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Satoh TK, Mellett M, Meier-Schiesser B, Fenini G, Otsuka A, Beer HD, Rordorf T, Maul JT, Hafner J, Navarini AA, Contassot E, French LE. IL-36γ drives skin toxicity induced by EGFR/MEK inhibition and commensal Cutibacterium acnes. J Clin Invest 2020; 130:1417-1430. [PMID: 31805013 PMCID: PMC7269569 DOI: 10.1172/jci128678] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 11/15/2019] [Indexed: 12/24/2022] Open
Abstract
Epidermal growth factor receptor (EGFR) and MEK inhibitors (EGFRi/MEKi) are beneficial for the treatment of solid cancers but are frequently associated with severe therapy-limiting acneiform skin toxicities. The underlying molecular mechanisms are poorly understood. Using gene expression profiling we identified IL-36γ and IL-8 as candidate drivers of EGFRi/MEKi skin toxicity. We provide molecular and translational evidence that EGFRi/MEKi in concert with the skin commensal bacterium Cutibacterium acnes act synergistically to induce IL-36γ in keratinocytes and subsequently IL-8, leading to cutaneous neutrophilia. IL-36γ expression was the combined result of C. acnes–induced NF-κB activation and EGFRi/MEKi–mediated expression of the transcription factor Krüppel-like factor 4 (KLF4), due to the presence of both NF-κB and KLF4 binding sites in the human IL-36γ gene promoter. EGFRi/MEKi increased KLF4 expression by blockade of the EGFR/MEK/ERK pathway. These results provide an insight into understanding the pathological mechanism of the acneiform skin toxicities induced by EGFRi/MEKi and identify IL-36γ and the transcription factor KLF4 as potential therapeutic targets.
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Affiliation(s)
- Takashi K Satoh
- Department of Dermatology, University of Zürich, Zürich, Switzerland
| | - Mark Mellett
- Department of Dermatology, University of Zürich, Zürich, Switzerland
| | | | - Gabriele Fenini
- Department of Dermatology, University of Zürich, Zürich, Switzerland
| | - Atsushi Otsuka
- Department of Dermatology, Kyoto University, Kyoto, Japan
| | - Hans-Dietmar Beer
- Department of Dermatology, University of Zürich, Zürich, Switzerland.,Medical Faculty, University of Zürich, Zürich, Switzerland
| | - Tamara Rordorf
- Clinic for Oncology, University Hospital Zürich, Zürich, Switzerland
| | | | - Jürg Hafner
- Department of Dermatology, University of Zürich, Zürich, Switzerland.,Medical Faculty, University of Zürich, Zürich, Switzerland
| | - Alexander A Navarini
- Department of Dermatology, University of Zürich, Zürich, Switzerland.,Medical Faculty, University of Zürich, Zürich, Switzerland.,Department of Dermatology, University Hospital of Basel, Basel, Switzerland
| | - Emmanuel Contassot
- Department of Dermatology, University of Zürich, Zürich, Switzerland.,Medical Faculty, University of Zürich, Zürich, Switzerland
| | - Lars E French
- Department of Dermatology, University of Zürich, Zürich, Switzerland.,Medical Faculty, University of Zürich, Zürich, Switzerland.,Department of Dermatology and Allergology, Ludwig Maximilian University of Munich, Munich, Germany
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2
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Klufa J, Bauer T, Hanson B, Herbold C, Starkl P, Lichtenberger B, Srutkova D, Schulz D, Vujic I, Mohr T, Rappersberger K, Bodenmiller B, Kozakova H, Knapp S, Loy A, Sibilia M. Hair eruption initiates and commensal skin microbiota aggravate adverse events of anti-EGFR therapy. Sci Transl Med 2019; 11:eaax2693. [PMID: 31826981 DOI: 10.1126/scitranslmed.aax2693] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 07/30/2019] [Accepted: 10/11/2019] [Indexed: 12/11/2022]
Abstract
Epidermal growth factor receptor (EGFR)-targeted anticancer therapy induces stigmatizing skin toxicities affecting patients' quality of life and therapy adherence. The lack of mechanistic details underlying these adverse events hampers their management. We found that EGFR/ERK signaling is required in LRIG1-positive stem cells during de novo hair eruption to secure barrier integrity and prevent the invasion of commensal microbiota and inflammatory skin disease. EGFR-deficient epidermis is permissive for microbiota outgrowth and displays an atopic-like TH2-dominated signature. The opening of the follicular ostia during hair eruption allows invasion of commensal microbiota into the hair follicle, initiating an additional TH1 and TH17 response culminating in chronic folliculitis. Restoration of epidermal ERK signaling via prophylactic FGF7 treatment or transgenic SOS expression rescues the barrier defect in the absence of EGFR, highlighting a therapeutic anchor point. These data reveal that commensal skin microbiota provoke atopic-like inflammatory skin diseases by invading into the follicular opening of erupting hair.
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Affiliation(s)
- Jörg Klufa
- Institute of Cancer Research, Department of Medicine I, Medical University of Vienna and Comprehensive Cancer Center, Vienna 1090, Austria
| | - Thomas Bauer
- Institute of Cancer Research, Department of Medicine I, Medical University of Vienna and Comprehensive Cancer Center, Vienna 1090, Austria.
| | - Buck Hanson
- Division of Microbial Ecology, Department of Microbiology and Ecosystem Science, Research Network Chemistry meets Microbiology, University of Vienna, Vienna 1090, Austria
| | - Craig Herbold
- Division of Microbial Ecology, Department of Microbiology and Ecosystem Science, Research Network Chemistry meets Microbiology, University of Vienna, Vienna 1090, Austria
| | - Philipp Starkl
- CeMM-Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna 1090, Austria
- Laboratory of Infection Biology, Department of Medicine I, Medical University of Vienna, Vienna 1090, Austria
| | - Beate Lichtenberger
- Institute of Cancer Research, Department of Medicine I, Medical University of Vienna and Comprehensive Cancer Center, Vienna 1090, Austria
| | - Dagmar Srutkova
- Laboratory of Gnotobiology, Institute of Microbiology, Czech Academy of Sciences, v.v.i., Novy Hradek 549 22, Czech Republic
| | - Daniel Schulz
- Institute of Molecular Life Sciences, University of Zurich, Zurich 8057, Switzerland
| | - Igor Vujic
- Department of Dermatology and Venereology, Medical Institution Rudolfstiftung, Vienna 1030, Austria
- Department of Dermatology, Medical University of Vienna, Vienna 1090, Austria
| | - Thomas Mohr
- Institute of Cancer Research, Department of Medicine I, Medical University of Vienna and Comprehensive Cancer Center, Vienna 1090, Austria
| | - Klemens Rappersberger
- Department of Dermatology and Venereology, Medical Institution Rudolfstiftung, Vienna 1030, Austria
| | - Bernd Bodenmiller
- Institute of Molecular Life Sciences, University of Zurich, Zurich 8057, Switzerland
| | - Hana Kozakova
- Laboratory of Gnotobiology, Institute of Microbiology, Czech Academy of Sciences, v.v.i., Novy Hradek 549 22, Czech Republic
| | - Sylvia Knapp
- CeMM-Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna 1090, Austria
- Laboratory of Infection Biology, Department of Medicine I, Medical University of Vienna, Vienna 1090, Austria
| | - Alexander Loy
- Division of Microbial Ecology, Department of Microbiology and Ecosystem Science, Research Network Chemistry meets Microbiology, University of Vienna, Vienna 1090, Austria
| | - Maria Sibilia
- Institute of Cancer Research, Department of Medicine I, Medical University of Vienna and Comprehensive Cancer Center, Vienna 1090, Austria.
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Suleiman AA, Frechen S, Scheffler M, Zander T, Nogova L, Kocher M, Jaehde U, Wolf J, Fuhr U. A Modeling and Simulation Framework for Adverse Events in Erlotinib-Treated Non-Small-Cell Lung Cancer Patients. AAPS JOURNAL 2015; 17:1483-91. [PMID: 26286677 DOI: 10.1208/s12248-015-9815-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 08/06/2015] [Indexed: 01/25/2023]
Abstract
Treatment with erlotinib, an epidermal growth factor receptor tyrosine kinase inhibitor used for treating non-small-cell lung cancer (NSCLC) and other cancers, is frequently associated with adverse events (AE). We present a modeling and simulation framework for the most common erlotinib-induced AE, rash, and diarrhea, providing insights into erlotinib toxicity. We used the framework to investigate the safety of high-dose erlotinib pulses proposed to limit acquired resistance while treating NSCLC. Continuous-time Markov models were developed using rash and diarrhea AE data from 39 NSCLC patients treated with erlotinib (150 mg/day). Exposure and different covariates were investigated as predictors of variability. Rash was also tested as a survival predictor. Models developed were used in a simulation analysis to compare the toxicities of different regimens, including the previously mentioned pulsed strategy. Probabilities of experiencing rash or diarrhea were found to be highest early during treatment. Rash, but not diarrhea, was positively correlated with erlotinib exposure. In contrast with some common understandings, radiotherapy decreased transitioning to higher rash grades by 81% (p < 0.01), and experiencing rash was not correlated with positive survival outcomes. Model simulations predicted that the proposed pulsed regimen (1600 mg/week + 50 mg/day remaining week days) results in a maximum of 20% of the patients suffering from severe rash throughout the treatment course in comparison to 12% when treated with standard dosing (150 mg/day). In conclusion, the framework demonstrated that radiotherapy attenuates erlotinib-induced rash, providing an opportunity to use radiotherapy and erlotinib together, and demonstrated the tolerability of high-dose pulses intended to address acquired resistance to erlotinib.
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Affiliation(s)
- Ahmed Abbas Suleiman
- Department of Pharmacology, Clinical Pharmacology Unit, University Hospital of Cologne, Gleueler Str. 24, 50931, Cologne, Germany.
| | - Sebastian Frechen
- Department of Pharmacology, Clinical Pharmacology Unit, University Hospital of Cologne, Gleueler Str. 24, 50931, Cologne, Germany
| | - Matthias Scheffler
- Lung Cancer Group Cologne, Department I of Internal Medicine, Center for Integrated Oncology Cologne Bonn, University Hospital of Cologne, Cologne, Germany
| | - Thomas Zander
- Lung Cancer Group Cologne, Department I of Internal Medicine, Center for Integrated Oncology Cologne Bonn, University Hospital of Cologne, Cologne, Germany
| | - Lucia Nogova
- Lung Cancer Group Cologne, Department I of Internal Medicine, Center for Integrated Oncology Cologne Bonn, University Hospital of Cologne, Cologne, Germany
| | - Martin Kocher
- Department of Radiotherapy, University Hospital of Cologne, Cologne, Germany
| | - Ulrich Jaehde
- Institute of Pharmacy, Clinical Pharmacy Department, University of Bonn, Bonn, Germany
| | - Jürgen Wolf
- Lung Cancer Group Cologne, Department I of Internal Medicine, Center for Integrated Oncology Cologne Bonn, University Hospital of Cologne, Cologne, Germany
| | - Uwe Fuhr
- Department of Pharmacology, Clinical Pharmacology Unit, University Hospital of Cologne, Gleueler Str. 24, 50931, Cologne, Germany
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Abstract
OBJECTIVES To present a thorough literature review on the assessment, grading, and treatment of rash associated with targeted therapies for cancer treatment. To identify ways that nursing can impact a patient's treatment experience by understanding and properly managing treatment for the rash. DATA SOURCES Peer-reviewed journal articles, textbooks. CONCLUSION Identification and management of rash induced by targeted therapies may improve quality of life and allow patients to continue drug therapy for their cancer to offer best outcomes. IMPLICATIONS FOR NURSING PRACTICE Nurses are in a unique position to assess, grade, and manage rash in patients receiving targeted therapies. Nurses will often be the first point of contact for the patient experiencing a rash, and the proper triage and advice on management can help the patient tolerate these drugs and enable them to remain on treatment.
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Erythema multiforme, Stevens Johnson syndrome, and toxic epidermal necrolysis syndrome in patients undergoing radiation therapy: a literature review. Am J Clin Oncol 2014; 37:506-13. [PMID: 22892429 DOI: 10.1097/coc.0b013e31825d5835] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Erythema multiforme (EM), Stevens Johnson syndrome (SJS), and toxic epidermal necrolysis syndrome (TENS) are exfoliative disorders that may present as complications in some patients undergoing radiotherapy. The purpose of this literature review was to determine the reported frequency of these exanthemata in irradiated patients. METHODS A comprehensive search from 1903 to 2011, identified 89 articles with 165 cases. RESULTS Of 151 evaluable cases, 57 (38%) described EM; 46 (30.5%) SJS; 14 (9%) SJS/TENS overlap; and 34 (22.5%) TENS. Ninety-three percent underwent radiotherapy for either a primary or metastatic malignancy. A majority of patients were simultaneously treated with medications known to precipitate these exanthemata. Of the 61 patients receiving antiepileptic medications during radiotherapy, 48 were treated prophylactically and 13 for seizures, most frequently with phenytoin or phenobarbital. Amifostine was the second most common medication associated with radiotherapy and these reactions. Fourteen (23%) patients on anticonvulsant medication, and 11 (38%) on other medications died compared with 3 (8%) patients treated with radiotherapy alone (P = 0.002). No deaths occurred among irradiated patients receiving amifostine. CONCLUSIONS EM, SJS, and TENS were rarely reported in patients undergoing radiotherapy alone. The majority of SJS and TENS occurred in irradiated patients with concomitant prescribed medications.
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Bishop AJ, Chang M, Lacouture ME, Barker CA. EMPACT syndrome: limited evidence despite a high-risk cohort. J Neurooncol 2014; 119:129-34. [PMID: 24792490 DOI: 10.1007/s11060-014-1457-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 04/19/2014] [Indexed: 11/25/2022]
Abstract
Serious dermatologic adverse events such as erythema multiforme (EM) and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) have been reported in patients receiving antiepileptic drugs (AEDs) and cranial radiotherapy (RT). Given the frequency of AED-associated rashes and the infrequency of serious dermatologic adverse events after cranial RT, we sought to further assess the prevalence of cutaneous eruptions in patients receiving an AED before and after cranial RT. We reviewed medical records of patients taking AEDs while undergoing RT for a high-grade glioma and recorded demographic, disease, and treatment parameters, as well as the development of rashes. Rashes were found in 19 % of patients taking AEDs. Phenytoin was most commonly implicated (93 %) in rash formation compared with other AEDs (P < 0.0001), both before and during RT. Most rashes (76 %) occurred before starting RT (P < 0.0001). However, of those during RT, most were associated with phenytoin compared with other AEDs (P = 0.002). One case of SJS was noted in a patient receiving phenytoin prior to RT. While rashes were slightly less prevalent in patients receiving temozolomide compared with those not receiving temozolomide (3.4 vs 4.8 %), this difference was not statistically significant (P = 0.65). Rashes are relatively common in patients receiving AEDs, with the highest incidence associated with phenytoin. However, the risk of serious dermatologic events is low. There did not appear to be an association between the receipt of cranial radiotherapy and the development of AED-associated rash with phenytoin or other AEDs.
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Affiliation(s)
- Andrew J Bishop
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, 10065, USA
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Shah DR, Shah RR, Morganroth J. Tyrosine kinase inhibitors: their on-target toxicities as potential indicators of efficacy. Drug Saf 2013; 36:413-26. [PMID: 23620170 DOI: 10.1007/s40264-013-0050-x] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Tyrosine kinase inhibitors (TKIs) have revolutionized the treatment of certain forms of cancers, raising hopes for many patients with otherwise unresponsive tumours. While these agents are generally well tolerated, clinical experience with them has highlighted their unexpected association with serious toxic effects on various organs such as the heart, lungs, liver, kidneys, thyroid, skin, blood coagulation, gastrointestinal tract and nervous system. Many of these toxic effects result from downstream inhibition of vascular endothelial growth factor or epidermal growth factor signalling in cells of normal organs. Many of these undesirable effects such as hypertension, hypothyroidism, skin reactions and possibly proteinuria are on-target effects. Since tyrosine kinases are widely distributed with specific functional roles in different organs, this association is not too surprising. Various studies suggest that the development of these on-target effects indicates clinically desirable and effective inhibition of the corresponding ligand-mediated receptor linked with oncogenesis. This is reflected as improved efficacy in the subgroup of patients who develop these on-target adverse effects compared with those who do not. Inevitably, issues arise with respect to the regulatory assessment of efficacy and risk/benefit of the TKIs as well as the clinical approach to managing patients who develop these effects. Routine subgroup analysis of efficacy data from clinical trials (patients with and without on-target toxicity) may enable more effective clinical use of TKIs since (i) discontinuing or reducing the dose of the TKI has a negative impact if the tumour is TKI-responsive; and (ii) it is usually possible to manage these undesirable on-target effects with conventional clinical approaches. Prospective studies are needed to investigate this proposition further.
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Affiliation(s)
- Devron R Shah
- Rashmi Shah Consultancy Ltd, Birchdale, Gerrards Cross, Buckinghamshire SL9 7JA, UK
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8
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Zhao Q, Wang YN, Wang B. Spared Pre-irradiated Area in Pustular Lesions Induced by Icotinib Showing Decreased Expressions of CD1a+ Langerhans Cells and FGFR2. Jpn J Clin Oncol 2012; 43:200-4. [DOI: 10.1093/jjco/hys209] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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9
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Mehta VK. Radiotherapy and erlotinib combined: review of the preclinical and clinical evidence. Front Oncol 2012; 2:31. [PMID: 22645717 PMCID: PMC3355822 DOI: 10.3389/fonc.2012.00031] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Accepted: 03/17/2012] [Indexed: 12/12/2022] Open
Abstract
Epidermal growth factor receptor (EGFR) is often overexpressed in tumors and has been associated with poor prognosis in some cancer types. The introduction of inhibitors of EGFR, such as erlotinib, represents an important recent advance in the targeted treatment of cancer. Several studies have evaluated inhibitors of EGFR in combination with radiotherapy, and a strong biologic rationale exists for the use of this combination in certain cancer types, including head and neck squamous cell carcinoma, non-small cell lung cancer, glioblastoma, esophageal cancer, and pancreatic cancer. Preclinical and clinical studies are underway to evaluate the combination of erlotinib with radiotherapy. To date, the results suggest that this approach is at least feasible and may result in modest improvement in outcomes compared with either modality alone.
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Affiliation(s)
- Vivek K. Mehta
- Department of Radiation Oncology, Swedish Cancer InstituteSeattle, WA, USA
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Peuvrel L, Bachmeyer C, Reguiai Z, Bachet JB, André T, Bensadoun RJ, Bouché O, Ychou M, Dréno B. Semiology of skin toxicity associated with epidermal growth factor receptor (EGFR) inhibitors. Support Care Cancer 2012; 20:909-21. [DOI: 10.1007/s00520-012-1404-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 02/03/2012] [Indexed: 10/28/2022]
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Lips IM, Koster MEY, Houwing RH, Vonk EJA. Erlotinib-Induced Rash Spares Previously Irradiated Skin. Strahlenther Onkol 2011; 187:499-501. [DOI: 10.1007/s00066-011-2232-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 04/18/2011] [Indexed: 11/24/2022]
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Gerber PA, Buhren BA, Kürle S, Homey B. [Therapy with epidermal growth factor receptor inhibitors. Clinical spectrum of cutaneous adverse effects]. Hautarzt 2011; 61:654-61. [PMID: 20628713 DOI: 10.1007/s00105-010-1943-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Recently, inhibitors of the epidermal growth factor receptor (EGFR), such as erlotinib, gefitinib, cetuximab or panitumumab, have been successfully established in the therapy of a variety of solid tumors. Cutaneous adverse effects are the most frequent side-effects of these so-called targeted cancer drugs and occur in 45-100% of patients. In addition to a characteristic papulo-pustular rash, adverse effects include painful paronychia, xerosis cutis, pruritus, alopecia or alterations of the hair structure. These often stigmatizing side-effects represent a serious threat to the patients' quality of life and compliance and may lead to dose-reduction or even cessation of the antineoplastic therapy. Considering the steadily growing numbers of patients who receive EGFR-targeting therapy, these medicament-associated cutaneous adverse effects are becoming increasingly more important in the routine clinical practice of dermatologists and oncologists.
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Affiliation(s)
- P A Gerber
- Hautklinik, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
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Kanakamedala MR, Packianathan S, Vijayakumar S. Lack of Cetuximab induced skin toxicity in a previously irradiated field: case report and review of the literature. Radiat Oncol 2010; 5:38. [PMID: 20478052 PMCID: PMC2893190 DOI: 10.1186/1748-717x-5-38] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Accepted: 05/17/2010] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Mutation, amplification or dysregulation of the EGFR family leads to uncontrolled division and predisposes to cancer. Inhibiting the EGFR represents a form of targeted cancer therapy. CASE REPORT We report the case of 79 year old gentleman with a history of skin cancer involving the left ear who had radiation and surgical excision. He had presented with recurrent lymph node in the left upper neck. We treated him with radiation therapy concurrently with Cetuximab. He developed a skin rash over the face and neck area two weeks after starting Cetuximab, which however spared the previously irradiated area. CONCLUSION The etiology underlying the sparing of the previously irradiated skin maybe due to either decrease in the population of EGFR expressing cells or decrease in the EGFR expression. We raised the question that "Is it justifiable to use EGFR inhibitors for patients having recurrence in the previously irradiated field?" We may need further research to answer this question which may guide the physicians in choosing appropriate drug in this scenario.
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Affiliation(s)
- Madhava R Kanakamedala
- Department of Radiation Oncology, University of Mississippi Medical Center, 350 W Woodrow Wilson Drive #1600, Jackson, MS 39213, USA
| | - Satyaseelan Packianathan
- Department of Radiation Oncology, University of Mississippi Medical Center, 350 W Woodrow Wilson Drive #1600, Jackson, MS 39213, USA
| | - Srinivasan Vijayakumar
- Department of Radiation Oncology, University of Mississippi Medical Center, 350 W Woodrow Wilson Drive #1600, Jackson, MS 39213, USA
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Eguren C, Domínguez-Fernández I, Santiago-Sánchez-Mateos D, García-Díez A. Erupción acneiforme inducida por erlotinib que respeta el área de piel previamente irradiada. ACTAS DERMO-SIFILIOGRAFICAS 2010. [DOI: 10.1016/j.ad.2009.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Eguren C, Domínguez-Fernández I, Santiago-Sánchez-Mateos D, García-Díez A. Erlotinib-induced Acneiform Rash Not Affecting Previously Irradiated Skin. ACTAS DERMO-SIFILIOGRAFICAS 2010. [DOI: 10.1016/s1578-2190(10)70612-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Lin NU, Kasparian E, Morganstern DE, Beard C. Geographic Distribution of Lapatinib-Induced Skin Rash: Sparing of Abdominal Skin Persists in the Transverse Rectus Abdominis Myocutaneous Flap. J Clin Oncol 2009; 27:e218-9. [DOI: 10.1200/jco.2009.22.7868] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Nancy U. Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Clair Beard
- Department of Radiation Oncology, Brigham & Women's Hospital, Boston, MA
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Han SS, Lee M, Park GH, Bang SH, Kang YK, Kim TW, Lee JL, Chang HM, Ryu MH. Investigation of papulopustular eruptions caused by cetuximab treatment shows altered differentiation markers and increases in inflammatory cytokines. Br J Dermatol 2009; 162:371-9. [PMID: 19903175 DOI: 10.1111/j.1365-2133.2009.09536.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Epidermal growth factor receptor (EGFR) critically regulates tumour cell division, survival and metastasis. Agents that inhibit EGFR have been used in the treatment of advanced-stage malignancies, but cause variable cutaneous side-effects, most often papulopustular eruptions and xerosis. OBJECTIVES We assayed expression of inflammatory cytokines [interleukin (IL)-1alpha, tumour necrosis factor (TNF)-alpha, interferon (IFN)-gamma, human leucocyte antigen (HLA)-DR and intercellular adhesion molecule (ICAM)-1], differentiation markers (filaggrin, involucrin and loricrin) and phosphorylated EGFRs (pEGFRs) in papulopustular eruptions to determine the association between these markers and the eruptions caused by cetuximab. PATIENTS/METHODS Twelve papulopustular lesion biopsies were selected from patients with colon cancer who had received cetuximab treatment. Immunohistochemistry and immunofluorescence with a confocal laser scanning microscopy were performed. RESULTS Filaggrin expression decreased and expression of involucrin, various inflammatory markers (IL-1alpha, TNF-alpha, ICAM-1 and HLA-DR) increased and the expression of pEGFR was markedly downregulated in papulopustular eruptions. In perilesions, decreased pEGFR expression was noted in hair follicles compared with interfollicular epidermis. The increase of IL-1alpha and TNF-alpha was observed in perilesions as in the lesions. CONCLUSIONS The early inflammatory events (IL-1alpha and TNF-alpha expression) seen, and the lack of pEGFR in perilesional follicles, indicate that inflammatory events induced by EGFR inhibition may initiate papulopustular eruptions along with the altered differentiations. The decrease of filaggrin may contribute to the pathogenesis of the xerosis caused by cetuximab.
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Affiliation(s)
- S S Han
- Department of Dermatology, Asan Medical Center, SongPa-Gu PyongNab-Dong, Seoul 138-736, Korea
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Clinical Significance of Skin Toxicity due to EGFR-Targeted Therapies. JOURNAL OF ONCOLOGY 2009; 2009:849051. [PMID: 19584908 PMCID: PMC2699661 DOI: 10.1155/2009/849051] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Accepted: 04/07/2009] [Indexed: 11/28/2022]
Abstract
Many small molecules and monoclonal antibodies blocking the activity of Epidermal Growth factor receptor (EGFR) have been developed and have shown clinical activity in patients with non-small cell lung cancer (NSCLC), pancreatic cancer, and colorectal cancer (CRC), and are in clinical development for a range of other solid tumors. The toxicity profile of such agents is characterized by a typical pattern of cutaneous reactions.
In this paper we reviewed the current available data regarding the clinical significance of skin reaction due to EGFR targeted agents. We show that skin toxicity can be considered as predictive marker of response to such drugs and that it is not disease specific; however its potential prognostic value is still to be proven.
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Li T, Perez-Soler R. Skin toxicities associated with epidermal growth factor receptor inhibitors. Target Oncol 2009; 4:107-19. [DOI: 10.1007/s11523-009-0114-0] [Citation(s) in RCA: 206] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Accepted: 04/17/2009] [Indexed: 11/24/2022]
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Bilimoria KY, Bentrem DJ, Hansen NM, Bethke KP, Rademaker AW, Ko CY, Winchester DP, Winchester DJ. Comparison of sentinel lymph node biopsy alone and completion axillary lymph node dissection for node-positive breast cancer. J Clin Oncol 2009; 27:2946-53. [PMID: 19364968 DOI: 10.1200/jco.2008.19.5750] [Citation(s) in RCA: 249] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE For women with breast cancer, the role of completion axillary lymph node dissection (ALND) after identification of nodal metastases by sentinel lymph node biopsy (SLNB) has been questioned. Our objectives were to assess national nodal evaluation practice patterns and to examine differences in recurrence and survival for SLNB alone versus SLNB with completion ALND. PATIENTS AND METHODS From the National Cancer Data Base (1998 to 2005), women with clinically node-negative breast cancer who underwent SLNB and who had nodal metastases were identified. Practice patterns and outcomes were examined for patients who underwent SLNB alone versus SLNB with completion ALND (median follow-up, 63 months). RESULTS Of 97,314 patients, 20.8% underwent SLNB alone, and 79.2% underwent SLNB with completion ALND. In 2004 to 2005, patients were significantly more likely to undergo SLNB alone if they were older, had smaller tumors, or were treated at non-National Cancer Institute-designated cancer centers. In patients with macroscopic nodal metastases (n = 20,075 during 1998 to 2000), there was a nonsignificant trend toward better outcomes for completion ALND (v SLNB alone) after analysis was adjusted for differences between the two groups: axillary recurrence (hazard ratio [HR], 0.58; 95% CI, 0.32 to 1.06) and overall survival (HR, 0.89; 95% CI, 0.76 to 1.04). In patients with microscopic nodal metastases (n = 2,203 during 1998 to 2000), there were no significant differences in axillary recurrence or survival for patients who underwent SLNB alone versus completion ALND. CONCLUSION Compared with SLNB alone, completion ALND does not appear to improve outcomes for breast cancer patients with microscopic nodal metastases; however, there was a nonsignificant trend toward better outcomes with completion ALND for those with macroscopic disease.
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Affiliation(s)
- Karl Y Bilimoria
- Cancer Programs, American College of Surgeons, Chicago, IL 60611, USA
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21
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Musio D, Parisi E, Dionisi F, Parisi G, Caiazzo R, Bulzonetti N, Lichtner M, Raffetto N, Vullo V, Banelli E. Irradiated fields spared Stevens-Johnson syndrome in a patient undergoing radiotherapy for bone metastases. Jpn J Radiol 2009; 27:103-6. [PMID: 19373540 DOI: 10.1007/s11604-008-0297-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Accepted: 10/30/2008] [Indexed: 11/30/2022]
Affiliation(s)
- Daniela Musio
- Department of Radiation Oncology, University Sapienza, via del Policlinico, 155 00161, Rome, Italy
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22
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Rodeck U. Skin toxicity caused by EGFR antagonists-An autoinflammatory condition triggered by deregulated IL-1 signaling? J Cell Physiol 2009; 218:32-4. [DOI: 10.1002/jcp.21585] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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23
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Gerber PA, Enderlein E, Homey B. The Koebner-phenomenon in epidermal growth factor receptor inhibitor-induced cutaneous adverse effects. J Clin Oncol 2008; 26:2790-2. [PMID: 18509193 DOI: 10.1200/jco.2007.16.0077] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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24
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Heidary N, Naik H, Burgin S. Chemotherapeutic agents and the skin: An update. J Am Acad Dermatol 2008; 58:545-70. [PMID: 18342708 DOI: 10.1016/j.jaad.2008.01.001] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2007] [Revised: 01/07/2008] [Accepted: 01/10/2008] [Indexed: 12/17/2022]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Noushin Heidary
- Ronald O. Perelman Department of Dermatology, New York University, New York, USA
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25
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Berger B, Belka C. Severe skin reaction secondary to concomitant radiotherapy plus cetuximab. Radiat Oncol 2008; 3:5. [PMID: 18226196 PMCID: PMC2248588 DOI: 10.1186/1748-717x-3-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Accepted: 01/28/2008] [Indexed: 11/14/2022] Open
Abstract
The therapeutic use of monoclonal antibodies against the epidermal growth factor receptor (EGFR) is specifically associated with dermatologic reactions of variable severity. Recent evidence suggests superiority of the EGFR inhibitor (EGFRI) cetuximab plus radiotherapy compared to radiotherapy alone in patients with squamous cell carcinoma of the head and neck. Although not documented in a study population, several reports indicate a possible overlap between radiation dermatitis and the EGFRI-induced skin rash. We here present a case of severe skin reaction secondary to the addition of cetuximab to radiotherapy.
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Affiliation(s)
- Bernhard Berger
- Department of Radiation Oncology, University of Tübingen, Germany.
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26
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Deslandres M, Sibaud V, Chevreau C, Delord J. Effets secondaires cutanés des nouvelles molécules anticancéreuses : focus sur les molécules ciblant les récepteurs tyrosine kinase et le récepteur à l’EGF. Ann Dermatol Venereol 2008; Spec No 1:16-24. [DOI: 10.1016/s0151-9638(08)70093-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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27
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Lynch TJ, Kim ES, Eaby B, Garey J, West DP, Lacouture ME. Epidermal growth factor receptor inhibitor-associated cutaneous toxicities: an evolving paradigm in clinical management. Oncologist 2007; 12:610-21. [PMID: 17522250 DOI: 10.1634/theoncologist.12-5-610] [Citation(s) in RCA: 273] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Epidermal growth factor receptor inhibitors (EGFRIs) have demonstrated improved overall survival in patients with non-small cell lung cancer, pancreatic cancer, and colorectal cancer; however, their use is associated with dermatologic reactions of varying severity. The similar spectrum of events observed with monoclonal antibodies and tyrosine kinase inhibitors suggests such toxicities are a class effect. While such reactions do not necessarily require any alteration in EGFRI treatment, being best addressed through symptomatic treatment, there is limited evidence on which to base such therapies. In October 2006, at an international and interdisciplinary EGFRI dermatologic toxicity forum, the underlying mechanisms of these toxicities were discussed and commonly used therapeutic interventions were evaluated. Our aim was to reach a current consensus on management strategies. A three-tiered, EGFRI-focused toxicity grading system is suggested for the purposes of therapeutic decision making, and as a framework on which to build a stepwise approach to intervention. This approach to successful management is specifically tailored to accurately categorize dermatologic toxicity associated with EGFRIs, and can be easily applied by all health care professionals. The goal is to maximize quality of life in patients who are being treated with these agents--many of whom will be on these drugs for several months or even years.
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Affiliation(s)
- Thomas J Lynch
- Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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28
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Mitra SS. In Reply. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.13.1425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Sankha S. Mitra
- Sussex Cancer Centre, Royal Sussex County Hospital, Brighton, United Kingdom
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29
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Gerber PA, Enderlein E, Homey B, Muller A, Boelke E, Budach W. Radiation-Induced Prevention of Erlotinib-Induced Skin Rash Is Transient: A New Aspect Toward the Understanding of Epidermal Growth Factor Receptor Inhibitor–Associated Cutaneous Adverse Effects. J Clin Oncol 2007; 25:4697-8; author reply 4698-9. [DOI: 10.1200/jco.2007.12.8330] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Peter Arne Gerber
- Department of Dermatology, Heinrich-Heine-University, Duesseldorf, Germany
| | - Elaine Enderlein
- Department of Dermatology, Heinrich-Heine-University, Duesseldorf, Germany
| | - Bernhard Homey
- Department of Dermatology, Heinrich-Heine-University, Duesseldorf, Germany
| | - Anja Muller
- Department of Radiation Oncology, Heinrich-Heine-University, Duesseldorf, Germany
| | - Edwin Boelke
- Department of Radiation Oncology, Heinrich-Heine-University, Duesseldorf, Germany
| | - Wilfried Budach
- Department of Radiation Oncology, Heinrich-Heine-University, Duesseldorf, Germany
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30
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Giovannini M, Gregorc V, Viganò MG, Spreafico A, Ghio D, Dell'Oca I, Bolognesi A, Villa E. Endothelial growth factor receptor inhibition after radiotherapy. J Thorac Oncol 2007; 2:662. [PMID: 17607125 DOI: 10.1097/jto.0b013e318074de48] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Monica Giovannini
- Department of Medical Oncology, San Raffaele Scientific Institute, Milan, Italy.
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31
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Huang YJ, Liu SF, Wang CJ, Huang MY. Exacerbated radiodermatitis and bilateral subdural hemorrhage after whole brain irradiation combined with epidermal growth factor receptor tyrosine kinase inhibitors for brain metastases in lung cancer. Lung Cancer 2007; 59:407-10. [PMID: 17804114 DOI: 10.1016/j.lungcan.2007.07.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2007] [Revised: 06/27/2007] [Accepted: 07/16/2007] [Indexed: 11/22/2022]
Abstract
A 57-year-old male developed an adenocarcinoma lung cancer in November 2003. He received the full course chemotherapy but without a significant regression. The targeted therapy gefitinib was prescribed 2 years after diagnosis, producing a very good partial response. However, brain metastasis was diagnosed. A whole brain irradiation was performed for 37.5Gy with a fraction size of 2.5Gy and gefitinib was replaced with erlotinib on the 5th day after radiation therapy commenced for disease progressing. Unexpectedly, the patient developed a severe skin reaction in the region exposed to the radiation field, and a bilateral subdural hemorrhage, following radiation therapy. The reaction was thought to be triggered by the combination of radiation and epidermal growth factor receptor tyrosine kinase inhibitors, which may be responsible for hypersensitizing the radiation response in normal tissue in the unique individual.
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Affiliation(s)
- Yu-Jie Huang
- Department of Radiation Oncology, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao Sung Hsiang, Kaohsiung Hsien 833, Taiwan.
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32
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Affiliation(s)
- Sankha S. Mitra
- Royal Sussex County Hospital, Brighton and Sussex University Hospitals National Health Service Trust, Brighton, United Kingdom
| | - Kannon Nathan
- Royal Sussex County Hospital, Brighton and Sussex University Hospitals National Health Service Trust, Brighton, United Kingdom
| | - Richard Simcock
- Royal Sussex County Hospital, Brighton and Sussex University Hospitals National Health Service Trust, Brighton, United Kingdom
| | - Anthony Chalmers
- Royal Sussex County Hospital, Brighton and Sussex University Hospitals National Health Service Trust, Brighton, United Kingdom
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33
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Lacouture ME, Hwang C, Marymont MH, Patel J. Temporal Dependence of the Effect of Radiation on Erlotinib-Induced Skin Rash. J Clin Oncol 2007; 25:2140; author reply 2141. [PMID: 17513824 DOI: 10.1200/jco.2006.09.4045] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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34
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Bossi P, Liberatoscioli C, Bergamini C, Locati LD, Fava S, Rinaldi G, Orlandi E, Olmi P, Tagliabue E, Ménard S, Licitra L. Previously irradiated areas spared from skin toxicity induced by cetuximab in six patients: implications for the administration of EGFR inhibitors in previously irradiated patients. Ann Oncol 2007; 18:601-2. [PMID: 17074970 DOI: 10.1093/annonc/mdl409] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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35
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Abstract
The increased target specificity of epidermal growth factor receptor (EGFR) inhibitors (EGFRIs) is associated with the reduction or abolition of nonspecific and haematopoietic side effects. However, coincident inhibition of receptor activity in tissues that depend on EGFR signalling for normal function has undesirable consequences. Because of the key role of EGFR signalling in skin, dermatological toxicities have frequently been described with EGFRIs. The resultant significant physical and psycho-social discomfort might lead to interruption or dose modification of anticancer agents. There is an urgent need for an improved understanding of these toxicities to develop adequate staging systems and mechanistically driven therapies, and to ensure quality of life and consistent antineoplastic therapy.
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Affiliation(s)
- Mario E Lacouture
- SERIES Clinic and Cancer Skin Care Program, Department of Dermatology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Suite 1600, Chicago, Illinois 60611, USA.
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