Dose-intensified weekly paclitaxel induces multiple nail disorders

Dose-Finding Study of Weekly Docetaxel plus Estramustine in Patients with Hormone-Refractory Metastatic Prostate Cancer

Objective

The aim of this phase I study was to find the maximum tolerated dose of weekly docetaxel in association with estramustine in hormone-refractory prostate cancer.

Methods

Eleven patients with hormone-refractory prostate cancer were treated with escalating weekly doses of docetaxel (level I, 3 patients, 30 mg/m2; level II, 3 patients, 35 mg/m2, level III, 3 patients, 40 mg/m2; level IV, 2 patients, 45 mg/m2) associated with fixed dosage of estramuscine (840 mg/day).

Results

In level I, there was only one episode of grade 3 neutropenia; grade 1 nausea and vomiting were registered in 1 patient; in 1 patient mild edema of the lower limbs was noted. In level II, grade 2 stomatitis and grade 1 sensory symptoms occurred in 1 patient, and grade 1 edema in 1 case. In level III, grade 2 edema was noted in 2 patients, damage to nails in 1 patient, asthenia in 1 patient, grade 1 neuropathy in 2 patients, and grade 1 nausea in 1 patient. In level IV, grade 2 edema was present in 1 patient, grade 3 edema in 1 patient, changes with fall of nails and grade 2 erythema of face in 2 patients, asthenia in 2 patients, grade 1 neuropathy in both patients. Nine patients had a more than a 50% decrease in PSA after 2 cycles of therapy.

Conclusions

The results of the study suggest a good tolerability of weekly 35 mg/m2 docetaxel in hormone-refractory prostate cancer in association with estramustine.

Nail Toxicity Induced by Cancer Chemotherapy

Purpose. To provide a comprehensive literature review of chemotherapy-induced nail toxicity, including clinical presentation, implicated drugs and approaches for prevention and management.

Data sources. A search of MEDLINE and EMBASE (1966—2008) databases was conducted using the terms (and variations of the terms) antineoplastic agents, nails, nail toxicity, onycholysis, and paronychia. Bibliographies from selected articles were reviewed for appropriate references.

Data extraction. The retrieved literature was reviewed to include all articles relevant to the clinical presentation, diagnosis, incidence, prevention, and treatment of chemotherapy-induced nail toxicity.

Data synthesis. Nail toxicity is a relatively uncommon adverse effect linked to a number of chemotherapeutic agents. Clinical presentation varies, depending on which nail structure is affected and the severity of the insult. Nail changes may involve all or some nails. Toxicity may be asymptomatic and limited to cosmetic concerns, however, more severe effects, involving pain and discomfort can occur. Taxanes and anthracyclines are the antineoplastic drug groups most commonly implicated. It is suggested that the administration schedule may influence the incidence of nail abnormalities, for example reported cases linked to the weekly administration of paclitaxel.

Before instituting chemotherapy, patients should be educated regarding potential nail toxicities and strategies for prevention implemented. Management includes appropriate nail cutting, avoiding potential irritants, topical, or oral antimicrobials, and possibly cessation or dose reduction of the offending agent. Cryotherapy, through the application of frozen gloves or socks, has been beneficial in reducing docetaxel-induced nail toxicity and may be effective for other drugs. J Oncol Pharm Practice (2009) 15: 143—155.

Acute felon as a complication of systemic paclitaxel therapy: case report and review of the literature

Breast cancer now affects 1 in 8 American women and the taxane agent paclitaxel (Taxol Bristol-Myers Squibb) is a major tool in the treatment of many such patients. Hand surgeons are therefore likely to encounter upper extremity complications related to the use of taxane therapy. We present an unusual case of a felon developing in a breast cancer patient on paclitaxel therapy with no antecedent history of trauma. Whereas onycholysis and subungual hemorrhage are reported complications of taxane therapy (Fig. 1), an acute felon with or without associated paronychia is an unusual and more aggressive manifestation of this drug-related nail dystrophy.

Onycholysis and subungual haemorrhages secondary to systemic chemotherapy (paclitaxel)

Paclitaxel is a chemotherapic agent of the taxane family used in treatment of malignant solid tumory. We report here the case of a 40-year old woman referred to our clinic for nail changes involving all 20 digits and developed after 5 months of paclitaxel intake, due to a breast carcinoma. Clinical examination revealed red-brown discoloration of the nails associated with hematomas and onycholysis. The nail changes were very painful and the patient complained of discharge of bad-smelling yellow brown opaque fluid from underneath the nail plate. Hemorrhagic onycholysis and subungual abscesses are a possible side effect of taxane treatment that should be early recognized to prevent serious complications.

Taxane-induced nail changes: incidence, clinical presentation and outcome

The clinical characteristics of nail changes in seven patients receiving taxane-containing chemotherapy are described. They include nail pigmentation, subungual hematoma, Beau's lines and onycholysis and subungual suppuration. The incidence of such changes (ranging from 0% to 44%) is reviewed from a Medline search of the literature.

Docetaxel-induced nail dystrophy

A 73-year-old man with metastatic prostate cancer treated with weekly docetaxel chemotherapy for 5 months developed an acute nail dystrophy restricted to the fingernails. This was characterized by onycholysis, subungual haemorrhage and acute paronychia, progressing to a subungual abscess of the right index finger. Nail bed hyperaemia and haemosiderin-like nail bed discoloration were present. Nail plate avulsion was performed to decompress the acutely painful subungual abscess. The right thumb, middle finger and left index finger demonstrated early, proximal white subungual collections of pus obscuring the lunula (onychophosis). Central nail plate fenestrations with a surgical drill led to exudation of purulent material. Cultures of the subungual abscess material yielded mixed organisms, possibly related to administration of flucloxacillin for 1 week prior to presentation. The patient completed a further two courses of docetaxel without sequelae, and the nail dystrophy appears to be resolving. Docetaxel-induced nail changes are a common adverse effect, occurring in 30-40% of patients. Mild changes do not usually warrant the discontinuation of treatment.