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Martel J, Hanania HL, Patel AB. Immune checkpoint inhibitor-induced cutaneous toxicities: a review of histopathologic and clinical features. Hum Pathol 2023; 140:144-172. [PMID: 37141978 DOI: 10.1016/j.humpath.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) represent an emerging treatment option for a variety of cancer types. Through inhibition of programmed cell death protein 1 (PD-1), programmed cell death ligand 1 (PD-L1), and/or cytotoxic lymphocyte-associated antigen-4 (CTLA-4), ICIs activate the host's immune system causing a heightened anti-tumor response. However, off-target effects of ICIs can result in numerous different immune-related cutaneous adverse events (irCAEs). Beyond impacting quality of life, irCAEs can lead to dose limitations or discontinuation of anti-cancer therapies. Correct diagnosis is necessary for expedient and appropriate management. Skin biopsies are often performed to increase diagnostic accuracy and guide clinical management. An extensive literature review was performed using the PubMed database to identify the reported clinical and histopathologic features of irCAEs. This comprehensive review primarily details the histopathologic features of various irCAEs reported to date. Clinical presentation and immunopathogenesis are also discussed in relation to histopathology.
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Affiliation(s)
- Julianna Martel
- Department of Dermatology, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | | | - Anisha B Patel
- Department of Dermatology, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA.
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Macklin M, Yadav S, Jan R, Reid P. Checkpoint Inhibitor-Associated Scleroderma and Scleroderma Mimics. Pharmaceuticals (Basel) 2023; 16:259. [PMID: 37259404 PMCID: PMC9962184 DOI: 10.3390/ph16020259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 10/28/2023] Open
Abstract
Immune checkpoint inhibitors (ICI) are the standard of care for various malignancies and have been associated with a wide spectrum of complications that are phenotypically akin to primary autoimmune diseases. While the literature on these toxicities is growing, there is a paucity of data regarding ICI-associated scleroderma which can carry significant morbidity and limit the ability to continue effective ICI therapy. Our review aimed to analyze the current literature on ICI-associated systemic scleroderma (ICI-SSc) and key scleroderma mimics. Cases of ICI-SSc had notable differences from primary SSc, such as fewer vascular features and less seropositivity (such as scleroderma-specific antibodies and antinuclear antibodies). We found that patients with a diagnosis of SSc prior to the start of ICI can also experience flares of pre-existing disease after ICI treatment used for their cancer. Regarding scleroderma mimics, several cases of ICI-eosinophilic fasciitis have also been described with variable clinical presentations and courses. We found no cases of scleroderma mimics: ICI-scleromyxedema or ICI-scleroedema. There is a critical need for multi-institutional efforts to collaborate on developing a patient database and conducting robust, prospective research on ICI-scleroderma. This will ultimately facilitate more effective clinical evaluations and management for ICI-scleroderma.
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Affiliation(s)
- Michael Macklin
- Section of Rheumatology, Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Sudeep Yadav
- Section of Rheumatology, Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Reem Jan
- Section of Rheumatology, Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Pankti Reid
- Section of Rheumatology, Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, University of Chicago Medical Center, Chicago, IL 60637, USA
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Farrugia S, Mercieca L, Betts A, Refalo N, Boffa MJ. Scleroderma Secondary to Pembrolizumab: A Case Report and Review of 19 Cases of Anti-PD-1-Induced Scleroderma. Case Rep Oncol 2023; 16:846-856. [PMID: 37900813 PMCID: PMC10601745 DOI: 10.1159/000533373] [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: 02/28/2023] [Accepted: 07/24/2023] [Indexed: 10/31/2023] Open
Abstract
Immune checkpoint inhibitors are increasingly being used to treat various malignancies. Despite their efficacy, they are known to potentially cause immune-related adverse effects, including dermatological manifestations. A rare cutaneous immune-related adverse effect is scleroderma, which has been reported to occur with anti-programmed cell death-1 (PD-1) agents such as pembrolizumab and nivolumab. This may present with skin tightening and hardening at any point during or after immunotherapy. We present the case of a 54-year-old Caucasian woman who, following 16 doses of pembrolizumab for breast cancer, developed clinical features of scleroderma confirmed on histology. She was initially treated with oral corticosteroids, followed by oral psoralen-UVA, with poor response, but eventually improved with methotrexate. A literature review revealed 12 other cases of scleroderma following pembrolizumab treatment and 6 cases of scleroderma following nivolumab treatment. Males and females were both affected, and their ages ranged from 33 to 81 years. Scleroderma developed at different stages of pembrolizumab or nivolumab therapy. Although scleroderma is not commonly drug-induced, anti-PD-1 agents may be a rare cause and it is important to elicit an accurate drug history, including immunotherapy, in such cases.
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Affiliation(s)
| | - Liam Mercieca
- Department of Dermatology, Mater Dei Hospital, Msida, Malta
| | | | - Nick Refalo
- Department of Oncology, Sir Anthony Mamo Oncology Centre, Msida, Malta
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Muhaj F, Karri PV, Moody W, Brown A, Patel AB. Mucocutaneous adverse events to immune checkpoint inhibitors. FRONTIERS IN ALLERGY 2023; 4:1147513. [PMID: 36938327 PMCID: PMC10017442 DOI: 10.3389/falgy.2023.1147513] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 02/15/2023] [Indexed: 03/06/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy. Since the approval of ipilimumab in 2011, a total of nine ICIs have gained indications for various solid and hematologic malignancies. The expanding use of ICIs in oncology underscores the need for diagnosis and treatment expertise in immune related adverse events (irAE). Cutaneous toxicities are the earliest and most common irAE in this class of therapy. In addition to the more frequent reactions including vitiligo, lichenoid dermatitis, psoriasiform dermatitis, other less common skin toxicities including bullous dermatoses, neutrophilic dermatoses, and autoimmune dermato-rheumatologic diseases have been reported. Even though less than 3% of cutaneous irAEs (irCAEs) are classified as grade 3 or higher events, irCAEs can greatly impact quality of life. Appropriate management of irCAEs is critical to avoid unwarranted interruptions or discontinuation of lifesaving immunotherapy.
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Affiliation(s)
- Fiorinda Muhaj
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Padmavathi V. Karri
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Department of Dermatology, University of Texas Health Science Center- Houston, Houston, TX, United States
| | - Wylie Moody
- Department of Internal Medicine, HCA Houston Healthcare West, Houston, TX, United States
| | - Alexandria Brown
- Department of Internal Medicine, Texas Health Presbyterian Hospital, Dallas, TX, United States
| | - Anisha B. Patel
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Correspondence: Anisha B. Patel
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Sun G, Liu H, Shi X, Tan P, Tang W, Chen X, Sun G, Yang W, Kong X, Zheng Z, Cao H, Shao G. Treatment of patients with cancer using PD‑1/PD‑L1 antibodies: Adverse effects and management strategies (Review). Int J Oncol 2022; 60:74. [PMID: 35485291 PMCID: PMC9084612 DOI: 10.3892/ijo.2022.5364] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 03/14/2022] [Indexed: 12/12/2022] Open
Abstract
In 2020, there were an estimated 19.3 million new cancer cases and close to 10 million cancer deaths worldwide. Cancer remains one of the leading causes of death. In recent years, with the continuous improvement of our understanding of tumor immunotherapy, immunotherapeutics, such as immune checkpoint inhibitors, have gradually become a hot spot for tumor treatment. Amongst these, programmed cell death protein 1/programmed cell death protein ligand 1 (PD-1/PD-L1) related inhibitors, such as nivolumab and pembrolizumab, atezolizumab, avelumab and durvalumab have been shown to exhibit a high level of efficacy in several types of tumors. It has been confirmed that these inhibitors play an important role in the anti-tumor process, significantly improving the survival rate of patients and delaying the progress of the underlying cancer. However, its method of therapeutic interference and potential for damaging the immune system has caused concern regarding its suitability. As these adverse effects are caused by an immune response to endogenous tissues, they are designated as immune-related adverse events (irAEs). In this review, the typical irAEs reported in recent years and the management strategies adopted are highlighted, to serve as a reference in assessing the clinical response to these adverse reactions.
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Affiliation(s)
- Guangshun Sun
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Hanyuan Liu
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Xuesong Shi
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Pengyu Tan
- Department of Food Science and Engineering, Nanjing Xiaozhuang University, Nanjing, Jiangsu 211166, P.R. China
| | - Weiwei Tang
- Hepatobiliary/Liver Transplantation Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Living Donor Transplantation, Chinese Academy of Medical Sciences, Nanjing, Jiangsu 215005, P.R. China
| | - Xin Chen
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Guoqiang Sun
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Weijun Yang
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Xiangyi Kong
- Hepatobiliary/Liver Transplantation Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Living Donor Transplantation, Chinese Academy of Medical Sciences, Nanjing, Jiangsu 215005, P.R. China
| | - Zhiying Zheng
- Hepatobiliary/Liver Transplantation Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Living Donor Transplantation, Chinese Academy of Medical Sciences, Nanjing, Jiangsu 215005, P.R. China
| | - Hongyong Cao
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Guoqiang Shao
- Department of Nuclear Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
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