosine kinase inhibitors, immune checkpoint inhibitors, and the combination of these agents used for the treatment of GU cancers. It provides a guide on diagnosis and initial management of these rashes for medical oncologists.

Eruptive keratoacanthoma secondary to immune checkpoint inhibitors: a narrative review

The use of immunotherapy is an emerging treatment option for advanced malignancies. Cutaneous adverse events following cancer immunotherapy are well-documented in the literature. The rarer cutaneous adverse effects are less characterized, including eruptive keratoacanthomas (KA). Despite surgical excision remaining the treatment of choice for KA, several case reports have shown intralesional injections to be an effective, non-invasive treatment modality for this cutaneous adverse event. We reviewed the PubMed database for patients presenting with eruptive KA secondary to immune checkpoint inhibitor use. We also included three previously unpublished cases from our own institution. We identified a total of 19 patients (47.4% male, mean age 78.9 years, range 67-92 years). Patients were treated with intralesional injections, systemic agents, or alternative therapy (n = 7, 5, 7 respectively). Improvement of eruptive KA was observed in 89.5% of patients. Immunotherapy was continued or restarted in 13 of 19 cases. Intralesional injection of triamcinolone or methotrexate resulted in complete resolution in all patients when response was characterized. We believe intralesional injections may be an effective, less invasive treatment option than surgical excision when treating eruptive keratoacanthomas secondary to immunotherapy.

An overview of immunotoxicity in drug discovery and development

The immune system is one of the common targets of drugs' toxicity (Immunotoxicity) and/or efficacy (Immunotherapy). Immunotoxicity leads to adverse effects on human health, which raises serious concerns for the regulatory agencies. Currently, immunotoxicity assessment is conducted using different in vitro and in vivo assays. In silico and in vitro human cell-based immunotoxicity assays should also be explored for screening purposes as these are time and cost effective as well as for ethical reasons. For in vivo studies, tier 1-3 assessments (Tier 1: hematology, serum globulin levels, lymphoid organ's weight and histopathology; Tier 2: immunophenotyping, TDAR and cell mediated immunity; and Tier 3: host resistance) should be used. These non-clinical in vivo assessments are useful to select immunological endpoints for clinical trials as well as for precautionary labeling. As per regulatory guidelines, adverse immunogenicity information of drug should be included in product's labeling to make health care practitioner aware of safety concerns before prescribing medicines and patient management (USFDA, 2022a, 2022b). This review mainly focuses on the importance of immunotoxicity assessment during drug discovery and development.

An updated review of immune checkpoint inhibitors in cutaneous oncology: Beyond melanoma

Over the last decade, immune checkpoint inhibitors (ICIs) have been established as an integral component of the contemporary anticancer armamentarium. In dermatology, ICIs are most established as treatment of advanced melanoma. However, emerging evidence has demonstrated that their utility in cutaneous oncology extends to a variety of other non-melanoma malignancies. This review provides an update of the evidence from clinical trials, real world analyses, and translational research over the last three years in cutaneous malignancies beyond melanoma. Special focus is presented on areas warranting further evaluation - including populations underrepresented in or excluded from clinical trials; new and emerging treatment scenarios beyond patients with metastatic disease; novel combination approaches; and the urgent need for reliable predictive biomarkers to identify predictors of response. Collaboration between oncologists, dermatologists and dermatological surgeons is essential to progress our understanding and treatment of patients with advanced cutaneous malignancies.

Delayed and immediate cutaneous adverse events during pembrolizumab combination chemotherapy against cervical cancer: Case series

Immune checkpoint inhibitors (ICIs), such as pembrolizumab (PEM), are widely recognized for their antitumor efficacy, but they can also lead to various cutaneous adverse events (CAEs). While most CAEs can be managed with topical corticosteroids, severe cases may necessitate halting immunotherapy. The incidence of severe CAEs is notably higher in combination therapies involving ICIs than in monotherapies, emphasizing the need for stringent, long-term management strategies. This includes potential modifications or discontinuations of the combination therapy. PEM, when added to the conventional paclitaxel + cisplatin (or carboplatin) ± bevacizumab regimen, has shown significant improvements in overall and progression-free survival for patients with Stage IVB metastatic or locally uncontrolled recurrent cervical cancer. This case series retrospectively examined the incidence and management of CAEs in 19 female patients treated with this combination therapy between October 2022 and May 2023. Four patients exhibiting CTCAE grade 3 were identified. The four cases of severe CAEs involved erythema multiforme after the initial course of PEM combination chemotherapy. Notably, three patients experienced immediate hypersensitivity reactions, including anaphylaxis, during subsequent treatments. This observation underscores the necessity for rigorous dermatological monitoring of patients undergoing PEM combination chemotherapy. Such vigilance is crucial for early detection of adverse reactions and timely adjustment of treatment regimens, thereby enhancing patient safety.

Observation on the Therapeutic Efficacy of Camrelizumab Combined with Chemotherapy in Non-small Cell Lung Cancer and the Cutaneous Immune-related Adverse Events: A Retrospective Study

INTRODUCTION

Immunotherapy targeting PD-1/PD-L1 shows significant benefits in lung cancer. Cutaneous immune-related adverse events (irAEs) are frequent, early-developing side effects of ICIs, and their potential role as prognostic markers in non-small cell lung cancer (NSCLC) therapy requires further exploration.

METHODS

Data of patients with NSCLC treated with camrelizumab Combined with chemotherapy were collected at Xuzhou Medical University from 2019 to 2023. Cutaneous irAEs were monitored using CTCAE v5.0, and therapeutic efficacy was assessed using RECIST 1.1 criteria for ORR and PFS. Multivariable Cox regression analysis identified independent predictors of PFS, and a nomogram was constructed to predict survival outcomes.

RESULTS

Data from 151 patients were analyzed. Significant differences in the objective response rate (ORR, P = 0.016) and progression-free survival (PFS, P < 0.0001) were detected between NSCLC patients, either with cirAEs or not. Besides, PFS was significantly different in NSCLC patients who were subgrouped by the time of first cutaneous irAEs occurrence (P = 0.011), duration of cutaneous irAEs (P = 0.002), grade of cutaneous irAEs (P = 0.002), the number of cutaneous irAEs(P = 0.021). The multivariable analysis also revealed that cirAEs were positively associated with survival outcomes (HR: 0.316, 95% CI, 0.193- 0.519, P.0.001) for PFS. The nomogram was formulated based on the results of multivariate analysis and validated using an internal bootstrap resampling approach, which showed that the nomogram exhibited a sufficient level of discrimination according to the C-index 0.80 (95% CI, 0.748-0.850).

CONCLUSION

The presence of cirAEs in NSCLC patients treated with camrelizumab combined with chemotherapy is indicative of better treatment efficacy and prognosis. This study supports the utility of cirAEs as biomarkers for predicting the validity of immunotherapy in NSCLC. It proposes a novel, multi-parameter prognostic model to assess patient outcomes more accurately.

Immune Checkpoint Inhibitor-Associated Cutaneous Adverse Events: Mechanisms of Occurrence

Immunotherapy, particularly that based on blocking checkpoint proteins in many tumors, including melanoma, Merkel cell carcinoma, non-small cell lung cancer (NSCLC), triple-negative breast (TNB cancer), renal cancer, and gastrointestinal and endometrial neoplasms, is a therapeutic alternative to chemotherapy. Immune checkpoint inhibitor (ICI)-based therapies have the potential to target different pathways leading to the destruction of cancer cells. Although ICIs are an effective treatment strategy for patients with highly immune-infiltrated cancers, the development of different adverse effects including cutaneous adverse effects during and after the treatment with ICIs is common. ICI-associated cutaneous adverse effects include mostly inflammatory and bullous dermatoses, as well as severe cutaneous side reactions such as rash or inflammatory dermatitis encompassing erythema multiforme; lichenoid, eczematous, psoriasiform, and morbilliform lesions; and palmoplantar erythrodysesthesia. The development of immunotherapy-related adverse effects is a consequence of ICIs' unique molecular action that is mainly mediated by the activation of cytotoxic CD4+/CD8+ T cells. ICI-associated cutaneous disorders are the most prevalent effects induced in response to anti-programmed cell death 1 (PD-1), anti-cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4), and anti-programmed cell death ligand 1 (PD-L1) agents. Herein, we will elucidate the mechanisms regulating the occurrence of cutaneous adverse effects following treatment with ICIs.

Successful Treatment of Immune Checkpoint Inhibitor-Induced Bullous Pemphigoid with Omalizumab: A Case Report and Review of the Literature

Background

Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment by enhancing the immune system's ability to target cancer cells. However, ICIs can lead to immune-related adverse events (irAEs), including dermatologic manifestations such as bullous pemphigoid (BP).

Objective

To evaluate the efficacy and safety of omalizumab and other biologics in the treatment of ICI-induced refractory bullous pemphigoid and to derive a strategy for selecting biologic treatments for this condition.

Methods

A 48-year-old female with pulmonary squamous cell carcinoma developed erythema and blisters following tislelizumab treatment. Despite initial steroid therapy (1.8 mg/kg/day), new blisters formed. Laboratory tests revealed elevated BP180/230 levels, confirming BP diagnosis. Treatments with intravenous corticosteroids, cyclosporine, and dapsone were ineffective. Omalizumab 300 mg every four weeks was initiated based on elevated serum IgE levels. The patient's response was monitored over four weeks. A comprehensive literature review was conducted, including 4 relevant articles.

Results

Omalizumab treatment resulted in the cessation of blister formation and significant symptom alleviation within one week. The overall treatment duration was four weeks, with stable improvement observed. Follow-up for 4 months with no recurrence.

Conclusion

This case illustrates the challenges of managing ICI-induced BP and highlights omalizumab as a potentially effective treatment option. The study proposes a personalized therapeutic strategy for refractory ICI-induced BP, emphasizing the selection of biologic agents based on specific immune profiles, including serum markers like IgE, eosinophils, and cytokine levels.

Cutaneous adverse events due to checkpoint inhibitors - a retrospective analysis at a tertiary referral hospital in Switzerland 2019-2022

Introduction

Checkpoint inhibitors are increasingly important in anti-cancer treatment. Therefore, knowledge of immune-related cutaneous adverse events (ir-cAE) is crucial for therapy management and continuation.

Objective

The study aimed to analyze the incidence of cutaneous adverse events caused by checkpoint inhibitor therapy, including their clinical presentation, management, and impact on further treatment.

Methods

This is a descriptive, monocentric retrospective study that uses data from the electronic health record system at a tertiary referral hospital in Central Switzerland from September 2019 to September 2022. The electronic health records of patients who received a therapy with checkpoint inhibitors were examined for age, sex, type of immunotherapy, time to occurrence of ir-cAEs, characteristics of the ir-cAEs, the treatment approach, and the continuation or cessation of the therapy due to ir-cAEs.

Results

Out of 431 patients, for 131 patients (30.4%) at least one ir-cAE event was documented. In particular, 109 (25.3%) experienced pruritus and 61 (14.2%) showed a maculopapular exanthema. The severity of the ir-cAE was mild in 88 patients (67.2% out of those with ir-cAEs). Ir-cAE were observed in 10 out of 20 patients (50%) treated with ipilimumab/nivolumab and in 15 out of 24 (62.5%) treated with durvalumab. In 15 patients (3.5%), checkpoint inhibitor therapy had to be discontinued due to cutaneous side effects.

Conclusions

This study showed that approximately one third of the patients experienced ir-cAEs. The most frequently observed ir-cAEs were pruritus, maculopapular exanthema and xerosis cutis. In general, the dermatological manifestations are mild and responsive to topical treatment or self-limiting with no requirement for treatment interruption.

Dermatologic toxicities of antibody-drug conjugates

Antibody-drug conjugates (ADCs) are a new and emerging category of oncologic treatments that combine the target specificity of a monoclonal antibody with a cytotoxic payload. These drugs are associated with unique cutaneous toxicities that vary across agents. Currently, there are eleven ADCs with regulatory approval for solid and liquid tumors and over 80 ADCs currently in clinical development, it is critical for dermatologists to recognize and appropriately mitigate the cutaneous toxicities associated with these therapies. This clinical review will summarize the novel mechanisms and indications of approved ADCs, discuss dermatologic toxicities demonstrated in clinical trials and postmarketing studies, and impart recognition and management guidance when encountering these reactions to help maintain patients safely and comfortably on their medications.

Pembrolizumab related perforated appendicitis

INTRODUCTION

Pembrolizumab is a humanized monoclonal antibody IgG4 programmed cell death protein 1 antagonist, and its use in oncology has been increasing in recent years, providing durable and favorable responses and tolerable toxicity profiles in various types of cancer. We describe a case of pembrolizumab related perforated appendicitis in a patient with stage 3C malignant melanoma (MM).

CASE REPORT

A 70-year-old male patient who had no known disease was diagnosed with MM as a result of the excision of the mass on his right shoulder. The disease stage was stage 3C (pT4aN1bM0). Subsequently, adjuvant pembrolizumab treatment was started. A few days after the fourth maintenance course, he presented to the emergency department complaining of abdominal pain, nausea and vomiting. Emergency abdominal tomography showed a significant increase in the diameter of the appendix vermiformis, peritoneal thickening and appendiceal wall defects that could be significant in terms of perforation.

MANAGEMENT AND OUTCOME

The mentioned finding and given the clinical presentation, was attributed to a perporating of the appendix, so the patient was hospitalized in the Department of Surgery and the patient underwent emergency appendectomy. Histological findings were consistent with appendicitis. After a day in the hospital, the abdominal pain subsided, C-reactive protein tended to decrease and the patient was discharged.

DISCUSSION

In patients who develop acute abdominal pain with or without diarrhea during immunotherapy, urgent imaging, endoscopic and clinical evaluation should be performed, and bowel perforation, although rare, should be considered as a potential complication of any immunotherapy.

Successful treatment of PD1-inhibitor induced psoriasiform dermatitis using IL-17 blockade without compromising immunotherapy efficacy

INTRODUCTION

Pembrolizumab is a monoclonal PD-1 inhibitor used in the treatment of lung cancer in addition to several other malignancies. Psoriasiform dermatitis is a well-documented adverse effect.

CASE REPORT

We present a 68 year-old-male with a 50-year smoking history and a 30-year remote history of plaque psoriasis, limited to the knees and elbows, who presented with metastatic non-small cell lung cancer. He was started on a chemotherapy regimen of carboplatin, paclitaxel, and pembrolizumab. One month later, he presented to dermatology with diffuse erythematous scaly papules coalescing into plaques on 80% of body surface area (BSA).

MANAGEMENT & OUTCOME

Pembrolizumab treatment was paused. The patient was prescribed triamcinolone 0.1% twice daily, but still had significant BSA at one-month and was started on an Il-17 inhibitor, ixekizumab, clearing the psoriasiform dermatitis. He was rechallenged with pembrolizumab every 3 weeks and repeat PET/CT demonstrated excellent tumor response.

DISCUSSION

This case prompted a literature review to further characterize the use of IL-17 inhibitors for psoriasiform dermatitis in the setting of ICI therapy. All six cases demonstrated improvement of psoriasiform dermatitis, with two cases showing partial response and four cases showing complete resolution. In three of the six cases, the patients exhibited clinical response to the primary malignancy after rechallenging with ICI, while remaining on an IL-17 inhibitor. Our case, in conjunction with the other reported cases, seems to suggest that IL-17 blockade can maintain a fine balance in this challenging clinical scenario by treating psoriasiform dermatitis without compromising the efficacy of immunotherapy.

Immunocyte membrane-derived biomimetic nano-drug delivery system: a pioneering platform for tumour immunotherapy

Tumor immunotherapy characterized by its high specificity and minimal side effects has achieved revolutionary progress in the field of cancer treatment. However, the complex mechanisms of tumor immune microenvironment (TIME) and the individual variability of patients' immune system still present significant challenges to its clinical application. Immunocyte membrane-coated nanocarrier systems, as an innovative biomimetic drug delivery platform, exhibit remarkable advantages in tumor immunotherapy due to their high targeting capability, good biocompatibility and low immunogenicity. In this review we summarize the latest research advances in biomimetic delivery systems based on immune cells for tumor immunotherapy. We outline the existing methods of tumor immunotherapy including immune checkpoint therapy, adoptive cell transfer therapy and cancer vaccines etc. with a focus on the application of various immunocyte membranes in tumor immunotherapy and their prospects and challenges in drug delivery and immune modulation. We look forward to further exploring the application of biomimetic delivery systems based on immunocyte membrane-coated nanoparticles, aiming to provide a new framework for the clinical treatment of tumor immunity.

Factors inducing cutaneous adverse reactions in cancer patients treated with PD-1 and PD-L1 inhibitors: a machine-learning algorithm approach

BACKGROUND

Immune checkpoint inhibitors (ICIs) show promise in cancer treatment but can lead to immune-related adverse events (irAEs), notably affecting the skin. Understanding the factors behind these skin reactions is crucial for effective management during treatment. Hence, the aim of this study was to uncover associations between patient characteristics and cutaneous adverse reactions among cancer patients undergoing ICI treatment.

METHODS

The study involved 209 cancer patients receiving ICIs. Statistical methods, including the chi-square test, Fisher's exact test, and multivariable logistic regression, were employed to analyze variables such as hypertension, antihistamine use, cancer metastasis, diabetes, and opioid usage. Additionally, machine learning techniques, including logistic regression, elastic net, random forest, and support vector machines (SVM), were utilized to develop predictive models anticipating skin-related adverse events.

RESULTS

Results highlighted significant associations between specific patient attributes and the incidence of skin reactions post-ICI treatment. Notably, patients using antihistamines or with cancer metastasis exhibited higher rates of skin adverse reactions, while those with diabetes or using opioids displayed lower incidence rates. Robust performance in forecasting these adverse events was observed, particularly in the predictive models employing logistic regression and elastic net.

CONCLUSIONS

This pioneering study contributes crucial insights into predictive modeling for ICI-induced skin reactions, emphasizing the importance of personalized treatment strategies. By identifying risk factors and utilizing tailored predictive models, healthcare providers can proactively manage adverse events, optimizing the benefits of ICIs while mitigating potential side effects.

Treatment of Pembrolizumab-Induced Mucocutaneous Lichen Planus With Metronidazole

This case report describes a man in his 50s with a diffuse pruritic rash after initiating treatment with pembrolizumab and enfortumab vedotin for metastatic urothelial carcinoma.

Rheumatic Immune-Related Adverse Events With Anti-cyclic Citrullinated Peptide Positivity and Cutaneous Adverse Drug Reactions: A Case Report

We report the case of a patient who experienced rheumatic immune-related adverse events (irAEs) with anti-cyclic citrullinated peptide (anti-CCP) positivity and cutaneous adverse drug reactions. A 59-year-old woman with malignant melanoma who was treated with nivolumab as postoperative adjuvant therapy developed polyarthralgia with anti-CCP positivity and dermatologic adverse events caused by celecoxib or lansoprazole. Her rheumatic and cutaneous symptoms greatly improved with oral glucocorticoid treatment. The findings of this case suggest that after treatment with immune checkpoint inhibitors, it is necessary to pay attention to irAEs and provide appropriate treatment.