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To treat or not to treat: PD-L1 inhibitor-induced keratoacanthoma and squamous cell carcinoma. Arch Dermatol Res 2022; 315:903-915. [PMID: 36394634 DOI: 10.1007/s00403-022-02468-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/25/2022] [Accepted: 11/07/2022] [Indexed: 11/18/2022]
Abstract
Keratoacanthoma (KA) and squamous cell carcinoma (SCC) are rare side effects of programmed cell death ligand-1 (PD-L1) inhibitors that can disrupt therapy. There is no consensus on optimal treatment. We investigated the management strategy and factors influencing pathophysiology. An institutional cancer registry and literature search were used for this retrospective study. Only PD-L1-induced KA and SCC cases were included. Pathology specimens were stained with immune markers and management strategies were analyzed. Four cases were identified at our institution. Immunohistochemistry of atypical keratinocytes revealed PD-1/PD-L1 positivity, high p53, and low bcl-2 for all cases with differential expression of CD44 and beta-catenin for KA versus SCC. Nivolumab was continued or temporarily held with complete resolution. In addition, a literature search identified 30 additional cases of KA/SCC after PDL-1 inhibitor use. The most common treatment was excision/destruction followed by topical and/or intralesional corticosteroids. Therapy was definitely withheld in 22% of KA patients and in 9% of SCC cases. The expression of PD-L1 by atypical keratinocytes helps to explain the effects of nivolumab on the development of cutaneous neoplasms. The expression of immune markers provides mechanistic insights into pathophysiology. Management may be achieved with conservative therapy and without treatment interruption.
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2
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Star P, Jackett LA, Cheung K, Wilmott JS, Ho G, Smith A, Long GV, Scolyer RA, Martin LK. Multiple eruptive squamoproliferative lesions during
anti‐PD1
immunotherapy for metastatic melanoma: pathogenesis, immunohistochemical analysis and treatment. Dermatol Ther 2022; 35:e15472. [DOI: 10.1111/dth.15472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/12/2022] [Accepted: 03/22/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Phoebe Star
- Melanoma Institute Australia The University of Sydney Sydney New South Wales Australia
| | - Louise A. Jackett
- Melanoma Institute Australia The University of Sydney Sydney New South Wales Australia
- Tissue Pathology and Diagnostic Oncology Royal Prince Alfred Hospital and NSW Health Pathology Sydney New South Wales Australia
| | - Karen Cheung
- Skin & Cancer Foundation Australia / Douglass Hanly Moir Pathology Darlinghurst New South Wales Australia
| | - James S. Wilmott
- Melanoma Institute Australia The University of Sydney Sydney New South Wales Australia
| | - Genevieve Ho
- Melanoma Institute Australia The University of Sydney Sydney New South Wales Australia
| | - Annika Smith
- Melanoma Institute Australia The University of Sydney Sydney New South Wales Australia
| | - Georgina V. Long
- Melanoma Institute Australia The University of Sydney Sydney New South Wales Australia
- Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
- Royal North Shore and Mater Hospitals Sydney Australia
- Charles Perkins Centre The University of Sydney Sydney New South Wales Australia
| | - Richard A. Scolyer
- Melanoma Institute Australia The University of Sydney Sydney New South Wales Australia
- Tissue Pathology and Diagnostic Oncology Royal Prince Alfred Hospital and NSW Health Pathology Sydney New South Wales Australia
- Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
- Charles Perkins Centre The University of Sydney Sydney New South Wales Australia
| | - Linda K. Martin
- Melanoma Institute Australia The University of Sydney Sydney New South Wales Australia
- Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
- Faculty of Medicine and Health The University of New South Wales Sydney Australia
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3
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Schwartz RJ, Ho G, Smith A, Collgros H, Regio Pereira A, Gouveia B, Long GV, Menzies AM, Potter AJ, Paver E, Star P, Scolyer RA, Martin LK. Successful treatment of eruptive keratoacanthomas with actitretin for patients on checkpoint inhibitor immunotherapy. J Eur Acad Dermatol Venereol 2022; 36:e445-e448. [PMID: 35043483 DOI: 10.1111/jdv.17940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 01/05/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Rodrigo J Schwartz
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Department of Dermatology, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Genevieve Ho
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Annika Smith
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Helena Collgros
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Amanda Regio Pereira
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Sydney, Australia.,Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Bruna Gouveia
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Royal North Shore and Mater Hospitals, Sydney, Australia.,Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Alexander M Menzies
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Royal North Shore and Mater Hospitals, Sydney, Australia
| | - Alison J Potter
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, University of New South Wales, Sydney, Australia.,Tissue and Pathology Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, Australia
| | - Elizabeth Paver
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Tissue and Pathology Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, Australia
| | - Phoebe Star
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Tissue and Pathology Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, Australia.,Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Linda K Martin
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
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4
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Kunadia A, Shulman K, Sami N. Spironolactone-Induced Lichenoid Drug Reaction and Subsequent Diffuse Eruptive Squamous Cell Carcinomas Successfully Treated With Systemic Methotrexate. Cureus 2021; 13:e17713. [PMID: 34650887 PMCID: PMC8489780 DOI: 10.7759/cureus.17713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 09/04/2021] [Indexed: 12/02/2022] Open
Abstract
Antihypertensive agents such as spironolactone have been reported to cause lichenoid drug eruptions. Eruptive keratoacanthomas (KA), considered to be well-differentiated squamous cell carcinoma (SCC), may develop in the setting of such lichenoid reactions. Thus, definitive treatment is imperative. This case report describes a patient on spironolactone who developed a lichenoid drug eruption followed by eruptive KAs and SCC. The treatment approach used systemic methotrexate. While most treatment regimens for widespread eruptive KA/SCC employ intralesional methotrexate, this case demonstrated the utility of its systemic counterpart. This may have also facilitated the resolution of the patient’s lichenoid eruption. There are only three other reports in the literature describing a spironolactone-induced lichenoid drug eruption. Further investigations are needed to evaluate the adverse cutaneous effects of spironolactone as well as the efficacy of systemic methotrexate in treating patients with a significant number of SCCs arising from lichenoid drug eruptions.
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Affiliation(s)
- Anuj Kunadia
- Medicine, University of Central Florida College of Medicine, Orlando, USA
| | | | - Naveed Sami
- Internal Medicine, University of Central Florida College of Medicine, Orlando, USA
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5
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Park JH, Yoon D, Lee J, Oh SJ, Kim HJ, Lee JH, Lee DY. Clinical profile of cutaneous adverse events of immune checkpoint inhibitors in a single tertiary center. J Dermatol 2021; 48:979-988. [PMID: 33878219 DOI: 10.1111/1346-8138.15824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 01/16/2021] [Accepted: 02/06/2021] [Indexed: 01/23/2023]
Abstract
Programmed death 1 (PD-1)/programmed death ligand 1 (PD-L1) inhibitors have demonstrated their efficacy in the treatment of various malignancies. Despite their benefits, their immunomodulatory activities can cause unpredictable cutaneous adverse events (CAE). This study aimed to identify characteristics of CAE in patients treated with PD-1/PD-L1 inhibitors through the medical records, photographs, and pathology reports. Fifty CAE occurred in 47 (2.75%) of 1711 patients treated with PD-1/PD-L1 inhibitors. Pruritic, psoriasiform, urticarial, and acneiform eruptions were the four most common types. Melanoma patients showed CAE more frequently than other malignancies. Acneiform eruption occurred more often at ages under 60 years. Urticarial eruption appeared earlier, while keratoacanthoma appeared later after immunotherapy. The overall survival times were not significantly different between the two groups with and without CAE by Kaplan-Meier analysis (p = 0.055). Studies on CAE may provide more information to understand these drugs and to help manage the patients.
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Affiliation(s)
- Ji-Hye Park
- Department of Dermatology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dokyoung Yoon
- Department of Dermatology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeeyun Lee
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Se Jin Oh
- Department of Dermatology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Je Kim
- Department of Dermatology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Hee Lee
- Department of Dermatology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Youn Lee
- Department of Dermatology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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6
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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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7
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Simonsen AB, Kaae J, Ellebaek E, Svane IM, Zachariae C. Cutaneous adverse reactions to anti-PD-1 treatment-A systematic review. J Am Acad Dermatol 2020; 83:1415-1424. [PMID: 32320766 DOI: 10.1016/j.jaad.2020.04.058] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 02/06/2023]
Abstract
The use of the humanized monoclonal anti-programmed cell death 1 antibodies pembrolizumab and nivolumab as potent anticancer therapies is rapidly increasing. However, since their approval, numerous cases of cutaneous reactions have been reported. Cutaneous adverse reactions to these agents have yet to be fully characterized and range from nonspecific eruptions to recognizable skin manifestations, which may be localized and vary from mild to life threatening. This systematic review article provides an overview of the various adverse cutaneous reactions to pembrolizumab and nivolumab therapy and offers suggestions for their management.
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Affiliation(s)
- Anne Birgitte Simonsen
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Jeanette Kaae
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Eva Ellebaek
- Department of Oncology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Inge Marie Svane
- Department of Oncology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Claus Zachariae
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
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8
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Kaul S, Kaffenberger BH, Choi JN, Kwatra SG. Cutaneous Adverse Reactions of Anticancer Agents. Dermatol Clin 2019; 37:555-568. [DOI: 10.1016/j.det.2019.05.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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9
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Affiliation(s)
- Nina K. Antonov
- Department of Dermatology, Columbia University Irving Medical Center, New York, New York
| | - Kesav G. Nair
- Medical Oncology, Whittingham Cancer Center, Norwalk Hospital, Norwalk, Connecticut
| | - Charles L. Halasz
- Department of Dermatology, Columbia University Irving Medical Center, New York, New York
- Correspondence to: Charles L. Halasz, MD, 149 East Avenue, Suite 20, Norwalk, CT 06851.
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10
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Diaz-Perez JA, Beveridge MG, Victor TA, Cibull TL. Granulomatous and lichenoid dermatitis after IgG4 anti-PD-1 monoclonal antibody therapy for advanced cancer. J Cutan Pathol 2018; 45:434-438. [PMID: 29468713 DOI: 10.1111/cup.13133] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/10/2018] [Accepted: 02/16/2018] [Indexed: 01/14/2023]
Abstract
Nivolumab is a fully human IgG4 monoclonal antibody directed against programmed cell death protein 1 (PD-1). PD-1 inhibition allows T-cell activation and recruitment to destroy cancer cells. Checkpoint inhibitors have shown significant survival advantage and relatively low side-effects in comparison with conventional chemotherapy in several types of advanced cancer. Granulomatous cutaneous reactions have been reported showing sarcoidal and panniculitic morphology. Here we present a case of drug-induced lichenoid and granulomatous dermatitis after checkpoint inhibitor therapy observed in a 63-year-old male treated with nivolumab for advanced glioblastoma. This morphology has not been previously reported. We documented a high number of CD8+ T-cells within the lesions. Additionally, we review the side-effects observed with the use of checkpoint inhibitors, with special focus on cutaneous manifestations.
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Affiliation(s)
- Julio A Diaz-Perez
- Department of Pathology, NorthShore University Health System, University of Chicago, Evanston, Illinois
| | - Mara G Beveridge
- Department of Dermatology, NorthShore University Health System, University of Chicago, Evanston, Illinois
| | - Thomas A Victor
- Department of Pathology, NorthShore University Health System, University of Chicago, Evanston, Illinois
| | - Thomas L Cibull
- Department of Pathology, NorthShore University Health System, University of Chicago, Evanston, Illinois
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11
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Bednarek R, Marks K, Lin G. Eruptive keratoacanthomas secondary to nivolumab immunotherapy. Int J Dermatol 2018; 57:e28-e29. [PMID: 29318617 DOI: 10.1111/ijd.13893] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 11/29/2017] [Accepted: 12/02/2017] [Indexed: 01/15/2023]
Affiliation(s)
- Robert Bednarek
- Department of Dermatology, Geisinger Medical Center, Danville, PA, USA
| | - Katherine Marks
- Department of Dermatology, Geisinger Medical Center, Danville, PA, USA
| | - George Lin
- Department of Pathology, Division of Dermatopathology, Geisinger Medical Center, Danville, PA, USA
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