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Allais BS, Fay CJ, Kim DY, Semenov YR, LeBoeuf NR. Cutaneous immune-related adverse events from immune checkpoint inhibitor therapy: Moving beyond "maculopapular rash". Immunol Rev 2023; 318:22-36. [PMID: 37583051 DOI: 10.1111/imr.13257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/27/2023] [Indexed: 08/17/2023]
Abstract
Uncoupling toxicity from therapeutic effect lies at the foundation of the current state of the field of cutaneous immune-related adverse events to immune checkpoint inhibitor therapy. This will be achieved through understanding the drivers of toxicity, tumor response, and resistance via large, well-powered population-level studies, institutional cohort data, and cellular-level data. Increasing diagnostic specificity through the application of consensus disease definitions has the power to improve clinical care and each approach to research. Cutaneous immune-related adverse events are associated with increased survival, and their treatment must invoke the maintenance of a delicate balance between immunosuppression, anti-tumor effect of immune checkpoint inhibitor therapy, and quality of life. The multidisciplinary care of cancer patients with adverse events is critical to optimizing clinical and translational research outcomes and, as such, dermatologists are vital to moving the study of cutaneous adverse events forward.
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Affiliation(s)
- Blair S Allais
- Inova Schar Cancer Institute, Melanoma and Skin Cancer Center, Fairfax, Virginia, USA
| | - Christopher J Fay
- The Center for Cutaneous Oncology, Department of Dermatology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel Y Kim
- Harvard-MIT Health Sciences and Technology Program, Harvard Medical School, Boston, Massachusetts, USA
| | - Yevgeniy R Semenov
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nicole R LeBoeuf
- The Center for Cutaneous Oncology, Department of Dermatology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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2
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Wang J, Hu X, Jiang W, Zhou W, Tang M, Wu C, Liu W, Zuo X. Analysis of the clinical characteristics of pembrolizumab-induced bullous pemphigoid. Front Oncol 2023; 13:1095694. [PMID: 36937423 PMCID: PMC10022695 DOI: 10.3389/fonc.2023.1095694] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 02/16/2023] [Indexed: 03/06/2023] Open
Abstract
Background Pembrolizumab, a programmed cell death protein 1 checkpoint inhibitor, is a novel drug used to treat a variety of advanced malignancies. However, it can also result in many immune-related adverse events, with cutaneous toxicities being the most frequent. Regarding pembrolizumab-induced skin adverse reactions, bullous pemphigoid (BP) has the worst effects on quality of life. Recently, there have been more and more reports of BP incidents resulting from pembrolizumab therapy in patients with cancer. This study aimed to define the clinical characteristics, diagnosis and management of pembrolizumab-induced BP and identify potential differences between classical BP and pembrolizumab-induced BP. Methods Case reports, case series, and case analyses of pembrolizumab-induced BP up to 10 December 2022 were collected for retrospective analysis. Results Our study included 47 patients (33 males and 14 females) from 40 studies. The median age was 72 years (range 42-86 years). The median time to cutaneous toxicity was 4 months (range 0.7-28 months), and the median time to bullae formation was 7.35 months (range 0.7-32 months). The most common clinical features were tense bullae and blisters (85.11%), pruritus (72.34%), and erythema (63.83%) on the limbs and trunk. In 20 of the 22 cases tested, the serum anti-BP180 autoantibodies were positive. However, in 10 cases (91.90%, 10/11) the circulating autoantibodies of anti-BP230 were negative. 40 patients had skin biopsies and the skin biopsy revealed subepidermal bullae or blister eosinophil infiltration in 75.00% of patients with pembrolizumab-induced BP, 10.00% of patients with lymphocyte infiltration and 20.00% of patients with neutrophil infiltration. There were 20 patients (50%) with eosinophilic infiltration around the superficial dermis vessels, 8 patients (20.00%) with lymphocyte infiltration around the superficial dermis vessels, and 4 patients (10.00%) with neutrophil infiltration around the superficial dermis vessels. Direct immunofluorescence detected linear immunoglobulin G (IgG) IgG and/or complement C3 along the dermo-epidermal junction in 36 patients (94.74%) with BP. IgG positivity was detected by indirect immunofluorescence in 81.82% of patients with BP. All patients were in complete remission (95.65%,44/46) or partial remission (4.35%, 2/46) of BP, whereas 9/46 patients had a relapse or refractory. The majority of patients achieved BP remission after discontinuation of pembrolizumab with a combination of topically and systemically administered steroid treatments, or other medications. The median duration of BP remission was 2 months (range 0.3-15 months). Conclusion A thorough diagnosis of pembrolizumab-induced BP should be made using clinical signs, biochemical markers, histopathological and immunopathological tests. Pembrolizumab-induced BP had similar clinical characteristics to classic BP. Temporary or permanent discontinuation of pembrolizumab therapy may be required in patients with perbolizumab-induced BP depending on the severity of BP and the response to medication. Pembrolizumab-induced BP may be effectively treated using topical and systemic steroid treatments in combination with other medications (e.g., doxycycline, niacinamide, dapsone, rituximab, intravenous immunoglobulins, dupilumab, cyclophosphamide, methotrexate, mycophenolate mofetil, and infliximab). Clinicians should provide better management to patients with BP receiving pembrolizumab to prevent progression and ensure continuous cancer treatment.
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Affiliation(s)
- Jianglin Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xin Hu
- Department of Pharmacy, Taojiang County People’s Hospital, Yiyang, China
| | - Wei Jiang
- Department of Pharmacy, Nanxian Hospital of Traditional Chinese Medicine, Yiyang, China
| | - Wenjie Zhou
- Department of Pharmacy, Yongzhou Third People’s Hospital, Yongzhou, China
| | - Mengjie Tang
- Department of Pathology, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Cuifang Wu
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Wei Liu
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Wei Liu,
| | - Xiaocong Zuo
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
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3
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Golle L, Michl C, Kreft B. [Bullous drug reaction after pembrolizumab administration: two case reports]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2022; 73:959-964. [PMID: 35925211 PMCID: PMC9700574 DOI: 10.1007/s00105-022-05018-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/18/2022] [Indexed: 06/15/2023]
Abstract
Severe, blistering, adverse drug reactions involving the skin include Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Allopurinol, anticonvulsants, sulphonamide antibiotics and non-steroidal anti-inflammatory drugs in the oxicam class have been repeatedly described as triggers. Increasingly, immunotherapies are also coming into focus as triggers of severe skin reactions. Two patients with bullous skin symptoms after administration of the checkpoint inhibitor pembrolizumab are presented. As the clinical picture does not always allow an unequivocal classification, a histological assessment is often indispensable.
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Affiliation(s)
- L Golle
- Universitätsklinik und Poliklinik für Dermatologie und Venerologie, Universitätsklinikum Halle (Saale), Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland.
| | - C Michl
- Universitätsklinik und Poliklinik für Dermatologie und Venerologie, Universitätsklinikum Halle (Saale), Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland
| | - B Kreft
- Universitätsklinik und Poliklinik für Dermatologie und Venerologie, Universitätsklinikum Halle (Saale), Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland
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4
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He J, Duan X, Liu T, Yang H, Jiang J, Mu Y. A Case of Systemic Severe Bullous Pemphigoid Caused by Long-Term Sintilimab Treatment for Renal Cell Carcinoma. Clin Cosmet Investig Dermatol 2022; 15:1611-1614. [PMID: 35975195 PMCID: PMC9375974 DOI: 10.2147/ccid.s374449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/04/2022] [Indexed: 11/23/2022]
Abstract
Immune-related adverse events have been reported in relation to programmed cell death protein-1 (PD-1). However, there are few reports on PD-1 inhibitor-induced bullous pemphigoid. We report the case of a patient who developed bullous pemphigoid following long-term administration of sintilimab for renal cell carcinoma. He developed scattered erythema, blisters, and generalized pruritus for 1 week before admission. Histopathology showed subepidermal blisters and direct immunofluorescence showed linear deposition of immunoglobulin G and complement 3 on the basement membrane; the level of BP180 was 146.93U/mL. A regimen containing methylprednisolone, minocycline, and niacinamide was administered and the patient was discharged following resolution of symptoms.
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Affiliation(s)
- Jia He
- Department of Dermatology, Affiliated Hospital of North Sichuan Medical College, Nanchong, People's Republic of China
| | - Xi Duan
- Department of Dermatology, Affiliated Hospital of North Sichuan Medical College, Nanchong, People's Republic of China
| | - Ting Liu
- Department of Dermatology, Affiliated Hospital of North Sichuan Medical College, Nanchong, People's Republic of China
| | - Hao Yang
- Department of Dermatology, Affiliated Hospital of North Sichuan Medical College, Nanchong, People's Republic of China
| | - Jingjing Jiang
- Department of Dermatology, Affiliated Hospital of North Sichuan Medical College, Nanchong, People's Republic of China
| | - Yunzhu Mu
- Department of Dermatology, Affiliated Hospital of North Sichuan Medical College, Nanchong, People's Republic of China
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Poto R, Troiani T, Criscuolo G, Marone G, Ciardiello F, Tocchetti CG, Varricchi G. Holistic Approach to Immune Checkpoint Inhibitor-Related Adverse Events. Front Immunol 2022; 13:804597. [PMID: 35432346 PMCID: PMC9005797 DOI: 10.3389/fimmu.2022.804597] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/07/2022] [Indexed: 12/12/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) block inhibitory molecules, such as cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), programmed cell death protein 1 (PD-1), or its ligand, programmed cell death protein ligand 1 (PD-L1) and enhance antitumor T-cell activity. ICIs provide clinical benefits in a percentage of patients with advanced cancers, but they are usually associated with a remarkable spectrum of immune-related adverse events (irAEs) (e.g., rash, colitis, hepatitis, pneumonitis, endocrine, cardiac and musculoskeletal dysfunctions). Particularly patients on combination therapy (e.g., anti-CTLA-4 plus anti-PD-1/PD-L1) experience some form of irAEs. Different mechanisms have been postulated to explain these adverse events. Host factors such as genotype, gut microbiome and pre-existing autoimmune disorders may affect the risk of adverse events. Fatal ICI-related irAEs are due to myocarditis, colitis or pneumonitis. irAEs usually occur within the first months after ICI initiation but can develop as early as after the first dose to years after ICI initiation. Most irAEs resolve pharmacologically, but some appear to be persistent. Glucocorticoids represent the mainstay of management of irAEs, but other immunosuppressive drugs can be used to mitigate refractory irAEs. In the absence of specific trials, several guidelines, based on data from retrospective studies and expert consensus, have been published to guide the management of ICI-related irAEs.
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Affiliation(s)
- Remo Poto
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Teresa Troiani
- Medical Oncology, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Gjada Criscuolo
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | | | - Fortunato Ciardiello
- Medical Oncology, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Gilda Varricchi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,World Allergy Organization (WAO) Center of Excellence, Naples, Italy.,Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy
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6
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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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7
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Ho RS. Ongoing Concerns Regarding Finasteride for the Treatment of Male-Pattern Androgenetic Alopecia. JAMA Dermatol 2021; 157:25-26. [PMID: 33175098 DOI: 10.1001/jamadermatol.2020.3384] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Roger S Ho
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
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8
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Inoue G, Utsumi T, Yoshizawa A. Uncommon esophagitis associated with nivolumab and ipilimumab therapy. Dig Endosc 2021; 33:467-468. [PMID: 33251627 DOI: 10.1111/den.13902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Genki Inoue
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takahiro Utsumi
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akihiko Yoshizawa
- Department of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
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9
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Clawson RC, Tabata MM, Chen ST. Pemphigus vulgaris flare in a patient treated with nivolumab. Dermatol Ther 2021; 34:e14871. [PMID: 33571394 DOI: 10.1111/dth.14871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/22/2021] [Accepted: 02/06/2021] [Indexed: 02/01/2023]
Affiliation(s)
| | - Mika M Tabata
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Steven T Chen
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
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10
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Wang E, Kraehenbuehl L, Ketosugbo K, Kern JA, Lacouture ME, Leung DYM. Immune-related cutaneous adverse events due to checkpoint inhibitors. Ann Allergy Asthma Immunol 2021; 126:613-622. [PMID: 33609771 DOI: 10.1016/j.anai.2021.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/13/2021] [Accepted: 02/10/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To familiarize the reader with the most common cutaneous adverse events with immune checkpoint inhibitors (CPIs) and their grading and treatment. DATA SOURCES Recent research articles, relevant review articles, and case series/reports in English from the PubMed database mostly, from 2010 onward. STUDY SELECTIONS Most data are from retrospective studies and case series. Older studies regarding the mechanism were included if they were of particular importance. RESULTS An understanding of this review should enable the reader to identify specific skin disorders in patients receiving immune CPIs, grade the adverse event, and be able to treat or refer the patient as needed. CONCLUSION Allergists/immunologists need to be familiar with these immune-related cutaneous adverse events because their incidence will increase with the ever-expanding use of CPIs and, in particular, because patients will certainly continue to be referred suspecting drug allergies.
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Affiliation(s)
- Evelyn Wang
- Department of Pediatrics, National Jewish Health, Denver, Colorado
| | - Lukas Kraehenbuehl
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Swim Across America/Ludwig Collaborative Laboratory, Immunology Program, Parker Institute for Cancer Immunotherapy, Memorial Sloan Kettering Cancer Center, New York, New York; Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kwami Ketosugbo
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jeffrey A Kern
- Cancer Center, Division of Oncology, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Mario E Lacouture
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Dermatology, Weill Cornell Medical College, New York, New York
| | - Donald Y M Leung
- Department of Pediatrics, National Jewish Health, Denver, Colorado.
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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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Pujalte-Martin M, Rocher F, Cardot-Leccia N, Giacchero D, Borchiellini D. Immune checkpoint inhibitor-induced bullous pemphigoid: Towards a new class of drug-drug interaction? Eur J Cancer 2020; 138:122-124. [PMID: 32877796 DOI: 10.1016/j.ejca.2020.07.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/22/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Marc Pujalte-Martin
- Department of Medical Oncology, Centre Antoine Lacassagne, Université Côte d'Azur, Nice, France.
| | - Fanny Rocher
- Regional Center of PharmacoVigilance, CHU Nice, Université Côte d'Azur, France
| | | | - Damien Giacchero
- Dermatology Unit, Centre Antoine Lacassagne, Université Côte d'Azur, Nice, France
| | - Delphine Borchiellini
- Department of Medical Oncology, Centre Antoine Lacassagne, Université Côte d'Azur, Nice, France
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13
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He C, Qu T. Immune checkpoint inhibitor-related cutaneous adverse events. Asia Pac J Clin Oncol 2020; 16:e149-e153. [PMID: 32786166 DOI: 10.1111/ajco.13364] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 04/20/2020] [Indexed: 12/17/2022]
Abstract
Cutaneous toxicities are the most prevalent immune-related adverse events. Various reactions have been reported. In this review, we summarized the clinicopathologic manifestations, treatment strategies, relevance to tumor outcomes, and rechallenge considerations of cutaneous immune-related adverse events.
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Affiliation(s)
- Chunxia He
- Department of Dermatology, National Clinical Research Center for Skin and Immune Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Tao Qu
- Department of Dermatology, National Clinical Research Center for Skin and Immune Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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14
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Lessons to be Learnt from Real-World Studies on Immune-Related Adverse Events with Checkpoint Inhibitors: A Clinical Perspective from Pharmacovigilance. Target Oncol 2020; 15:449-466. [PMID: 32725437 PMCID: PMC7434791 DOI: 10.1007/s11523-020-00738-6] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The advent of immune checkpoint inhibitors (ICIs) caused a paradigm shift both in drug development and clinical practice; however, by virtue of their mechanism of action, the excessively activated immune system results in a multitude of off-target toxicities, the so-called immune-related adverse events (irAEs), requiring new skills for timely diagnosis and a multidisciplinary approach to successfully manage the patients. In the recent past, a plethora of large-scale pharmacovigilance analyses have characterized various irAEs in terms of spectrum and clinical features in the real world. This review aims to summarize and critically appraise the current landscape of pharmacovigilance studies, thus deriving take-home messages for oncologists. A brief primer to study design, conduction, and data interpretation is also offered. As of February 2020, 30 real-world postmarketing studies have characterized multiple irAEs through international spontaneous reporting systems, namely WHO Vigibase and the US FDA Adverse Event Reporting System. The majority of studies investigated a single irAE and provided new epidemiological evidence about class-specific patterns of irAEs (i.e. anti-cytotoxic T-lymphocyte antigen 4 [CTLA-4] versus anti-programmed cell death 1 [PD-1] receptor, and its ligand [PD-L1]), kinetics of appearance, co-occurrences (overlap) among irAEs, and fatality rate. Oncologists should be aware of both strengths and limitations of these pharmacovigilance analyses, especially in terms of data interpretation. Optimal management (including rechallenge), predictivity of irAEs (as potential biomarkers of effectiveness), and comparative safety of ICIs (also in terms of combination regimens) represent key research priorities for next-generation real-world studies.
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15
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Abstract
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that target inhibitory molecules, such as cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), programmed cell death protein 1 (PD-1), or its ligand, programmed cell death protein ligand 1 (PD-L1), and lead to immune activation in the tumor micro-environment. ICIs can induce durable treatment responses in patients with advanced cancers, but they are commonly associated with immune related adverse events (irAEs) such as rash, colitis, hepatitis, pneumonitis, and endocrine and musculoskeletal disorders. Almost all patients experience some form of irAE, but high grade irAEs occur in approximately half of those on combination therapy (eg, anti-CTLA-4 plus anti-PD-1), and up to one quarter receiving ICI monotherapy. Fatal irAEs occur in approximately 1.2% of patients on CTLA-4 blockade and 0.4% of patients receiving PD-1 or PD-L1 blockade, and case fatality rates are highest for myocarditis and myositis. IrAEs typically occur in the first three months after ICI initiation, but can occur as early as one day after the first dose to years after ICI initiation. The mainstay of treatment is with corticosteroids, but tumor necrosis factor inhibitors are commonly used for refractory irAEs. Although ICIs are generally discontinued when high grade irAEs occur, ICI discontinuation alone is rarely adequate to resolve irAEs. Consensus guidelines have been published to help guide management, but will likely be modified as our understanding of irAEs grows.
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Affiliation(s)
- Karmela K Chan
- Weill Cornell Medicine, Hospital for Special Surgery, New York, USA
| | - Anne R Bass
- Weill Cornell Medicine, Hospital for Special Surgery, New York, USA
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16
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Aggarwal P. Pyoderma gangrenosum adverse event with Rituximab use: A postmarketing pharmacovigilance analysis. Dermatol Ther 2020; 33:e13221. [PMID: 31925868 DOI: 10.1111/dth.13221] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 12/29/2019] [Indexed: 12/11/2022]
Abstract
Rituximab is a monoclonal antibody that is used for the treatment of certain malignancies and autoimmune conditions. Pyoderma gangrenosum is a rare painful ulcer that can be fatal in some cases and can also reoccur after treatment. The objective of this paper was to analyze whether a statistically significant signal exists between Rituximab and pyoderma gangrenosum in the Food and Drug Administration Adverse Event Reporting System (FAERS). A disproportionality analysis was carried out on cases from January 1, 2004 to March 31, 2019 in the FAERS. Frequentist methods of relative reporting ratio, reporting odds ratio (ROR), and proportional reporting ratio (PRR) and the Bayesian-based IC025 metric were used in order to assess the adverse event signal. Thirty-two cases were found in FAERS in which the drug Rituximab was administered and pyoderma gangrenosum was reported as an adverse event. The lower 95% CI of the information component was 0.97, the lower 95% CI of ROR was 2.18, the PRR was 3.09 and Chi-squared was 42.16, which indicates a statistically significant signal. The signal is supported by six case reports in the literature that describe a total of 14 patients who developed pyoderma gangrenosum after Rituximab administration. When administering Rituximab, clinicians should monitor for the occurrence of symptoms representing pyoderma gangrenosum.
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Yatim A, Bohelay G, Grootenboer-Mignot S, Prost-Squarcioni C, Alexandre M, Le Roux-Villet C, Martin A, Maubec E, Caux F. Paraneoplastic Pemphigus Revealed by Anti-programmed Death-1 Pembrolizumab Therapy for Cutaneous Squamous Cell Carcinoma Complicating Hidradenitis Suppurativa. Front Med (Lausanne) 2019; 6:249. [PMID: 31750309 PMCID: PMC6848154 DOI: 10.3389/fmed.2019.00249] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/16/2019] [Indexed: 11/17/2022] Open
Abstract
A 64-year-old patient developed a widespread autoimmune mucocutaneous blistering disease 3 weeks after the initiation of the anti-programmed death-1 (anti-PD-1) pembrolizumab therapy administered for a locally advanced cutaneous squamous cell carcinoma (SCC) of the buttocks arising from hidradenitis suppurativa. A diagnosis of paraneoplastic pemphigus (PNP) was made based on the presence of a suprabasal acantholysis associated with intercellular deposits of immunoglobulin G and C3 on basement membrane zone. Analysis of the patient's sera was positive on monkey bladder and detected circulating antibodies against desmoglein 3 and desmoplakin I prior to the initiation of pembrolizumab. At that time, the patient had few localized blisters limited to the peri-tumoral skin of the buttocks with acantholysis but without in vivo immune deposits. Pembrolizumab therapy was discontinued and a complete remission of PNP was obtained using oral steroids. Reintroduction of pembrolizumab resulted in flare of PNP. Given the close temporal relation between pembrolizumab initiation and the subsequent clinical expression of a widespread PNP, the patient was diagnosed with pre-existing subclinical PNP exacerbated by PD-1 inhibitor. The extreme rarity of PNP in the setting of cutaneous SCC and the effects of challenge, dechallenge, and rechallenge of pembrolizumab argue in favor of a checkpoint inhibitor related adverse effect. Our case is the first PNP associated with anti-PD-1 therapy and serological follow-up suggest that one infusion of pembrolizumab is sufficient to allow clinical expression of underlying pemphigus auto-immunity.
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Affiliation(s)
- Ahmad Yatim
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases MALIBUL, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France
| | - Gérôme Bohelay
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases MALIBUL, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France
| | - Sabine Grootenboer-Mignot
- Laboratory of Immunology and Referral Center for Autoimmune Bullous Diseases MALIBUL, Bichat Hospital, AP-HP, Paris, France
| | - Catherine Prost-Squarcioni
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases MALIBUL, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France.,Department of Pathology, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France
| | - Marina Alexandre
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases MALIBUL, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France
| | - Christelle Le Roux-Villet
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases MALIBUL, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France
| | - Antoine Martin
- Department of Pathology, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France
| | - Eve Maubec
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases MALIBUL, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France
| | - Frédéric Caux
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases MALIBUL, Avicenne Hospital, AP-HP, University Paris 13, Bobigny, France
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