Complications of Therapy and a Diagnostic Dilemma Case

Comprehensive analysis of the immunological landscape of pituitary adenomas: implications of immunotherapy for pituitary adenomas

PURPOSES

Immunotherapies for solid tumor are gaining traction in the clinic, however, the immunological landscape of pituitary adenomas (PAs) is not well defined. In the present study, we used the RNA-seq data of PAs to investigate the impact of immunological landscape on clinical features of pituitary adenomas and aim to evaluate the potential immunotherapy for PAs.

METHODS

We analyzed tumor-infiltrating immune cells in 115 PA samples using RNA-seq. Main immune cell types (B cells, CD8⁺ T cells, CD4⁺ T cells, macrophages and NK cells) were detected from the expression of genes. The association between immune cells abundance and immune checkpoint, as well as inflammatory factors were analyzed. 10 additional patients were enrolled for validation.

RESULTS

In RNA sequencing data, landscape of PAs were identified. Our computationally inferred immune infiltrates significantly associate with patient clinical features. Growth hormone-secreting adenomas (GHomas) were found with higher B cells and CD8⁺ T cells infiltration. Moreover, GHomas showed relative different genetic background, significant invasive behavior and independently correlated with reduced progress-free time. Tumor progression was related to increased expression of PD-1/PD-L1 and was associated with higher immune infiltration. Analysis of cancer-testis antigen expression and CD8⁺ T-cell abundance suggested CTAG2 and TSPYL6 were potential immunotherapeutic targets in GHomas and non-functioning adenomas, respectively.

CONCLUSIONS

Tumor-infiltrating immune cells confer important clinical and biological implications. Our results of immune-infiltrate levels in PAs may inform effective cancer vaccine and checkpoint blockade therapies and make it possible to take immunotherapy into invasive PAs.

Clinical Management of Cutaneous Toxicity of Anti-EGFR Agents

Cutaneous toxicity is the most evident adverse effect of epidermal growth factor receptor (EGFR) inhibitors because of the specific role played by EGFR in skin biophysiology. Dermatological adverse reactions, mainly folliculocentric, have been widely reported in the literature. However, the mechanism of these reactions is not well defined and their management is still a matter of debate. In this paper keratinocyte differentiation, activation and pathways regulating gene expression are reviewed in order to improve the understanding of adverse skin reactions and obtain success in their management. The authors had the opportunity to treat skin reactions induced by cetuximab in a cohort of patients affected by metastatic colorectal carcinoma. The aims of this clinical approach were to control the signs and symptoms of skin toxicity in order to avoid delay in cancer therapy and to use nondrug agents for the treatment of drug-induced skin reactions.

Paronychia induced by the epidermal growth factor receptor inhibitor cetuximab

While the development of epidermal growth factor receptor inhibitors has been hailed as a remarkable triumph in the field of oncology, it has inherited with it a host of cutaneous side-effects that have been increasingly observed in a substantial number of patients in the recent years. One cutaneous manifestation that may inflict significant pain and affect activities of daily living among some of the patients receiving epidermal growth factor receptor inhibitors is paronychia. A case of paronychia associated with the use of cetuximab in the management of KRAS wild-type midrectal adenocarcinoma along with its management has been described.

Evidence-Based Treatment Options for the Management of Skin Toxicities Associated with Epidermal Growth Factor Receptor Inhibitors

Objective:

To compile evidence from randomized controlled trials, case series, and case reports to identify the effectiveness of various therapeutic agents for the treatment and prevention of dermatologie effects secondary to epidermal growth factor receptor inhibitor (EGFRI) administration.

Data Sources:

Literature was accessed through PubMed (2002–May 2009) and Scopus (2002–March 2009), using the terms epidermal growth factor receptor inhibitor, cetuximab, erlotinib, gefilinib, panitumumab, management, skin toxicity, and cutaneous effects. In addition, reference citations from publications identified were reviewed.

Study Selection and Data Extraction:

An evaluation of published clinical trials, case series, case reports, and clinical management guidelines that studied the treatment options for EGFRI-induced skin toxicities was performed. Studies that reported dosing regimens and treatment outcomes were included in this review.

Data Synthesis:

Management of EGFRI-induced skin toxicities has been documented in 2 randomized controlled trials, 3 case series, and 10 case reports in a total of 156 patients. There is strong evidence for the use of topical antibiotics to manage EGFRI skin toxicities. Controversy exists regarding the use of corticosteroids and retinoids for the management of EGFRI-induced rash. Several variables are noted among the number of case series and case reports, such as follow-up duration of the intervention, making any comparisons difficult.

Conclusions:

Overall, antibiotics are the most common treatment option and have the potential to reduce the severity of skin rash. Well-designed clinical studies with proper recording of relevant data on the management of EGFRI-induced dermatologie effects are needed to properly evaluate the use of various therapeutic agents. Apart from randomized controlled trials, comprehensive case reports are also important for clinical evaluation on a case-by-case basis.

Nail Toxicity Induced by Cancer Chemotherapy

Purpose. To provide a comprehensive literature review of chemotherapy-induced nail toxicity, including clinical presentation, implicated drugs and approaches for prevention and management.

Data sources. A search of MEDLINE and EMBASE (1966—2008) databases was conducted using the terms (and variations of the terms) antineoplastic agents, nails, nail toxicity, onycholysis, and paronychia. Bibliographies from selected articles were reviewed for appropriate references.

Data extraction. The retrieved literature was reviewed to include all articles relevant to the clinical presentation, diagnosis, incidence, prevention, and treatment of chemotherapy-induced nail toxicity.

Data synthesis. Nail toxicity is a relatively uncommon adverse effect linked to a number of chemotherapeutic agents. Clinical presentation varies, depending on which nail structure is affected and the severity of the insult. Nail changes may involve all or some nails. Toxicity may be asymptomatic and limited to cosmetic concerns, however, more severe effects, involving pain and discomfort can occur. Taxanes and anthracyclines are the antineoplastic drug groups most commonly implicated. It is suggested that the administration schedule may influence the incidence of nail abnormalities, for example reported cases linked to the weekly administration of paclitaxel.

Before instituting chemotherapy, patients should be educated regarding potential nail toxicities and strategies for prevention implemented. Management includes appropriate nail cutting, avoiding potential irritants, topical, or oral antimicrobials, and possibly cessation or dose reduction of the offending agent. Cryotherapy, through the application of frozen gloves or socks, has been beneficial in reducing docetaxel-induced nail toxicity and may be effective for other drugs. J Oncol Pharm Practice (2009) 15: 143—155.

Severe acneiform eruption induced by cetuximab (Erbitux)

Epidermal growth factor has an important role in the regulation of proliferation and differentiation in epidermal keratinocytes, as well as in the survival, angiogenesis and metastasis of cancer cells. Cetuximab is a chimeric monoclonal antibody selective for the epidermal growth factor receptor that induces a broad range of cellular responses that enhance tumor sensitivity to radiotherapy and chemotherapeutic agents. However, it can cause adverse events in the patient including acneiform eruption, asthenia, abdominal pain and nausea/vomiting. We report a case of severe acneiform eruption induced by cetuximab in a 56-year-old man with colorectal cancer and liver metastases.

Chemotherapeutic agents and the skin: An update

Chemotherapeutic agents give rise to numerous well described adverse effects that may affect the skin, hair, mucous membranes, or nails. The mucocutaneous effects of longstanding agents have been extensively studied and reviewed. Over the last 2 decades, a number of new molecular entities for the treatment of cancer have been approved by the United States Food and Drug Administration (FDA). This article reviews the cutaneous toxicity patterns of these agents. It also reviews one drug that has not received FDA approval but is in use outside the United States and is important dermatologically. Particular emphasis is placed on the novel signal transduction inhibitors as well as on newer literature pertaining to previously described reactions.

LEARNING OBJECTIVES

At the completion of this learning activity, participants should able to list the newer chemotherapeutic agents that possess significant mucocutaneous side effects and describe the range of reactions that are seen with each drug. In addition, they should be able to formulate appropriate management strategies for these reactions.

Cutaneous reactions related to systemic immunomodulators and targeted therapeutics

The arrival of targeted therapeutics into the oncology clinic, while enthusiastically anticipated, introduced the oncologist to dermatologic events that can pose challenging management issues. The dermatologic effects of these targeted agents appear to be more frequent than those with cytotoxic therapy and are not uniform; that is, different agents have distinct dermatologic toxicities. Interestingly, dermatologic toxicity may correlate with antitumor activity with some of these targeted agents. The correlation of rash with response and survival in particular mandates the development of effective and appropriate management strategies. The nature and challenges of the dermatologic events observed to date with epidermal growth factor receptor inhibitors, multikinase inhibitors, proteosome inhibitors, BCR-ABL tyrosine kinase inhibitors, and immunomodulatory drugs will be addressed in this review.

The emerging role of cetuximab in head and neck cancer: a 2007 perspective

The integration of targeted therapies into clinical practice constitutes the paradigm of oncology treatment in the current era. Cetuximab, a recombinant human/mouse chimeric epidermal growth factor (EGFR) monoclonal antibody is a targeted agent that has seen expanding indication in recent years. Originally approved for colorectal cancer, its role in the treatment of squamous cell carcinoma of the head and neck has augmented treatment options for patients who are refractory to or cannot tolerate platinum. This article will review the science underlying cetuximab, data supporting its use in patients with locally advanced and recurrent/metastatic disease, common toxicities of therapy, and the integration of this treatment with radiation therapy.

Impact and management of skin toxicity associated with anti-epidermal growth factor receptor therapy: survey results

Biologic agents targeting the epidermal growth factor receptor (EGFR) have emerged as a robust treatment option for various solid tumors. Despite lower systemic side effects than conventional chemotherapy, the majority of patients treated with these agents experience cutaneous toxicities, including papulopustular rashes, hair and nail changes, xerosis and pruritus, which have a significant impact on health and quality of life. Currently no consensus or management guidelines exist for these untoward events. Therefore, a retrospective survey was carried out across 110 oncology practioners in the US that were administering EGFR inhibitors. Providers were queried on the impact and management of these untoward events in their practices. Responses suggest that combination therapies (topical and oral) were more effective than either therapy alone, and also lead to a more rapid resolution of the papulopustular rash. Providers also reported that patients frequently complained of physical symptoms associated with the rash (itching and pain), and that they had a positive perception when being treated for their cutaneous side effects. The survey results support that attentive cutaneous care is important in patients treated with EGFR inhibitors, and that proactive/combined interventions may enhance quality of life and optimize consistent drug administration.

Hypersensitivity reactions to biological drugs

OBJECTIVES

To review the current evidence regarding hypersensitivity reactions related to the administration of biological drugs in the management of cancer, and to provide the nurse with appropriate interventions related to the management of hypersensitivity reactions.

DATA SOURCES

Review articles and research studies from the medical and nursing literature.

CONCLUSION

Current evidence is available regarding the types of reactions that are associated with the administration of biological drugs in the management of cancer. Medical and nursing studies that review the most effective management of hypersensitivity reactions related to the administration of biological drugs. A review of "best practice" is offered in this article regarding the management of hypersensitivity reactions related to the administration of biological drugs.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play a key role in the early identification of hypersensitivity reactions. Management of hypersensitivity reactions must be rapid for optimal patient outcomes.

Acneiform eruptions associated with epidermal growth factor receptor–targeted chemotherapy

A relatively newer class of chemotherapy agents, known as the epidermal growth factor receptor inhibitors (EGF-RIs), is being used to treat advanced stages of solid tumors. Acneiform eruptions are a frequent adverse effect and one which has been associated with increased survival in some studies. We describe 3 patients who presented shortly after initiation of EGF-RI therapy. Characteristics included an absence of comedones, facial and truncal involvement, and a perifollicular lymphoneutrophilic infiltrate detected on biopsy. Lesion counts were reduced with topical adapalene and oral tetracyclines in two patients. Patient 3 had dramatic clearance with low-dose isotretinoin (20 mg daily) until completion of EGF-RI therapy. Acneiform eruptions are a common adverse reaction to EGF-RI therapy and can be treated with traditional acne therapy. This should not be considered a drug hypersensitivity eruption or allergy, and patients should continue therapy. For patients with severe eruptions, oral isotretinoin is a consideration.

Nail toxicity associated with epidermal growth factor receptor inhibitor therapy

As the use of epidermal growth factor receptor inhibitors becomes more widespread, increasing data are being collected regarding both efficacy and toxicity. Cutaneous toxicities are emerging not only as the most relevant class-related events, but also as potentially important markers of response to therapy. Although a follicular eruption is the most frequent cutaneous manifestation of epidermal growth factor receptor inhibition, ingrown nails, paronychia, and xerosis and desquamation of the digits, all of which occur in a substantial number of patients, require attention from treating oncologists and dermatologists. These nail disorders are mostly mild to moderate in severity, but, if not properly managed, can result in significant pain and interfere with activities of daily living. Descriptions of the nail and periungual toxicities associated with epidermal growth factor receptor inhibitor therapy and prevention and treatment strategies are presented.

Non-Rash Skin Toxicities Associated with Novel Targeted Therapies

Many novel targeted agents have emerged against a variety of malignancies. Although papulopustular rash is the most commonly observed side effect associated with many of these agents, several non-rash skin toxicities have been identified that frequently result in the delay or discontinuation of anticancer therapy. These toxicities include skin hyperpigmentation, xerosis, pruritus, hair growth and color abnormalities, periungual and nail alterations, and hand-foot skin reaction. It is important to recognize these toxicities, so that they can be diagnosed early and treatment or dose modification can be initiated, if necessary. This review discusses several non-rash dermatologic toxicities observed with targeted therapeutic agents and guidelines for their diagnosis and treatment.

Chemotherapy and Cutaneous Toxicities: Implications for Oncology Nurses

OBJECTIVE

To review common cutaneous effects and dermatologic or cutaneous toxicities related to the administration of chemotherapy. These range from mostly cosmetic, such as hyperpigmentation or alopecia, to dose-limiting toxicities such as palmar-plantar erythrodysesthesia or hand-foot syndrome.

DATA SOURCES

Current research, published literature, and internet resources.

CONCLUSION

Assessment and grading of associated toxicities of therapy is an integral part of caring for this patient population. Early intervention may reduce toxicities associated with therapies for this patient population

IMPLICATIONS FOR NURSING PRACTICE

As more patients receive chemotherapy, dermatologic effects are becoming more common. Oncology nurses must be skilled in managing these side effects.

Kutane Nebenwirkungen einer EGF-Rezeptor-Blockade und deren Management

The receptor of the epidermal growth factor (EGF-receptor) plays a role in the pathogenesis of many human carcinomas. Recent strategies in anti-tumor therapy target the EGF-receptor, e.g., by the EGF-receptor blocking monoclonal antibody cetuximab or by small molecules inhibiting the tyrosine kinase activity of the EGF-receptor, such as gefitinib and erlotinib. The EGF-receptor is also expressed in normal human skin; in clinical trials with different EGF-receptor inhibitors, cutaneous side effects were common. We report on cutaneous side effects of EGF-receptor blockade, in particular acneiform lesions, xerosis and paronychia, and discuss their management.

Efectos cutáneos de los inhibidores del receptor del factor de crecimiento epidérmico

Epidermal growth factor receptor (EGFR) inhibitors are a new group of drugs used in the treatment of several malignancies. Three molecules are approved at the moment: gefitinib and erlotinib for the treatment of non-small-cell lung cancer, and cetuximab for colorectal cancer. These drugs originate cutaneous side effects with a high frequency: acneiform rashes, paronychia and generalized xerodermia. In this paper we review these common side effects and how to manage them.

Management of Rash and Other Toxicities in Patients Treated with Epidermal Growth Factor Receptor—Targeted Agents

Inhibition of the epidermal growth factor receptor (EGFR) represents one of the most important avenues for research and development in the field of cancer therapy. The EGFR is a member of the ErbB receptor tyrosine kinase (TK) family, which also includes ErbB-2 (HER2/neu), ErbB-3 (HER3), and ErbB-4 (HER4). Current EGFR therapies available for use include monoclonal antibodies, such as cetuximab, and small-molecule EGFR TK inhibition by agents such as erlotinib. Side effects of these agents include dermatologic manifestations without the bone marrow suppressive properties of chemotherapy. Understanding of rash and how it relates to EGFR inhibitor toxicity and, perhaps more importantly, EGFR inhibitor response must be more clearly defined with clinical trials. The optimum management of rash in patients receiving anti-EGFR therapy remains somewhat controversial; this is secondary to imprecise classification of rash as well as the lack of clinical trials to determine the most appropriate treatment algorithm for these patients. We propose a treatment strategy to help aggressively treat dermatologic side effects allowing patients to continue receiving therapy without dose interruption or drug discontinuation.

HER1/EGFR inhibitor-associated rash: future directions for management and investigation outcomes from the HER1/EGFR inhibitor rash management forum

Skin rash associated with HER1/epidermal growth factor receptor (EGFR) inhibitors is common. The lack of clinical and patient guidance for this often chronic and sometimes distressing side effect makes rash management and etiology investigation high priorities. To address this, oncologists and dermatologists with experience with HER1/EGFR inhibitors attended the HER1/EGFR Inhibitor Rash Management Forum. Recommendations include continued analysis of the correlation between rash and clinical outcome and improving the accuracy and reproducibility of terminology and grading systems. Because acne vulgaris has a unique pathology, and the pathology and etiology of rash are unclear yet distinct from acne vulgaris, using such terms as acne, acne-like, or acneiform should be avoided. Until there is a specific dermatological definition, rash is best described using phenotypic terms for its appearance and location. It is currently unknown which agents are best for treating rash. Clinical trials of rash treatments are urgently required, and suggestions for agents to consider are made based on current knowledge. The effect of dose reduction or interruption on rash should also be investigated. Secondarily infected rash may be more frequent than has been previously recognized, and some investigators favor empiric use of an oral antibiotic if this appears to be the case. Suggestions for patients include makeup to camouflage the rash and an emollient to prevent and alleviate skin dryness. The increasing use of HER1/EGFR-targeted agents makes managing rash important. We hope the outcomes from this Forum provide background for future studies.