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Pach J, Valido K, Belzer A, Leventhal JS. The Use of Biologic Agents for the Treatment of Cutaneous Immune-Related Adverse Events from Immune Checkpoint Inhibitors: A Review of Reported Cases. Am J Clin Dermatol 2024; 25:595-607. [PMID: 38767827 DOI: 10.1007/s40257-024-00866-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/22/2024]
Abstract
Cutaneous immune-related adverse events encompass a spectrum of dermatological manifestations, including lichenoid reactions, psoriasiform eruptions, eczematous dermatitis, immunobullous disorders, granulomatous reactions, pruritus, vitiligo, and severe cutaneous adverse reactions such as Stevens-Johnson syndrome. The conventional approach to treating high-grade or refractory cutaneous immune-related adverse events has involved high-dose systemic corticosteroids. However, their use is limited owing to the potential disruption of antitumor responses and associated complications. To address this, corticosteroid-sparing targeted immunomodulators have been explored as therapeutic alternatives. Biologic agents, commonly employed for non-cutaneous immune-related adverse events such as colitis, are increasingly recognized for their efficacy in treating various patterns of cutaneous immune-related adverse events, including psoriasiform, immunobullous, and Stevens-Johnson syndrome-like reactions. This review consolidates findings from the English-language literature, highlighting the use of biologic agents in managing diverse cutaneous immune-related adverse event patterns, also encompassing maculopapular, eczematous, and lichenoid eruptions, pruritus, and transient acantholytic dermatosis (Grover disease). Despite the established efficacy of these agents, further research is necessary to explore their long-term effects on antitumor responses.
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Affiliation(s)
- Jolanta Pach
- Yale University School of Medicine, New Haven, CT, USA
| | - Kailyn Valido
- Yale University School of Medicine, New Haven, CT, USA
| | - Annika Belzer
- Yale University School of Medicine, New Haven, CT, USA
| | - Jonathan S Leventhal
- Department of Dermatology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
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2
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Wang Q, Tian R, Zhang D, Nong X. Bullous pemphigoid induced by camrelizumab. Indian J Dermatol Venereol Leprol 2024; 0:1-3. [PMID: 38841931 DOI: 10.25259/ijdvl_68_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 02/15/2024] [Indexed: 06/07/2024]
Affiliation(s)
- Qin Wang
- Department of Dermatology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Rongqian Tian
- Department of Dermatology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Di Zhang
- Department of Dermatology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xiang Nong
- Department of Dermatology, First Affiliated Hospital of Kunming Medical University, Kunming, China
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3
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Earland N, Zhang W, Usmani A, Nene A, Bacchiocchi A, Chen DY, Sznol M, Halaban R, Chaudhuri AA, Newman AM. CD4 T cells and toxicity from immune checkpoint blockade. Immunol Rev 2023; 318:96-109. [PMID: 37491734 PMCID: PMC10838135 DOI: 10.1111/imr.13248] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/27/2023] [Indexed: 07/27/2023]
Abstract
Immune-related toxicities, otherwise known as immune-related adverse events (irAEs), occur in a substantial fraction of cancer patients treated with immune checkpoint inhibitors (ICIs). Ranging from asymptomatic to life-threatening, ICI-induced irAEs can result in hospital admission, high-dose corticosteroid treatment, ICI discontinuation, and in some cases, death. A deeper understanding of the factors underpinning severe irAE development will be essential for improved irAE prediction and prevention, toward maximizing the benefits and safety profiles of ICIs. In recent work, we applied mass cytometry, single-cell RNA sequencing, single-cell V(D)J sequencing, bulk RNA sequencing, and bulk T-cell receptor (TCR) sequencing to identify pretreatment determinants of severe irAE development in patients with advanced melanoma. Across 71 patients separated into three cohorts, we found that two baseline features in circulation-elevated activated CD4 effector memory T-cell abundance and TCR diversity-are associated with severe irAE development, independent of the affected organ system within 3 months of ICI treatment initiation. Here, we provide an extended perspective on this work, synthesize and discuss related literature, and summarize practical considerations for clinical translation. Collectively, these findings lay a foundation for data-driven and mechanistic insights into irAE development, with the potential to reduce ICI morbidity and mortality in the future.
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Affiliation(s)
- Noah Earland
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
- Division of Biology and Biomedical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Wubing Zhang
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA, USA
| | - Abul Usmani
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Antonella Bacchiocchi
- Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
| | - David Y. Chen
- Division of Dermatology, Washington University School of Medicine, St. Louis, MO, USA
- Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Mario Sznol
- Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Medicine, Division of Medical Oncology, Yale University School of Medicine, New Haven, CT, USA
| | - Ruth Halaban
- Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
| | - Aadel A. Chaudhuri
- Division of Cancer Biology, Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
- Division of Biology and Biomedical Sciences, Washington University School of Medicine, St. Louis, MO, USA
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
- Department of Computer Science and Engineering, Washington University in St. Louis, St. Louis, MO, USA
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA
| | - Aaron M. Newman
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
- Stanford Cancer Institute, Stanford University, Stanford, CA, USA
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4
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Teng YS, Yu S. Molecular Mechanisms of Cutaneous Immune-Related Adverse Events (irAEs) Induced by Immune Checkpoint Inhibitors. Curr Oncol 2023; 30:6805-6819. [PMID: 37504358 PMCID: PMC10378098 DOI: 10.3390/curroncol30070498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/14/2023] [Accepted: 07/15/2023] [Indexed: 07/29/2023] Open
Abstract
Over the past few decades, immune checkpoint inhibitors (ICIs) have emerged as promising therapeutic options for the treatment of various cancers. These novel treatments effectively target key mediators of immune checkpoint pathways. Currently, ICIs primarily consist of monoclonal antibodies that specifically block cytotoxic T-lymphocyte antigen 4 (CTLA-4), programmed cell death 1 (PD-1), programmed cell death-ligand 1 (PD-L1), and lymphocyte activation gene 3 protein (LAG-3). Despite the notable efficacy of ICIs in cancer treatment, they can also trigger immune-related adverse events (irAEs), which present as autoimmune-like or inflammatory conditions. IrAEs have the potential to affect multiple organ systems, with cutaneous toxicities being the most commonly observed. Although cutaneous irAEs are typically of low-grade severity and can usually be managed effectively, there are cases where severe irAEs can become life-threatening. Therefore, early recognition and a comprehensive understanding of the mechanisms underlying cutaneous irAEs are crucial for improving clinical outcomes in cancer patients. However, the precise pathogenesis of cutaneous irAEs remains unclear. This review focuses on the skin manifestations induced by ICIs, the prognosis related to cutaneous irAEs, and the exploration of potential mechanisms involved in cutaneous irAEs.
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Affiliation(s)
- Yi-Shan Teng
- Department of Dermatology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
| | - Sebastian Yu
- Department of Dermatology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
- Department of Dermatology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
- Neuroscience Research Center, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
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Niebel D, Wilsmann-Theis D, Bieber T, Berneburg M, Wenzel J, Braegelmann C. Bullous Pemphigoid in Patients Receiving Immune-Checkpoint Inhibitors and Psoriatic Patients—Focus on Clinical and Histopathological Variation. Dermatopathology (Basel) 2022; 9:60-81. [PMID: 35323203 PMCID: PMC8947168 DOI: 10.3390/dermatopathology9010010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/10/2022] [Accepted: 03/16/2022] [Indexed: 12/07/2022] Open
Abstract
Background: The most common autoimmune blistering disease, bullous pemphigoid (BP), shows an increased prevalence in psoriatic patients and oncologic patients undergoing immune-checkpoint blockade (ICB). Even though the same autoantigens (BP180/BP230) are detectable, it remains obscure whether clinical or histopathological differences exist between these different groups of BP patients. In this study, we strived to analyze this matter based on own data and previously published reports. Methods: We performed an institutional chart review from 2010–2020 to identify BP patients with psoriasis (n = 6) or underlying ICB (n = 4) and matched them with idiopathic cases of BP (n = 33). We compared clinical characteristics, subtypes, and dermatopathological determinants (e.g., tissue eosinophilia/neutrophilia, papillary edema, lymphocytic infiltration) among the groups. Results: ICB-associated BP affects men more often and might show mucosal involvement more frequently. We found no statistically significant dermatopathological differences among the groups. Conclusions: Clinicians should be aware of an increased risk of BP in patients with psoriasis and oncologic patients receiving ICB; atypical pruritic skin lesions should prompt a workup including a skin biopsy for histopathology and direct immunofluorescence in these patients. Larger studies might be necessary to detect slight dermatopathological variation.
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Affiliation(s)
- Dennis Niebel
- Department of Dermatology, University Hospital Regensburg, 93053 Regensburg, Germany;
- Correspondence: ; Tel.: +49-941-944-9620
| | - Dagmar Wilsmann-Theis
- Department of Dermatology and Allergy, University Hospital Bonn, 53105 Bonn, Germany; (D.W.-T.); (T.B.); (J.W.); (C.B.)
| | - Thomas Bieber
- Department of Dermatology and Allergy, University Hospital Bonn, 53105 Bonn, Germany; (D.W.-T.); (T.B.); (J.W.); (C.B.)
| | - Mark Berneburg
- Department of Dermatology, University Hospital Regensburg, 93053 Regensburg, Germany;
| | - Joerg Wenzel
- Department of Dermatology and Allergy, University Hospital Bonn, 53105 Bonn, Germany; (D.W.-T.); (T.B.); (J.W.); (C.B.)
| | - Christine Braegelmann
- Department of Dermatology and Allergy, University Hospital Bonn, 53105 Bonn, Germany; (D.W.-T.); (T.B.); (J.W.); (C.B.)
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Cunningham-Bussel A, Wang J, Prisco LC, Martin LW, Vanni KM, Zaccardelli A, Nasrallah M, Gedmintas L, MacFarlane LA, Shadick NA, Awad MM, Rahma O, LeBoeuf NR, Gravallese EM, Sparks JA. Predictors of Rheumatic Immune-Related Adverse Events and De Novo Inflammatory Arthritis After Immune Checkpoint Inhibitor Treatment for Cancer. Arthritis Rheumatol 2022; 74:527-540. [PMID: 34397169 PMCID: PMC8847547 DOI: 10.1002/art.41949] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/29/2021] [Accepted: 08/05/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To identify predictors of rheumatic immune-related adverse events (irAEs) following immune checkpoint inhibitor (ICI) treatment for cancer. METHODS We performed a case-control study to predict the occurrence of rheumatic irAEs in cancer patients who initiated ICI treatment at Mass General Brigham and the Dana-Farber Cancer Institute between 2011 and 2020. We screened for the presence of rheumatic irAEs by reviewing the medical records of patients evaluated by rheumatologists or those prescribed nonglucocorticoid immunomodulatory drugs after the time of ICI initiation (baseline). Review of medical records confirmed the presence of rheumatic irAEs and the indications necessitating immunomodulatory drug treatment. Controls were defined as patients who did not experience rheumatic irAEs, did not have preexisting rheumatic disease, did not have a clinical evaluation by a rheumatologist after ICI treatment, did not receive an immunomodulatory drug after ICI, did not receive systemic glucocorticoids after ICI, and survived at least 6 months after the initial ICI treatment. We used logistic regression to estimate the odds ratios (ORs) (with 95% confidence intervals [95% CIs]) for the risk of a rheumatic irAE in the presence of various baseline predictors. RESULTS A total of 8,028 ICI recipients were identified (mean age 65.5 years, 43.1% female, 31.8% with lung cancer). After ICI initiation, 404 patients (5.0%) were evaluated by rheumatologists, and 475 patients (5.9%) received an immunomodulatory drug to treat any irAEs. There were 226 confirmed rheumatic irAE cases (2.8%) and 118 de novo inflammatory arthritis cases (1.5%). Rheumatic diseases (either preexisting rheumatic diseases or rheumatic irAEs) were a common indication for immunomodulatory drug use (27.9%). Baseline predictors of rheumatic irAEs included melanoma (multivariable OR 4.06 [95% CI 2.54-6.51]) and genitourinary (GU) cancer (OR 2.22 [95% CI 1.39-3.54]), both relative to patients with lung cancer; combination ICI treatment (OR 2.35 [95% CI 1.48-3.74]), relative to patients receiving programmed death 1 inhibitor monotherapy; autoimmune disease (OR 2.04 [95% CI 1.45-2.85]) and recent glucocorticoid use (OR 2.13 [95% CI 1.51-2.98]), relative to patients not receiving a glucocorticoid, compared to the 2,312 controls without rheumatic irAEs. Predictors of de novo inflammatory arthritis were similar to those of rheumatic irAEs. CONCLUSION We identified novel predictors of rheumatic irAE development in cancer patients, including baseline presence of melanoma, baseline presence of GU tract cancer, preexisting autoimmune disease, receiving or having received combination ICI treatment, and receiving or having received glucocorticoids. The proportion of cancer patients experiencing rheumatic irAEs may be even higher than was reported in the present study, since we used stringent criteria to identify cases of rheumatic irAEs. Our findings could be used to identify cancer patients at risk of developing rheumatic irAEs and de novo inflammatory arthritis and may help further elucidate the pathogenesis of rheumatic irAEs in patients with cancer who are receiving ICI treatment.
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Affiliation(s)
- Amy Cunningham-Bussel
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Jiaqi Wang
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Lauren C. Prisco
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Lily W. Martin
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Kathleen M.M. Vanni
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Alessandra Zaccardelli
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Mazen Nasrallah
- Harvard Medical School, Boston, MA, USA,Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, United States
| | - Lydia Gedmintas
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Lindsey A. MacFarlane
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Nancy A. Shadick
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Mark M. Awad
- Harvard Medical School, Boston, MA, USA,Dana-Farber Cancer Institute, Boston, MA, USA
| | - Osama Rahma
- Harvard Medical School, Boston, MA, USA,Dana-Farber Cancer Institute, Boston, MA, USA
| | - Nicole R. LeBoeuf
- Harvard Medical School, Boston, MA, USA,Dana-Farber Cancer Institute, Boston, MA, USA,Department of Dermatology, Brigham and Women’s Hospital
| | - Ellen M. Gravallese
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Jeffrey A. Sparks
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
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7
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Bhardwaj M, Chiu MN, Pilkhwal Sah S. Adverse cutaneous toxicities by PD-1/PD-L1 immune checkpoint inhibitors: Pathogenesis, Treatment, and Surveillance. Cutan Ocul Toxicol 2022; 41:73-90. [PMID: 35107396 DOI: 10.1080/15569527.2022.2034842] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Introduction-The therapeutic use of humanized monoclonal programmed cell death 1 (PD-1) (pembrolizumab, and nivolumab) and programmed cell death ligand-1 (PD-L1) (atezolizumab, avelumab, durvalumab) immune checkpoint inhibitors (ICPi) as potent anticancer therapies is rapidly increasing. The mechanism of signaling of anti-PD-1/PD-L1 involves triggering cytotoxic CD4+/CD8 + T cell activation and subsequent abolition of cancer cells which induces specific immunologic adverse events that are specific to these therapies. These drugs can cause numerous cutaneous reactions and are characterized as the most frequent immune-related adverse events (irAEs). Majority of cutaneous irAEs range from nonspecific eruptions to detectible skin manifestations, which may be self-limiting and present acceptable skin toxicity profiles, while some may produce life-threatening complications.Objective-.This review aims to illuminate the associated cutaneous irAEs related to drugs used in oncology along with the relevant mechanism(s) and management.Areas covered-Literature was searched using various databases including Pub-Med, Google Scholar, and Medline. The search mainly involved research articles, retrospective studies, case reports, and clinicopathological findings. With this review article, an overview of the cutaneous irAEs with anti-PD-1/PD-L1 therapy, as well as suggestions, have been provided, so that their recognition at early stages could help in better management and would prevent treatment discontinuation.Article highlightsCutaneous adverse effects are the most prevalent immune-related adverse events induced by anti-PD-1/PD-L1 immune-checkpoint antibodies.Cutaneous toxicities mainly manifest in the form of maculopapular rash and pruritus.More specific cutaneous complications can also occur, including vitiligo, worsened psoriasis, lichenoid dermatitis, mucosal involvement (e.g., oral lichenoid reaction), dermatomyositis, lupus erythematosus.Cutaneous manifestations can be life-threatening including Stevens-Johnson syndrome/toxic epidermal necrolysis (TEN).Dermatologic toxicities are usually mild, readily manageable, and rarely result in significant morbidity.Adequate management of the cutaneous adverse event and recognition in early stages could lead to the prevention of worsening of the lesions and limit treatment disruption.
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Affiliation(s)
- Maitry Bhardwaj
- Faculty of Pharmaceutical Sciences, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, 160014, India
| | - Mei Nee Chiu
- Faculty of Pharmaceutical Sciences, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, 160014, India
| | - Sangeeta Pilkhwal Sah
- Faculty of Pharmaceutical Sciences, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, 160014, India
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8
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Lozano AX, Chaudhuri AA, Nene A, Bacchiocchi A, Earland N, Vesely MD, Usmani A, Turner BE, Steen CB, Luca BA, Badri T, Gulati GS, Vahid MR, Khameneh F, Harris PK, Chen DY, Dhodapkar K, Sznol M, Halaban R, Newman AM. T cell characteristics associated with toxicity to immune checkpoint blockade in patients with melanoma. Nat Med 2022; 28:353-362. [PMID: 35027754 DOI: 10.1038/s41591-021-01623-z] [Citation(s) in RCA: 134] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 11/09/2021] [Indexed: 12/15/2022]
Abstract
Severe immune-related adverse events (irAEs) occur in up to 60% of patients with melanoma treated with immune checkpoint inhibitors (ICIs). However, it is unknown whether a common baseline immunological state precedes irAE development. Here we applied mass cytometry by time of flight, single-cell RNA sequencing, single-cell V(D)J sequencing, bulk RNA sequencing and bulk T cell receptor (TCR) sequencing to study peripheral blood samples from patients with melanoma treated with anti-PD-1 monotherapy or anti-PD-1 and anti-CTLA-4 combination ICIs. By analyzing 93 pre- and early on-ICI blood samples and 3 patient cohorts (n = 27, 26 and 18), we found that 2 pretreatment factors in circulation-activated CD4 memory T cell abundance and TCR diversity-are associated with severe irAE development regardless of organ system involvement. We also explored on-treatment changes in TCR clonality among patients receiving combination therapy and linked our findings to the severity and timing of irAE onset. These results demonstrate circulating T cell characteristics associated with ICI-induced toxicity, with implications for improved diagnostics and clinical management.
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Affiliation(s)
- Alexander X Lozano
- Department of Materials Science and Engineering, Stanford University, Stanford, CA, USA.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Aadel A Chaudhuri
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA. .,Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA. .,Department of Computer Science & Engineering, Washington University, St. Louis, MO, USA. .,Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA.
| | - Aishwarya Nene
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | | | - Noah Earland
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Matthew D Vesely
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
| | - Abul Usmani
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Brandon E Turner
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA, USA
| | - Chloé B Steen
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA, USA.,Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Bogdan A Luca
- Stanford Center for Biomedical Informatics Research, Stanford University, Stanford, CA, USA
| | - Ti Badri
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT, USA
| | - Gunsagar S Gulati
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA, USA
| | - Milad R Vahid
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA, USA
| | - Farnaz Khameneh
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA, USA
| | - Peter K Harris
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - David Y Chen
- Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA.,Division of Dermatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Kavita Dhodapkar
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Mario Sznol
- Department of Medicine, Division of Medical Oncology, Yale University School of Medicine, New Haven, CT, USA.,Yale Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | - Ruth Halaban
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA.,Yale Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | - Aaron M Newman
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA, USA. .,Department of Biomedical Data Science, Stanford University, Stanford, CA, USA.
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9
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Pospischil I, Hoetzenecker W. Arzneimittelexantheme unter modernen zielgerichteten Therapien - Immuncheckpoint- und EGFR-Inhibitoren. J Dtsch Dermatol Ges 2021; 19:1621-1645. [PMID: 34811897 DOI: 10.1111/ddg.14641_g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/19/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Isabella Pospischil
- Universitätsklinik für Dermatologie und Venerologie, Kepler Universitätsklinikum, Johannes Kepler Universität, Linz, Österreich
| | - Wolfram Hoetzenecker
- Universitätsklinik für Dermatologie und Venerologie, Kepler Universitätsklinikum, Johannes Kepler Universität, Linz, Österreich
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10
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Pospischil I, Hoetzenecker W. Drug eruptions with novel targeted therapies - immune checkpoint and EGFR inhibitors. J Dtsch Dermatol Ges 2021; 19:1621-1643. [PMID: 34811916 PMCID: PMC9299005 DOI: 10.1111/ddg.14641] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/19/2021] [Indexed: 12/25/2022]
Abstract
Given the increasing use of novel targeted therapies, dermatologists are constantly confronted with novel cutaneous side effects of these agents. A rapid diagnosis and appropriate management of these side effects are crucial to prevent impairment of the patients' quality of life and interruptions of essential cancer treatments. Immune checkpoint and EGFR inhibitors are frequently used targeted therapies for various malignancies and are associated with a distinct spectrum of cutaneous adverse events. Exanthematous drug eruptions represent a particular diagnostic challenge in these patients. Immune checkpoint inhibitors can elicit a plethora of immune-related exanthemas, most commonly maculopapular, lichenoid, and psoriasiform eruptions. Additionally, autoimmune bullous dermatoses and exanthemas associated with connective tissue diseases may arise. In cases of severe, atypical or therapy-resistant presentations an extensive dermatological investigation including a skin biopsy is recommended. Topical and systemic steroids are the mainstay of treatment. Papulopustular eruptions represent the major cutaneous adverse effect of EGFR inhibitor therapy, occurring in up to 90 % of patients within the first two weeks of therapy, depending on the agent. Besides topical antibiotics and steroids, oral tetracyclines are the first choice in systemic treatment and can also be used as prophylaxis.
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Affiliation(s)
- Isabella Pospischil
- Department of Dermatology, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Wolfram Hoetzenecker
- Department of Dermatology, Kepler University Hospital, Johannes Kepler University, Linz, Austria
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11
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Quach HT, Johnson DB, LeBoeuf NR, Zwerner JP, Dewan AK. Cutaneous adverse events caused by immune checkpoint inhibitors. J Am Acad Dermatol 2021; 85:956-966. [PMID: 34332798 DOI: 10.1016/j.jaad.2020.09.054] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 11/25/2022]
Abstract
IMPORTANCE Immune checkpoint inhibitors (ICIs) have emerged as active therapies for a variety of cancers. Cutaneous toxicities are common immune-related adverse events and patients will often be referred to dermatologists for evaluation. OBSERVATIONS Cutaneous adverse events to ICIs can have a variety of clinical presentations. Among the more common are eczematous, morbilliform, and lichenoid dermatoses, as well as vitiligo and pruritus. Less common adverse events include psoriasiform dermatoses, bullous disorders, and severe cutaneous adverse reactions, including Stevens-Johnson syndrome, toxic epidermal necrolysis, and drug reaction with eosinophilia and systemic symptoms. Because of the immunologic mechanism of ICIs, there are also a variety of rheumatologic adverse reactions with cutaneous manifestations, such as scleroderma, dermatomyositis, cutaneous lupus erythematosus, and various vasculitides. These cutaneous reactions often respond to topical or systemic steroids, although specific toxicities may have alternative treatments available. CONCLUSIONS AND RELEVANCE As they become more widely prescribed, dermatologists will see an increasing number of patients with cutaneous adverse events caused by ICI therapies. Accurately diagnosing and treating these toxicities is paramount to achieving the most favorable outcomes for patients.
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Affiliation(s)
- Henry T Quach
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Nicole R LeBoeuf
- Department of Dermatology, The Center for Cutaneous Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeffrey P Zwerner
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anna K Dewan
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee.
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12
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Wang X, Suppa M, Bruderer P, Sirtaine N, Aspeslagh S, Kerger J. A Late Dermatologic Presentation of Bullous Pemphigoid Induced by Anti-PD-1 Therapy and Associated with Unexplained Neurological Disorder. Case Rep Oncol 2021; 14:861-867. [PMID: 34248552 PMCID: PMC8255709 DOI: 10.1159/000514806] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 01/22/2021] [Indexed: 11/25/2022] Open
Abstract
Immunotherapy has become the standard of care for various cancer types. The widespread use of immune checkpoints inhibitors confronts us with a whole range of novel immune-related adverse events. Skin toxicity is one of the most frequent adverse events. In this article, we report a case of anti-PD-1 induced late bullous pemphigoid (BP) with mucosal erosions and associated with a troublesome neurological disorder of undetermined origin in a patient with metastatic melanoma. Skin biopsy was essential to make the diagnosis and rapid initiation of systemic prednisolone played a role in favorable clinical outcome of BP. We will discuss the difficulty of early diagnosis of BP, its unusual association with neurological disorders, and the specific management of this particular dermatological entity.
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Affiliation(s)
- Xiaoxiao Wang
- Department of Medical Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Mariano Suppa
- Department of Dermatology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium.,Department of Dermatology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Pascal Bruderer
- Department of Dermatology, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Nicolas Sirtaine
- Department of Pathology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Sandrine Aspeslagh
- Department of Medical Oncology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Joseph Kerger
- Department of Medical Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
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13
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Efficacy and safety of tetracyclines for pemphigoid: a systematic review and meta-analysis. Arch Dermatol Res 2021; 314:191-201. [PMID: 33774726 DOI: 10.1007/s00403-021-02216-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 02/16/2021] [Accepted: 02/26/2021] [Indexed: 10/21/2022]
Abstract
The aim of this review was to evaluate the efficacy and safety of tetracyclines for treatment of pemphigoid. We searched PubMed, EMBASE, Ovid, Web of Science, and the Cochrane Library for studies involving pemphigoid patients treated with tetracyclines published in English before 29 February 2020. References of included studies were also screened to widen the scope of the literature search. Data regarding predefined clinical outcomes of 341 patients from 77 studies were extracted and analyzed. A meta-analysis was conducted on the basis of 4 studies including 2 randomized controlled trials and 2 comparative studies. The patients had a mean age of 74.60 ± 13.18 years, 45.4% were males, and 54.6% were females. There were 185 patients with mild-to-moderate and 143 patients with severe disease. The average initial doses were 1.62 ± 0.39 g/day for tetracycline, 0.20 ± 0.01 g/day for doxycycline, and 0.11 ± 0.05 g/day for minocycline. The average time on tetracyclines was 3.74 ± 5.99 months, and 261 (81.3%) patients reported partial or complete remission. Relapses occurred in 72 (28.3%) cases. Adverse effects were experienced by 130 (41.9%) patients. The pooled ORs for short-term effectiveness, relapse, adverse effects, and 1-year survival in patients treated with oral tetracyclines vs. systemic corticosteroids were 0.40 (95% CI, 0.22-0.76), 0.69 (95% CI, 0.44-1.10), 0.47 (95% CI, 0.27-0.82) and 2.02 (95% CI, 1.16-3.50), respectively. Compared to doxycycline and minocycline, tetracycline was significantly associated with better treatment outcomes and fewer adverse effects (p < 0.05). This review revealed tetracyclines' efficacy and safety in pemphigoid treatment and may offer support for clinical use of tetracyclines in pemphigoid.
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14
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Abstract
Cutaneous adverse drug reactions produce a significant clinical, financial, and psychological burden on our healthcare industry. The importance of considering a drug reaction in the cause of any dermatitis is underscored by the diversity of clinical manifestations and the prolific rate of drug discovery and approval. We present an update on the variety of drug reactions encountered in the inpatient and outpatient setting. Immunomodulatory drugs used in oncology will be reviewed separately as their clinical manifestations cross many reaction patters and morphologies.
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Affiliation(s)
- Robert T Spaulding
- Division of Dermatology, University of Louisville School of Medicine, Louisville, Kentucky, USA.
| | - Cindy E Owen
- Division of Dermatology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Jeffrey P Callen
- Division of Dermatology, University of Louisville School of Medicine, Louisville, Kentucky, USA
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15
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Management of Immune-Related Cutaneous Adverse Reactions to PD-1 and PD-L1 Inhibitors for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00314-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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16
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Choi J, Anderson R, Blidner A, Cooksley T, Dougan M, Glezerman I, Ginex P, Girotra M, Gupta D, Johnson D, Shannon VR, Suarez-Almazor M, Rapoport BL, Lacouture ME. Multinational Association of Supportive Care in Cancer (MASCC) 2020 clinical practice recommendations for the management of severe dermatological toxicities from checkpoint inhibitors. Support Care Cancer 2020; 28:6119-6128. [PMID: 32856211 DOI: 10.1007/s00520-020-05706-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/20/2020] [Indexed: 02/07/2023]
Abstract
Immune checkpoint inhibitors (ICIs) frequently result in cutaneous immune-related adverse events (IrAEs). Although the majority of these events are mild-to-moderate in severity, up to 5% are severe, which may lead to morbidity and dose interruption or discontinuation of ICI therapy. In addition, up to 25% of dermatologic IrAEs are corticosteroid-refractory or corticosteroid-dependent. These 2020 MASCC recommendations cover the diagnosis and management of cutaneous IrAEs with a focus on moderate-to-severe and corticosteroid-resistant events. Although the usage of immune-suppressive therapy has been advocated in this setting, there is a lack of randomized clinical trial data to provide a compelling level of evidence of its therapeutic benefit.
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Affiliation(s)
- Jennifer Choi
- Division of Oncodermatology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ronald Anderson
- Faculty of Health Sciences, Department of Immunology, University or Pretoria, Corner Doctor Savage Road and Bophelo Road, PO Box 667, Pretoria, 0002, South Africa
| | - Ada Blidner
- Laboratory of Immunopathology, Institute of Biology and Experimental Medicine-CONICET, Buenos Aires, Argentina
| | - Tim Cooksley
- Manchester University Foundation Trust, Manchester, UK.,The Christie, University of Manchester, Manchester, UK
| | - Michael Dougan
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Ilya Glezerman
- Renal Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | | | - Monica Girotra
- Endocrine Division, Department of Medicine, Weill Cornell Medical College (MG, AF), New York, NY, USA.,Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Dipti Gupta
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Douglas Johnson
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA
| | - Vickie R Shannon
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria Suarez-Almazor
- Section of Rheumatology and Clinical Immunology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bernardo L Rapoport
- Faculty of Health Sciences, Department of Immunology, University or Pretoria, Corner Doctor Savage Road and Bophelo Road, PO Box 667, Pretoria, 0002, South Africa. .,The Medical Oncology Centre of Rosebank, 129 Oxford Road, Saxonwold, 2196, Johannesburg, South Africa.
| | - Mario E Lacouture
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, Outpatient Center, New York, NY, USA
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17
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Muntyanu A, Netchiporouk E, Gerstein W, Gniadecki R, Litvinov IV. Cutaneous Immune-Related Adverse Events (irAEs) to Immune Checkpoint Inhibitors: A Dermatology Perspective on Management [Formula: see text]. J Cutan Med Surg 2020; 25:59-76. [PMID: 32746624 DOI: 10.1177/1203475420943260] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Immune checkpoint inhibitors have proven to be efficacious for a broad spectrum of solid organ malignancies. These monoclonal antibodies lead to cytotoxic T-cell activation and subsequent elimination of cancer cells. However, they can also lead to immune intolerance and immune-related adverse event (irAEs) that are new and specific to these therapies. Cutaneous irAEs are the most common, arising in up to 34% of patients on PD-1 inhibitors and 43% to 45% on CTLA-4 inhibitors. The most common skin manifestations include maculopapular eruption, pruritus, and vitiligo-like lesions. A grading system has been proposed, which guides management of cutaneous manifestations based on the percent body surface area (BSA) involved. Cutaneous irAEs may prompt clinicians to reduce drug doses, add systemic steroids to the regiment, and/or discontinue lifesaving immunotherapy. Thus, the goal is for early identification and concurrent management to minimize treatment interruptions. We emphasize here that the severity of the reaction should not be graded based on BSA involvement alone, but rather on the nature of the primary cutaneous pathology. For instance, maculopapular eruptions rarely affect <30% BSA and can often be managed conservatively with skin-directed therapies, while Stevens-Johnson syndrome (SJS) affecting even 5% BSA should be managed aggressively and the immunotherapy should be discontinued at once. There is limited literature available on the management of the cutaneous irAEs and most studies present anecdotal evidence. We review the management strategies and provide recommendations for psoriatic, immunobullous, maculopapular, lichenoid, acantholytic eruptions, vitiligo, alopecias, vasculitides, SJS/toxic epidermal necrolysis, and other related skin toxicities.
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Affiliation(s)
- Anastasiya Muntyanu
- 54473507266 Division of Dermatology, McGill University, Montreal, QC, Canada
| | - Elena Netchiporouk
- 54473507266 Division of Dermatology, McGill University, Montreal, QC, Canada
| | - William Gerstein
- 54473507266 Division of Dermatology, McGill University, Montreal, QC, Canada
| | - Robert Gniadecki
- 3158 Division of Dermatology, University of Alberta, Edmonton, AB, Canada
| | - Ivan V Litvinov
- 54473507266 Division of Dermatology, McGill University, Montreal, QC, Canada
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