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Oskam JA, Danesh-Meyer HV. Neuro-ophthalmic complications of modern anti-cancer drugs. Graefes Arch Clin Exp Ophthalmol 2024; 262:2269-2281. [PMID: 38345654 PMCID: PMC11222285 DOI: 10.1007/s00417-023-06350-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 12/01/2023] [Accepted: 12/18/2023] [Indexed: 07/04/2024] Open
Abstract
PURPOSE Targeted cancer therapies have been responsible for a dramatic shift in treatment strategies for cancer, and the number of drugs, classes, and indications are continually growing. Neuro-ophthalmic complications of these medications are an uncommon but important subset of adverse events which profoundly impact vision. This review aims to collate studies and reports of known neuro-ophthalmic complications of targeted therapies and describe their management. METHODS The anti-cancer drugs included in the review were any drugs targeting specific molecules involved in the cancer disease process. PubMed, EMBASE, and Web of Science were searched using the generic names of each drug and keywords of neuro-ophthalmic conditions. The prescribing information published by the US Food and Drug Administration (FDA) for each drug was also reviewed. RESULTS Several classes of targeted anti-cancer drugs were found to cause neuro-ophthalmic adverse effects. Immune checkpoint inhibitors are responsible for a raft of immune-related adverse events such as optic neuritis, ischemic optic neuropathy, PRES, and myasthenia gravis. Therapies with anti-VEGF activity can provoke posterior reversible leukoencephalopathy, which commonly presents with visual loss and can be fatal if not treated promptly. Inhibitors of BCR-ABL1, VEGF, ALK, and proteasomes have all been linked to optic nerve disorders which can have debilitating consequences for vision. CONCLUSION The neuro-ophthalmic complications of modern anti-cancer drugs can limit or necessitate the withdrawal of these life-prolonging medications. Ophthalmologists should be alert for neuro-ophthalmic complications in these medications to facilitate prompt diagnosis and treatment and reduce the risk of severe and permanent consequences.
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Affiliation(s)
- Joshua A Oskam
- School of Optometry and Vision Science, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.
- Department of Ophthalmology, Greenlane Clinical Centre, Auckland, Auckland, New Zealand.
| | - Helen V Danesh-Meyer
- Department of Ophthalmology, Greenlane Clinical Centre, Auckland, Auckland, New Zealand
- Department of Ophthalmology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Ouchane K, Bellefkih FZ, Benchakroun N, Bourhafour M, Chekrine T, Bouchbika Z, Jouhadi H, Tawfiq N, Sahraoui S. Reversible posterior leukoencephalopathy syndrome following carboplatin and paclitaxel in cervical cancer: Case report. SAGE Open Med Case Rep 2024; 12:2050313X241257444. [PMID: 38812836 PMCID: PMC11135113 DOI: 10.1177/2050313x241257444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 05/09/2024] [Indexed: 05/31/2024] Open
Abstract
Posterior reversible leukoencephalopathy is a rare radio-clinical entity that has gained increasing recognition over the last two decades. It is associated with various etiologies: arterial hypertension, autoimmune diseases, chemotherapy, and immunosuppressive drugs. Several cases have already been reported following cancer therapy. Posterior reversible leukoencephalopathy is characterized by capital clinical signs (headache, seizures, confusional syndrome, and visual disorders) and radiological abnormalities (cerebral edema predominantly in the posterior regions). We report the case of a 38-year-old female patient diagnosed with posterior reversible leukoencephalopathy after receiving Carboplatin and Paclitaxel chemotherapy for recurrent cervical cancer, which was revealed by a generalized seizure. Brain magnetic resonance imaging showed T2 Flair hyper signals in the parieto-occipital regions. This complication is rare but is probably underdiagnosed due to a lack of awareness and limited hindsight. Rapid diagnosis is essential to prevent acute neurological complications, which can be life-threatening or functionally crippling regardless of neoplasia.
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Affiliation(s)
- Karima Ouchane
- Oncology Department, Mohammed IV Cancer Treatment Center, Ibn Rochd Hospital University, Hassan II University, Casablanca, Morocco
| | - Fatima Zahra Bellefkih
- Radiation Oncology Department, Mohammed IV Cancer Treatment Center, Ibn Rochd Hospital University, Hassan II University, Casablanca, Morocco
| | - Nadia Benchakroun
- Oncology Department, Mohammed IV Cancer Treatment Center, Ibn Rochd Hospital University, Hassan II University, Casablanca, Morocco
- Radiation Oncology Department, Mohammed IV Cancer Treatment Center, Ibn Rochd Hospital University, Hassan II University, Casablanca, Morocco
| | - Mouna Bourhafour
- Oncology Department, Mohammed IV Cancer Treatment Center, Ibn Rochd Hospital University, Hassan II University, Casablanca, Morocco
| | - Tarik Chekrine
- Oncology Department, Mohammed IV Cancer Treatment Center, Ibn Rochd Hospital University, Hassan II University, Casablanca, Morocco
- Radiation Oncology Department, Mohammed IV Cancer Treatment Center, Ibn Rochd Hospital University, Hassan II University, Casablanca, Morocco
| | - Zineb Bouchbika
- Oncology Department, Mohammed IV Cancer Treatment Center, Ibn Rochd Hospital University, Hassan II University, Casablanca, Morocco
- Radiation Oncology Department, Mohammed IV Cancer Treatment Center, Ibn Rochd Hospital University, Hassan II University, Casablanca, Morocco
| | - Hassan Jouhadi
- Oncology Department, Mohammed IV Cancer Treatment Center, Ibn Rochd Hospital University, Hassan II University, Casablanca, Morocco
- Radiation Oncology Department, Mohammed IV Cancer Treatment Center, Ibn Rochd Hospital University, Hassan II University, Casablanca, Morocco
| | - Nezha Tawfiq
- Oncology Department, Mohammed IV Cancer Treatment Center, Ibn Rochd Hospital University, Hassan II University, Casablanca, Morocco
- Radiation Oncology Department, Mohammed IV Cancer Treatment Center, Ibn Rochd Hospital University, Hassan II University, Casablanca, Morocco
| | - Souha Sahraoui
- Oncology Department, Mohammed IV Cancer Treatment Center, Ibn Rochd Hospital University, Hassan II University, Casablanca, Morocco
- Radiation Oncology Department, Mohammed IV Cancer Treatment Center, Ibn Rochd Hospital University, Hassan II University, Casablanca, Morocco
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Lei CL, Gui XL, Wang LY, Guo YJ, Li Y. Analysis of drug-induced posterior reversible encephalopathy syndrome using the food and drug administration adverse drug events reporting system database. Expert Opin Drug Saf 2024; 23:607-616. [PMID: 38478961 DOI: 10.1080/14740338.2024.2327510] [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: 06/26/2023] [Accepted: 01/03/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE In this retrospective pharmacovigilance study, we gathered data on drug-induced posterior reversible encephalopathy syndrome (PRES). Our goal was to identify the primary suspect drugs in PRES by analyzing the Food and Drug Administration Adverse Events Reporting System (FAERS) database. METHODS We identified and analyzed reports of PRES listed in the FAERS database between 2004 and 2021. Using the reporting odds ratio and 95% confidence interval, we evaluated the safety signals for each of the drugs associated with PRES. RESULTS We reviewed 11,077 reports of adverse events corresponding to PRES. The primary suspect drug categories were antineoplastics, immunosuppressants, and glucocorticoids. PRES was 24.77% more likely to occur in females than in males. Drug-induced PRES usually occurs in individuals with cancer, those who have undergone an organ/stem cell transplant, and those with autoimmune conditions. CONCLUSION Our results show that the drugs most commonly suspected to cause PRES were antineoplastics, immunosuppressants, and glucocorticoids. Future studies are needed to illuminate the pathophysiological alterations that underlie PRES. In the meantime, prescribers and patients should be made aware of the potential risks of PRES associated with pharmaceutical therapy, and the summaries of product characteristics for individual drugs should be updated to include this information.
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Affiliation(s)
- Cai-Lu Lei
- Department of Pharmacy, Guangxi Medical University Cancer Hospital, Nanning, China
- School of Pharmaceutical Science, Guangxi Medical University, Nanning, China
| | - Xiao-Long Gui
- Department of Gastrointestinal & Gland Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lin-Yu Wang
- Department of Pharmacy, Guangxi Medical University Cancer Hospital, Nanning, China
| | - You-Jia Guo
- Department of Pharmacy, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Yan Li
- Department of Pharmacy, Guangxi Medical University Cancer Hospital, Nanning, China
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4
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Tang L, Ding C, Li H, Yin G, Zhang H, Liu WS, Ji Y, Li H. A pharmacovigilance study of adverse event profiles and haemorrhagic safety of bevacizumab based on the FAERS database. Expert Opin Drug Saf 2024; 23:213-220. [PMID: 37581403 DOI: 10.1080/14740338.2023.2248876] [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: 03/14/2023] [Revised: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Bevacizumab is used for the treatment of advanced malignant tumors; it acts by inhibiting angiogenesis. This study aimed to examine adverse events (AEs) of bevacizumab, especially hemorrhage, using the Food and Drug Administration Adverse Event Reporting System (FAERS) database. RESEARCH DESIGN AND METHODS The reporting odds ratio (ROR) and proportional reporting ratio (PRR) were used to analyze the AEs of bevacizumab using FAERS registration data from January 2004 to September 2022. Clinical information regarding hemorrhagic signals was further analyzed. RESULTS The number of bevacizumab-associated AE reports was 96,477. Our study found that 892 significant preferred terms (PTs) were spread throughout 25 organ systems. The system organ classes (SOCs) focus on general disorders, administration site conditions, blood and lymphatic system disorders, injury, poisoning, and procedural complications. A total of 2,847 bevacizumab-related hemorrhage cases were reported, and 37 hemorrhagic signals were identified. Hemorrhagic signals were focused on SOC levels in vascular, gastrointestinal, and nervous system disorders. Colorectal, lung, and breast cancers are the three most common malignancies associated with BV-induced hemorrhage. CONCLUSION The AE report from the present study confirms the majority of label information for bevacizumab, while also identifying new AEs. In addition, this was a large descriptive study of bevacizumab-induced hemorrhage.
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Affiliation(s)
- Linlin Tang
- Department of Pharmacy, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, China
| | - Chuanhua Ding
- Department of Pharmacy, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, China
| | - Hongying Li
- Department of Pharmacy, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, China
| | - Guoqiang Yin
- Department of Pharmacy, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, China
| | - Haixia Zhang
- Department of Pharmacy, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, China
| | - Wen Shan Liu
- Department of Pharmacy, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, China
| | - Yinghui Ji
- Department of Pharmacy, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, China
| | - Hui Li
- Department of Pharmacy, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, China
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Isaac MFG, Alkhatib R, Ho CL. MRI characteristics of chemotherapy-related central neurotoxicity: a pictorial review. Insights Imaging 2024; 15:12. [PMID: 38228948 DOI: 10.1186/s13244-023-01602-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/21/2023] [Indexed: 01/18/2024] Open
Abstract
The relentless advancement of chemotherapeutic agents has enhanced survival rates among cancer patients. However, this success comes with an increased prevalence of chemotherapy-induced neurotoxicity, which often mimics the symptoms of metastatic disease or paraneoplastic syndromes and poses a diagnostic challenge for clinicians. Imaging, particularly MRI, plays a pivotal role in unraveling this conundrum.This comprehensive review explores the MRI patterns associated with central neurotoxicities induced by various chemotherapeutic agents. Our objective is to provide radiologists and clinicians with illustrative diagrams that offer a structured approach to diagnosing these conditions. By enhancing the understanding of these distinctive MRI patterns, we aim to facilitate accurate and timely diagnosis, ultimately improving patient care in the context of evolving cancer treatments.Critical relevance statementThis article describes the essential role of MRI in identifying distinct patterns of chemotherapy-induced central neurotoxicity, enabling early diagnosis and improved patient care within the field of clinical radiology.Key points• Chemotherapy-induced neurotoxicity is a growing concern for cancer patients, and MRI is a key tool in diagnosis.• This review highlights distinctive MRI patterns associated with various chemotherapy-induced neurotoxicities.• Understanding these patterns improves patient care, ensuring timely intervention and accurate diagnosis in the complex world of cancer treatment.
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Affiliation(s)
- Mina F G Isaac
- Department of Radiology, Heartland Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Rugaiyah Alkhatib
- Department of Diagnostic Radiology, Sengkang General Hospital, Sengkang Eastway, Sengkang, 110, Singapore
| | - Chi Long Ho
- Department of Diagnostic Radiology, Sengkang General Hospital, Sengkang Eastway, Sengkang, 110, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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6
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Weller M, Le Rhun E, Van den Bent M, Chang SM, Cloughesy TF, Goldbrunner R, Hong YK, Jalali R, Jenkinson MD, Minniti G, Nagane M, Razis E, Roth P, Rudà R, Tabatabai G, Wen PY, Short SC, Preusser M. Diagnosis and management of complications from the treatment of primary central nervous system tumors in adults. Neuro Oncol 2023; 25:1200-1224. [PMID: 36843451 PMCID: PMC10326495 DOI: 10.1093/neuonc/noad038] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Indexed: 02/28/2023] Open
Abstract
Central nervous system (CNS) tumor patients commonly undergo multimodality treatment in the course of their disease. Adverse effects and complications from these interventions have not been systematically studied, but pose significant challenges in clinical practice and impact function and quality of life, especially in the management of long-term brain tumor survivors. Here, the European Association of Neuro-Oncology (EANO) has developed recommendations to prevent, diagnose, and manage adverse effects and complications in the adult primary brain CNS tumor (except lymphomas) patient population with a specific focus on surgery, radiotherapy, and pharmacotherapy. Specifically, we also provide recommendations for dose adaptations, interruptions, and reexposure for pharmacotherapy that may serve as a reference for the management of standard of care in clinical trials. We also summarize which interventions are unnecessary, inactive or contraindicated. This consensus paper should serve as a reference for the conduct of standard therapy within and outside of clinical trials.
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Affiliation(s)
- Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Emilie Le Rhun
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Martin Van den Bent
- The Brain Tumour Center at the Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Susan M Chang
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Timothy F Cloughesy
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Roland Goldbrunner
- Center of Neurosurgery, Department of General Neurosurgery, University of Cologne, Cologne, Germany
| | - Yong-Kil Hong
- Brain Tumor Center, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Rakesh Jalali
- Neuro Oncology Cancer Management Team, Apollo Proton Cancer Centre, Chennai, India
| | - Michael D Jenkinson
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust & University of Liverpool, Liverpool, UK
| | - Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico Le Scotte, Siena, Italy
- IRCCS Neuromed, Pozzilli, IS, Italy
| | - Motoo Nagane
- Department of Neurosurgery, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Evangelia Razis
- Third Department of Medical Oncology, Hygeia Hospital, Marousi, Athens, Greece
| | - Patrick Roth
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Roberta Rudà
- Division of Neuro-Oncology, Department of Neuroscience, City of Health and Science and University of Turin, Turin, Italy
| | - Ghazaleh Tabatabai
- Department of Neurology & Neuro-Oncology, Hertie Institute for Clinical Brain Research, Center for Neurooncology, Comprehensive Cancer Center, German Cancer Consortium (DKTK), Partner site Tübingen, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Patrick Y Wen
- Center for Neuro-oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Susan C Short
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Department of Clinical Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthias Preusser
- Division of Oncology, Department of Medicine 1, Medical University, Vienna, Austria
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7
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Zou X, Zhou P, Lv W, Liu C, Liu J. Posterior reversible encephalopathy syndrome after anlotinib treatment for small cell lung cancer: A case report and literature review. Front Pharmacol 2023; 14:1126235. [PMID: 36814495 PMCID: PMC9939648 DOI: 10.3389/fphar.2023.1126235] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 01/23/2023] [Indexed: 02/08/2023] Open
Abstract
Anlotinib is an oral multi-targeted tyrosine kinase inhibitor as a third-line and subsequent treatment for patients with small cell lung cancer (SCLC) in China. The neurotoxicity is less reported. Posterior reversible encephalopathy syndrome (PRES) is characterized by headaches, seizures, encephalopathy, and visual disturbances, as well as focal reversible vasogenic edema seen on neuroimages. Here, we presented a case of PRES in a small cell lung cancer (SCLC) patient associated with anlotinib. A 37-year-old female patient, who had a history of diabetes, with extensive-stage SCLC received anlotinib after third-line chemotherapy. Ten cycles of anlotinib later, the patient experienced visual disturbance and was diagnosed with PRES based on the typical demyelination of white matter obtained in the brain magnetic resonance. During anlotinib therapy, the patient did not develop anti-VEGF therapy-induced hypertension. Subsequently, the patient stopped anlotinib, but she did not recover from symptoms. We also summarized the characteristics of fifty-four cases of PRES caused by antiangiogenic drugs in the literature. Based on our experience and the literature review, the incidence of PRES induced by antiangiogenic drugs is low, and the symptom can resolve upon stopping the medications. However, some cases still have a poor prognosis and the underlying mechanism requires further investigation. In addition, early detection and treatment of PRES are essential for physicians.
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Affiliation(s)
- Xiaomeng Zou
- Department of Clinical Medical College, Weifang Medical University, Weifang, China,Department of Oncology, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Peng Zhou
- Department of Medical Imaging Center, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Wei Lv
- Department of Cardiology, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Chuanyong Liu
- Department of Oncology, Central Hospital Affiliated to Shandong First Medical University, Jinan, China,*Correspondence: Jie Liu, ; Chuanyong Liuand,
| | - Jie Liu
- Department of Oncology, Central Hospital Affiliated to Shandong First Medical University, Jinan, China,*Correspondence: Jie Liu, ; Chuanyong Liuand,
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8
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John KJ, Pillai DP, Roy RA, Mathew P, Chacko KP, John JK. Central Variant Posterior Reversible Encephalopathy Syndrome in a Pregnant Woman With Eclampsia: A Case Report. Neurohospitalist 2022; 12:682-686. [PMID: 36147753 PMCID: PMC9485688 DOI: 10.1177/19418744221110360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
Posterior Reversible Encephalopathy Syndrome (PRES) is a clinico-radiological diagnosis characterized by acute or subacute neurological symptoms. A 27-year-old woman at 35 weeks of pregnancy, who presented with generalized tonic-clonic seizures had persistently low Glasgow Coma Scale (GCS) score after delivery of the baby. Magnetic Resonance Imaging (MRI) of the brain showed T-2 Fluid Attenuated Inversion Recovery (FLAIR) hyperintensities in the brainstem, bilateral medial cerebellar hemispheres, bilateral medial temporal lobes, bilateral thalami, lentiform and caudate nuclei, and bilateral fronto-parieto-occipital lobes. There was diffusion restriction in bilateral caudate nuclei, left thalamus and right frontal lobe, and microhemorrhages in the left thalamus. These findings were suggestive of central variant PRES. She improved with strict blood pressure control and anti-edema measures. A repeat MRI brain on day 10 showed significant improvement, and she had no residual neurological deficits. The central variant of PRES is a rare entity that has to be considered in a patient presenting with neurological deficits in the setting of uncontrolled blood pressure, eclampsia, immunomodulatory medication use, or renal failure. While most patients with PRES fully recover with timely therapy targeted at reversing the primary cause, some may have residual neurological deficits or rarely, die.
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Affiliation(s)
- Kevin John John
- Department of Critical Care, Believers Church Medical College Hospital, Thiruvalla, India
| | - Deep P Pillai
- Department of Neurology, Believers Church Medical College Hospital, Thiruvalla, India
| | - Rhea Anne Roy
- Department of Neurology, Believers Church Medical College Hospital, Thiruvalla, India
| | - Philip Mathew
- Department of Critical Care, Believers Church Medical College Hospital, Thiruvalla, India
| | - Kuruvilla P Chacko
- Department of Gynecology, Believers Church Medical College Hospital, Thiruvalla, India
| | - John K John
- Department of Neurology, Believers Church Medical College Hospital, Thiruvalla, India
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PRES and RCVS: Two Distinct Entities or a Spectrum of the Same Disease? J Stroke Cerebrovasc Dis 2022; 31:106472. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106472] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 03/14/2022] [Accepted: 03/20/2022] [Indexed: 12/24/2022] Open
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Neurotoxicity of Tumor Immunotherapy: The Emergence of Clinical Attention. JOURNAL OF ONCOLOGY 2022; 2022:4259205. [PMID: 35087588 PMCID: PMC8789457 DOI: 10.1155/2022/4259205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 12/10/2021] [Accepted: 12/15/2021] [Indexed: 02/05/2023]
Abstract
Tumor immunotherapy brings substantial and long-term clinical benefits that can even cure tumors. However, the accumulation of evidence suggests that immunotherapy also induces severe and complex neurologic immune-related adverse events (ir-AEs) and even leads to immunotherapy-related death, which arouses the concern of clinicians. The timely and accurate identification of neurotoxicity helps clinicians detect and treat these complications early, thereby enhancing treatment efficiency and improving the prognosis of patients. At present, the mechanism of neurotoxicity caused by immunotherapy has not been completely elucidated. This paper mainly reviews the clinical features, pathogenesis, and therapeutic strategies of neurologic ir-AEs.
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11
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Lau DK, Mencel J, Chau I. Safety and efficacy review of aflibercept for the treatment of metastatic colorectal cancer. Expert Opin Drug Saf 2022; 21:589-597. [PMID: 34986714 DOI: 10.1080/14740338.2022.2008905] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Anti-angiogenic drugs are an efficacious class of therapy in the treatment of patients with metastatic colorectal cancer (mCRC). Aflibercept, a vascular endothelial growth factor (VEGF) trap which binds the angiogenic factors VEGF-A, VEGF-B, and placental growth factor (PIGF) is approved in combination with FOLFIRI chemotherapy following progression after an oxaliplatin-containing regimen. AREAS COVERED This report provides a review of the practice-changing clinical studies which have established the use of anti-angiogenic therapy as second-line therapy in mCRC including aflibercept with FOLFIRI (5FU, leucovorin, irinotecan). This review also evaluates aflibercept with other chemotherapy regimens as well as efficacy and safety data from real-world studies. EXPERT OPINION Aflibercept in combination with FOLFIRI chemotherapy is an established safe and efficacious regimen for the treatment of mCRC as second-line chemotherapy. Although several toxicities have been described, the majority are either low grade or manageable by drug cessation and supportive therapies. For optimal outcomes, patient selection and close observation of toxicities is essential.
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Affiliation(s)
- David K Lau
- Gastrointestinal and Lymphoma Unit, The Royal Marsden NHS Foundation Trust, London and Surrey, United Kingdom
| | - Justin Mencel
- Gastrointestinal and Lymphoma Unit, The Royal Marsden NHS Foundation Trust, London and Surrey, United Kingdom
| | - Ian Chau
- Gastrointestinal and Lymphoma Unit, The Royal Marsden NHS Foundation Trust, London and Surrey, United Kingdom
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12
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Cardiovascular toxicity of angiogenesis inhibitors and immune checkpoint inhibitors: synergistic anti-tumour effects at the cost of increased cardiovascular risk? Clin Sci (Lond) 2021; 135:1649-1668. [PMID: 34283204 DOI: 10.1042/cs20200300] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 06/26/2021] [Accepted: 06/30/2021] [Indexed: 12/11/2022]
Abstract
In the past two decades, treatment outcomes for a wide range of malignancies have improved remarkably due to the development of novel anti-cancer therapies, including vascular endothelial growth factor inhibitors (VEGFIs) and immune checkpoint inhibitors (ICIs). Despite their unprecedented anti-tumour effects, it is becoming increasingly clear that both types of agents are associated with specific cardiovascular toxicity, including hypertension, congestive heart failure, myocarditis and acceleration of atherosclerosis. Currently, VEGFI and ICI combination therapy is recommended for the treatment of advanced renal cell carcinoma (RCC) and has shown promising treatment efficacy in other tumour types as well. Consequently, VEGFI and ICI combination therapy will most likely become an important therapeutic strategy for various malignancies. However, this combinatory approach is expected to be accompanied by a substantial increase in cardiovascular risk, as both types of agents could act synergistically to induce cardiovascular sequelae. Therefore, a comprehensive baseline assessment and adequate monitoring by specialised cardio-oncology teams is essential in case these agents are used in combination, particularly in high-risk patients. This review summarises the mechanisms of action and treatment indications for currently registered VEGFIs and ICIs, and discusses their main vascular and cardiac toxicity. Subsequently, we provide the biological rationales for the observed promising synergistic anti-tumour effects of combined VEGFI/ICI administration. Lastly, we speculate on the increased risk for cardiovascular toxicity in case these agents are used in combination and its implications and future directions for the clinical situation.
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13
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Hypertension in neonates treated with intravitreal bevacizumab for retinopathy of prematurity. J Perinatol 2021; 41:1426-1431. [PMID: 33686120 DOI: 10.1038/s41372-021-01021-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/28/2021] [Accepted: 02/17/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate if preterm neonates developed systemic hypertension after intravitreal bevacizumab for retinopathy of prematurity. METHODS Patients who received treatment between January 1, 2011 and January 31, 2019 were eligible for inclusion. Patients with pre-existing hypertension, congenital eye disease, or who were discharged within 72 h of treatment were excluded. Charts were reviewed for baseline data, co-morbidities, and the development of systemic hypertension within 4 weeks post treatment. RESULTS After exclusions, 64 patients were analyzed. New-onset systemic hypertension was identified in 44 (69%) infants. There were no statistical differences in the demographic characteristics or presence of co-morbidities between the hypertensive and non-hypertensive groups. Of those who developed hypertension, the majority presented within the first week post treatment (55%). CONCLUSIONS The majority of infants who received intravitreal bevacizumab developed new-onset systemic hypertension after treatment. Further studies may explore hypertension as a potential side effect of bevacizumab in the neonatal population.
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Manzari MT, Shamay Y, Kiguchi H, Rosen N, Scaltriti M, Heller DA. Targeted drug delivery strategies for precision medicines. NATURE REVIEWS. MATERIALS 2021; 6:351-370. [PMID: 34950512 PMCID: PMC8691416 DOI: 10.1038/s41578-020-00269-6] [Citation(s) in RCA: 313] [Impact Index Per Article: 104.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 05/05/2023]
Abstract
Progress in the field of precision medicine has changed the landscape of cancer therapy. Precision medicine is propelled by technologies that enable molecular profiling, genomic analysis, and optimized drug design to tailor treatments for individual patients. Although precision medicines have resulted in some clinical successes, the use of many potential therapeutics has been hindered by pharmacological issues, including toxicities and drug resistance. Drug delivery materials and approaches have now advanced to a point where they can enable the modulation of a drug's pharmacological parameters without compromising the desired effect on molecular targets. Specifically, they can modulate a drug's pharmacokinetics, stability, absorption, and exposure to tumours and healthy tissues, and facilitate the administration of synergistic drug combinations. This Review highlights recent progress in precision therapeutics and drug delivery, and identifies opportunities for strategies to improve the therapeutic index of cancer drugs, and consequently, clinical outcomes.
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Affiliation(s)
- Mandana T. Manzari
- Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- These authors have contributed equally to this work
| | - Yosi Shamay
- Faculty of Biomedical Engineering, Technion-Israel Institute of Technology, Haifa, Israel
- These authors have contributed equally to this work
| | - Hiroto Kiguchi
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- These authors have contributed equally to this work
| | - Neal Rosen
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer, New York, NY, USA
| | - Maurizio Scaltriti
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer, New York, NY, USA
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel A. Heller
- Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
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Abstract
The proliferation of targeted anticancer agents over the last two decades has revolutionized cancer treatment and improved survival in many previously refractory malignancies. However, many agents are associated with characteristic ophthalmic adverse effects. It is important that ophthalmologists recognize and maintain a high index of suspicion for these side effects in patients on targeted therapy. Most ophthalmic adverse effects can be treated with specific ocular therapy without discontinuation of cancer treatment, although it is important to be aware of the life-threatening and vision-threatening circumstances that would require therapy cessation in conjunction with the patient's oncologist. This review aims to summarize the ophthalmic adverse effects of targeted and hormonal anticancer agents and briefly describe their management.
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Abraham P, Longardner K, Chen P, Huisa B, Handwerker J. Case 279: Central-Variant Posterior Reversible Encephalopathy Syndrome. Radiology 2020; 296:239-243. [DOI: 10.1148/radiol.2020181547] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Peter Abraham
- From the School of Medicine (P.A.) and Departments of Neurosciences (K.L., P.C., B.H.) and Radiology (J.H.), University of California San Diego Medical Center, 200 West Arbor Dr, San Diego, CA 92103
| | - Katie Longardner
- From the School of Medicine (P.A.) and Departments of Neurosciences (K.L., P.C., B.H.) and Radiology (J.H.), University of California San Diego Medical Center, 200 West Arbor Dr, San Diego, CA 92103
| | - Patrick Chen
- From the School of Medicine (P.A.) and Departments of Neurosciences (K.L., P.C., B.H.) and Radiology (J.H.), University of California San Diego Medical Center, 200 West Arbor Dr, San Diego, CA 92103
| | - Branko Huisa
- From the School of Medicine (P.A.) and Departments of Neurosciences (K.L., P.C., B.H.) and Radiology (J.H.), University of California San Diego Medical Center, 200 West Arbor Dr, San Diego, CA 92103
| | - Jason Handwerker
- From the School of Medicine (P.A.) and Departments of Neurosciences (K.L., P.C., B.H.) and Radiology (J.H.), University of California San Diego Medical Center, 200 West Arbor Dr, San Diego, CA 92103
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Zappia F, Verzicco I, Simoni R, Ferrari M, Coghi P, Bozzetti F, Cannone V, Volpi R, Cabassi A. Posterior reversible encephalopathy syndrome in an oncological normotensive patient: evidence for a pathogenic role of concomitant low magnesium serum levels and chemotherapy treatment. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:365-372. [PMID: 32420975 PMCID: PMC7569613 DOI: 10.23750/abm.v91i2.8685] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 07/21/2019] [Indexed: 12/12/2022]
Abstract
Background: Posterior reversible encephalopathy (PRES) is a rare syndrome characterized by headache, confusion, seizures, visual changes and white matter edema at radiological imaging. Its pathophysiology is not clarified and different causes, including uncontrolled hypertension, eclampsia, chemotherapy and hypomagnesemia have been suggested. Case report: A woman affected by stage IV breast cancer with lower extremity deep vein thrombosis treated with low-molecular-weight-heparin, currently in therapy with Palbociclib/Fulvestrant (antiCDK4 and 6/estrogen receptor antagonist) but previously treated with several other chemotherapy lines (including VEGF inhibitor bevacizumab), was admitted to our Internal Medicine department because of ascites and abdominal pain. She was treated with diuretics (and paracentesis). Recently (six-month earlier) a pan-encephalic radiotherapy was done because of brain and skull metastasis. Among blood tests, low serum levels of hypomagnesemia were observed. She developed PRES that rapidly progressed to lethargy, unresponsiveness till coma without changes in blood pressure. Magnetic Resonance Imaging study showed bilateral parieto-occipital edema and a thrombosis of left transverse and sigmoid sinuses. Anti-edema therapy, intravenous supplementation of magnesium and decoagulation were started, with complete and rapid recovery (within 18 hours) of clinical and radiologic changes. Conclusions: PRES diagnosis was based on the rapid clinical recovery after antiedema treatment and magnesium supplementation. Low magnesium level related to both diuretic and Fulvestrant/Palbociclib therapies and recent radiotherapy can represent potential mechanisms favouring PRES development. The previous bevacizumab treatment may also be involved as a PRES predisposing factor. The concomitant occurrence of cerebral thrombosis can have precipitated the clinical situation. (www.actabiomedica.it)
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Malik MT, Majeed MF, Zand R. Serotonin Syndrome Presenting as a Posterior Reversible Encephalopathy Syndrome. Case Rep Neurol 2020; 12:63-68. [PMID: 32231545 PMCID: PMC7098365 DOI: 10.1159/000505907] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 01/12/2020] [Indexed: 11/19/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neurological syndrome characterized by an altered level of consciousness, headaches, seizure, and visual changes. PRES has several different etiologies, including malignant hypertension, eclampsia, and certain medications. Here, we describe a 41-year-old woman who presented with altered mental status. She had a preliminary diagnosis of serotonin syndrome as she was on many different serotonin-sparing agents, but her imaging findings were consistent with PRES. After her medications were reviewed and the causative agent was removed, the patient's neurological exam and imaging findings improved, and she returned to her baseline. To our knowledge, this is a unique case of PRES caused by serotonin syndrome secondary to venlafaxine usage.
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Affiliation(s)
| | | | - Ramin Zand
- Geisinger Health System, Danville, Pennsylvania, USA
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19
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Complications and Toxicities Associated with Cancer Therapies in the Intensive Care Unit. ONCOLOGIC CRITICAL CARE 2020. [PMCID: PMC7121489 DOI: 10.1007/978-3-319-74588-6_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Advances in the management of hematologic malignancies and solid tumors have given rise to diverse modalities to treat cancer other than cytotoxic chemotherapy, including targeted therapies, immunotherapies, and cellular therapies. Currently, there are over 175 FDA-approved antineoplastic agents in the United States, many with a diverse and profound toxicity profile. Complications of antineoplastic therapy may result in the need for intensive care unit (ICU) admission to provide acute symptom management. Accordingly, ICU providers caring for cancer patients should have a working knowledge of the toxicities and complications associated with antineoplastic therapy.
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A Rare Case of Cyclophosphamide-Induced Posterior Reversible Encephalopathy Syndrome in a Patient with Anti-GBM Vasculitis, and Review of Current Literature. Case Rep Neurol Med 2019; 2019:2418597. [PMID: 31662928 PMCID: PMC6791264 DOI: 10.1155/2019/2418597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/03/2019] [Accepted: 07/21/2019] [Indexed: 11/20/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinical syndrome of headache, altered mental status, and seizures with reversible mainly posterior leukoencephalopathy on neuroimaging. Precipitating factors for PRES are multifactorial and include autoregulatory failure due to changes in blood pressure, metabolic derangements, and cytotoxic medications. We report the second case of cyclophosphamide-induced PRES in a patient with anti-glomerular basement membrane (Anti-GBM) positive vasculitis. In the acute setting, PRES can be challenging to distinguish from cerebral venous sinus thrombosis or cerebral vasculitis based on clinical presentation. Neuroimaging with magnetic resonance imaging (MRI) of the brain along with a vessel imaging, can help reach the diagnosis.
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Chanal E, Bouleftour W, Rivoirard R, Bosaki C, Forges F, Jacquin JP, Fournel P, Mery B, Saban-Roche L. [Posterior Reversible Encephalopathy Syndrome (PRES): About 4 cases]. Presse Med 2019; 48:1026-1031. [PMID: 31653541 DOI: 10.1016/j.lpm.2019.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 08/01/2019] [Accepted: 08/14/2019] [Indexed: 10/25/2022] Open
Affiliation(s)
- Edouard Chanal
- Institut de cancérologie Lucien-Neuwirth, département d'oncologie médicale, 108, bis avenue Albert-Raimond, 42271 Saint Priest en Jarez, France
| | - Wafa Bouleftour
- Institut de cancérologie Lucien-Neuwirth, département d'oncologie médicale, 108, bis avenue Albert-Raimond, 42271 Saint Priest en Jarez, France.
| | - Romain Rivoirard
- Institut de cancérologie Lucien-Neuwirth, département d'oncologie médicale, 108, bis avenue Albert-Raimond, 42271 Saint Priest en Jarez, France
| | - Claire Bosaki
- Institut de cancérologie Lucien-Neuwirth, département d'oncologie médicale, 108, bis avenue Albert-Raimond, 42271 Saint Priest en Jarez, France
| | - Fabien Forges
- Institut de cancérologie Lucien-Neuwirth, département de pharmacie, 42271 Saint-Priest-en-Jarez, France
| | - Jean-Philippe Jacquin
- Institut de cancérologie Lucien-Neuwirth, département d'oncologie médicale, 108, bis avenue Albert-Raimond, 42271 Saint Priest en Jarez, France
| | - Pierre Fournel
- Institut de cancérologie Lucien-Neuwirth, département d'oncologie médicale, 108, bis avenue Albert-Raimond, 42271 Saint Priest en Jarez, France
| | - Benoite Mery
- Institut de cancérologie Lucien-Neuwirth, département d'oncologie médicale, 108, bis avenue Albert-Raimond, 42271 Saint Priest en Jarez, France
| | - Léa Saban-Roche
- Institut de cancérologie Lucien-Neuwirth, département d'oncologie médicale, 108, bis avenue Albert-Raimond, 42271 Saint Priest en Jarez, France
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22
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Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome: Distinct Clinical Entities with Overlapping Pathophysiology. Radiol Clin North Am 2019; 57:1133-1146. [PMID: 31582040 DOI: 10.1016/j.rcl.2019.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The clinical and radiologic manifestations of posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome are reviewed. The relationship between these entities is discussed. A hypothesis of a common underlying pathophysiology is proposed and substantiated based on the current medical literature.
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Cacho-Díaz B, Lorenzana-Mendoza NA, Salmerón-Moreno K, Reyes-Soto G, Castillo-Rangel C, Corona-Cedillo R, Escobar-Ceballos S, de la Garza-Salazar JG. Chemotherapy-induced posterior reversible encephalopathy syndrome: Three case reports. Medicine (Baltimore) 2019; 98:e15691. [PMID: 31083272 PMCID: PMC6531111 DOI: 10.1097/md.0000000000015691] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
RATIONALE Posterior reversible encephalopathy syndrome (PRES) has been associated with the use of several medications, including chemotherapeutic agents. PATIENT CONCERNS A 65-year-old woman was diagnosed with adenocarcinoma of the ovary, after sixth-line treatment with topotecan, at the beginning of the fourth cycle, she was admitted to the emergency room for presenting tonic-clonic seizures, visual disturbance, and hypertension. A 66-year-old woman was diagnosed with bilateral breast cancer; due to disease progression, treatment with paclitaxel and gemcitabine was started, 1 month after the last dose of chemotherapy, she was admitted to the emergency room for suffering severe headache, altered mental status, tonic-clonic seizures, and hypertension. A 60-year-old patient diagnosed with breast cancer on the left side, underwent second-line chemotherapy with gemcitabine, carboplatin, and bevacizumab, and 1 month after the last dose of chemotherapy, she was also admitted to the emergency room due to altered mental status, vomiting, tonic-clonic seizures, and hypertension. DIAGNOSIS They were diagnosed as PRES based on physical examination, laboratory findings, and imaging techniques that revealed diffuse lesions and edema within the parieto-occipital regions. INTERVENTIONS They received support treatment with blood pressure (BP) control, seizures were controlled with a single anti-epileptic agent, and chemotherapeutic agents from the onset of PRES to its resolution were discontinued. OUTCOMES All these patients improved after medical treatment was started. LESSONS Medical personnel and therapeutic establishments need to be made aware about this chemotherapy-induced neurologic complication.
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Cabanillas ME, Takahashi S. Managing the adverse events associated with lenvatinib therapy in radioiodine-refractory differentiated thyroid cancer. Semin Oncol 2018; 46:57-64. [PMID: 30685073 DOI: 10.1053/j.seminoncol.2018.11.004] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 11/21/2018] [Indexed: 02/06/2023]
Abstract
Lenvatinib is a multikinase inhibitor of vascular endothelial growth factor (VEGF) receptors 1-3, fibroblast growth factor receptors 1-4, RET, KIT, and platelet-derived growth factor receptor-α. Lenvatinib is approved as a monotherapy for the treatment of radioiodine-refractory differentiated thyroid cancer and in combination with everolimus for the second-line treatment of advanced renal cell carcinoma. Lenvatinib is also under investigation for the treatment of several malignancies including unresectable hepatocellular carcinoma. Although lenvatinib is associated with favorable efficacy, it is associated with adverse events (AEs) that the clinician will have to closely monitor for and proactively manage. Most of these AEs are known class effects of VEGF-targeted therapies, including hypertension, diarrhea, fatigue or asthenia, decreased appetite, and weight loss. This review summarizes the safety profile of lenvatinib and offers guidance for the management of both frequent and rare AEs. We discuss the potential mechanisms underlying these AEs and present practical recommendations for managing toxicities. The development of treatment plans that include prophylactic and therapeutic strategies for the management of lenvatinib-associated AEs has the potential to improve patient quality of life, optimize adherence, minimize the need for dose reductions, treatment interruptions, or discontinuations, and maximize patient outcomes.
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Affiliation(s)
- Maria E Cabanillas
- Department of Endocrine Neoplasia & Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Shunji Takahashi
- Department of Medical Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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25
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Pistone A, Durieux V, Grigoriu B, Meert AP. Management of Acute Complications of Targeted Therapy in Patients With Cancer: A Review of Cases Managed in ICU. J Intensive Care Med 2018; 34:435-448. [PMID: 30165779 DOI: 10.1177/0885066618787788] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Targeted therapies, molecules in full expansion, are not free of side effects that can lead patients to intensive care. We performed an extensive review of the published evidence and propose a management strategy for acute complications of targeted therapy in critically ill patients with cancer. METHODS The literature search was performed in August 2017 using the Ovid Medline system by a scientific librarian and physicians. We made a review of cases admitted in intensive care unit (ICU) and a review of toxicities of grades greater or equal to 3. RESULTS Our search selected 59 articles. The main cardiovascular side effects requiring ICU are heart failure, which is generally reversible, severe hypertension, thrombotic and ischemic events, and rhythm disturbances. The main pulmonary side effects are interstitial lung disease essentially caused by crizotinib, respiratory infections, pneumothorax, and alveolar hemorrhage. The main gastrointestinal side effects are fulminant hepatitis that may be fatal, colitis that may be complicated by hemorrhage, and perforation. The main neurological side effect is posterior reversible encephalopathy syndrome essentially caused by bevacizumab. The main other side effects are Steven-Johnson syndrome, necrotizing fasciitis, and anaphylactic reactions. CONCLUSIONS The side effects induced by targeted therapies may be fatal but are generally potentially reversible. The main treatment includes stopping current therapy and symptomatic management. Treatment rechallenge should be discussed on a case-by-case basis.
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Affiliation(s)
- Aureliano Pistone
- 1 Unité de soins intensifs et urgences oncologiques, service de médecine interne, Institut Jules Bordet, Université libre de Bruxelles (ULB), Bruxelles, Belgium
| | - Valérie Durieux
- 2 Bibliothèque des Sciences de la Santé, Université libre de Bruxelles (ULB), Bruxelles, Belgium.,3 Laboratoire de Médecine Factuelle, Faculté de Médecine, Université libre de Bruxelles (ULB), Bruxelles, Belgium
| | - Bogdan Grigoriu
- 1 Unité de soins intensifs et urgences oncologiques, service de médecine interne, Institut Jules Bordet, Université libre de Bruxelles (ULB), Bruxelles, Belgium
| | - Anne-Pascale Meert
- 1 Unité de soins intensifs et urgences oncologiques, service de médecine interne, Institut Jules Bordet, Université libre de Bruxelles (ULB), Bruxelles, Belgium
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Abstract
OBJECTIVE The hallmarks of cancer are mechanisms that cells develop to undergo malignant transformation. The targeting of these hallmarks by newer cancer therapies results in new mechanisms of response, toxicity, and resistance. The purpose of this article is to review these hallmarks, their associated targeted therapies, imaging features of responses, and toxicities. CONCLUSION Ten hallmarks, among them proliferative signaling, angiogenesis, immune response, and genome instability, are reviewed. Molecular targeted therapies, including antiangiogenic factors and immune checkpoint inhibitors, target these hallmarks.
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Abstract
This last decade has yielded more robust development of cancer treatments and first-in-class agents than ever before. Since 2006, nearly one hundred new drugs have received regulatory approval for the treatment of hematological and solid organ neoplasms. Moreover, older conventional therapies have received approval for new clinical indications and are being used in combination with these newer small-molecule targeted treatments. The nervous system is vulnerable to many of the traditional cancer therapies, manifesting both already well-described acute and chronic toxicities. However, newer agents may produce toxicities that may seem indistinguishable from the underlying cancer. Early recognition of neurotoxicities from new therapeutics is vital to avoid irreversible neurological injury. This review focuses on cancer therapies in use in the last 10 years and approved by the FDA from January 2006 through January 1, 2017.
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Affiliation(s)
- Alicia M Zukas
- Department of Neurology, Virginia Commonwealth University, Richmond, Virginia
| | - David Schiff
- Department of Neurology, University of Virginia, Charlottesville, Virginia
- Department of Neurological Surgery, and Medicine, University of Virginia, Charlottesville, Virginia
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Shah RR. Anti-Angiogenic Tyrosine Kinase Inhibitors and Reversible Posterior Leukoencephalopathy Syndrome: Could Hypomagnesaemia Be the Trigger? Drug Saf 2017; 40:373-386. [PMID: 28181126 DOI: 10.1007/s40264-017-0508-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Reversible posterior leukoencephalopathy syndrome (RPLS), also known frequently as posterior reversible encephalopathy syndrome (PRES), is a characteristic acute neuro-radiology syndrome with clinical presentation that typically includes acute hypertension, seizures and other neurological symptoms and signs. Many patients with RPLS have (a history of) pre-existing hypertension and in receipt of diuretics. It is being diagnosed more frequently and in association with an increasing number of morbidities and medications. Drugs most frequently implicated are immunosuppressant drugs and anticancer agents, including a number of anti-angiogenic tyrosine kinase inhibitors (TKIs). Hypomagnesaemia is a frequent finding at presentation in RPLS patients, which is known to lead to or aggravate hypertension. Pre-eclampsia, a variant of RPLS, responds effectively to intravenous magnesium. Cyclosporin, tacrolimus and some TKIs that induce RPLS are also known to give rise to both hypertension and hypomagnesaemia. This raises an interesting hypothesis that hypomagnesaemia may play a contributory role in triggering RPLS in some patients by acutely raising the blood pressure further. Additional systematic studies are required to test this hypothesis. If the hypothesis is confirmed, hypomagnesaemia offers an effective target for risk mitigation and prevention of RPLS in patients identified at risk.
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Affiliation(s)
- Rashmi R Shah
- Pharmaceutical Consultant, 8 Birchdale, Gerrards Cross, Buckinghamshire, UK.
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29
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Arnold D, Fuchs CS, Tabernero J, Ohtsu A, Zhu AX, Garon EB, Mackey JR, Paz-Ares L, Baron AD, Okusaka T, Yoshino T, Yoon HH, Das M, Ferry D, Zhang Y, Lin Y, Binder P, Sashegyi A, Chau I. Meta-analysis of individual patient safety data from six randomized, placebo-controlled trials with the antiangiogenic VEGFR2-binding monoclonal antibody ramucirumab. Ann Oncol 2017; 28:2932-2942. [PMID: 28950290 PMCID: PMC5834052 DOI: 10.1093/annonc/mdx514] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Ramucirumab, the human immunoglobulin G1 monoclonal antibody receptor antagonist of vascular endothelial growth factor receptor 2, has been approved for treating gastric/gastroesophageal junction, non-small-cell lung, and metastatic colorectal cancers. With the completion of six global, randomized, double-blind, placebo-controlled, phase III trials across multiple tumor types, an opportunity now exists to further establish the safety parameters of ramucirumab across a large patient population. MATERIALS AND METHODS An individual patient meta-analysis across the six completed phase III trials was conducted and the relative risk (RR) and associated 95% confidence intervals (CIs) were derived using fixed-effects or mixed-effects models for all-grade and high-grade adverse events (AEs) possibly related to vascular endothelial growth factor pathway inhibition. The number needed to harm was also calculable due to the placebo-controlled nature of all six registration standard trials. RESULTS A total of 4996 treated patients (N = 2748 in the ramucirumab arm and N = 2248 in the control, placebo arm) were included in this meta-analysis. Arterial thromboembolic events [ATE; all-grade, RR: 0.8, 95% CI 0.5-1.3; high-grade (grade ≥3), RR: 0.9, 95% CI 0.5-1.7], venous thromboembolic events (VTE; all-grade, RR: 0.7, 95% CI 0.5-1.1; high-grade, RR: 0.7, 95% CI 0.4-1.2), high-grade bleeding (RR: 1.1, 95% CI 0.8-1.5), and high-grade gastrointestinal (GI) bleeding (RR: 1.1, 95% CI 0.7-1.7) did not demonstrate a definite increased risk with ramucirumab. A higher percentage of hypertension, proteinuria, low-grade (grade 1-2) bleeding, GI perforation, infusion-related reaction, and wound-healing complications were observed in the ramucirumab arm compared with the control arm. CONCLUSIONS Ramucirumab may be distinct among antiangiogenic agents in terms of ATE, VTE, high-grade bleeding, or high-grade GI bleeding by showing no clear evidence for an increased risk of these AEs in this meta-analysis of a large and diverse patient population. Ramucirumab is consistent with other angiogenic inhibitors in the risk of developing certain AEs. Clinical Trial Numbers: NCT00917384 (REGARD), NCT01170663 (RAINBOW), NCT01168973 (REVEL), NCT01183780 (RAISE), NCT01140347 (REACH), and NCT00703326 (ROSE).
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MESH Headings
- Angiogenesis Inhibitors/adverse effects
- Angiogenesis Inhibitors/immunology
- Angiogenesis Inhibitors/therapeutic use
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/immunology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/immunology
- Antineoplastic Agents, Immunological/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/immunology
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Clinical Trials, Phase III as Topic
- Humans
- Randomized Controlled Trials as Topic
- Risk Assessment
- Vascular Endothelial Growth Factor Receptor-2/immunology
- Ramucirumab
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Affiliation(s)
- D Arnold
- Oncology, Instituto CUF de Oncologia (I.C.O.), Lisbon, Portugal
| | - C S Fuchs
- Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA
| | - J Tabernero
- Medical Oncology Department, Vall d’Hebron University Hospital and Institute of Oncology (VHIO), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - A Ohtsu
- Department of Gastrointestinal Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - A X Zhu
- Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, USA
| | - E B Garon
- Hematology Oncology, David Geffen School of Medicine at UCLA Translational Research in Oncology-US Network, Santa Monica, USA
| | - J R Mackey
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Canada
| | - L Paz-Ares
- Medical Oncology Department, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - A D Baron
- Division of Hematology Oncology, California Pacific Medical Center, San Francisco, USA
| | - T Okusaka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - T Yoshino
- Department of Gastrointestinal Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - H H Yoon
- Division of Medical Oncology, Mayo Clinic, Rochester, USA
| | - M Das
- Oncology, Eli Lilly and Company, Indianapolis, USA
| | - D Ferry
- Oncology, Eli Lilly and Company, Bridgewater, USA
| | - Y Zhang
- Oncology, Eli Lilly and Company, Bridgewater, USA
| | - Y Lin
- Oncology, Eli Lilly and Company, Indianapolis, USA
| | - P Binder
- Oncology, Eli Lilly and Company, Bridgewater, USA
| | - A Sashegyi
- Oncology, Eli Lilly and Company, Indianapolis, USA
| | - I Chau
- Department of Medicine, Royal Marsden Hospital, Sutton, UK
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Neuro-ophthalmic side effects of molecularly targeted cancer drugs. Eye (Lond) 2017; 32:287-301. [PMID: 29052609 DOI: 10.1038/eye.2017.222] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 07/31/2017] [Indexed: 12/20/2022] Open
Abstract
The past two decades has been an amazing time in the advancement of cancer treatment. Molecularly targeted therapy is a concept in which specific cellular molecules (overexpressed, mutationally activated, or selectively expressed proteins) are manipulated in an advantageous manner to decrease the transformation, proliferation, and/or survival of cancer cells. In addition, increased knowledge of the role of the immune system in carcinogenesis has led to the development of immune checkpoint inhibitors to restore and enhance cellular-mediated antitumor immunity. The United States Food and Drug Administration approval of the chimeric monoclonal antibody (mAb) rituximab in 1997 for the treatment of B cell non-Hodgkin lymphoma ushered in a new era of targeted therapy for cancer. A year later, trastuzumab, a humanized mAb, was approved for patients with breast cancer. In 2001, imatinib was the first small-molecule kinase inhibitor approved. The approval of ipilimumab-the first in class immune checkpoint inhibitor-in 2011 serves as a landmark period of time in the resurgence of immunotherapy for cancer. Despite the notion that increased tumor specificity results in decreased complications, toxicity remains a major hurdle in the development and implementation of many of the targeted anticancer drugs. This article will provide an overview of the current cellular and immunological understanding of cancer pathogenesis-the foundation upon which molecularly targeted therapies were developed-and a description of the ocular and neuro-ophthalmic toxicity profile of mAbs, immune checkpoint inhibitors, and small-molecule kinase inhibitors.
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Li M, Kroetz DL. Bevacizumab-induced hypertension: Clinical presentation and molecular understanding. Pharmacol Ther 2017; 182:152-160. [PMID: 28882537 DOI: 10.1016/j.pharmthera.2017.08.012] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bevacizumab is a vascular endothelial growth factor-A-specific angiogenesis inhibitor indicated as an adjunct to chemotherapy for the treatment of several types of cancer. Hypertension is commonly observed during bevacizumab treatment, and high-grade toxicity can limit therapy and lead to other cardiovascular complications. The factors that contribute to interindividual variability in blood pressure response to bevacizumab treatment are not well understood. In this review, we outline research efforts to understand the mechanisms and pathophysiology of hypertension resulting from bevacizumab treatment. Moreover, we highlight current knowledge of the pharmacogenetics of bevacizumab-induced hypertension, which may be used to develop strategies to prevent or minimize this toxicity.
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Affiliation(s)
- Megan Li
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Deanna L Kroetz
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, United States.
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Furubayashi N, Negishi T, Iwai H, Nagase K, Nakamura M. Sorafenib-induced reversible posterior leukoencephalopathy in patients with renal cell carcinoma: A report of two cases. Mol Clin Oncol 2017; 7:281-284. [PMID: 28781802 DOI: 10.3892/mco.2017.1291] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 05/31/2017] [Indexed: 11/06/2022] Open
Abstract
Reversible posterior leukoencephalopathy syndrome (RPLS) is a rare clinicoradiological syndrome that is characterized by neurological symptoms, including seizures, headaches, visual abnormalities, confusion and encephalopathy, accompanied by vasogenic edema of the posterior white matter observed on neuroimaging. Sorafenib is an inhibitor of pro-angiogenic receptor tyrosine kinases, such as vascular endothelial growth factor receptor 2, platelet-derived growth factor receptor β, and vascular endothelial growth factor receptor 3. In the previous research literature, only one case of sorafenib-induced RPLS, in a patient with hepatocellular carcinoma, has been reported. The current report presents two cases of sorafenib-induced RPLS in patients with metastases from a renal cell carcinoma. In the first case, a 75-year-old female patient developed a fever, fell down and was unable to move her limbs as instructed after 11 days of sorefenib treatment. Brain magnetic resonance imaging (MRI) demonstrated no typical RPLS findings. As all of the symptoms were resolved after sorafenib discontinuation, sorafenib was restarted. However, the patient remained unable to walk steadily and to articulate properly after 10 days. MRI again demonstrated no notable findings, and her condition improved only after discontinuation of the sorafenib. In the second case, a 75-year-old male patient experienced a fall due to loss of consciousness. T2-weighted and fluid-attenuated inversion recovery MRI revealed high-intensity signals on both sides of the cerebellar hemisphere and pons, and also partially on both sides of the frontal lobe. At 33 days after sorafenib discontinuation, he had recovered sufficiently to walk by himself with a walker, and a repeat MRI revealed a significant improvement. Although one case took a longer time, both cases were fortunately reversible by discontinuation of sorafenib treatment and administration of combined-modality therapy (including oxygen, steroids, verapamil, digoxin and nicardipine hydrochloride). The oncology community should be alerted to this uncommon and life-threatening adverse event.
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Affiliation(s)
- Nobuki Furubayashi
- Department of Urology, National Hospital Organization Kyushu Cancer Center, Fukuoka 811-1395, Japan
| | - Takahito Negishi
- Department of Urology, National Hospital Organization Kyushu Cancer Center, Fukuoka 811-1395, Japan
| | - Hidenori Iwai
- Department of Urology, National Hospital Organization Kyushu Cancer Center, Fukuoka 811-1395, Japan
| | - Kei Nagase
- Department of Urology, National Hospital Organization Kyushu Cancer Center, Fukuoka 811-1395, Japan
| | - Motonobu Nakamura
- Department of Urology, National Hospital Organization Kyushu Cancer Center, Fukuoka 811-1395, Japan
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Shinagare AB, Krajewski KM, Braschi-Amirfarzan M, Ramaiya NH. Advanced Renal Cell Carcinoma: Role of the Radiologist in the Era of Precision Medicine. Radiology 2017; 284:333-351. [DOI: 10.1148/radiol.2017160343] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Atul B. Shinagare
- From the Department of Imaging, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215; and Department of Radiology, Brigham and Women’s Hospital, Boston, Mass
| | - Katherine M. Krajewski
- From the Department of Imaging, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215; and Department of Radiology, Brigham and Women’s Hospital, Boston, Mass
| | - Marta Braschi-Amirfarzan
- From the Department of Imaging, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215; and Department of Radiology, Brigham and Women’s Hospital, Boston, Mass
| | - Nikhil H. Ramaiya
- From the Department of Imaging, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215; and Department of Radiology, Brigham and Women’s Hospital, Boston, Mass
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Kamiya-Matsuoka C, Tummala S. Electrographic patterns in patients with posterior reversible encephalopathy syndrome and seizures. J Neurol Sci 2017; 375:294-298. [DOI: 10.1016/j.jns.2017.02.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 02/04/2017] [Accepted: 02/07/2017] [Indexed: 11/24/2022]
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Minion LE, Tewari KS. The safety and efficacy of bevacizumab in the treatment of patients with recurrent or metastatic cervical cancer. Expert Rev Anticancer Ther 2017; 17:191-198. [PMID: 27748633 DOI: 10.1080/14737140.2016.1246187] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Bevacizumab is a recombinant humanized monoclonal antibody against vascular endothelial growth factor (VEGF). (Avastin; Genetech, Inc, San Francisco, CA) Angiogenesis is blocked by the binding of bevacizumab to VEGF, inhibiting the binding of this ligand to the VEGF receptor. On 14 August 2014 the Food and Drug Administration (FDA) approved use of bevacizumab in persistent, recurrent, or metastatic cervical cancer. Areas covered: Herein we review pharmacodynamics and kinetics, clinical data and treatment-related toxicities of bevacizumab in the treatment of metastatic, recurrent or persistent cervical cancer. Additionally, future areas of development are reviewed. Expert commentary: Anti-angiogenesis therapy with bevacizumab is central to metastatic, persistent, and recurrent cervical cancer treatment. Additional anti-angiogenesis drugs are in development. Future studies will need to establish if the addition of multiple anti-angiogenesis agents or anti-angiogenesis in combination with immunotherapy is more effective than bevacizumab with chemotherapy.
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Affiliation(s)
- Lindsey E Minion
- a The Division of Gynecologic Oncology, Department of Obstetrics & Gynecology , University of California, Irvine Medical Center , Orange , CA , USA
| | - Krishnansu S Tewari
- a The Division of Gynecologic Oncology, Department of Obstetrics & Gynecology , University of California, Irvine Medical Center , Orange , CA , USA
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Toledano M, Fugate JE. Posterior reversible encephalopathy in the intensive care unit. HANDBOOK OF CLINICAL NEUROLOGY 2017; 141:467-483. [PMID: 28190431 DOI: 10.1016/b978-0-444-63599-0.00026-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is increasingly diagnosed in the emergency department, and medical and surgical intensive care units. PRES is characterized by acute onset of neurologic symptoms in the setting of blood pressure fluctuations, eclampsia, autoimmune disease, transplantation, renal failure, or exposure to immunosuppressive or cytotoxic drugs, triggers known to admit patients to the intensive care unit (ICU). Although the exact pathophysiology remains unknown, there is growing consensus that PRES results from endothelial dysfunction. Because of the heterogeneous nature of the disorder, it is probable that different mechanisms of endothelial injury are etiologically important in different clinical situations. The presence of bilateral vasogenic edema on brain imaging, particularly in parieto-occipital regions, is of great diagnostic utility but PRES remains a clinical diagnosis. Although largely reversible, PRES can result in irreversible neurologic injury and even death. The range of clinical and radiographic manifestations of the syndrome is probably broader than previously thought, and it is imperative that clinicians become familiar with the full spectrum of the disorder, as prompt recognition and elimination of an inciting factor improve outcome. PRES may be the most frequent toxic-metabolic encephalopathy seen in the ICU.
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Affiliation(s)
- M Toledano
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - J E Fugate
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
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Acute Kidney Injury, Recurrent Seizures, and Thrombocytopenia in a Young Patient with Lupus Nephritis: A Diagnostic Dilemma. Case Rep Nephrol 2016; 2016:7104098. [PMID: 28044115 PMCID: PMC5164895 DOI: 10.1155/2016/7104098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 11/13/2016] [Indexed: 12/21/2022] Open
Abstract
Introduction. Posterior reversible encephalopathy syndrome (PRES) is a constellation of clinical and radiologic findings. Fluctuations in blood pressure, seizures, and reversible brain MRI findings mainly in posterior cerebral white matter are the main manifestations. PRES has been associated with multiple conditions such as autoimmune disorders, pregnancy, organ transplant, and thrombotic microangiopathy (TMA). Case Presentation. A 22-year-old woman with history of Systemic Lupus Erythematous complicated with chronic kidney disease secondary to lupus nephritis class IV presented with recurrent seizures and uncontrolled hypertension. She was found to have acute kidney injury and thrombocytopenia. Repeat kidney biopsy showed diffuse endocapillary and extracapillary proliferative and membranous lupus nephritis (ISN-RPS class IV-G+V) and endothelial swelling secondary to severe hypertension but no evidence of TMA. Brain MRI showed reversible left frontal and parietal lesions that resolved after controlling the blood pressure, making PRES the diagnosis. Conclusion. PRES is an important entity that must be recognized and treated early due to the potential reversibility in the early stages. Physicians must have high suspicion for these unusual presentations. We present a case where performing kidney biopsy clinched the diagnosis in our patient with multiple confounding factors.
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Acute neurovascular events in cancer patients receiving anti-vascular endothelial growth factor agents: Clinical experience in Paris University Hospitals. Eur J Cancer 2016; 66:75-82. [PMID: 27529757 DOI: 10.1016/j.ejca.2016.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 07/11/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite the increasing and broadening use of agents targeting the vascular endothelial growth factor (VEGF) pathway, little is known on their acute neurovascular toxicities. METHODS This retrospective, multi-centre study examined the characteristics of patients with solid tumours who experienced an ischaemic or haemorrhagic stroke, a transient ischaemic accident (TIA) or a posterior reversible encephalopathy syndrome (PRES) while under anti-VEGF and until 8 weeks after termination of treatment and evaluated their management in our institutions from 2004 to 2014. Patients with newly diagnosed or progressive cerebral metastases at the time of the acute neurovascular event were excluded. RESULTS Thirty-four patients (55.9% men) were identified, and experienced either ischaemic stroke (n = 18), PRES (n = 9), TIA (n = 6) or haemorrhagic stroke (n = 1). At initiation of anti-VEGF agents, 64.7% of patients had previous cardiovascular risk factors, and 52.9% had hypertension. Eight patients (23.5%) had received cerebral radiotherapy, five of which concomitantly to anti-VEGF treatment. Six (17%) patients died in the 8 weeks following the acute neurovascular event, and only 55.9% recovered their initial neurological status. Overall, 1-year and 2-year survival rates after the acute neurovascular event were 67.9% and 50%, respectively. When anti-VEGF agents were reintroduced (n = 6), severe vascular toxicity recurred in two patients. CONCLUSIONS Neurovascular events under VEGF treatments are potentially severe, and the management of comorbid conditions has to be improved. A prospective collection of data and standardised management of such events is therefore being structured in our institutions.
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Abstract
This chapter reviews the neurologic complications of medications administered in the hospital setting, by class, introducing both common and less common side effects. Detail is devoted to the interaction between pain, analgesia, sedation, and their residual consequences. Antimicrobials are given in nearly every hospital setting, and we review their capacity to produce neurologic sequelae with special devotion to cefepime and the antiviral treatment of human immunodeficiency virus. The management of hemorrhagic stroke has become more complex with the introduction of novel oral anticoagulants, and we provide an update on what is known about reversal of the new oral anticoagulants. Both central and peripheral nervous system complications of immunosuppressants and chemotherapies are reviewed. Because diagnosis is generally based on clinical acumen, alone, neurotoxic syndromes resulting from psychotropic medications may be easily overlooked until severe dysautonomia develops. We include a practical approach to the diagnosis of serotonin syndrome and neuroleptic malignant syndrome.
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Affiliation(s)
- Elliot T Dawson
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, Rochester, MN, USA.
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A New Look at Toxicity in the Era of Precision Oncology: Imaging Findings, Their Relationship With Tumor Response, and Effect on Metastasectomy. AJR Am J Roentgenol 2016; 207:4-14. [DOI: 10.2214/ajr.15.15480] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Berger MD, Lenz HJ. The safety of monoclonal antibodies for treatment of colorectal cancer. Expert Opin Drug Saf 2016; 15:799-808. [DOI: 10.1517/14740338.2016.1167186] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Martin D. Berger
- Division of Medical Oncology, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Heinz-Josef Lenz
- Division of Medical Oncology, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Preventive Medicine, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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McClung EC, Wenham RM. Profile of bevacizumab in the treatment of platinum-resistant ovarian cancer: current perspectives. Int J Womens Health 2016; 8:59-75. [PMID: 27051317 PMCID: PMC4803258 DOI: 10.2147/ijwh.s78101] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Patients with platinum-resistant ovarian cancer have progression of disease within 6 months of completing platinum-based chemotherapy. While several chemotherapeutic options exist for the treatment of platinum-resistant ovarian cancer, the overall response to any of these therapies is ~10%, with a median progression-free survival of 3–4 months and a median overall survival of 9–12 months. Bevacizumab (Avastin), a humanized, monoclonal antivascular endothelial growth factor antibody, has demonstrated antitumor activity in the platinum-resistant setting and was recently approved by US Food and Drug Administration for combination therapy with weekly paclitaxel, pegylated liposomal doxorubicin, or topotecan. This review summarizes key clinical trials investigating bevacizumab for recurrent, platinum-resistant ovarian cancer and provides an overview of efficacy, safety, and quality of life data relevant in this setting. While bevacizumab is currently the most studied and clinically available antiangiogenic therapy, we summarize recent studies highlighting novel alternatives, including vascular endothelial growth factor-trap, tyrosine kinase inhibitors, and angiopoietin inhibitor trebananib, and discuss their application for the treatment of platinum-resistant ovarian cancer.
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Affiliation(s)
- E Clair McClung
- Department of Gynecologic Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Robert M Wenham
- Department of Gynecologic Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
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Posterior reversible encephalopathy syndrome in cancer patients: a single institution retrospective study. J Neurooncol 2016; 128:75-84. [DOI: 10.1007/s11060-016-2078-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 02/15/2016] [Indexed: 10/22/2022]
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The optimal regimen of bevacizumab for recurrent glioblastoma: does dose matter? J Neurooncol 2015; 127:493-502. [PMID: 26721244 DOI: 10.1007/s11060-015-2025-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
Abstract
The FDA-approved schedule and dose of bevacizumab (BVZ) for recurrent glioblastoma (rGB) (10 mg/kg q 2 weeks) were adopted from systemic cancer protocols. No dose-defining studies have been performed for glioblastoma. We began using BVZ for the treatment of rGB in 2005 at the dose of 5 mg/kg every 2 weeks combined with irinotecan, and later as single agent. Our previous report of 20 patients treated with BVZ 5 mg/kg every 2 weeks showed similar response rates and overall survival (OS) compared to other BVZ treatment protocols, with less adverse effects. In this study we retrospectively reviewed our 7 year experience with BVZ in 162 rGB patients. Treatment outcomes were analyzed from 87 patients who received BVZ at 5 mg/kg and 75 patients at 10 mg/kg. While median age was similar in both groups, the median KPS was significantly higher in the group treated with 10 mg/kg BVZ (85 versus 60). There was no significant difference in OS or progression free survival (PFS) between the groups treated with BVZ 5 versus 10 mg/kg. Overall survival was significantly improved in the subgroup treated with cytotoxic therapy in addition to BVZ 10 mg/kg. There were more adverse events seen with BVZ 10 mg/kg. There is no significant difference in OS for rGB treated with BVZ 5 mg/kg versus 10 mg/kg when given as monotherapy. The smaller dose was slightly less toxic. Addition of cytotoxic therapy resulted in prolongation of OS in a small subgroup of BVZ 10 mg/kg.
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Posterior reversible encephalopathy syndrome: clinical and radiological manifestations, pathophysiology, and outstanding questions. Lancet Neurol 2015; 14:914-925. [PMID: 26184985 DOI: 10.1016/s1474-4422(15)00111-8] [Citation(s) in RCA: 660] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 04/08/2015] [Accepted: 05/27/2015] [Indexed: 12/12/2022]
Abstract
Almost two decades have elapsed since posterior reversible encephalopathy syndrome (PRES) was described in an influential case series. This usually reversible clinical syndrome is becoming increasingly recognised, in large part because of improved and more readily available brain imaging. Although the pathophysiological changes underlying PRES are not fully understood, endothelial dysfunction is a key factor. A diagnosis of PRES should be considered in the setting of acute neurological symptoms in patients with renal failure, blood pressure fluctuations, use of cytotoxic drugs, autoimmune disorders, or eclampsia. Characteristic radiographic findings include bilateral regions of subcortical vasogenic oedema that resolve within days or weeks. The presence of haemorrhage, restricted diffusion, contrast enhancement, and vasoconstriction are all compatible with a diagnosis. In most cases, PRES resolves spontaneously and patients show both clinical and radiological improvements. The range of symptoms that can comprise the syndrome might be broader than usually thought. In its mild form, this disorder might cause only one clinical symptom (headache or seizure) and radiographically might show few areas of vasogenic oedema or even normal brain imaging in some rare cases. In severe forms, PRES might cause substantial morbidity and even mortality, most often as a result of acute haemorrhage or massive posterior fossa oedema causing obstructive hydrocephalus or brainstem compression.
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Frantzen L, Rondeau-Lutz M, Mosquera F, Martinez C, Labani A, Weber JC. [Reversible posterior encephalopathy syndrome and cardiomyopathy after bevacizumab therapy]. Rev Med Interne 2015; 37:50-2. [PMID: 26031739 DOI: 10.1016/j.revmed.2015.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 03/16/2015] [Accepted: 04/28/2015] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Bevacizumab is an antibody directed against VEGF-A. It is approved for the treatment of many cancer diseases. Its side effects are currently not well known by physicians. CASE REPORT A 70-year-old female with metastatic colonic adenocarcinoma was admitted in the intensive care unit because of a coma, four days after having received a combined monthly chemotherapy containing bevacizumab, oxaliplatine, 5 fluorouracil, and folinic acid for the fourth time. On clinical examination, she presented with lower limbs spasticity and hypertension. Etiologic investigations, including cerebral tomodensitometry, cerebrospinal fluid examination, psychotropic drugs urinary testing, and electroencephalogram, were negative. Consciousness improved without any other treatment than nicardipine and urapidil, but the patient was initially confused. Cerebral magnetic resonance imaging showed changes suggestive of posterior reversible encephalopathy syndrome, but also involving frontal lobes. There were additional biological and echocardiographic changes suggestive of cardiac involvement. The patient recovered completely of both cardiac and neurologic manifestations 10 days later. CONCLUSION Physicians should be aware of cardiovascular adverse effects of bevacizumab. High blood pressure must be treated to avoid more severe complications. When a posterior reversible encephalopathy syndrome occurs, cardiac involvement should be investigated.
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Affiliation(s)
- L Frantzen
- Service de médecine interne NHC, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
| | - M Rondeau-Lutz
- Service de médecine interne NHC, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France.
| | - F Mosquera
- Service de médecine interne NHC, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
| | - C Martinez
- Service de médecine interne NHC, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France; Faculté de médecine de Strasbourg, université de Strasbourg, 4, rue Kirschleger, 67085 Strasbourg cedex, France
| | - A Labani
- Service de radiologie, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France; Faculté de médecine de Strasbourg, université de Strasbourg, 4, rue Kirschleger, 67085 Strasbourg cedex, France
| | - J C Weber
- Service de médecine interne NHC, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France; Faculté de médecine de Strasbourg, université de Strasbourg, 4, rue Kirschleger, 67085 Strasbourg cedex, France
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Singer S, Grommes C, Reiner AS, Rosenblum MK, DeAngelis LM. Posterior Reversible Encephalopathy Syndrome in Patients With Cancer. Oncologist 2015; 20:806-11. [PMID: 26032137 DOI: 10.1634/theoncologist.2014-0149] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 03/05/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is characterized by neurologic symptoms with typical lesions on neuroimaging and may be associated with chemotherapy and immunosuppressive agents used in patients with cancer. We described the spectrum of PRES at a major cancer center. METHODS We reviewed charts of adults with PRES between 2005 and 2011 at Memorial Sloan Kettering Cancer Center for clinical information and outcome. RESULTS We identified 21 women (68%) and 10 men (median cohort age: 58 years). Solid tumors (n = 22, 71%) were more common than hematologic (n = 8) or primary brain malignancies (n = 1). Prior brain irradiation (16%) and central nervous system metastases (10%) were uncommon. There were 55% who received chemotherapy or targeted therapy within the month preceding PRES, including 6 patients who received bevacizumab; PRES followed allogeneic stem cell transplantation in 5 (16%). Presenting symptoms included confusion (71%), seizure (58%), and headache (48%). Maximum systolic and diastolic blood pressures were similar among patients grouped by cancer type, chemotherapy or bevacizumab use, and atypical imaging. Moreover, 37% of patients with both magnetic resonance imaging (MRI) and computed tomography (CT) had normal CT concurrent with PRES on MRI, and 84% returned to neurologic baseline at a median of 7.5 days (range: 1-167 days) from onset. Successful anticonvulsant taper was achieved in 51%. Chemotherapy rechallenge was attempted in 41% without recurrent PRES. Autopsy revealed nonspecific changes isolated to radiographically affected areas in one of two patients. CONCLUSION Recent chemotherapy, particularly bevacizumab, is common in cancer patients with PRES. Clinical and radiographic presentations may vary; MRI appears more sensitive than CT. Anticonvulsant taper and chemotherapy rechallenge is often possible. IMPLICATIONS FOR PRACTICE Posterior reversible encephalopathy syndrome is characterized by neurologic symptoms with typical lesions on neuroimaging and may be associated with chemotherapy and immunosuppressive agents used in patients with cancer. Clinical and radiographic presentations are protean, and magnetic resonance imaging is more sensitive than computed tomography. Recovery is common, and many patients can be successfully rechallenged with the apparently offending chemotherapy agent or regimen.
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Affiliation(s)
- Samuel Singer
- Departments of Neurology, Epidemiology and Biostatistics, and Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Christian Grommes
- Departments of Neurology, Epidemiology and Biostatistics, and Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anne S Reiner
- Departments of Neurology, Epidemiology and Biostatistics, and Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Marc K Rosenblum
- Departments of Neurology, Epidemiology and Biostatistics, and Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lisa M DeAngelis
- Departments of Neurology, Epidemiology and Biostatistics, and Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Tirumani SH, Fairchild A, Krajewski KM, Nishino M, Howard SA, Baheti AD, Rosenthal MH, Jagannathan JP, Shinagare AB, Ramaiya NH. Anti-VEGF Molecular Targeted Therapies in Common Solid Malignancies: Comprehensive Update for Radiologists. Radiographics 2015; 35:455-74. [DOI: 10.1148/rg.352140119] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Brandes AA, Bartolotti M, Tosoni A, Poggi R, Franceschi E. Practical management of bevacizumab-related toxicities in glioblastoma. Oncologist 2015; 20:166-75. [PMID: 25568148 DOI: 10.1634/theoncologist.2014-0330] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Bevacizumab, currently an option for treatment of different types of tumors including glioblastoma, has a peculiar toxicity profile related to its antiangiogenic effect. Because some bevacizumab-related adverse events can be life threatening, it is important to identify risk factors and to establish treatment protocols to minimize treatment-related morbidity and mortality. In glioblastoma patients, the risk of developing certain side effects, such as gastrointestinal perforation, venous thromboembolism, and intracranial hemorrhages, is slightly higher than in patients treated with bevacizumab for other tumor types. We performed a systematic review of the side effects of bevacizumab and their incidence, causal mechanisms, and available treatments. Finally, we identified risk factors and proposed preventive and therapeutic measures for these adverse events.
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Affiliation(s)
- Alba A Brandes
- Department of Medical Oncology, Bellaria Hospital, Azienda USL - IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Marco Bartolotti
- Department of Medical Oncology, Bellaria Hospital, Azienda USL - IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Alicia Tosoni
- Department of Medical Oncology, Bellaria Hospital, Azienda USL - IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Rosalba Poggi
- Department of Medical Oncology, Bellaria Hospital, Azienda USL - IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Enrico Franceschi
- Department of Medical Oncology, Bellaria Hospital, Azienda USL - IRCCS Institute of Neurological Sciences, Bologna, Italy
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Hayashi R, Kitazawa K, Sanada D, Kato N, Ohkoshi T, Katsumata Y, Yamaguchi S. Diffuse Leukoencephalopathy Associated with Dialysis Disequilibrium Syndrome. Intern Med 2015; 54:2753-8. [PMID: 26521906 DOI: 10.2169/internalmedicine.54.4938] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 52-year-old woman, previously treated for gastric cancer, began hemodialysis (HD) to treat the onset of severe acidemia. After her initial HD sessions, she suffered from a prolonged coma for approximately ten days. Magnetic resonance imaging revealed diffuse leukoencephalopathy, with increased apparent diffusion coefficient. Magnetic resonance spectroscopy showed a reduction of the N-acetylaspartate/creatine ratio. Her neuroimaging findings gradually resolved. Her transient cerebral white matter lesions were thought to be interstitial edema derived from dialysis disequilibrium syndrome (DDS), which might have been amplified by subclinical brain injury due to past chemotherapy. Her history of cancer chemotherapy may be a risk factor for an exacerbation of DDS.
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Affiliation(s)
- Ryuichiro Hayashi
- Department of Neurology, Yokohama Municipal Citizen's Hospital, Japan
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