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Grice S, Olsson-Brown A, Naisbitt DJ, Hammond S. Immunological Drug-Drug Interactions Affect the Efficacy and Safety of Immune Checkpoint Inhibitor Therapies. Chem Res Toxicol 2024; 37:1086-1103. [PMID: 38912648 PMCID: PMC11256900 DOI: 10.1021/acs.chemrestox.4c00067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 06/02/2024] [Accepted: 06/07/2024] [Indexed: 06/25/2024]
Abstract
With the rapid expansion in the development and clinical utility of immune checkpoint inhibitors (ICIs) for oncology, the continual evaluation of the safety profile of such agents is imperative. The safety profile of ICIs as monotherapy is dominated by immune-related adverse events, which can be considered as an extension of the mechanism of action of these immunomodulatory drugs. Further to this, an emerging theme is that ICI treatment can significantly impact upon the tolerability of coadministered medications. Numerous reports in literature indicate that ICIs may alter the immunological perception of coadministered drugs, resulting in undesirable reactions to a variety of concomitant medications. These reactions can be severe in manifestation, including hepatotoxicity and Stevens-Johnson Syndrome (SJS)/toxic epidermal necrolysis (TEN), but may also have detrimental impact on malignancy control. To minimize the impact of such drug-drug interactions on patients, it is imperative to identify medications that may cause these reactions, understand the underlying mechanisms, consider the timing and dosing of comedication, and explore alternative medications with comparable efficacies. Improving our understanding of how concomitant medications affect the safety and efficacy of ICIs can allow for potential culprit drugs to be identified/removed/desensitized. This approach will allow the continuation of ICI therapy that may have been discontinued otherwise, thereby improving malignant control and patient and drug development outcomes.
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Affiliation(s)
- Sophie Grice
- Department
of Molecular and Clinical Pharmacology, Institute of Translational
Medicine, University of Liverpool, Liverpool L69 3GE, U.K.
| | - Anna Olsson-Brown
- Department
of Molecular and Clinical Pharmacology, Institute of Translational
Medicine, University of Liverpool, Liverpool L69 3GE, U.K.
- Sussex
Cancer Centre, University Hospitals Sussex, Brighton BN2 5BD, U.K.
| | - Dean J. Naisbitt
- Department
of Molecular and Clinical Pharmacology, Institute of Translational
Medicine, University of Liverpool, Liverpool L69 3GE, U.K.
| | - Sean Hammond
- Department
of Molecular and Clinical Pharmacology, Institute of Translational
Medicine, University of Liverpool, Liverpool L69 3GE, U.K.
- ApconiX, Alderley Edge SK10 4TG, U.K.
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2
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Wei BM, Fox LP, Kaffenberger BH, Korman AM, Micheletti RG, Mostaghimi A, Noe MH, Rosenbach M, Shinkai K, Kwah JH, Phillips EJ, Bolognia JL, Damsky W, Nelson CA. Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms. Part I. Epidemiology, pathogenesis, clinicopathological features, and prognosis. J Am Acad Dermatol 2024; 90:885-908. [PMID: 37516359 DOI: 10.1016/j.jaad.2023.02.072] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 02/11/2023] [Accepted: 02/26/2023] [Indexed: 07/31/2023]
Abstract
Drug-induced hypersensitivity syndrome (DiHS), also known as drug reaction with eosinophilia and systemic symptoms (DRESS), is a severe cutaneous adverse reaction (SCAR) characterized by an exanthem, fever, and hematologic and visceral organ involvement. Anticonvulsants, antibiotics, and allopurinol are the most common triggers. The pathogenesis involves a complex interplay between drugs, viruses, and the immune system primarily mediated by T-cells. DiHS/DRESS typically presents with a morbilliform eruption 2-6 weeks after drug exposure, and is associated with significant morbidity, mortality, and risk of relapse. Long-term sequelae primarily relate to organ dysfunction and autoimmune diseases. Part I of this continuing medical education activity on DiHS/DRESS provides an update on epidemiology, novel insights into pathogenesis, and a description of clinicopathological features and prognosis.
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Affiliation(s)
- Brian M Wei
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Lindy P Fox
- Department of Dermatology, University of California, San Francisco, California
| | | | - Abraham M Korman
- Department of Dermatology, The Ohio State University, Columbus, Ohio
| | - Robert G Micheletti
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arash Mostaghimi
- Department of Dermatology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Megan H Noe
- Department of Dermatology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Misha Rosenbach
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kanade Shinkai
- Department of Dermatology, University of California, San Francisco, California
| | - Jason H Kwah
- Department of Medicine, Section of Rheumatology, Allergy and Immunology, Yale School of Medicine, New Haven, Connecticut
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jean L Bolognia
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - William Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut; Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Caroline A Nelson
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut.
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3
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Basilicata M, Terrano V, D’Aurelio A, Bruno G, Troiani T, Bollero P, Napolitano S. Oral Adverse Events Associated with BRAF and MEK Inhibitors in Melanoma Treatment: A Narrative Literature Review. Healthcare (Basel) 2024; 12:105. [PMID: 38201012 PMCID: PMC10778825 DOI: 10.3390/healthcare12010105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Melanoma cancer represents the most lethal type of skin cancer originating from the malignant transformation of melanocyte cells. Almost 50% of melanomas show the activation of BRAF mutations. The identification and characterization of BRAF mutations led to the development of specific drugs that radically changed the therapeutic approach to melanoma. METHODS We conducted a narrative review of the literature according to a written protocol before conducting the study. This article is based on previously conducted studies. We identified articles by searching electronic databases (Medline, Google Scholar and PubMed). We used a combination of "melanoma", "Braf-Mek inhibitors", " targeted therapy" and "oral side effects". RESULTS Eighteen studies were reported in this article showing the relationship between the use of targeted therapy in melanoma cancer and the development of oral side effects, such as mucositis, hyperkeratosis and cellular proliferation. CONCLUSION Targeted therapy plays an important role in the treatment of melanoma cancer, showing a notable increase in response rate, prolonged progression-free survival and overall survival in BRAF-mutated melanoma patients. Oral side effects represent a common finding over the course of treatment. However, these adverse effects can be easily managed in a multidisciplinary approach involving collaboration between medical oncologists and dental doctors.
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Affiliation(s)
- Michele Basilicata
- UOSD Special Care Dentistry, Department of Experimental Medicine and Surgery, University of Roma Tor Vergata, 00133 Rome, Italy; (M.B.); (A.D.); (P.B.)
- UniCamillus-Saint Camillus, International University of Health Sciences, 00131 Rome, Italy
| | - Vincenzo Terrano
- Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80138 Napoli, Italy; (V.T.); (T.T.); (S.N.)
| | - Alessandro D’Aurelio
- UOSD Special Care Dentistry, Department of Experimental Medicine and Surgery, University of Roma Tor Vergata, 00133 Rome, Italy; (M.B.); (A.D.); (P.B.)
| | - Giovanni Bruno
- Department of Neuroscience, University of Padua, 35121 Padova, Italy
- Department of Industrial Engineering, University of Tor Vergata, 00133 Rome, Italy
| | - Teresa Troiani
- Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80138 Napoli, Italy; (V.T.); (T.T.); (S.N.)
| | - Patrizio Bollero
- UOSD Special Care Dentistry, Department of Experimental Medicine and Surgery, University of Roma Tor Vergata, 00133 Rome, Italy; (M.B.); (A.D.); (P.B.)
| | - Stefania Napolitano
- Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80138 Napoli, Italy; (V.T.); (T.T.); (S.N.)
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4
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Evaluation of Delayed-Type Hypersensitivity to Antineoplastic Drugs-An Overview. Cancers (Basel) 2023; 15:cancers15041208. [PMID: 36831549 PMCID: PMC9954236 DOI: 10.3390/cancers15041208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/30/2023] [Accepted: 02/10/2023] [Indexed: 02/17/2023] Open
Abstract
Nowadays, clinical practice encounters the problem of delayed-type hypersensitivity (DTH) induced by several drugs. Antineoplastic treatments are among the drugs which show an elevated proportion of DHT reactions, leading to the worsening of patients' quality of life. The range of symptoms in DHT reactions can vary from mild, such as self-limiting maculopapular eruptions, to severe, such as Stevens-Johnson Syndrome. The development of these reactions supposes a negative impact, not only by limiting patients' quality of life, but also leading to economic loss due to market withdrawal of the affected drugs and high hospitalization costs. However, despite this problem, there are no available standard in vitro or in vivo methods that allow for the evaluation of the sensitizing potential of drugs in the preclinical phase. Therefore, the aim of this review is to summarize the skin reactions caused by the different antineoplastic families, followed by a comprehensive evaluation of the in vitro and in vivo methods used to detect DTHs and that could be suitable to test antineoplastic hypersensitivity reactions.
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Batinac T, Hlača N, Simetić L, Valković F, Peternel S, Prpić-Massari L. Stevens-Johnson Syndrome and Severe Anaemia: A Case of Toxicity Induced by Vemurafenib plus Cobimetinib following Pembrolizumab for Metastatic Melanoma. Acta Derm Venereol 2022; 102:adv00650. [PMID: 35146529 PMCID: PMC9558335 DOI: 10.2340/actadv.v102.1433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
| | | | | | | | - Sandra Peternel
- Department of Dermatovenereology, Clinical Hospital Center Rijeka, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, HR-51000, Rijeka, Croatia.
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6
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Go RS, Jacobsen E, Baiocchi R, Buhtoiarov I, Butler EB, Campbell PK, Coulter DW, Diamond E, Flagg A, Goodman AM, Goyal G, Gratzinger D, Hendrie PC, Higman M, Hogarty MD, Janku F, Karmali R, Morgan D, Raldow AC, Stefanovic A, Tantravahi SK, Walkovich K, Zhang L, Bergman MA, Darlow SD. Histiocytic Neoplasms, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 19:1277-1303. [PMID: 34781268 DOI: 10.6004/jnccn.2021.0053] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Histiocytic neoplasms are rare hematologic disorders accounting for less than 1% of cancers of the soft tissue and lymph nodes. Clinical presentation and prognosis of these disorders can be highly variable, leading to challenges for diagnosis and optimal management of these patients. Treatment often consists of systemic therapy, and recent studies support use of targeted therapies for patients with these disorders. Observation ("watch and wait") may be sufficient for select patients with mild disease. These NCCN Guidelines for Histiocytic Neoplasms include recommendations for diagnosis and treatment of adults with the most common histiocytic disorders: Langerhans cell histiocytosis, Erdheim-Chester disease, and Rosai-Dorfman disease.
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Affiliation(s)
| | - Eric Jacobsen
- Dana-Farber/Brigham and Women's Cancer Center
- Massachusetts General Hospital Cancer Center
| | - Robert Baiocchi
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Ilia Buhtoiarov
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute Cleveland Clinic Children's Hospital
| | | | - Patrick K Campbell
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | | | - Aron Flagg
- Yale Cancer Center/Smilow Cancer Hospital
| | | | | | | | - Paul C Hendrie
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | - Filip Janku
- The University of Texas MD Anderson Cancer Center
| | - Reem Karmali
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
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7
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Maloney NJ, Rana J, Yang JJ, Zaba LC, Kwong BY. Clinical features of drug-induced hypersensitivity syndrome to BRAF inhibitors with and without previous immune checkpoint inhibition: a review. Support Care Cancer 2021; 30:2839-2851. [PMID: 34546454 DOI: 10.1007/s00520-021-06543-9] [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: 03/28/2021] [Accepted: 09/04/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Cutaneous reactions to BRAF inhibitors are common, but severe reactions resembling or consistent with drug-induced hypersensitivity syndrome (DIHS)/drug reaction with eosinophilia and systemic symptoms (DRESS) are relatively rare. Several reports suggest that cutaneous reactions including DRESS/DIHS to BRAF inhibitors are more frequent and severe in the setting of previous immune checkpoint inhibition (ICI). METHODS To characterize existing literature on these reports, we queried the PubMed/MEDLINE database for cases of DIHS/DRESS to BRAF inhibitors. RESULTS We identified 23 cases of DIHS to BRAF inhibitors following checkpoint inhibition and 14 cases without prior checkpoint inhibitor therapy. In both cohorts, DIHS occurred relatively early, with median time to onset from drug exposure of 8-10 days. Patients who received prior ICI were less likely to have peripheral eosinophilia (26% vs 71%), atypical lymphocytes (9% vs 50%), renal involvement (61% vs 79%), hepatic involvement (52% vs 86%), and lymphadenopathy (9% vs 43%) compared to patients who did not receive prior ICI. Thrombocytopenia was more common with prior ICI (17% vs 7%). Only patients who received prior ICI experienced hypotension (26%) during the course of their DIHS. All cases of BRAF-induced DIHS generally improved on systemic steroids/supportive care, and no cases of death were identified. CONCLUSION Dermatologists should consider a diagnosis of DIHS following BRAF inhibitor initiation, particularly in the setting of past checkpoint inhibition, with atypical features including relatively rapid onset and steroid responsiveness, lack of peripheral eosinophilia, lymphocytosis, or lymphadenopathy, and increased risk of thrombocytopenia and hypotension.
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Affiliation(s)
- Nolan J Maloney
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, 780 Welch Road, CJ220F, Palo Alto, CA, 94304-5779, USA
| | - Jasmine Rana
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, 780 Welch Road, CJ220F, Palo Alto, CA, 94304-5779, USA
| | - Jason J Yang
- Division of Dermatology, Department of Medicine, David Geffen School of Medicine At UCLA, Los Angeles, CA, USA
| | - Lisa C Zaba
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, 780 Welch Road, CJ220F, Palo Alto, CA, 94304-5779, USA
| | - Bernice Y Kwong
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, 780 Welch Road, CJ220F, Palo Alto, CA, 94304-5779, USA.
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8
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Drug-induced hypersensitivity syndrome like reaction with angioedema and hypotension associated with BRAF inhibitor use and antecedent immune checkpoint therapy. JAAD Case Rep 2021; 13:147-151. [PMID: 34195327 PMCID: PMC8234355 DOI: 10.1016/j.jdcr.2021.04.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
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9
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Coleman EL, Olamiju B, Leventhal JS. Potentially life‑threatening severe cutaneous adverse reactions associated with tyrosine kinase inhibitors (Review). Oncol Rep 2020; 45:891-898. [PMID: 33650659 DOI: 10.3892/or.2020.7911] [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: 04/20/2020] [Accepted: 10/21/2020] [Indexed: 11/05/2022] Open
Abstract
Tyrosine kinase inhibitors (TKIs) have emerged as a new frontier of cancer therapy. These agents include inhibitors of epidermal growth factor receptor (EGFR), human epidermal growth factor receptor 2 (HER2), BRAF, mitogen‑activated protein kinase kinase (also referred to as MEK), bcr‑abl, c‑KIT, platelet‑derived growth factor (PDGFR), fibroblast growth factor receptor (FGFR), anaplastic lymphoma kinase (ALK) and vascular endothelial growth factor (VEGF). Along with the evolving applications of TKIs, there has been an increased recognition of the breadth of potential cutaneous toxicities to these agents. In this review, we provide an overview of potentially life‑threatening severe cutaneous adverse reactions (SCARs) that may occur during therapy with TKIs. These toxicities include Stevens‑Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP).
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10
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Torres‐Navarro I, de Unamuno‐Bustos B, Botella‐Estrada R. Systematic review of BRAF/MEK inhibitors‐induced Severe Cutaneous Adverse Reactions (SCARs). J Eur Acad Dermatol Venereol 2020; 35:607-614. [DOI: 10.1111/jdv.16894] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/22/2020] [Accepted: 07/29/2020] [Indexed: 12/13/2022]
Affiliation(s)
- I. Torres‐Navarro
- Dermatology Department Hospital Universitario y Politécnico la Fe València Spain
| | - B. de Unamuno‐Bustos
- Dermatology Department Hospital Universitario y Politécnico la Fe València Spain
| | - R. Botella‐Estrada
- Dermatology Department Hospital Universitario y Politécnico la Fe València Spain
- Department of Medicine Universitat de València València Spain
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11
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Zhu C, Zhu Y, Pan H, Chen Z, Zhu Q. Current Progresses of Functional Nanomaterials for Imaging Diagnosis and Treatment of Melanoma. Curr Top Med Chem 2019; 19:2494-2506. [PMID: 31642783 DOI: 10.2174/1568026619666191023130524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 09/29/2019] [Accepted: 09/30/2019] [Indexed: 12/16/2022]
Abstract
Melanoma is a malignant skin tumor that results in poor disease prognosis due to unsuccessful
treatment options. During the early stages of tumor progression, surgery is the primary approach
that assures a good outcome. However, in the presence of metastasis, melanoma hasbecome almost
immedicable, since the tumors can not be removed and the disease recurs easily in a short period of
time. However, in recent years, the combination of nanomedicine and chemotherapeutic drugs has offered
promising solutions to the treatment of late-stage melanoma. Extensive studies have demonstrated
that nanomaterials and their advanced applications can improve the efficacy of traditional chemotherapeutic
drugs in order to overcome the disadvantages, such as drug resistance, low drug delivery rate and
reduced targeting to the tumor tissue. In the present review, we summarized the latest progress in imaging
diagnosis and treatment of melanoma using functional nanomaterials, including polymers,
liposomes, metal nanoparticles, magnetic nanoparticles and carbon-based nanoparticles. These
nanoparticles are reported widely in melanoma chemotherapy, gene therapy, immunotherapy, photodynamic
therapy, and hyperthermia.
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Affiliation(s)
- Congcong Zhu
- Department of Pharmacy, Shanghai Dermatology Hospital, Tongji University School of Medicine, Shanghai 200443, China
| | - Yunjie Zhu
- Cellular Biomedicine Group Inc., Shanghai 201210, China
| | - Huijun Pan
- Department of Pharmacy, Shanghai Dermatology Hospital, Tongji University School of Medicine, Shanghai 200443, China
| | - Zhongjian Chen
- Department of Pharmacy, Shanghai Dermatology Hospital, Tongji University School of Medicine, Shanghai 200443, China
| | - Quangang Zhu
- Department of Pharmacy, Shanghai Dermatology Hospital, Tongji University School of Medicine, Shanghai 200443, China
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12
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Poduje S, Brozić JM, Prkačin I, Delaš Aždajić M, Goren A. Vemurafenib and cobimetinib‐induced toxic epidermal necrolysis in a patient with metastatic melanoma. Dermatol Ther 2019; 33:e13174. [DOI: 10.1111/dth.13174] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 11/19/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Sanja Poduje
- Department of Dermatology and VenerologySestre milosrdnice University Hospital Center Zagreb Croatia
| | - Jasmina M. Brozić
- Department of Oncology and Nuclear MedicineSestre milosrdnice University Hospital Center Zagreb Croatia
| | - Ivana Prkačin
- Department of Dermatology and VenerologySestre milosrdnice University Hospital Center Zagreb Croatia
| | - Marija Delaš Aždajić
- Department of Dermatology and VenerologySestre milosrdnice University Hospital Center Zagreb Croatia
| | - Andy Goren
- Department of DermatologyApplied Biology, Inc. Irvine California
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13
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Cytokine release syndrome as an important differential diagnosis of severe skin toxicity with organ damage during switch from immunotherapy to targeted therapy in metastatic melanoma. Melanoma Res 2019; 29:107-108. [DOI: 10.1097/cmr.0000000000000544] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Naqash AR, File DM, Ziemer CM, Whang YE, Landman P, Googe PB, Collichio FA. Cutaneous adverse reactions in B-RAF positive metastatic melanoma following sequential treatment with B-RAF/MEK inhibitors and immune checkpoint blockade or vice versa. A single-institutional case-series. J Immunother Cancer 2019; 7:4. [PMID: 30621779 PMCID: PMC6323838 DOI: 10.1186/s40425-018-0475-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 12/06/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND With the advent of immune-checkpoint inhibitors and targeted treatments (TT), there have been unprecedented response rates and survival in advanced melanoma, but the optimal sequencing of these two treatments modalities is unknown. Combining or sequencing these agents could potentially result in unique toxicities. Cutaneous adverse events (CAE) after sequential exposure to these agents represents one toxicity that needs further description. METHODS After retrospectively reviewing charts of patients from 2015 to 2018, we identified six patients who experienced CAEs after recent exposure to sequential immunotherapy and TT or vice versa for the treatment for metastatic melanoma at the University of North Carolina, Chapel Hill. Skin biopsies were available in five patients. RESULTS Five patients received TT after immunotherapy, and one patient received immunotherapy after TT. TT consisted of vemurafenib/cobimetinib (V/C) in five patients with four patients starting V/C immediately before manifesting with a CAE. In patients receiving V/C after immunotherapy, the median time from beginning V/C to development of CAE was 14.5 days. The clinical presentation of diffuse morbilliform rash, fevers, hypotension, and end-organ damage raised concern for Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome. Histopathological features of lympho-eosinophilic infiltrate were supportive of a drug eruption. Immunotherapy or TT were re-initiated in five patients within 1-8 weeks after resolution of the index CAE. This resulted in two patients re-experiencing the CAE. Both of these patients were off prednisone at the time of therapy re-initiation, whereas none of the patients who were restarted on targeted therapy with a steroid overlap had a rash recurrence. CONCLUSIONS Sequential treatment using immunotherapy and TT, especially the sequence of V/C after immunotherapy appears to be the most common trigger for CAE with a median time to onset of approximately 2 weeks. Although the clinical presentation of these CAEs can be dramatic, they respond well to prednisone therapy. This unique presentation suggests that it may be reasonably safe to re-challenge certain patients with a steroid overlap after rash resolution.
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Affiliation(s)
- Abdul Rafeh Naqash
- Department of Medicine, Division of Hematology/Oncology, Vidant Cancer Center at East Carolina University, 600 Moye Blvd, Greenville, NC, 27834, USA.
| | - Danielle M File
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina, 170 Manning Drive, Chapel Hill, NC, 27599, USA
| | - Carolyn M Ziemer
- Department of Dermatology, University of North Carolina, Chapel Hill, NC, 27516, USA
| | - Young E Whang
- Department of Medicine, Division of Hematology/Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina, 170 Manning Drive, Chapel Hill, NC, 27599, USA
| | - Paula Landman
- UNC Health Care, The University of North Carolina, 170 Manning Drive, Chapel Hill, NC, 27599, USA
| | - Paul B Googe
- Department of Dermatology, Pathology and Laboratory Medicine, University of North Carolina School of Medicine, 250 Bell Tower Drive CB#7287, Chapel Hill, NC, 27599, USA
| | - Frances A Collichio
- Department of Medicine, Division of Hematology/Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina, 170 Manning Drive, Chapel Hill, NC, 27599, USA
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