Targeted treatment using monoclonal antibodies and tyrosine-kinase inhibitors in pregnancy

Adverse effects of tyrosine kinase inhibitors in cancer therapy: pathophysiology, mechanisms and clinical management

Since their invention in the early 2000s, tyrosine kinase inhibitors (TKIs) have gained prominence as the most effective pathway-directed anti-cancer agents. TKIs have shown significant utility in the treatment of multiple hematological malignancies and solid tumors, including chronic myelogenous leukemia, non-small cell lung cancers, gastrointestinal stromal tumors, and HER2-positive breast cancers. Given their widespread applications, an increasing frequency of TKI-induced adverse effects has been reported. Although TKIs are known to affect multiple organs in the body including the lungs, liver, gastrointestinal tract, kidneys, thyroid, blood, and skin, cardiac involvement accounts for some of the most serious complications. The most frequently reported cardiovascular side effects range from hypertension, atrial fibrillation, reduced cardiac function, and heart failure to sudden death. The potential mechanisms of these side effects are unclear, leading to critical knowledge gaps in the development of effective therapy and treatment guidelines. There are limited data to infer the best clinical approaches for the early detection and therapeutic modulation of TKI-induced side effects, and universal consensus regarding various management guidelines is yet to be reached. In this state-of-the-art review, we examine multiple pre-clinical and clinical studies and curate evidence on the pathophysiology, mechanisms, and clinical management of these adverse reactions. We expect that this review will provide researchers and allied healthcare providers with the most up-to-date information on the pathophysiology, natural history, risk stratification, and management of emerging TKI-induced side effects in cancer patients.

Case report: Osimertinib administration during pregnancy in a woman with advanced EGFR-mutant non-small cell lung cancer

Lung cancer (LC) is one of the most common causes of death worldwide. The identification of oncogene-addicted driving mutations suitable for targeted therapy has improved clinical outcomes in advanced diseases. Clinical trials, on the other hand, rarely involve vulnerable groups such as pregnant women. We report a 37-year-old woman with advanced non-small cell lung cancer (NSCLC) harboring an exon 19 deletion of EGFR treated with afatinib. After the initial treatment, the patient achieved a complete response and had an unplanned pregnancy. Targeted therapy was withheld during the first trimester and resumed with osimertinib in the second trimester in which the patient developed oligohydramnios and intrauterine growth restriction (IUGR) of the baby. Osimertinib was delayed at two different times during the third trimester with complete resolution of the oligohydramnios. The baby was born at 37.3 weeks of gestation (WOG) with no signs of congenital disorders. After delivery, the mother restarted osimertinib and maintained a complete response. This case suggests that osimertinib could be an acceptable option for tumor control during pregnancy in EGFR-mutant NSCLC. This information do not replace current recommendations for avoiding pregnancy and promoting contraceptive usage in patients receiving any cancer therapy.

Transplacental Passage and Fetal Effects of Antineoplastic Treatment during Pregnancy

Simple Summary

In this paper we perform an introduction about pregnancy-associated cancer (PAC) and transplacental passage of antineoplastic agents. Furthermore, we describe therapeutic use and potential toxic effects of chemotherapeutic drug (alkylating agents, antimetabolites agents, anthracyclines, topoisomerase inhibitors, antimitotic agents, actinomycin-D, bleomycin) and targeted agents during pregnancy. This manuscript may be a useful and practical guide for the management of PAC, which is a challenge for clinicians that have to consider alike maternal benefits and fetal potential risks correlated to the antineoplastic treatment.

Abstract

The incidence of PAC is relatively infrequent among pregnant women. However, it has gradually increased in recent years, becoming a challenging area for clinicians that should take into account in the same way maternal benefits and fetal potential risks correlated to the antineoplastic treatment. None of the antineoplastic drugs is completely risk-free during the pregnancy, the timing of exposure and transplacental transfer properties influence the toxicity of the fetus. Despite the lack of guidelines about the management of PAC, several studies have described the use and the potential fetal and neonatal adverse events of antineoplastic drugs during pregnancy. We provide a review of the available literature about the transplacental passage and fetal effects of chemotherapy and targeted agents, to guide the clinicians in the most appropriate choices for the management of PAC.

Use of pertuzumab and trastuzumab during pregnancy

Trastuzumab and pertuzumab are monoclonal antibodies used for the treatment of breast cancer. Until now, there have been no reports on the use of pertuzumab during pregnancy and on its potential effects on the fetus. Herein, we present a breast cancer patient who received trastuzumab and pertuzumab treatment during the first 20 weeks of pregnancy. This 22-year-old patient initially diagnosed with invasive ductal carcinoma of the breast was found to be negative for estrogen receptor and progesterone receptor and positive for human epidermal growth factor receptor in the immunohistochemical examination. At the time of diagnosis, she had metastatic lesions and a protocol of docetaxel, trastuzumab, pertuzumab, q21, and zolendronic acid 4 mg every month was started. Following six courses of therapy, she had near-complete response, and, after administration of the same course of treatment for two additional cycles, treatment with pertuzumab plus trastuzumab was continued. While she was being followed-up with remission, a 20-week pregnancy was detected. A fetal ultrasound examination showed oligohydramnios and right renal agenesis. Treatment was stopped, and the fetus was monitored. After 7 weeks of follow-up, fetal growth retardation and anhydramnios were detected. The pregnancy was terminated. Fetal autopsy showed no urinary system pathology, but macroscopic and microscopic hyperplasia of the right adrenal gland was identified. Concomitant use of pertuzumab and trastuzumab during pregnancy may be associated with an unresolved oligohydramnios and/or anhydramnios risk. Extreme caution should be used when these monoclonal antibodies are administered during pregnancy.

Trastuzumab in the Treatment of Pregnant Breast Cancer Patients - an Overview of the Literature

Breast cancer is one of the most common malignancies which appear during pregnancy. Since women are increasingly not giving birth until they are at a more advanced age, it can be assumed that the incidence of pregnancy-related breast cancers will continue to increase in the future. Because of pregnancy-induced changes and conservative diagnosis, these carcinomas are frequently not detected until they are at an advanced stage and thus generally require systemic adjuvant therapy. The available data on optimal chemotherapeutic management are limited. Particularly for the use of the target agent trastuzumab which could crucially contribute to improving the prognosis in the therapy of HER2-overexpressing breast cancer in non-pregnant women, there is a lack of definitive information regarding the profile of action and safety in pregnancy as well as with regard to any long-term effects on the child. Thirty-eight pregnancies on trastuzumab for the treatment of breast cancer were able to be analysed in the literature currently available. Information can be gained from this and conclusions can be drawn which can individualise and decisively improve therapeutic options in the future for the pregnant breast cancer patient.

Cancer During Pregnancy: The Oncologist Overview

Although a rare and challenging condition, cancer during pregnancy should promptly be identified and treated. Not only standards of care guidelines for the underlying disease are taken into account, but also fetal safety might be weighted for clinical decisions. Frequent lack of experience and knowledge about this condition could lead to late diagnosis, imprecise management, suboptimal treatment and fetal and maternal harm. Therefore, this review aims to summarize the current evidence regarding the epidemiology, clinical presentation, diagnostic workup, staging and treatment, including novel treatment modalities for patients diagnosed with cancer during pregnancy.

Comparative safety and efficacy of tyrosine kinase inhibitors (TKIs) in the treatment setting of different types of leukemia, and different types of adenocarcinoma

Tyrosine kinase inhibitors (TKIs) are blockers of tyrosine kinase proteins which are known for the activation of signaling pathways especially in neoplastic cells. TKIs are among targeted anticancer medications that are available in the market. Imatinib was introduced in the late 1990s as the first TKI medicine in oncology, followed by gefitinib, erlotinib, sorafenib, sunitinib, dasatanib and the list of TKIs is being updated nearly every month. To review the safety, efficacy, and current clinical stage of TKIs in different malignancies, particularly leukemia, advanced gastrointestinal and breast cancer, whole literature over the last decade (2006 to 2017) were searched to find all related studies. Criticizing current data indicates that TKIs have shown better clinical outcome in terms of both safety and efficacy compared to conventional therapies. Meanwhile, regarding the results of available clinical trials, the best approach into maximizing the benefits of this novel targeting therapy and also minimizing the undesirable adverse effects, is to evaluate the pharmacogenetic data of patients before allocating these agents in their treatment setting.

[Management of side effects of targeted therapies in renal cancer: sexual disorders]

Since sexual disorders were not specifically studied in the principal series, epidemiological data is scarce. Nevertheless, in practice, when sexuality is dealt with during the monitoring of patients undergoing targeted therapies, more than half of the patients questioned say that they attach importance to their quality of sex life, despite the severity of their metastatic renal cancer. At the start of treatment, it is therefore important to inform patients of the possible occurrence of problems and to encourage them to report them. During treatment, screening for sexual disorders by questioning is desirable: desire, lubrication, dyspareunia, erectile dysfunction. In the event of the onset of a sexual disorder during treatment, it is not usually necessary to stop or modify the treatment. Therapeutic measures depend on the discomfort felt and are under the control of the specialist: erectile dysfunction, male libido disorders, vaginal dryness and vulvovaginitis. A consultation with an oncology psychologist and/or sex therapist is useful, if possible with the partner, based on the impact of the sexual problems.

Gynecologic malignancy in pregnancy

Gynecologic malignancy during pregnancy is a stressful problem. For the diagnosis and treatment of malignancy during pregnancy, a multidisciplinary approach is needed. Patients should be advised about the benefits and risk of treatment. When selecting a treatment for malignancy during pregnancy, the physiologic changes that occur with the pregnancy should be considered. Various diagnostic procedures that do not harm the fetus can be used. Laparoscopic surgery or laparotomy may be safely performed. The staging approach and treatment should be standard. Systemic chemotherapy during the first trimester should be delayed if possible. Radiation therapy should preferably start postpartum. Although delivery should be delayed preferably until after 35 weeks of gestation, termination of pregnancy may be considered when immediate treatment is required. Subsequent pregnancies do not increase the risk of malignancy recurrence.

Clinical review: kinase inhibitors: adverse effects related to the endocrine system

CONTEXT

The use of kinase inhibitors (KIs) in the treatment of cancer has become increasingly common, and practitioners must be familiar with endocrine-related side effects associated with these agents. This review provides an update to the clinician regarding the management of potential endocrinological effects of KIs.

EVIDENCE ACQUISITION

PubMed was employed to identify relevant manuscripts. A review of the literature was conducted, and data were summarized and incorporated.

EVIDENCE SYNTHESIS

KIs, including small molecule KIs and monoclonal antibodies directed against kinases, have emerged over the past decade as an important class of anticancer agents. KIs specifically interfere with signaling pathways that are dysregulated in certain types of cancers and also target common mechanisms of growth, invasion, metastasis, and angiogenesis. Currently, at least 20 KIs are approved as cancer therapeutics. However, KIs may affect a broad spectrum of targets and may have additional, unidentified mechanisms of action at the cellular level due to overlap between signaling pathways in the tumor cell and endocrine system. Recent reports in the literature have identified side effects associated with KIs, including alterations in thyroid function, bone metabolism, linear growth, gonadal function, fetal development, adrenal function, and glucose metabolism.

CONCLUSIONS

Clinicians need to monitor the thyroid functions of patients on KIs. In addition, bone density and vitamin D status should be assessed. Special care should be taken to follow linear growth and development in children taking these agents. Clinicians should counsel patients appropriately on the potential adverse effects of KIs on fetal development.

Gynaecological cancers in pregnancy

Cervical and ovarian cancers are the most common gynaecological cancers diagnosed during pregnancy. In early-stage cervical cancer during the first and at the beginning of the second trimester, the two main considerations for management of the patient are the tumour size (and stage) and nodal staging. MRI and laparoscopic lymphadenectomy are useful for clinicians planning a potentially conservative approach. The management of patients with locally advanced cervical disease is controversial and should be discussed on a case-by-case basis according to the tumour size, radiological findings, the term of pregnancy, and the patient's wishes. Different histological types of malignant ovarian diseases arise during pregnancy and their management depends on the diagnosis (histological subtypes, tumour differentiation, and nodal status), the tumour stage, and the trimester of the pregnancy. In patients with peritoneal spread or high-risk early-stage disease, neoadjuvant chemotherapy with pregnancy preservation could be appropriate.

Fetal and Neonatal Illnesses Caused or Influenced by Maternal Transplacental IgG and/or Therapeutic Antibodies Applied During Pregnancy

The human fetus is protected by the mother’s antibodies. At the end of the pregnancy, the concentration of maternal antibodies is higher in the cord blood, than in the maternal circulation. Simultaneously, the immune system of the fetus begins to work and from the second trimester, fetal IgM is produced by the fetal immune system specific to microorganisms and antigens passing the maternal-fetal barrier. The same time the fetal immune system has to cope and develop tolerance and T_REG cells to the maternal microchimeric cells, latent virus-carrier maternal cells and microorganisms transported through the maternal-fetal barrier.

The maternal phenotypic inheritance may hide risks for the newborn, too. Antibody mediated enhancement results in dengue shock syndrome in the first 8 month of age of the baby.

A series of pathologic maternal antibodies may elicit neonatal illnesses upon birth usually recovering during the first months of the life of the offspring. Certain antibodies, however, may impair the fetal or neonatal tissues or organs resulting prolonged recovery or initiating prolonged pathological processes of the children.

The importance of maternal anti-idiotypic antibodies are believed to prime the fetal immune system with epitopes of etiologic agents infected the mother during her whole life before pregnancy and delivery.

The chemotherapeutical and biological substances used for the therapy of the mother will be transcytosed into the fetal body during the last two trimesters of pregnancy. The long series of the therapeutic monoclonal antibodies and conjugates has not been tested systematically yet. The available data are summarised in this chapter.

The innate immunity plays an important role in fetal defence. The concentration of interferon is relative high in the placenta. This is probably one reason, why the therapeutic interferon treatment of the mother does not impair the fetal development.

Chemotherapy for breast cancer in pregnancy: evidence and guidance for oncologists

It has been estimated that up to 3.8% of breast cancers may be diagnosed in women who are pregnant, with an estimated 1 in 3000-3500 deliveries occurring in women with breast cancer. Owing to the lack of large randomized trials available to guide our clinical practice, our decisions regarding adjuvant systemic management are based on retrospective analyses, case reports and a small number of prospective studies. A tailored approach to treatment is required with careful consideration given at all stages to the needs of the mother and risks to the foetus. Management is critically influenced by the stage of pregnancy, especially the first trimester. Anthracycline-based chemotherapy may be administered during the second and third trimesters, with apparently few short-term implications. Limited data shows the taxanes may also be given with few adverse events at these stages. Weekly fractionation regimens may allow closer monitoring of pregnancy with prompt termination of agents, if necessary. Data concerning the long-term risks of systemic anticancer treatment are limited. All stages of patient management should be discussed within a multidisciplinary team and a clear consensus of treatment options communicated to the mother. Delaying chemotherapy until after delivery may be reasonable in some cases, but where the delay is likely to be prolonged, a decision must be made on the basis of risks versus benefits.

Effect of the maternofetal and milk transfer of the anti-epidermal growth factor receptor monoclonal antibody 7A7 in mice

OBJECTIVES

To study the maternofetal and milk transfer of an anti-epidermal growth factor receptor (EGFR) monoclonal antibody (MAb) and its effects on conceptus, we administered to pregnant and lactating dams the murine anti-EGFR MAb 7A7 in an autologus model.

STUDY DESIGN

For determining the embryo-fetal toxicity, 7A7 at gestational days (GD) 6, 8, 12 and 14 were intravenously administered. Clinical signs and body weights were recorded. On GD 18 pregnant mice were euthanized and the alive and dead fetuses were examined. For measuring the maternofetal transfer mice were dosed on GD 14 with (125)I-7A7, after 24 h, mice were euthanized and main maternal organs and fetuses were counted separately for radioactivity. For studying the MAb transferred throughout the milk, lactating dams were intravenously dosed on lactation day (LD) 2 with (125)I-7A7. Blood samples were obtained from dams at different times post. One lactating pup from each dam was also euthanized at different times, and their blood and gastric milk were removed and the radioactivities measured.

RESULTS

The administration of the 7A7 did not elicit toxicity to adult pregnant mice nevertheless; there was evidence of embryo-fetal toxicity in the 7A7 group characterized by a decrease in litters' body weights and head deformities. The maternofetal transfer of (125)I-7A7 antibody on GD 15 was only of a 4%.

CONCLUSION

Results suggest that 7A7 crosses placenta and it is transferred in a superior quantity to pups through the milk and that anti-EGFR MAbs have a potential toxic effect to fetuses.

Endocrine side effects of broad-acting kinase inhibitors

Targeted therapy in oncology consists of drugs that specifically interfere with abnormal signaling pathways that are dysregulated in cancer cells. Tyrosine kinase inhibitors (TKIs) take advantage of unique oncogenes that are activated in certain types of cancer, and also target common mechanisms of growth, invasion, metastasis, and angiogenesis. However, many kinase inhibitors for cancer therapy are somewhat nonselective, and most have additional mechanisms of action at the cellular level, which are not completely understood. The use of these agents has increased our knowledge of important side effects, of which the practicing clinician must be aware. Recently, proposed endocrine-related side effects of these agents include alterations in thyroid function, bone metabolism, linear growth, gonadal function, fetal development, and glucose metabolism, and adrenal function. This review summarizes the most recent data on the endocrine side effects of TKIs.

Assessing the risk to health care staff from long-term exposure to anticancer drugs--the case of monoclonal antibodies

Today the occupational health and safety risk involved when handling most anticancer drugs is well recognized and, as a result of regulatory requirements, safety measures have been established. There is little knowledge about the occupational hazard posed by handling monoclonal antibodies assigned to ATC Class L01XC. The aim of our study was to evaluate the occupational risk of monoclonal antibodies. Using the information obtained in a systematic review of the literature, the potentially dangerous properties of the active drug substances were assessed using a specially devised algorithm. As a result, all monoclonal antibodies in question were categorized as substances with developmental toxicity. In addition, gemtuzumab ozogamicin was categorized as mutagenic. In view of the high molecular weights and the proteinogenic nature of monoclonal antibodies, the route of exposure for health care staff is limited to inhalation, unless there is an accident. Employers should implement the necessary administrative and engineering controls. Employees should adhere to the standards in order to avoid occupational exposure. The hazard assessment algorithm devised and the evaluation procedure may also be used for other drugs considered to be dangerous.