1
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Becker SL, Kody S, Fett NM, Hines A, Alavi A, Ortega-Loayza AG. Approach to the Atypical Wound. Am J Clin Dermatol 2024; 25:559-584. [PMID: 38744780 DOI: 10.1007/s40257-024-00865-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
The heterogeneity of atypical wounds can present diagnostic and therapeutic challenges; however, as the prevalence of atypical wounds grows worldwide, prompt and accurate management is increasingly an essential skill for dermatologists. Addressing the underlying cause of an atypical wound is critical for successful outcomes. An integrated approach with a focus on pain management and patient engagement is recommended to facilitate enduring wound closure. Advances in treatment, in addition to further research and clinical training, are necessary to address the expanding burden of atypical wounds.
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Affiliation(s)
- Sarah L Becker
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | - Shannon Kody
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | - Nicole M Fett
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | | | - Afsaneh Alavi
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA.
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2
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Khan B, Qahwaji RM, Alfaifi MS, Mobashir M. Nivolumab and Ipilimumab Acting as Tormentors of Advanced Tumors by Unleashing Immune Cells and Associated Collateral Damage. Pharmaceutics 2024; 16:732. [PMID: 38931856 PMCID: PMC11207028 DOI: 10.3390/pharmaceutics16060732] [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: 03/18/2024] [Revised: 04/22/2024] [Accepted: 05/01/2024] [Indexed: 06/28/2024] Open
Abstract
Combining immune checkpoint inhibitors, specifically nivolumab (anti-PD-1) and ipilimumab (anti-CTLA-4), holds substantial promise in revolutionizing cancer treatment. This review explores the transformative impact of these combinations, emphasizing their potential for enhancing therapeutic outcomes across various cancers. Immune checkpoint proteins, such as PD1 and CTLA4, play a pivotal role in modulating immune responses. Blocking these checkpoints unleashes anticancer activity, and the synergy observed when combining multiple checkpoint inhibitors underscores their potential for enhanced efficacy. Nivolumab and ipilimumab harness the host's immune system to target cancer cells, presenting a powerful approach to prevent tumor development. Despite their efficacy, immune checkpoint inhibitors are accompanied by a distinct set of adverse effects, particularly immune-related adverse effects affecting various organs. Understanding these challenges is crucial for optimizing treatment strategies and ensuring patient well-being. Ongoing clinical trials are actively exploring the combination of checkpoint inhibitory therapies, aiming to decipher their synergistic effects and efficacy against diverse cancer types. This review discusses the mechanisms, adverse effects, and various clinical trials involving nivolumab and ipilimumab across different cancers, emphasizing their transformative impact on cancer treatment.
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Affiliation(s)
- Bushra Khan
- Department of Biosciences, Jamia Millia Islamia, New Delhi 110025, India;
| | - Rowaid M. Qahwaji
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah 22233, Saudi Arabia;
- Hematology Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Mashael S. Alfaifi
- Department of Epidemiology, Faculty of Public Health and Health Informatics, Umm Al-Qura University, Makkah 21955, Saudi Arabia;
| | - Mohammad Mobashir
- Department of Microbiology, Tumor and Cell Biology (MTC), Karolinska Institute, Solnavägen 9, 171 65 Solna, Sweden
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3
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Plachouri KM, Florou V, Georgiou V, Georgiou S. Cutaneous Side Effects of Modern Targeted Therapy and Immunotherapy in Patients with Dermatological Malignancies. Cancers (Basel) 2023; 15:3126. [PMID: 37370736 DOI: 10.3390/cancers15123126] [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: 04/12/2023] [Revised: 05/24/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
The advent of immunotherapy and targeted therapies in treating dermatological malignancies has dramatically changed the landscape of dermato-oncology in recent years. Their superior efficacy compared to previous therapeutic options, such as chemotherapy, has resulted in their use in treating devastating malignancies, such as melanoma or unresectable/metastatic basal cell and squamous cell carcinoma. Skin toxicity is a critical safety consideration, among other adverse reactions, that can occur under treatment with these agents. This article aims to summarize the cutaneous side effects of immune checkpoint inhibitors and targeted dermato-oncological therapies. Although the skin side effects of these agents are primarily mild, they can occasionally affect the decision for treatment continuation and the quality of life of the affected patients. Therefore, physicians must be acquainted with the specific cutaneous toxicity profile of such treatments to mitigate their impact on the patients and optimize the overall outcome of dermato-oncological therapy.
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Affiliation(s)
- Kerasia-Maria Plachouri
- Dermatology Department, University General Hospital of Patras, University of Patras, 265 04 Rio, Greece
| | - Vaia Florou
- Division of Oncology, Department of Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 841112, USA
| | - Vasileios Georgiou
- School of Medicine, University General Hospital of Patras, University of Patras, 265 04 Rio, Greece
| | - Sophia Georgiou
- Dermatology Department, University General Hospital of Patras, University of Patras, 265 04 Rio, Greece
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4
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Reschke R, Shapiro JW, Yu J, Rouhani SJ, Olson DJ, Zha Y, Gajewski TF. Checkpoint Blockade-Induced Dermatitis and Colitis Are Dominated by Tissue-Resident Memory T Cells and Th1/Tc1 Cytokines. Cancer Immunol Res 2022; 10:1167-1174. [PMID: 35977003 PMCID: PMC9530647 DOI: 10.1158/2326-6066.cir-22-0362] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/22/2022] [Accepted: 08/15/2022] [Indexed: 01/07/2023]
Abstract
Immune checkpoint blockade is therapeutically successful for many patients across multiple cancer types. However, immune-related adverse events (irAE) frequently occur and can sometimes be life threatening. It is critical to understand the immunologic mechanisms of irAEs with the goal of finding novel treatment targets. Herein, we report our analysis of tissues from patients with irAE dermatitis using multiparameter immunofluorescence (IF), spatial transcriptomics, and RNA in situ hybridization (RISH). Skin psoriasis cases were studied as a comparison, as a known Th17-driven disease, and colitis was investigated as a comparison. IF analysis revealed that CD4+ and CD8+ tissue-resident memory T (TRM) cells were preferentially expanded in the inflamed portion of skin in cutaneous irAEs compared with healthy skin controls. Spatial transcriptomics allowed us to focus on areas containing TRM cells to discern functional phenotype and revealed expression of Th1-associated genes in irAEs, compared with Th17-asociated genes in psoriasis. Expression of PD-1, CTLA-4, LAG-3, and other inhibitory receptors was observed in irAE cases. RISH technology combined with IF confirmed expression of IFNγ, CXCL9, CXCL10, and TNFα in irAE dermatitis, as well as IFNγ within TRM cells specifically. The Th1-skewed phenotype was confirmed in irAE colitis cases compared with healthy colon.
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Affiliation(s)
- Robin Reschke
- Department of Pathology, University of Chicago, Chicago, Illinois
| | - Jason W. Shapiro
- Center for Research Informatics, University of Chicago, Chicago, Illinois
| | - Jovian Yu
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - Sherin J. Rouhani
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - Daniel J. Olson
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - Yuanyuan Zha
- Human Immunological Monitoring Facility, University of Chicago, Chicago, Illinois
| | - Thomas F. Gajewski
- Department of Pathology, University of Chicago, Chicago, Illinois
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
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5
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Immune-Related Uncommon Adverse Events in Patients with Cancer Treated with Immunotherapy. Diagnostics (Basel) 2022; 12:diagnostics12092091. [PMID: 36140493 PMCID: PMC9498261 DOI: 10.3390/diagnostics12092091] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/06/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
Immunotherapy has dramatically changed the therapeutic landscape of oncology, and has become standard of care in multiple cancer types in front or late lines of therapy, with some longstanding responses and outstanding results. Notwithstanding, its use has brought a totally unique spectrum of adverse events, characterized by a myriad of diverse manifestations affecting nearly every organ and system of the body, including the endocrine, nervous, cardiac, respiratory and gastrointestinal systems. Uncommon adverse events, defined as those occurring in less than 1% of patients, comprise an even more heterogeneous group of diseases that are being seen more recurrently as the use of immune check-point inhibitors increases and indications spread in different tumor types and stages. Here, we comprehensively review some uncommon, but exceedingly important, immune-related adverse events, with special emphasis in the clinical approach and diagnostic workup, aiming to reunite the evidence published previously, allowing an increase in awareness and knowledge from all specialists implicated in the diagnosis, treatment, and care of cancer patients treated with immunotherapy.
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6
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Sollena P, Cappilli S, Federico F, Schinzari G, Tortora G, Peris K. "Skin rashes" and immunotherapy in melanoma: distinct dermatologic adverse events and implications for therapeutic management. Hum Vaccin Immunother 2022; 18:1889449. [PMID: 33759689 PMCID: PMC9122307 DOI: 10.1080/21645515.2021.1889449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/24/2021] [Accepted: 02/07/2021] [Indexed: 12/17/2022] Open
Abstract
Immune checkpoint inhibitors have shown efficacy in the treatment of different cancers by stimulating the antitumoral activity of the patient's immune system, representing a major breakthrough in the field of cancer therapy. Monoclonal antibodies including anti-cytotoxic T-lymphocyte-associated protein 4, anti-programmed cell death protein 1 and its ligand inhibitors have been approved for advanced melanoma among other solid cancers. Although immunotherapy demonstrated a good safety profile, a new spectrum of multisystemic immune-related adverse events has been recently reported due to their use. Cutaneous reactions represent one of the leading adverse events, often reported in literature as "skin rash", and rarely further characterized in distinct dermatologic entities. Herein we describe the distinctive cutaneous rashes occurring during immunotherapies for advanced melanoma, discussing implications in the treatment management.
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Affiliation(s)
- Pietro Sollena
- Dermatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Simone Cappilli
- Dermatologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Federico
- Department of Pathology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Schinzari
- Department of Medical Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giampaolo Tortora
- Department of Medical Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Ketty Peris
- Dermatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Dermatologia, Università Cattolica del Sacro Cuore, Rome, Italy
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7
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Advances in the Pathomechanisms of Delayed Drug Hypersensitivity. Immunol Allergy Clin North Am 2022; 42:357-373. [PMID: 35469623 DOI: 10.1016/j.iac.2022.01.002] [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: 12/30/2022]
Abstract
Delayed drug hypersensitivity continues to contribute to major clinical problems worldwide. The clinical presentations of delayed drug hypersensitivity are diverse, ranging from mild skin rashes to life-threatening systemic reactions. The pathomechanism of delayed drug hypersensitivity involves human leukocyte antigens (HLA) presentation of drugs/metabolites to T cell receptors (TCR), resulting in T-cell activation. The pathogenesis of delayed drug hypersensitivity also has reactivation of the virus, and activation of many immune mediators. In this review, we discuss the immune pathogenesis, molecular interactions of HLA/drugs/TCR, and downstream signaling of cytotoxic proteins/cytokines/chemokines, as well as disease prevention and management for delayed drug hypersensitivity.
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8
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Chen CH, Yu HS, Yu S. Cutaneous Adverse Events Associated with Immune Checkpoint Inhibitors: A Review Article. Curr Oncol 2022; 29:2871-2886. [PMID: 35448208 PMCID: PMC9032875 DOI: 10.3390/curroncol29040234] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/15/2022] [Accepted: 04/15/2022] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have emerged as novel options that are effective in treating various cancers. They are monoclonal antibodies that target cytotoxic T-lymphocyte antigen 4 (CTLA-4), programmed cell death 1 (PD-1), and programmed cell death-ligand 1 (PD-L1). However, activation of the immune systems through ICIs may concomitantly trigger a constellation of immunologic symptoms and signs, termed immune-related adverse events (irAEs), with the skin being the most commonly involved organ. The dermatologic toxicities are observed in nearly half of the patients treated with ICIs, mainly in the form of maculopapular rash and pruritus. In the majority of cases, these cutaneous irAEs are self-limiting and manageable, and continuation of the ICIs is possible. This review provides an overview of variable ICI-mediated dermatologic reactions and describes the clinical and histopathologic presentation. Early and accurate diagnosis, recognition of severe toxicities, and appropriate management are key goals to achieve the most favorable outcomes and quality of life in cancer patients.
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Affiliation(s)
- Chieh-Hsun Chen
- Department of Dermatology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan;
| | - Hsin-Su Yu
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807378, Taiwan;
| | - Sebastian Yu
- Department of Dermatology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan;
- Department of Dermatology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
- Neuroscience Research Center, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
- Correspondence: ; Tel.: +886-7-3121101 (ext. 6103)
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9
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Skudalski L, Waldman R, Kerr PE, Grant-Kels JM. Melanoma: An update on systemic therapies. J Am Acad Dermatol 2022; 86:515-524. [PMID: 34915056 DOI: 10.1016/j.jaad.2021.09.075] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/10/2021] [Accepted: 09/11/2021] [Indexed: 10/19/2022]
Abstract
Despite advances in early detection as described in part 1 of this continuing medical education series, melanoma continues to be a large contributor to cutaneous cancer-related mortality. In a subset of patients with unresectable or metastatic disease, surgical clearance is often not possible; therefore, systemic and local therapies are considered. The second article in this series provides dermatologists with an up-to-date working knowledge of the treatment options that may be prescribed by oncologists for patients with unresectable stage III, stage IV, and recurrent melanoma.
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Affiliation(s)
- Lauren Skudalski
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Reid Waldman
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Philip E Kerr
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut; Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida.
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10
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Kortekaas Krohn I, Aerts JL, Breckpot K, Goyvaerts C, Knol E, Van Wijk F, Gutermuth J. T-cell subsets in the skin and their role in inflammatory skin disorders. Allergy 2022; 77:827-842. [PMID: 34559894 DOI: 10.1111/all.15104] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/11/2021] [Indexed: 12/20/2022]
Abstract
T lymphocytes (T cells) are major players of the adaptive immune response. Naive T cells are primed in the presence of cytokines, leading to polarization into distinct T-cell subsets with specific functions. These subsets are classified based on their T-cell receptor profile, expression of transcription factors, surface cytokine and chemokine receptors, and their cytokine production, which together determine their specific function. This review provides an overview of the various T-cell subsets and their function in several inflammatory skin disorders ranging from allergic inflammation to skin tumors. Moreover, we highlight similarities of T-cell responses across different skin disorders, demonstrating the presence of similar and opposing functions for the different T-cell subsets. Finally, we discuss the effects of currently available and promising therapeutic approaches to harness T cells in inflammatory skin diseases for which efficacy next to unwanted side effects provide new insights into the pathophysiology of skin disorders.
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Affiliation(s)
- Inge Kortekaas Krohn
- Vrije Universiteit Brussel (VUB)Skin Immunology & Immune Tolerance (SKIN) Research Group Brussels Belgium
- Vrije Universiteit Brussel (VUB)Universitair Ziekenhuis Brussel (UZ Brussel)Department of DermatologyUniversitair Ziekenhuis Brussel Brussels Belgium
| | - Joeri L. Aerts
- Vrije Universiteit Brussel (VUB)Neuro‐Aging and Viro‐Immunotherapy (NAVI) Research Group Brussels Belgium
| | - Karine Breckpot
- Vrije Universiteit Brussel (VUB)Laboratory for Molecular and Cellular Therapy (LMCT)Department of Biomedical Sciences Brussels Belgium
| | - Cleo Goyvaerts
- Vrije Universiteit Brussel (VUB)Laboratory for Molecular and Cellular Therapy (LMCT)Department of Biomedical Sciences Brussels Belgium
| | - Edward Knol
- Center for Translational Immunology University Medical Center Utrecht Utrecht The Netherlands
- Department Dermatology/Allergology University Medical Center Utrecht Utrecht The Netherlands
| | - Femke Van Wijk
- Center for Translational Immunology University Medical Center Utrecht Utrecht The Netherlands
| | - Jan Gutermuth
- Vrije Universiteit Brussel (VUB)Skin Immunology & Immune Tolerance (SKIN) Research Group Brussels Belgium
- Vrije Universiteit Brussel (VUB)Universitair Ziekenhuis Brussel (UZ Brussel)Department of DermatologyUniversitair Ziekenhuis Brussel Brussels Belgium
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11
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Pospischil I, Hoetzenecker W. Arzneimittelexantheme unter modernen zielgerichteten Therapien - Immuncheckpoint- und EGFR-Inhibitoren. J Dtsch Dermatol Ges 2021; 19:1621-1645. [PMID: 34811897 DOI: 10.1111/ddg.14641_g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/19/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Isabella Pospischil
- Universitätsklinik für Dermatologie und Venerologie, Kepler Universitätsklinikum, Johannes Kepler Universität, Linz, Österreich
| | - Wolfram Hoetzenecker
- Universitätsklinik für Dermatologie und Venerologie, Kepler Universitätsklinikum, Johannes Kepler Universität, Linz, Österreich
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12
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Pospischil I, Hoetzenecker W. Drug eruptions with novel targeted therapies - immune checkpoint and EGFR inhibitors. J Dtsch Dermatol Ges 2021; 19:1621-1643. [PMID: 34811916 PMCID: PMC9299005 DOI: 10.1111/ddg.14641] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/19/2021] [Indexed: 12/25/2022]
Abstract
Given the increasing use of novel targeted therapies, dermatologists are constantly confronted with novel cutaneous side effects of these agents. A rapid diagnosis and appropriate management of these side effects are crucial to prevent impairment of the patients' quality of life and interruptions of essential cancer treatments. Immune checkpoint and EGFR inhibitors are frequently used targeted therapies for various malignancies and are associated with a distinct spectrum of cutaneous adverse events. Exanthematous drug eruptions represent a particular diagnostic challenge in these patients. Immune checkpoint inhibitors can elicit a plethora of immune-related exanthemas, most commonly maculopapular, lichenoid, and psoriasiform eruptions. Additionally, autoimmune bullous dermatoses and exanthemas associated with connective tissue diseases may arise. In cases of severe, atypical or therapy-resistant presentations an extensive dermatological investigation including a skin biopsy is recommended. Topical and systemic steroids are the mainstay of treatment. Papulopustular eruptions represent the major cutaneous adverse effect of EGFR inhibitor therapy, occurring in up to 90 % of patients within the first two weeks of therapy, depending on the agent. Besides topical antibiotics and steroids, oral tetracyclines are the first choice in systemic treatment and can also be used as prophylaxis.
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Affiliation(s)
- Isabella Pospischil
- Department of Dermatology, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Wolfram Hoetzenecker
- Department of Dermatology, Kepler University Hospital, Johannes Kepler University, Linz, Austria
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13
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Paul P, Walker CP, Paul M, Dey D. Sweet's Syndrome in a Patient With Seropositive Rheumatoid Arthritis After Starting Adalimumab: Is Sweet's Syndrome Related to Rheumatoid Arthritis or Is It the Paradoxical Effect of Adalimumab? Cureus 2021; 13:e16804. [PMID: 34513410 PMCID: PMC8407047 DOI: 10.7759/cureus.16804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2021] [Indexed: 01/15/2023] Open
Abstract
Sweet’s syndrome is a rare acute febrile neutrophilic dermatosis accompanied by fever, neutrophilia, and asymmetrical distribution of tender erythematous skin lesions. The underlying biological pathways responsible for this inflammatory skin disorder are not yet clearly established. However, an association with autoimmune disease, neoplasm, and drugs could be indicative of unusual hypersensitivity involving proinflammatory cytokines. There are several case reports indicating an association between Sweet’s syndrome and rheumatoid arthritis (RA). Proinflammatory cytokines are considered to play a vital role in the pathogenesis of both RA and Sweet’s syndrome. Adalimumab works against proinflammatory cytokines and is considered a disease-modifying antirheumatic drug in RA; it is also reported to be effective in refractory Sweet’s syndrome. While adalimumab has been proven to be beneficial in autoimmune disorders and inflammatory conditions, there are also reports of paradoxical development of Sweet’s syndrome with adalimumab. In this report, we present a case of Sweet’s syndrome in a 74-year-old adult patient with a history of seropositive RA who developed Sweet’s syndrome within two months after the initiation of adalimumab therapy.
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Affiliation(s)
- Prodip Paul
- Internal Medicine, Geisinger Community Medical Center, Scranton, USA
| | - Chad P Walker
- Rheumatology, Geisinger Musculoskeletal Institute, Scranton, USA.,Rheumatology, Geisinger Health System, Scranton, USA
| | | | - Dipon Dey
- Epidemiology and Public Health, ZWH Medical Care PC, New York, USA
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14
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Abstract
PURPOSE OF REVIEW The past decade has witnessed unprecedented delivery to the clinical arena of a range of novel, innovative, and effective targeted anticancer therapies. These include immunotherapies, most prominently immune checkpoint inhibitors, as well as agents that target growth factors and cancer-related mutations. Many of these new cancer therapies are, however, associated with an array of toxicities, necessitating insight and vigilance on the part of attending physicians to achieve high-quality supportive care alongside toxicity management. In this review, we consider some of the key supportive care issues in toxicity management. RECENT FINDINGS Although both supportive care and targeted therapies have brought significant benefits to cancer care, the management of novel cancer therapy toxicities is nevertheless often complex. This is due in large part to the fact that target organs differ widely, particularly in the case of checkpoint inhibitors, with minor dermatological disorders being most common, while others, such as pneumonitis, are more severe and potentially life threatening. Accordingly, efficient management of these immune-related adverse events requires collaboration between multiple medical specialists. SUMMARY Supportive care is a key component in the management of new cancer therapy toxicities and needs to be incorporated into treatment pathways.
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Affiliation(s)
- Bernardo L Rapoport
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria
- The Medical Oncology Centre of Rosebank, Johannesburg, South Africa
- The Multinational Association for Supportive Care in Cancer (MASCC), Infection and Myelosuppression Study Group, Aurora, Ontario, Canada
| | - Tim Cooksley
- The Multinational Association for Supportive Care in Cancer (MASCC), Infection and Myelosuppression Study Group, Aurora, Ontario, Canada
- Manchester University Foundation Trust
- The Christie, University of Manchester, Manchester, UK
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, Tennessee, USA
| | - Ronald Anderson
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria
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15
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Curry JL, Chon SY, Marques-Piubelli ML, Chu EY. Cutaneous Toxicities in the Setting of Immune Checkpoint Blockade:: The Era of Oncodermatopathology. Surg Pathol Clin 2021; 14:209-224. [PMID: 34023101 DOI: 10.1016/j.path.2021.01.002] [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: 10/21/2022]
Abstract
Advancements in cancer therapy with monoclonal immune checkpoint antibody blockade have impacted the practice of all medical specialties. Cutaneous immune-related adverse events (irAEs) are a frequent, unintended, off-target consequence of immune checkpoint inhibitor (ICI) therapy that have ushered in the era of oncodermatopathology. Knowledge of the diverse morphologic types of cutaneous irAEs from ICI therapy allows further classification of cutaneous irAEs according to major histopathologic reaction patterns. Early studies suggest that immune mechanisms of lichenoid dermatitis irAE, psoriasiform dermatitis irAE, and bullous pemphigoid irAE show some similarities and differences from their histopathologic counterparts not associated with ICI therapy.
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Affiliation(s)
- Jonathan L Curry
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Susan Y Chon
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Mario L Marques-Piubelli
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Emily Y Chu
- Department of Dermatology, The University of Pennsylvania, Philadelphia, PA 19104, USA
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16
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Hsu YSO, Lu KL, Fu Y, Wang CW, Lu CW, Lin YF, Chang WC, Yeh KY, Hung SI, Chung WH, Chen CB. The Roles of Immunoregulatory Networks in Severe Drug Hypersensitivity. Front Immunol 2021; 12:597761. [PMID: 33717075 PMCID: PMC7953830 DOI: 10.3389/fimmu.2021.597761] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/18/2021] [Indexed: 12/12/2022] Open
Abstract
The immunomodulatory effects of regulatory T cells (Tregs) and co-signaling receptors have gained much attention, as they help balance immunogenic and immunotolerant responses that may be disrupted in autoimmune and infectious diseases. Drug hypersensitivity has a myriad of manifestations, which ranges from the mild maculopapular exanthema to the severe Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome (DRESS/DIHS). While studies have identified high-risk human leukocyte antigen (HLA) allotypes, the presence of the HLA allotype at risk is not sufficient to elicit drug hypersensitivity. Recent studies have suggested that insufficient regulation by Tregs may play a role in severe hypersensitivity reactions. Furthermore, immune checkpoint inhibitors, such as anti-CTLA-4 or anti-PD-1, in cancer treatment also induce hypersensitivity reactions including SJS/TEN and DRESS/DIHS. Taken together, mechanisms involving both Tregs as well as coinhibitory and costimulatory receptors may be crucial in the pathogenesis of drug hypersensitivity. In this review, we summarize the currently implicated roles of co-signaling receptors and Tregs in delayed-type drug hypersensitivity in the hope of identifying potential pharmacologic targets.
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Affiliation(s)
- Yun-Shiuan Olivia Hsu
- Department of Medical Education, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kun-Lin Lu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Yun Fu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chuang-Wei Wang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Chang Gung Immunology Consortium, Linkou, Taiwan
| | - Chun-Wei Lu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yu-Fen Lin
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Nursing, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Wen-Cheng Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Kun-Yun Yeh
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shuen-Iu Hung
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Chang Gung Immunology Consortium, Linkou, Taiwan
| | - Wen-Hung Chung
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Chang Gung Immunology Consortium, Linkou, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Dermatology, Chang Gung Hospital, Xiamen, China
- Department of Dermatology, Beijing Tsinghua Chang Gung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Dermatology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
- Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chun-Bing Chen
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Chang Gung Immunology Consortium, Linkou, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Dermatology, Chang Gung Hospital, Xiamen, China
- Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, Taiwan
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17
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Apalla Z, Papageorgiou C, Lallas A, Delli F, Fotiadou C, Kemanetzi C, Lazaridou E. Cutaneous Adverse Events of Immune Checkpoint Inhibitors: A Literature Review. Dermatol Pract Concept 2021; 11:e2021155. [PMID: 33614223 DOI: 10.5826/dpc.1101a155] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 12/12/2022] Open
Abstract
Immune checkpoints assist with self-tolerance and minimize collateral tissue damage when immune responses are activated. Although immune checkpoint inhibitors (CPIs) are characterized by a favorable risk/benefit ratio, immune checkpoint blockade has been associated with a new subset of autoimmune-like toxicities, named immune-related adverse events (irAEs). Dermatologic reactions are among the most prevalent irAEs triggered by CPIs. In a majority of cases they are self-limiting and readily manageable. However, it is not uncommon that they result in severe skin involvement and impairment of patients' quality of life. Awareness of the spectrum of cutaneous irAEs is mandatory for every clinician involved in the management of oncologic patients. The role of the dermatologists is essential because early recognition and appropriate management of skin toxicity may prevent dose modifications and discontinuation of CPIs. The latter is particularly relevant, considering that recent data suggest favorable oncologic response in patients developing irAEs.
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Affiliation(s)
- Zoe Apalla
- Second Dermatology Department, School of Medicine, Aristotle University of Thessaloniki, Greece
| | - Chryssoula Papageorgiou
- Second Dermatology Department, School of Medicine, Aristotle University of Thessaloniki, Greece
| | - Aimilios Lallas
- First Dermatology Department, School of Medicine, Aristotle University of Thessaloniki, Greece
| | - Florentina Delli
- State Dermatology Department, Hippokratio General Hospital of Thessaloniki, Greece
| | - Christina Fotiadou
- Second Dermatology Department, School of Medicine, Aristotle University of Thessaloniki, Greece
| | - Christina Kemanetzi
- Second Dermatology Department, School of Medicine, Aristotle University of Thessaloniki, Greece
| | - Elizabeth Lazaridou
- Second Dermatology Department, School of Medicine, Aristotle University of Thessaloniki, Greece
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18
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Abstract
Drug reactions resulting from chemotherapy agents are common and frequently affect the skin. Although often benign, a select few of these cutaneous reactions may necessitate immediate changes to the antineoplastic regimens. Given the diversity of chemotherapeutic skin reactions and their complex implications on patient management, an organized conceptual schema is imperative for proper patient care. We evaluate a number of commonly seen chemotherapy-induced skin toxicities organized by pathogenic mechanism and drug class, providing a framework for the identification and categorization of adverse events to prevent unrecognition. Groupings of these reactions include direct cytotoxicity and/or drug accumulation, immunologic hypersensitivity, and aberrant molecular signaling.
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Affiliation(s)
- Dylan Haynes
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon, USA
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon, USA.
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19
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Morris LM, Lewis HA, Cornelius LA, Chen DY, Rosman IS. Neutrophil-predominant bullous pemphigoid induced by checkpoint inhibitors: A case series. J Cutan Pathol 2020; 47:742-746. [PMID: 32196722 DOI: 10.1111/cup.13687] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 12/16/2022]
Abstract
Checkpoint inhibitors have been revolutionary in the treatment of metastatic melanoma, non-small-cell lung cancer, and renal cell carcinoma. By restricting negative feedback of T-cells, checkpoint inhibitors allow the immune system to identify and destroy malignant cells. This enhanced immune response is efficacious in the treatment of the aforementioned malignancies; however, it may lead to immune-related adverse events. Bullous pemphigoid (BP) is a well-documented cutaneous adverse reaction of checkpoint inhibitors, with a majority of cases reporting an eosinophil-predominant or mixed inflammatory infiltrate. We report two cases of neutrophil-predominant BP presenting in patients on checkpoint inhibitors.
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Affiliation(s)
- Lisa M Morris
- Columbia School of Medicine, University of Missouri, Columbia, Missouri
| | - Hal A Lewis
- Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri
| | - Lynn A Cornelius
- Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri
| | - David Y Chen
- Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri
| | - Ilana S Rosman
- Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri.,Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
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20
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Ellis SR, Vierra AT, Millsop JW, Lacouture ME, Kiuru M. Dermatologic toxicities to immune checkpoint inhibitor therapy: A review of histopathologic features. J Am Acad Dermatol 2020; 83:1130-1143. [PMID: 32360716 DOI: 10.1016/j.jaad.2020.04.105] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 04/03/2020] [Accepted: 04/20/2020] [Indexed: 02/08/2023]
Abstract
Antineoplastic agents that use the immune system have revolutionized cancer treatment. Specifically, implementation of immune checkpoint inhibitors, monoclonal antibodies that block cytotoxic T-lymphocyte-associated antigen-4, programmed cell death protein 1, or programmed cell death ligand 1 show improved and sustained responses in patients with cancer. However, these agents are associated with a plethora of adverse events, many manifesting in the skin. As the clinical application of cancer immunotherapies expands, understanding the clinical and histopathologic features of associated cutaneous toxicities becomes increasingly important to dermatologists, oncologists, and pathologists to ensure timely diagnosis and appropriate care. This review discusses cutaneous reactions to immune checkpoint inhibitors, focusing on histopathologic features.
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Affiliation(s)
- Samantha R Ellis
- Department of Dermatology, University of California, Davis, Sacramento, California; PotozkinMD Skincare Center, Danville, California
| | - Aren T Vierra
- Department of Dermatology, University of California, Davis, Sacramento, California
| | - Jillian W Millsop
- Department of Dermatology, Vacaville Medical Center, The Permanente Medical Group, Vacaville, California
| | - Mario E Lacouture
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maija Kiuru
- Department of Dermatology, University of California, Davis, Sacramento, California; Department of Pathology and Laboratory Medicine, University of California, Davis, Sacramento, California.
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21
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Yaşar HA, Akkus E, Heper A, Akay BN, Urun Y, Utkan G. Sweet's syndrome under ipilimumab therapy and a brief comparison of the cases in literature. J Oncol Pharm Pract 2020; 26:1762-1764. [PMID: 32089071 DOI: 10.1177/1078155220906885] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Ipilimumab is an anti-cytotoxic T lymphocyte antigen 4 (CTLA-4) antibody. Ipilimumab has shown improvement in overall survival in patients with advanced melanoma. Because ipilimumab activates the immune system against the tumor, ipilimumab is associated with adverse events related to immune system activation. Immune-associated side effects are frequently seen in the gastrointestinal system and skin. Sweet's syndrome (SS) is an uncommon inflammatory disorder. Some drugs or malignancy can cause SS. Only a few case reports have been reported of ipilimumab-associated SS. CASE A 53-year-old female with metastatic melanoma was treated with ipilimumab. After the fourth cycle, she developed painful lesions on her legs and hands. The pathologic biopsy of the lesions revealed neutrophilic dermatosis consistent with SS.Management and outcome: The patient was treated with 60 mg/day of prednisone for four days, nonsteroidal anti-inflammatory drugs and inhaler bronchodilator and steroid. She had symptomatic relief at the beginning of treatment. The prednisone doses were quickly tapered every three days. When the patient was treated with 10 mg/day of prednisone for three days, the skin nodules recurred. Prednisone 40 mg per day was re-started and then a slower taper by decreasing by 10 mg/day every week was instituted. After one-month treatment the prednisone dose was given as a 5 mg doses for one week and then stopped. No new lesions recurred after slower taper of prednisone. CONCLUSION Herein we report a case presented with SS under ipilimumab therapy. Melanoma patients treated with ipilimumab can develop SS. The clinicians should be aware of this condition.
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Affiliation(s)
- Hatime A Yaşar
- Department of Medical Oncology, Ankara University School of Medicine, Ankara, Turkey
| | - Erman Akkus
- Department of Internal Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Aylin Heper
- Department of Pathology, Ankara University School of Medicine, Ankara, Turkey
| | - Bengu N Akay
- Department of Dermatology, Ankara University School of Medicine, Ankara, Turkey
| | - Yuksel Urun
- Department of Medical Oncology, Ankara University School of Medicine, Ankara, Turkey
| | - Gungor Utkan
- Department of Medical Oncology, Ankara University School of Medicine, Ankara, Turkey
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22
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Coleman EL, Olamiju B, Leventhal JS. The life-threatening eruptions of immune checkpoint inhibitor therapy. Clin Dermatol 2020; 38:94-104. [DOI: 10.1016/j.clindermatol.2019.10.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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23
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Kaur A, Doberstein T, Amberker RR, Garje R, Field EH, Singh N. Immune-related adverse events in cancer patients treated with immune checkpoint inhibitors: A single-center experience. Medicine (Baltimore) 2019; 98:e17348. [PMID: 31593084 PMCID: PMC6799752 DOI: 10.1097/md.0000000000017348] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) like cytotoxic T-lymphocyte-associated protein 4 (anti-CTLA4) and programmed death cell protein 1 (anti-PD1) have revolutionized cancer treatment. As ICI use becomes widespread, more immune-related adverse events (irAE's) are being reported. Our aim was to investigate the frequency and nature of new irAE's as well as report the frequency of flare-ups of pre-existing autoimmune conditions occurring after ICI therapy.We performed a retrospective chart review of all patients treated for cancer with anti-PD1 or anti-CTLA4 or combination therapy at our tertiary care center from January 2014 to April 2016. Demographic data, cancer type and stage, irAE's (new immune disorders and disease flares of pre-existing autoimmune disorders on ICI therapy), and drug treatment information were extracted.We identified 220 patients treated with ICI therapy during the study period out of which 27% (60/220) developed irAE's. 11% in anti-CTLA4 group and 16% among anti-PD1 treated patients developed irAE's. IrAE's resulted in discontinuation of cancer therapy in 28% of those who developed irAE's. 21.4% had a flare of their autoimmune disease but only 1 required discontinuation of immunotherapy.IrAE's are an important emerging clinical disease entity for specialists to be aware of. Our study shows that ICI's can be safely used in patients with pre-existing autoimmune conditions with close monitoring. However, there is still a large unmet need to have a better understanding of how to systematically evaluate and manage patients with irAE's as well as for identifying the predictors of irAE's.
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Affiliation(s)
- Aneet Kaur
- Division of Immunology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | | | | | | | - Elizabeth Hirak Field
- Division of Immunology, University of Iowa and Clinics and Iowa City VA Medical Center
| | - Namrata Singh
- Division of Immunology, University of Iowa Hospitals and Clinics and Iowa City VA Medical Center, Iowa City, IA
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24
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Ravi V, Maloney NJ, Worswick S. Neutrophilic dermatoses as adverse effects of checkpoint inhibitors: A review. Dermatol Ther 2019; 32:e13074. [DOI: 10.1111/dth.13074] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/13/2019] [Accepted: 08/21/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Vignesh Ravi
- Department of DermatologyKeck School of Medicine at the University of Southern California Los Angeles California
| | - Nolan J. Maloney
- Division of Dermatology, Department of MedicineDavid Geffen School of Medicine at UCLA Los Angeles California
| | - Scott Worswick
- Department of DermatologyKeck School of Medicine at the University of Southern California Los Angeles California
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25
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Paulson KG, Lahman MC, Chapuis AG, Brownell I. Immunotherapy for skin cancer. Int Immunol 2019; 31:465-475. [PMID: 30753483 PMCID: PMC6626298 DOI: 10.1093/intimm/dxz012] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 02/04/2019] [Indexed: 12/12/2022] Open
Abstract
Among all tumor types, skin cancers are profoundly sensitive to immunotherapy. Indeed, the recently reported response rates for anti-PD-1 (anti-programmed-death 1) therapy for cutaneous malignant melanomas (MM), Merkel cell carcinomas, basal cell carcinomas, cutaneous squamous cell carcinomas and Kaposi sarcomas are all above 40%. This unique immunogenicity renders skin cancers as a paradigm for tumor-immune interactions and is driven by high mutational burdens, over-expressed tumor antigens and/or viral antigens. However, despite the clear demonstration of immunologic cure of skin cancer in some patients, most tumors develop either early (primary) or late (adaptive) resistance to immunotherapy. Resistance mechanisms are complex, and include contributions of tumor cell-intrinsic, T cell and microenvironment factors that have been recently further elucidated with the advent of single-cell technologies. This review will focus on the exciting progress with immunotherapy for skin cancers to date, and also our current understanding of the mechanisms of resistance to immunotherapy.
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Affiliation(s)
- Kelly G Paulson
- Clinical Research Division, Program in Immunology, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Divisions of Medical Oncology and Molecular Medicine, Departments of Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Miranda C Lahman
- Clinical Research Division, Program in Immunology, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Divisions of Medical Oncology and Molecular Medicine, Departments of Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Aude G Chapuis
- Clinical Research Division, Program in Immunology, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Divisions of Medical Oncology and Molecular Medicine, Departments of Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Isaac Brownell
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
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26
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Abstract
The incidence of metastatic melanoma continues to increase each decade. Although surgical treatment is often curative for localized stage I and stage II disease, the median survival for patients with distant metastases is less than 1 year. The last 2 decades have witnessed a breakthrough in therapeutic options with the development of immune checkpoint inhibitors, small molecule targeted therapy, and oncolytic viral therapy. This article provides an overview of the treatment options available for advanced melanoma, including chemotherapy, targeted therapy, immunotherapy, interleukin-2, and oncolytic viral agents.
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Affiliation(s)
- Leonora Bomar
- Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Aditi Senithilnathan
- Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Christine Ahn
- Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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27
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Coleman E, Panse G, Cowper S, Prebet T, Gore S, Leventhal J. Lobular neutrophilic panniculitis associated with DNA methyltransferase inhibitors in the treatment of myeloid disease. J Cutan Pathol 2019; 46:930-934. [PMID: 31254406 DOI: 10.1111/cup.13537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 06/14/2019] [Accepted: 06/24/2019] [Indexed: 11/28/2022]
Abstract
Cutaneous toxicities to DNA methyltransferase inhibitors are variable and include localized injection site reactions, ecchymoses, maculopapular eruptions, and neutrophilic dermatoses including pyoderma gangrenosum, Sweet syndrome, and neutrophilic eccrine hidradenitis. This series describes two patients diagnosed with lobular neutrophilic panniculitis arising during treatment of acute myelogenous leukemia with "hypomethylating drugs," including the first report of its occurrence with a next-generation agent. Differential diagnoses, histopathologic characteristics, treatment considerations, and proposed pathogenesis will be discussed.
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Affiliation(s)
- Emily Coleman
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Gauri Panse
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Shawn Cowper
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Thomas Prebet
- Department of Internal Medicine (Hematology and Oncology), Yale University School of Medicine, New Haven, Connecticut
| | - Steven Gore
- Department of Internal Medicine (Hematology and Oncology), Yale University School of Medicine, New Haven, Connecticut
| | - Jonathan Leventhal
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
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28
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Heath MS, Ortega-Loayza AG. Insights Into the Pathogenesis of Sweet's Syndrome. Front Immunol 2019; 10:414. [PMID: 30930894 PMCID: PMC6424218 DOI: 10.3389/fimmu.2019.00414] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/15/2019] [Indexed: 12/15/2022] Open
Abstract
Sweet's syndrome, also known as Acute Febrile Neutrophilic Dermatosis, is a rare inflammatory condition. It is considered to be the prototype disease of neutrophilic dermatoses, and presents with acute onset dermal neutrophilic lesions, leukocytosis, and pyrexia. Several variants have been described both clinically and histopathologically. Classifications include classic Sweet's syndrome, malignancy associated, and drug induced. The cellular and molecular mechanisms involved in Sweet's syndrome have been difficult to elucidate due to the large variety of conditions leading to a common clinical presentation. The exact pathogenesis of Sweet's syndrome is unclear; however, new discoveries have shed light on the role of inflammatory signaling, disease induction, and relationship with malignancy. These findings include an improved understanding of inflammasome activation, malignant transformation into dermal infiltrating neutrophils, and genetic contributions. Continued investigations into effective treatments and targeted therapy will benefit patients and improve our molecular understanding of inflammatory diseases, including Sweet's syndrome.
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Affiliation(s)
- Michael S Heath
- Oregon Health and Science University, Department of Dermatology, Portland, OR, United States
| | - Alex G Ortega-Loayza
- Oregon Health and Science University, Department of Dermatology, Portland, OR, United States
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29
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Abstract
Inflammatory skin diseases encompass a vast array of conditions. The field continues to expand and evolve with resurgence of conditions, through newly recognized medication adverse effects, and via more detailed descriptions of known dermatoses. The importance of clinicopathologic correlation and an up to date knowledge of dermatologic conditions cannot be overstated. This review focuses on an array of recent important developments in the histologic diagnosis of inflammatory conditions that affect the skin.
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30
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Grávalos C, Sanmartín O, Gúrpide A, España A, Majem M, Suh Oh HJ, Aragón I, Segura S, Beato C, Botella R. Clinical management of cutaneous adverse events in patients on targeted anticancer therapies and immunotherapies: a national consensus statement by the Spanish Academy of Dermatology and Venereology and the Spanish Society of Medical Oncology. Clin Transl Oncol 2018; 21:556-571. [PMID: 30284232 DOI: 10.1007/s12094-018-1953-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 09/11/2018] [Indexed: 12/17/2022]
Abstract
Progress in the understanding of many tumors has enabled the development of new therapies, such as those targeted at specific molecules involved in cell growth (targeted therapies) or intended to modulate the immune system (immunotherapy). However, along with the clinical benefit provided by these new treatments, new adverse effects have also appeared. Dermatological toxicities such as papulopustular eruptions, xerosis, and pruritus are common with EGFR inhibitors. Other adverse effects have also been described with PDGFR, BCR-ABL, and MAPK tyrosine kinase inhibitors, antiangiogenic drugs, and inhibitors at immune checkpoints such as CTLA-4 and PD-1/PD-L1. Onset of these adverse effects often causes dose reductions and/or delays in administering the prescribed therapy, which can affect patient survival and quality of life. It is, therefore, important to prevent the occurrence of these adverse effects, or to treat unavoidable ones as soon as possible. This requires cooperation between medical oncologists and dermatologists. This article reviews the various dermatological toxicities associated with targeted therapies and immunotherapies, along with their diagnosis and therapeutic management.
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Affiliation(s)
- C Grávalos
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Avenida de Córdoba km 5.4, 28041, Madrid, Spain.
| | - O Sanmartín
- Dermatology Department, Instituto Valenciano de Oncología, Valencia, Spain
| | - A Gúrpide
- Medical Oncology Department, Clínica Universitaria de Navarra, Pamplona, Spain
| | - A España
- Dermatology Department, Clínica Universitaria de Navarra, Pamplona, Spain
| | - M Majem
- Medical Oncology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - H J Suh Oh
- Dermatology Department, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - I Aragón
- Medical Oncology Department, Complejo Hospitalario Universitario de Huelva, Huelva, Spain
| | - S Segura
- Dermatology Department, Hospital del Mar, Barcelona, Spain
| | - C Beato
- Medical Oncology Department, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - R Botella
- Dermatology Service, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
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Wang L, Li N, Zhou L, Chen X, Tang W. Metastatic pulmonary melanoma complicated with erythroderma and recurrent sepsis. Respir Med Case Rep 2018; 25:204-206. [PMID: 30225190 PMCID: PMC6139490 DOI: 10.1016/j.rmcr.2018.09.004] [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: 12/03/2017] [Revised: 09/05/2018] [Accepted: 09/05/2018] [Indexed: 10/28/2022] Open
Abstract
Erythroderma is occasionally associated with lung cancer. Here we report a 69-year-old male who has history of melanoma from 8 years ago presented with erythroderma associated with skin, soft tissue and pulmonary infection. CT chest showed a single enlarging right upper lobe lung nodule. Biopsy showed evidence of adenocarcinoma, and eventually proven to be metastatic melanoma. The patient improved after antibiotics and antifungal treatment. To our knowledge, this is the first case of melanoma metastasis presented as erythroderma as paraneoplastic syndrome.
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Affiliation(s)
- Lining Wang
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Department of Hematology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ning Li
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ling Zhou
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaoyan Chen
- Department of Pathology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wei Tang
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Abstract
Cancer immunotherapy approaches have emerged as novel treatment regimens against cancer. A particularly interesting avenue is the concept of in situ vaccination, where immunostimulatory agents are introduced into an identified tumor to overcome local immunosuppression and, if successful, mount systemic antitumor immunity. We had previously shown that nanoparticles from cowpea mosaic virus (CPMV) are highly potent in inducing long-lasting antitumor immunity when used as an in situ vaccine in various tumor mouse models. Here we asked whether the nanoparticles from tobacco mosaic virus (TMV) could also be applied as an in situ vaccine and, if so, whether efficacy or mechanism of immune-activation would be affected by the nanoparticle size (300 × 18 nm native TMV vs 50 × 18 nm short TMV nanorods), shape (nanorods vs spherical TMV, termed SNP), or state of assembly (assembled TMV rod vs free coat protein, CP). Our studies indicate that CPMV, but less so TMV, elicits potent antitumor immunity after intratumoral treatment of dermal melanoma (B16F10 using C57BL/6 mice). TMV and TMVshort slowed tumor growth and increased survival time, however, at significantly lower potency compared to that of CPMV. There were no apparent differences between TMV, TMVshort, or the SNP indicating that the aspect ratio does not necessarily play a role in plant viral in situ vaccines. The free CPs did not elicit an antitumor response or immunostimulation, which may indicate that a multivalent assembly is required to trigger an innate immune recognition and activation. Differential potency of CPMV vs TMV can be explained with differences in immune-activation: data indicate that CPMV stimulates an antitumor response through recruitment of monocytes into the tumor microenvironment (TME), establishing signaling through the IFN-γ pathway, which also leads to recruitment of tumor-infiltrated neutrophils (TINs) and natural killer (NK) cells. Furthermore, the priming of the innate immune system also mounts an adaptive response with CD4+ and CD8+ T cell recruitment and establishment of effector memory cells. While the TMV treatment also lead to the recruitment of innate immune cells as well as T cells (although to a lesser degree), key differences were noted in cyto/chemokine profiling with TMV inducing a potent immune response early on characterized by strong pro-inflammatory cytokines, primarily IL-6. Together, data indicate that some plant viral nanotechnology platforms are more suitable for application as in situ vaccines than others; understanding the intricate differences and underlying mechanism of immune-activation may set the stage for clinical development of these technologies.
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Affiliation(s)
| | - Chao Wang
- Department of Biomedical Engineering
| | - Steven Fiering
- Department of Microbiology and Immunology
- Norris Cotton Cancer Center, Dartmouth University, Lebanon, New Hampshire 03756, United States
| | - Nicole F. Steinmetz
- Department of Biomedical Engineering
- Department of Radiology
- Department of Materials Science and Engineering
- Macromolecular Science and Engineering
- Division of General Medical Sciences-Oncology, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106, United States
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Dermatologic Reactions to Immune Checkpoint Inhibitors : Skin Toxicities and Immunotherapy. Am J Clin Dermatol 2018; 19:345-361. [PMID: 29256113 DOI: 10.1007/s40257-017-0336-3] [Citation(s) in RCA: 384] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The development of immune checkpoint inhibitors [monoclonal antibodies targeting cytotoxic T lymphocyte-associated antigen-4 (CTLA-4), programmed cell death protein 1 (PD-1) or programmed death ligand 1 (PD-L1)] represents a major breakthrough in cancer therapy. Although they present a favorable risk/benefit ratio, immune checkpoint blockade therapies have a very specific safety profile. Due to their unique mechanism of action, they entail a new spectrum of adverse events that are mostly immune related [immune-related adverse events (irAEs)], notably mediated by the triggering of cytotoxic CD4+/CD8+ T cell activation. Cutaneous toxicities appear to be one of the most prevalent irAEs, both with anti-PD-1 and anti-CTLA-4 agents or with the newly developed anti-PD-L1 agents, which corresponds to a class effect. They are observed in more than one-third of the treated patients, mainly in the form of a maculopapular rash (eczema-like spongiotic dermatitis) and pruritus. A wide range of other dermatologic manifestations can also occur, including lichenoid reactions, psoriasis, acneiform rashes, vitiligo-like lesions, autoimmune skin diseases (e.g., bullous pemphigoid, dermatomyositis, alopecia areata), sarcoidosis or nail and oral mucosal changes. In addition, the use of anti-CTLA-4 and anti-PD-1 therapies in combination is associated with the development of more frequent, more severe and earlier cutaneous irAEs compared to single agents. In most cases, these dysimmune dermatologic adverse events remain self-limiting and readily manageable. Early recognition and adequate management, however, are critical to prevent exacerbation of the lesions, to limit treatment interruption and to minimize quality of life impairment. This review describes the variable clinical and histopathologic aspects of dermatologic irAEs induced by immune checkpoint inhibitors. Appropriate treatment and counseling are also proposed, with a step-by-step approach for optimized management by both practicing oncologists and dermatologists.
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Boada A, Carrera C, Segura S, Collgros H, Pasquali P, Bodet D, Puig S, Malvehy J. Cutaneous toxicities of new treatments for melanoma. Clin Transl Oncol 2018; 20:1373-1384. [PMID: 29799097 DOI: 10.1007/s12094-018-1891-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/09/2018] [Indexed: 12/13/2022]
Abstract
New drugs against advanced melanoma have emerged during last decade. Target therapy and immunotherapy have changed the management of patients with metastatic disease. Along with its generalized use, drug toxicities have appeared and the skin is the target organ of a significant part of them. This revision summarizes the most common side effects and consensus management to improve the compliance of therapies and patients' quality of life. Among the BRAF inhibitors, main cutaneous side effects are photosensitivity, plantar hyperkeratosis, and the appearance of verrucal keratosis or squamous cell carcinoma. Special attention must be paid to the development of new primary melanomas or changes on nevi during BRAF inhibitor therapy. The most common cutaneous side effects of immunotherapy are rash, pruritus, and vitiligo. It remains controversial the possible role of these toxicities as markers of response to therapy.
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Affiliation(s)
- A Boada
- Dermatology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Crta/Canyet s/n., Badalona, 08016, Barcelona, Spain.
| | - C Carrera
- Melanoma Unit, Dermatology Department, Hospital Clinic, Institut d'investigacions biomèdiques August Pi i Sunyer (IDIBAPS), CIBERER, Universitat de Barcelona, Barcelona, Spain
| | - S Segura
- Dermatology Department, Hospital del Mar, Parc de Salut Mar, Fundació Institut Mar d'Investigacions Mèdiques, Barcelona, Spain
| | - H Collgros
- Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Sidney, Australia
| | - P Pasquali
- Dermatology Department, Pius Hospital Valls, Institut d'Investigació Sanitària Pere Virgili Valls, Tarragona, Spain
| | - D Bodet
- Dermatology Department, Hospital Universitari Vall d'Hebron, VHIR, Barcelona, Spain
| | - S Puig
- Melanoma Unit, Dermatology Department, Hospital Clinic, Institut d'investigacions biomèdiques August Pi i Sunyer (IDIBAPS), CIBERER, Universitat de Barcelona, Barcelona, Spain
| | - J Malvehy
- Melanoma Unit, Dermatology Department, Hospital Clinic, Institut d'investigacions biomèdiques August Pi i Sunyer (IDIBAPS), CIBERER, Universitat de Barcelona, Barcelona, Spain
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Sibaud V, Boulinguez S, Pagès C, Riffaud L, Lamant L, Chira C, Boyrie S, Vigarios E, Tournier E, Meyer N. [Dermatologic toxicities of immune checkpoint inhibitors]. Ann Dermatol Venereol 2018; 145:313-330. [PMID: 29678394 DOI: 10.1016/j.annder.2018.01.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 11/10/2017] [Accepted: 01/19/2018] [Indexed: 02/07/2023]
Abstract
The development of immune checkpoint inhibitors (monoclonal antibodies targeting PD-1/PD-L1 or CTLA-4) represents a significant advance in the treatment of multiple cancers. Given their particular mechanism of action, which involves triggering CD4+/CD8+ T-cell activation and proliferation, they are associated with a specific safety profile. Their adverse events are primarily immune-related, and can affect practically all organs. In this context, dermatological toxicity is the most common, though it mostly remains mild to moderate and does not require discontinuation of treatment. More than a third of patients are faced with cutaneous adverse events, usually in the form of a maculopapular rash, pruritus or vitiligo (only in patients treated for melanoma). Much more specific dermatologic disorders, however, may occur such as lichenoid reactions, induced psoriasis, sarcoidosis, auto-immune diseases (bullous pemphigoid, dermatomyositis, alopecia areata), acne-like rash, xerostomia, etc. Rigorous dermatological evaluation is thus mandatory in the case of atypical, persistent/recurrent or severe lesions. In this article, we review the incidence and spectrum of dermatologic adverse events reported with immune checkpoint inhibitors. Finally, a management algorithm is proposed.
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Affiliation(s)
- V Sibaud
- Oncologie médicale, institut Claudius-Regaud, institut universitaire du cancer Toulouse Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France; Oncodermatologie, institut universitaire du cancer Toulouse Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France.
| | - S Boulinguez
- Oncodermatologie, institut universitaire du cancer Toulouse Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
| | - C Pagès
- Oncodermatologie, institut universitaire du cancer Toulouse Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
| | - L Riffaud
- Oncodermatologie, institut universitaire du cancer Toulouse Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
| | - L Lamant
- Anatomo-pathologie, institut universitaire du cancer Toulouse Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
| | - C Chira
- Radiothérapie, institut universitaire du cancer Toulouse Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
| | - S Boyrie
- Radiothérapie, institut universitaire du cancer Toulouse Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
| | - E Vigarios
- Médecine bucco-dentaire, institut Claudius-Regaud, institut universitaire du cancer Toulouse Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France; UFR d'odontologie, 3, rue des Maraîchers, 31062 Toulouse, France
| | - E Tournier
- Anatomo-pathologie, institut universitaire du cancer Toulouse Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
| | - N Meyer
- Oncodermatologie, institut universitaire du cancer Toulouse Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
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Nelson CA, Stephen S, Ashchyan HJ, James WD, Micheletti RG, Rosenbach M. Neutrophilic dermatoses: Pathogenesis, Sweet syndrome, neutrophilic eccrine hidradenitis, and Behçet disease. J Am Acad Dermatol 2018; 79:987-1006. [PMID: 29653210 DOI: 10.1016/j.jaad.2017.11.064] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/06/2017] [Accepted: 11/08/2017] [Indexed: 12/24/2022]
Abstract
Neutrophilic dermatoses are a heterogeneous group of inflammatory skin disorders that present with unique clinical features but are unified by the presence of a sterile, predominantly neutrophilic infiltrate on histopathology. The morphology of cutaneous lesions associated with these disorders is heterogeneous, which renders diagnosis challenging. Moreover, a thorough evaluation is required to exclude diseases that mimic these disorders and to diagnose potential associated infectious, inflammatory, and neoplastic processes. While some neutrophilic dermatoses may resolve spontaneously, most require treatment to achieve remission. Delays in diagnosis and treatment can lead to significant patient morbidity and even mortality. Therapeutic modalities range from systemic corticosteroids to novel biologic agents, and the treatment literature is rapidly expanding. The first article in this continuing medical education series explores the pathogenesis of neutrophilic dermatoses and reviews the epidemiology, clinical and histopathologic features, diagnosis, and management of Sweet syndrome, neutrophilic eccrine hidradenitis, and Behçet disease.
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Affiliation(s)
- Caroline A Nelson
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sasha Stephen
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hovik J Ashchyan
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William D James
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert G Micheletti
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Misha Rosenbach
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Tripathi A, Kaymakcalan MD, LeBoeuf NR, Harshman LC. Programmed cell death-1 pathway inhibitors in genitourinary malignancies: specific side-effects and their management. Curr Opin Urol 2018; 26:548-55. [PMID: 27517638 DOI: 10.1097/mou.0000000000000332] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitors such as those that target the programmed cell death (PD)-1 pathway harness the host immune system to elicit an antitumor response. Their remarkable clinical benefit has led to regulatory approvals in several malignancies including the genitourinary cancers, renal cell carcinoma, and urothelial carcinoma. This review will focus on the management of the toxicities encountered with these agents. RECENT FINDINGS Although generally well tolerated, a small proportion of patients (10-20%) treated with PD-1 directed agents as monotherapy can develop severe autoimmune manifestations, also known as, immune-related adverse events. These include but are not limited to rashes, pneumonitis, endocrinopathy, colitis, and immune-mediated hepatic dysfunction. Combining these agents with the anti-CTLA-4 antibody ipilimumab can be associated with a higher incidence of these toxicities. Early initiation of immunosuppression with corticosteroids and other agents when needed can help mitigate these toxicities and to date has not been shown to compromise their clinical benefit. SUMMARY The development of immune checkpoint inhibitors represents significant advances in anticancer therapy but their efficacy may come at the cost of autoimmune toxicities secondary to their induction of the immune system. Early recognition of these effects and aggressive upfront management is essential to safely administer these agents in routine clinical practice.
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Affiliation(s)
- Abhishek Tripathi
- aLank Center for Genitourinary Oncology, Dana-Farber Cancer Institute bThe Center for Cutaneous Oncology, Department of Dermatology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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38
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Mirza S, Hill E, Ludlow SP, Nanjappa S. Checkpoint inhibitor-associated drug reaction with eosinophilia and systemic symptom syndrome. Melanoma Res 2018; 27:271-273. [PMID: 28146044 DOI: 10.1097/cmr.0000000000000326] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Drug reaction with eosinophilia and systemic symptom syndrome is a potentially fatal drug reaction that must be recognized quickly. Ipilimumab and nivolumab are both important agents in the treatment of melanoma and continue to be studied in other malignancies. We believe the mainstay of therapy for immunotherapy-induced drug reaction with eosinophilia and systemic symptom syndrome is early recognition, discontinuation of the inciting agent, supportive care, and treatment with high dose corticosteroids with appropriate tapers that may reduce the length of internal organ injury in cases with liver or kidney involvement.
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Affiliation(s)
- Sayeef Mirza
- aDepartment of Internal Medicine, University of South Florida, Tampa, Florida, USA bMedicine, H. Lee Moffitt Cancer Center and Research Institute Departments of cPharmacy
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39
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Ngo L, Miller E, Valen P, Gertner E. Nivolumab induced remitting seronegative symmetrical synovitis with pitting edema in a patient with melanoma: a case report. J Med Case Rep 2018; 12:48. [PMID: 29478412 PMCID: PMC6389137 DOI: 10.1186/s13256-018-1579-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 01/21/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Novel immune checkpoint inhibitors have been often utilized for different types of malignancies as salvage therapy with varying success. One obstacle to immune checkpoint inhibitor use is the higher incidence of immune-mediated side effects that can prompt discontinuation of therapy. Remitting seronegative symmetrical synovitis with pitting edema has been described with immune checkpoint inhibitors only once previously. We report a case of a patient who developed remitting seronegative symmetrical synovitis with pitting edema related to immune checkpoint inhibitor therapy and stress that these symptoms can be managed without cessation of immune checkpoint inhibitor therapy. CASE PRESENTATION We present a 70-year-old white man who presented with 4 months of progressive inflammatory arthritis with pitting edema. He had been started on nivolumab therapy for his metastatic melanoma with excellent response prior to symptom onset. The symptoms started in his knees and subsequently involved both hands and feet. On evaluation, he was wheelchair bound and completely dependent for all activities of daily living. Evaluation revealed negative serological testing and plain film imaging. Ultrasound demonstrated diffuse flexor tenosynovitis and soft tissue swelling, and a diagnosis of remitting seronegative symmetrical synovitis with pitting edema was made. He was treated with orally administered corticosteroids (0.5 mg/kg per day) which improved his symptoms significantly and allowed him to regain prior independent functioning. His corticosteroids were tapered (0.15 mg/kg per day) but not discontinued and his nivolumab treatment was not interrupted. In follow up he continued to have stable control of his melanoma as well as his remitting seronegative symmetrical synovitis with pitting edema. CONCLUSIONS In conclusion we present the first case of nivolumab-induced remitting seronegative symmetrical synovitis with pitting edema that is controlled by maintenance low-dose orally administered corticosteroids allowing for continuation of nivolumab therapy. Clinicians who encounter mild-to-moderate immune checkpoint inhibitor immune-mediated adverse effects can consider maintaining immune checkpoint inhibitor therapy with concomitant low-dose corticosteroids rather than abrupt cessation of the immune checkpoint inhibitor.
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Affiliation(s)
- Linh Ngo
- University of Minnesota, Medicine Rheumatology Office, D615Mayo, 420 Delaware St SE, Minneapolis, MN 55455-034 USA
| | - Eric Miller
- Hennepin County Medical Center, Minneapolis, USA
| | - Peter Valen
- Minneapolis VA Medical Center, University of Minnesota, Minneapolis, USA
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40
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Abstract
PURPOSE OF REVIEW The goal of this paper is to review the major adverse cutaneous reactions that have been reported to the most commonly used biologics. RECENT FINDINGS Anti-TNF agents and immune checkpoint inhibitors have significant, immune-mediated cutaneous manifestations that can necessitate discontinuation. Anti-TNF agents, IL-6 inhibitors, and IL-12/23 inhibitors can paradoxically cause psoriasis flares or unmask previously undiagnosed psoriasis. IL-17 inhibitors are unique in increasing risk for Candida infections. Benign injection site reactions, non-specific rash, cellulitis, and hypersensitivity reactions are relatively common adverse events. A wide variety of cutaneous reactions caused by biologics have been reported, ranging from benign injection site reactions to life-threatening cutaneous reactions necessitating discontinuation of the implicated biologic agent.
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Affiliation(s)
- Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Amy S Levin
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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41
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Ipilimumab-induced acute generalized exanthematous pustulosis in a patient with metastatic melanoma. Melanoma Res 2018; 26:417-20. [PMID: 27031538 DOI: 10.1097/cmr.0000000000000261] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Ipilimumab is a new anti-cytotoxic T-lymphocyte antigen-4 monoclonal antibody that stimulates the immune response against melanoma. A 50-year-old man received ipilimumab for metastatic melanoma as part of a clinical trial. Two weeks after drug initiation, he developed a widespread oedematous erythema with sterile pustules. The histological examination showed subcorneal pustulosis formation with eosinophils. The clinical-pathological correlation was consistent with acute generalized exanthematous pustulosis. The symptoms resolved within 25 days after discontinuation of ipilimumab. We suspect that neutrophilic accumulation under the epidermis in this patient is a phenomenon similar to intraepithelial neutrophils aggregating on the surface epithelium over laminar propria in ipilimumab-induced colitis. To our knowledge, this is the first reported case of acute generalized exanthematous pustulosis associated with ipilimumab use in metastatic melanoma patients.
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42
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Adler NR, Murray WK, Brady B, McCormack C, Pan Y. Sweet syndrome associated with ipilimumab in a patient with metastatic melanoma. Clin Exp Dermatol 2018; 43:497-499. [PMID: 29396853 DOI: 10.1111/ced.13399] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2017] [Indexed: 12/20/2022]
Affiliation(s)
- N R Adler
- Victorian Melanoma Service, Alfred Hospital, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - W K Murray
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - B Brady
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - C McCormack
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Y Pan
- Victorian Melanoma Service, Alfred Hospital, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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43
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Liu RC, Consuegra G, Fernández-Peñas P. Management of the cutaneous adverse effects of antimelanoma therapy. Melanoma Manag 2017; 4:187-202. [PMID: 30190925 DOI: 10.2217/mmt-2017-0015] [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: 06/04/2017] [Accepted: 10/17/2017] [Indexed: 02/08/2023] Open
Abstract
The advent of targeted therapy and immunotherapy has revolutionized the management of advanced melanoma. However, these novel therapies are associated with adverse effects (AEs), of which cutaneous toxicities are the most frequently observed. These cutaneous AEs can exert significant morbidity and impact on patient quality of life, hence the recognition and management of AEs is fundamental in preventing interruption or cessation of survival-prolonging treatments. Additionally, knowledge of these AEs are necessary in order for healthcare professionals to counsel patients when starting treatment and in the initiation of AE prophylaxis. The incidence and clinical presentation of the cutaneous toxicities of novel melanoma therapies will be discussed, and treatment guidelines provided.
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Affiliation(s)
- Rose Congwei Liu
- Department of Dermatology, Westmead Hospital, Sydney 2145, Australia.,Westmead Clinical School, University of Sydney Medical School, Sydney 2145, Australia.,Department of Dermatology, Westmead Hospital, Sydney 2145, Australia.,Westmead Clinical School, University of Sydney Medical School, Sydney 2145, Australia
| | - Germana Consuegra
- Department of Dermatology, Westmead Hospital, Sydney 2145, Australia.,Westmead Clinical School, University of Sydney Medical School, Sydney 2145, Australia.,Department of Dermatology, Westmead Hospital, Sydney 2145, Australia.,Westmead Clinical School, University of Sydney Medical School, Sydney 2145, Australia
| | - Pablo Fernández-Peñas
- Department of Dermatology, Westmead Hospital, Sydney 2145, Australia.,Westmead Clinical School, University of Sydney Medical School, Sydney 2145, Australia.,Department of Dermatology, Westmead Hospital, Sydney 2145, Australia.,Westmead Clinical School, University of Sydney Medical School, Sydney 2145, Australia
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44
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Pathogenesis, clinical manifestations and management of immune checkpoint inhibitors toxicity. TUMORI JOURNAL 2017; 103:405-421. [PMID: 28497847 DOI: 10.5301/tj.5000625] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2017] [Indexed: 12/13/2022]
Abstract
Immune checkpoint inhibitors have emerged as an effective treatment for several tumor types and their use in clinical practice is expected to further increase in the immediate future. Although these agents are well tolerated, they are associated with a peculiar spectrum of toxicity, which is immune mediated and may potentially affect every organ. However, immune-related adverse events are mostly reversible if promptly diagnosed and adequately treated. Therefore, it is crucial that medical oncologists know how to diagnose and treat immune-related adverse events. This review focuses on the pathogenesis, clinical manifestations and management of immune-related toxicity of anti-CTLA-4 and anti-PD-1 antibodies.
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Genova C, Rossi G, Rijavec E, Biello F, Barletta G, Tagliamento M, Grossi F. Releasing the brake: safety profile of immune check-point inhibitors in non-small cell lung cancer. Expert Opin Drug Saf 2017; 16:573-585. [PMID: 28351171 DOI: 10.1080/14740338.2017.1313228] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Immune check-point inhibitors are now employed as single-agents in current practice for the treatment of advanced non-small cell lung cancer (NSCLC), while combinations of different inhibitors are being evaluated in clinical trials. Although the safety profile of these compounds, with particular reference to drugs targeting programmed death protein 1 (PD-1) and its ligand (PD-L1), is generally considered manageable, peculiar, immune-related toxicities may onset. Areas covered: This review focuses on the immune-related adverse events (irAEs) observed during immune check-point blockade in NSCLC and their management. The authors report the incidence of irAEs based on the currently available data involving NSCLC and provide recommendations on the general approach to irAEs, as well as indications for the most relevant site-specific events. Expert opinion: Since irAEs may involve a wide range of organs and systems and are potentially reversible if promptly treated, early diagnosis should always be achieved; this might be particularly challenging when other potential causes of toxicity are suspected, such as infections or concurrent treatments. Finally, drugs active on the PD-1/PD-L1 axis appear to be generally manageable even when they are administered to patients with relevant comorbidities, provided that adequate clinical monitoring is performed.
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Affiliation(s)
- Carlo Genova
- a Lung Cancer Unit , IRCCS AOU San Martino - IST National Cancer Research Institute , Genoa , Italy.,b Department of Internal Medicine, School of Medicine , University of Genoa , Genoa , Italy
| | - Giovanni Rossi
- a Lung Cancer Unit , IRCCS AOU San Martino - IST National Cancer Research Institute , Genoa , Italy
| | - Erika Rijavec
- a Lung Cancer Unit , IRCCS AOU San Martino - IST National Cancer Research Institute , Genoa , Italy
| | - Federica Biello
- a Lung Cancer Unit , IRCCS AOU San Martino - IST National Cancer Research Institute , Genoa , Italy
| | - Giulia Barletta
- a Lung Cancer Unit , IRCCS AOU San Martino - IST National Cancer Research Institute , Genoa , Italy
| | - Marco Tagliamento
- a Lung Cancer Unit , IRCCS AOU San Martino - IST National Cancer Research Institute , Genoa , Italy
| | - Francesco Grossi
- a Lung Cancer Unit , IRCCS AOU San Martino - IST National Cancer Research Institute , Genoa , Italy
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46
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Hwang S, Anforth R, Carlos G, Fernandez-Peñas P. Cutaneous Adverse Events of New Anti-melanoma Therapies: Classification and Management. ACTAS DERMO-SIFILIOGRAFICAS 2017. [DOI: 10.1016/j.adengl.2016.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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47
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Hwang S, Anforth R, Carlos G, Fernandez-Peñas P. Cutaneous Adverse Events of New Anti-melanoma Therapies: Classification and Management. ACTAS DERMO-SIFILIOGRAFICAS 2017; 108:6-16. [DOI: 10.1016/j.ad.2016.05.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 04/27/2016] [Accepted: 05/03/2016] [Indexed: 01/07/2023] Open
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48
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Curry JL, Tetzlaff MT, Nagarajan P, Drucker C, Diab A, Hymes SR, Duvic M, Hwu WJ, Wargo JA, Torres-Cabala CA, Rapini RP, Prieto VG. Diverse types of dermatologic toxicities from immune checkpoint blockade therapy. J Cutan Pathol 2016; 44:158-176. [PMID: 27859479 DOI: 10.1111/cup.12858] [Citation(s) in RCA: 162] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 11/03/2016] [Accepted: 11/06/2016] [Indexed: 12/28/2022]
Abstract
Immunomodulatory drugs that leverages host immune mechanisms to destroy tumor cells have been met with great promise in the treatment of cancer. Immunotherapy, targeting cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) and the programmed cell death 1 (PD-1) receptor and its ligand (PD-L1) have shown tremendous improvements in the survival of patients with advanced solid tumors. However, the development of dermatologic toxicity (DT) is a consequence to immunotherapy. Review of published reports of the DT to immunotherapy revealed patients receiving anti-CTCLA-4 antibody or anti-PD-1/PD-L1 antibody often develop a DT of any type and grade. In this article, of the 3825 patients who were treated with anti-PD-1 and of 556 patients receiving anti-PD-L1, DT of any type and grade were reported in 1474 (∼39%) and 95 (∼17%) of patients, respectively. The emergence of specific types of DT to immunotherapy is beginning to be recognized can be categorized into four groups: (a) inflammatory, (b) immunobullous, (c) alteration of keratinocytes and (d) alteration of melanocytes. Lichenoid dermatitis and bullous pemphigoid appear to be DT more associated with anti-PD-1/PD-L1 antibody. The DT profile in patients receiving immunotherapy is diverse, and early recognition of specific types of DT that clinicians may encounter is critical for optimal patient care.
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Affiliation(s)
- Jonathan L Curry
- Department of Pathology, Section of Dermatopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael T Tetzlaff
- Department of Pathology, Section of Dermatopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Priyadharsini Nagarajan
- Department of Pathology, Section of Dermatopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carol Drucker
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adi Diab
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sharon R Hymes
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Madeleine Duvic
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wen-Jen Hwu
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer A Wargo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carlos A Torres-Cabala
- Department of Pathology, Section of Dermatopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ronald P Rapini
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Victor G Prieto
- Department of Pathology, Section of Dermatopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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49
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Collins LK, Chapman MS, Carter JB, Samie FH. Cutaneous adverse effects of the immune checkpoint inhibitors. Curr Probl Cancer 2016; 41:125-128. [PMID: 28190531 DOI: 10.1016/j.currproblcancer.2016.12.001] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 12/10/2016] [Indexed: 10/20/2022]
Abstract
The immune checkpoint targeted agents, anti-cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) and anti-programed cell death 1 (PD-1) or anti-programmed death ligand 1 (PD-L1) inhibitors are frequently associated with cutaneous side effects that are often dose limiting and can lead to discontinuation of therapy. Ipilimumab, a CTLA-4 inhibitor, is most commonly associated with a morbilliform eruption on the trunk and extremities and pruritus. More severe cutaneous toxicities reported include toxic epidermal necrolysis and severe drug rash with eosinophila and systemic symptoms. Recent case reports of Sweet syndrome and cutaneous sarcoidosis have also recently been described after treatment with ipilimumab. The cutaneous events usually occur early in the course of treatment and are dose dependent. PD-1 inhibitors, nivolumab and pembrolizumab, induce similar but less severe toxicities compared with the CTLA-4 inhibitors. The most common cutaneous adverse events include lichenoid reactions, eczema, vitiligo, and pruritus. Lichenoid oral mucosal lesions located on the tongue, buccal mucosa, lips, or gingivae or located on all of these have also recently been described. The time of onset of the cutaneous events with the PD-1 inhibitors occurs later than that seen with the CTLA-4 inhibitors. Anti-PD-L1 antibodies, such as atezolizumab, have a similar side effect profile compared with the PD-1 inhibitors. Combination of immune checkpoint inhibitors, ipilimumab and nivolumab, has recently been approved for the treatment of advanced melanoma. The combination therapy is associated with a more severe side effect profile compared with the agents used as monotherapy. We discuss the most frequently encountered cutaneous side effects of the immune checkpoint inhibitors and review the recommended management strategies.
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Affiliation(s)
- Lindsey K Collins
- Section of Dermatology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - M Shane Chapman
- Section of Dermatology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Joi B Carter
- Section of Dermatology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Faramarz H Samie
- Section of Dermatology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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50
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Habre M, Habre SB, Kourie HR. Dermatologic adverse events of checkpoint inhibitors: what an oncologist should know. Immunotherapy 2016; 8:1437-1446. [DOI: 10.2217/imt-2016-0074] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Immune checkpoint inhibitors (ICI) represent a new revolutionary weapon in the armamentarium of anti-cancer therapies. The side effects of these new agents represent a new challenge for oncologists; they are usually unpredictable and sometimes life threatening, if not managed rapidly and adequately. The most frequent side effects are the dermatologic, but they are usually low grade side effects and consequently easily manageable. Rash, pruritus and vitiligo are the most frequent dermatologic side effects. We aimed in this review to describe first all the dermatologic side effects of ICI according to the subtype of ICI and combination therapies in the clinical trials, then to report all the rare case reports dermatologic side effects, and finally to present the management algorithm of these side effects.
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Affiliation(s)
- Maya Habre
- Department of Dermatology, St George Hospital University Medical Center, Beirut, Lebanon
| | - Samer Bassilios Habre
- Department of Plastic & Reconstructive Surgery, Hôtel-Dieu de France, Beirut, Lebanon
| | - Hampig R Kourie
- Oncology Department, Jules Bordet Institute, Brussels, Belgium
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