Incidence and severity of hand-foot syndrome in colorectal cancer patients treated with capecitabine: a single-institution experience

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.

Can inhibiting dihydropyrimidine dehydrogenase limit hand-foot syndrome caused by fluoropyrimidines?

Hand-foot syndrome (HFS) is a cutaneous adverse event that occurs in some patients treated with fluoropyrimidines. Although it is not life threatening, HFS can severely disrupt the daily lives of patients. HFS appears more frequently with 5-fluorouracil (5-FU) delivered by continuous infusion or with the 5-FU oral derivative capecitabine than with bolus 5-FU therapy. HFS is a leading cause of treatment interruption, dosage reduction, or, even, therapy discontinuation for patients on a capecitabine regimen. Interestingly, addition of a dihydropyrimidine dehydrogenase (DPD) inhibitor, such as uracil, 5-chloro-2,4-dihydroxypyridine, or eniluracil, to the fluoropyrimidine treatment regimen significantly diminishes the incidence of HFS. DPD inhibitors were initially combined with fluoropyrimidines to increase the efficacy of the drugs by impairing the DPD-mediated catabolism of 5-FU. However, with the accumulating findings from clinical trials that show the benefits of DPD inhibition on decreasing the risk of HFS, consideration should be given to changing the recommendations for the treatment of cancer patients with fluoropyrimidines to include DPD inhibitor components as standard therapy.

Candidate mechanisms for capecitabine-related hand-foot syndrome

AIMS

The oral fluoropyrimidine prodrug capecitabine is widely used in oncology. Capecitabine was designed to generate 5FU via the thymidine phosphorylase (TP) enzyme, preferentially expressed in tumoral tissues. Hand-foot syndrome (HFS) is a limiting toxicity of capecitabine. A pilot study on healthy volunteers was conducted in order to test the hypothesis that the occurrence of HFS could be related to tissue-specific expression of drug-metabolizing enzymes in the skin of the palm and sole. To this end, the expression of TP (activating pathway), dihydropyrimidine dehydrogenase (DPD, catabolic pathway) and cell proliferation (Ki67) were measured in the skin of the palm (target tissue for HFS) and of the lower back (control area).

METHODS

Two paired 4-mm diameter punch biopsy specimens (palm and back) were taken in 12 healthy volunteers. Immunohistochemical analyses were performed on frozen tissues.

RESULTS

Proliferation rate (Ki67 staining) was significantly higher in epidermal basal cells of the palm compared with the back (P = 0.008). Also, TP and DPD expression were significantly greater in the palm relative to the back (P = 0.039 and 0.012, respectively). TP and Ki67 expression were positively and significantly correlated in the palm.

CONCLUSIONS

The high proliferation rate of epidermal basal cells in the palm could make them more sensitive to the local action of cytotoxic drugs. TP-facilitated local production of 5FU in the palm during capecitabine treatment could explain the occurrence of HFS. This observation may support future strategies to limit the occurrence of HFS during capecitabine therapy.

Unilaterale akrale Nekrosen als Abortivform einer palmoplantaren Erythrodysästhesie

Hand-foot syndrome is a common toxic side-effect, particularly during chemotherapy, with an incidence of 6-64% overall and 10-24% for capecitabine (Xeloda) monotherapy. Consequently, differential diagnostic considerations should include hand-foot syndrome when acral skin lesions appear, particularly during capecitabine monotherapy. The dosage should be reduced or therapeutic regimen changed. We present a unique patient who while on capecitabine developed unilateral acral necrosis which should be classified as a minor form of hand-foot syndrome.

Hand-Fuß-Syndrom bei einem Patienten unter Capecitabin-Therapie

A 72-year-old patient with esophageal carcinoma developed a severe hand-foot syndrome during second-line therapy with the oral fluoropyrimidine capecitabine. We also summarize the current knowledge with regard to the hand-foot syndrome and distinguish it from palmoplantar erythrodysesthesia.

Hand-foot syndrome with scleroderma-like change induced by the oral capecitabine: a case report

Hand-foot syndrome (HFS) is a well-known adverse event associated with capecitabine, a prodrug of 5-Fluorouracil (5-FU). HFS manifests as acral erythema, with swelling and dysesthesia of the palms and plantar aspects of the feet, which in the absence of dosage reduction or drug cessation, progresses to moist desquamation and ulceration, resulting in serious infections and loss of function. We report a case of HFS, with scleroderma-like changes, apparently induced by capecitabine. In our case, capecitabine, given in the recommended dosage was observed to lead to hyperpigmentation of the palms and soles, followed by a distinct keratoderma-like thickening unfamiliar to usual cases of HFS. This case may provide important clues for revising the definition of HFS, and allow the formation of effective preventive strategies for this side effect of chemotherapy.

Capecitabine-induced diffuse palmoplantar keratoderma: is it a sequential event of hand-foot syndrome?

Capecitabine was developed as a prodrug of 5-fluorouracil (FU), with the goal of improving tolerability and intratumour drug concentrations through tumour-specific conversion to the active drug against numerous types of neoplasms. The most frequent adverse cutaneous reaction associated with capecitabine is hand foot syndrome (HFS), presented with symmetrical erythema, dysaesthesia, and desquamation on the palms and soles. Acquired palmoplantar keratoderma (PPK) can occur in various dermatoses associated with metabolic abnormalities, malignancies, and toxic agents. However, there has been no report of PPK after capecitabine chemotherapy. We report two cases of diffuse PPK, which developed in patients with metastatic breast cancer after one cycle of capecitabine chemotherapy. Because oral capecitabine is increasingly used for various solid tumours, clinicians should be aware that keratoderma can develop during capecitabine chemotherapy as a sequential event of HFS.

Palmar-plantar erythrodysesthesia associated with scrotal and penile involvement with capecitabine

Capecitabine is an orally active fluoropyrimidine that has been approved for first-line treatment of metastatic colorectal cancer when fluoropyrimidines alone are indicated. One of the toxicities described in the literature associated with capecitabine is palmar-plantar erythrodysesthesia. Based on a careful review of the literature, no reported cases of erythema, ulceration, and swelling that involves the penis and scrotum have been described in association with capecitabine. The following 2 cases illustrate palmar-plantar erythrodysesthesia with scrotal and penile involvement secondary to capecitabine.

Palmar-plantar erythrodysesthesia (PPE): a literature review with commentary on experience in a cancer centre

Palmar-plantar erythrodysesthesia (PPE) or hand-foot syndrome (HFS) is a relatively common side effect of cytotoxic chemotherapy. Many cytotoxic drugs have been reported to cause the condition but it is more frequently associated with 5 fluorouracil (5FU), liposomal doxorubicin and cytarabine. The oral 5FU precursor, capecitabine is frequently associated with PPE and with the recent extension of its use to adjuvant treatment, the incidence of PPE is likely to increase. The initial symptoms are dysesthesia and tingling in the palms, fingers and soles of feet and erythema, which may progress to burning pain with dryness, cracking, desquamation, ulceration and oedema. Palms of the hands are more frequently affected than soles of the feet. This condition is painful and distressing to patients and in some incidences it results in patients not being able to work or perform normal daily activities. It can also result in treatment interruptions which impact on the efficacy of the treatment regimen. Effective and appropriate patient education from a specialist nurse prior to treatment is an essential part of patient management which will facilitate early identification of the symptoms and therefore prevent treatment delays and PPE progression. This article reviews current knowledge of the condition, including classification, and discussion of the findings of a clinical audit in a cancer centre. It includes the incidence, grading, management and impact of PPE on normal daily activities.

Management of hand-foot syndrome induced by capecitabine

INTRODUCTION

Capecitabine (Xeloda) is a systemic prodrug of 5-fluorouracil (5-FU), which is administered in an oral formulation. Hand-foot syndrome (HFS) has proven to be a chronic dose-limiting toxicity of capecitabine, leading to significant morbidity in patients receiving this agent. The purpose of this review is to define the pathophysiology, risk factors, incidence and management of capecitabine-induced HFS.

METHODS

Literature for this review article was collected from the following databases: PubMed, CINAHL, and the proceedings of the American Society of Clinical Oncology (ASCO) confined to the years 1995-2006. The following key terms were used in the search: hand-foot syndrome, palmar-plantar erythrodysesthesia, capecitabine, Xeloda, colorectal cancer, and metastatic breast cancer.

RESULTS

HFS associated with capecitabine is a serious dose-limiting toxicity. Incidence of grade 3/4 toxicity is of extreme significance, and introduces the need for dose reductions and/or interruptions in capecitabine therapy. Drug-related therapies studied include topical emollients and creams, systemic and topical corticosteroids, nicotine patch, vitamin E, pyridoxine, and COX-2 inhibitors. However, due to the lack of randomized, controlled trials with these therapies, the current mainstay of treatment for the management of this toxicity is interruption of therapy and, if necessary, dose reduction.

CONCLUSION

Treatment interruption or dose reduction remain the only methods shown to effectively manage HFS, but supportive measures to reduce pain and discomfort and prevent secondary infection are very important. Many other prophylactic and treatment strategies have been investigated, with pyridoxine and COX-2 inhibitors being the most promising in case reports and retrospective studies; therefore, prospective, randomized, controlled trials are needed to prove their efficacy.

Palmar–plantar erythrodysesthesia due to docetaxel–capecitabine therapy is treated with vitamin E without dose reduction

Palmar-plantar erythrodysesthesia (PPE) is a distinctive and relatively frequent toxic reaction related to some chemotherapeutic agents. Doxorubicin, cytarabine, docetaxel, fluorouracil, and capecitabine are the most frequently implicated agents. Recently, taxanes, especially docetaxel, have been widely used in combination with capecitabine in patients with metastatic breast cancer (MBC). A high percentage of PPE has been seen in patients undergoing this combination therapy. PPE seems to be dose dependent and both peak drug concentration and total cumulative dose determine its occurrence. Withdrawal or dose reduction of the implicated drug usually gives rise to amelioration of the symptoms. Supportive treatments such as topical wound care, elevation, and cold compresses may help to relieve the pain. Use of systemic corticosteroids, pyridoxine (vitamin B6), blood flow reduction, and, recently, topical 99% dimethyl-sulfoxide have been used with variable outcomes. Vitamin E treatment has not been published before, especially without dose reduction of docetaxel-capecitabine therapy. Here we present five MBC patients treated with docetaxel-capecitabine combination therapy in whom PPE was observed during the clinical follow-up period. In all patients grade 2-3 PPE was observed. Vitamin E therapy was started at 300 mg/day p.o. without dose reduction of therapy and after 1 week of treatment PPE began to disappear. We suggest that it could be of interest to consider vitamin E as a preventive drug when drugs with a strong association with PPE are going to be administered.

Retrospective Study of Capecitabine and Celecoxib In Metastatic Colorectal Cancer

OBJECTIVE

COX-2 activation may mediate capecitabine induced toxicities, eg, hand-foot syndrome (HFS) and colorectal cancer progression, both of which may be improved by concurrent celecoxib.

PATIENTS AND METHODS

From October 2000 to December 2003, 66 patients with metastatic colorectal cancer received concurrent capecitabine at 1000 mg/m/d b.i.d. and celecoxib at 200 mg b.i.d. (XCEL). Twenty-four patients were chemo-naive, 42 patients were second-line; while 34 had XCEL with radiation.

RESULTS

The median duration of XCEL was 7.2 months (range, 1.5-38 months). Ninety percent of Grade 2/3 HFS (17%) occurred after 6 months and incidence of grade 3/4 diarrheas was 8%. The overall response rate was 38% (95% confidence interval [CI], 26-51%), with 11 patients (17%) achieving complete responses and 2 patients (3%) with near complete responses. Six patients (9%) become resectable after sustaining treatment response. The median progression-free survival (PFS) and overall survival (OS) was 8.3 months (95% CI, 7.0-11.0 months) and 22 months (95% CI, 17.8-31.5 months), respectively. Improved median PFS of 14.5 months (P = 0.0001) and OS of 31.5 months (P = 0.005) were noted in patients with normal lactate dehydrogenase (LDH) levels (n = 37) than patients with high levels of LDH (n = 29).

CONCLUSIONS

XCEL integrating radiation may improve response rate and survival and reduce toxicities, notably HFS for patients with metastatic colorectal cancer, leading to a randomized phase III study.

Small-Fiber Neuropathy Associated with Capecitabine (Xeloda)-induced Hand-foot Syndrome: A Case Report

Hand-foot syndrome commonly results from treatment with capecitabine and is associated with pain, dysesthesias, paresthesias, and temperature intolerance. The cause of these symptoms in hand-foot syndrome has not been determined. We present the clinical, electrophysiologic, and biopsy data from a patient with capecitabine-induced hand-foot syndrome as supporting evidence implicating small-fiber neuropathy as the cause of these neuropathic symptoms. A patient with stage 4 breast cancer who develops capecitabine-induced hand-foot syndrome is referred for clinical and electrophysiologic testing. Intraepidermal nerve fiber density is assessed. Clinical evaluation demonstrates markedly decreased pain and temperature sensation with preserved strength, proprioception, and light touch. Standard electrodiagnostic testing is normal. The assessment of epidermal nerve fiber density demonstrates marked small-fiber loss both proximally and distally. In conclusion, small-fiber neuropathy is a likely cause of the neuropathic symptoms encountered in capecitabine-induced hand-foot syndrome. Similar clinical, electrophysiologic, and pathologic assessments are needed to confirm this finding in larger populations.

Oral Xeloda plus bi-platinu two-way combined chemotherapy in treatment of advanced gastrointestinal malignancies

AIM: To compare the effect, adverse events, cost-effectiveness and dose intensity (DI) of oral Xeloda vs calcium folinate (CF)/5-FU combination chemotherapy in patients with advanced gastrointestinal malignancies, both combined with bi-platinu two-way chemotherapy.

METHODS: A total of 131 patients were enrolled and randomly selected to receive either oral Xeloda (X group) or CF/5-FU (control group). Oral Xeloda 1 000 mg/m² was administered twice daily from d 1 to 14 in X group, while CF 200 mg/m² was taken as a 2-h intravenous infusion followed by 5-FU 600 mg/m² intravenously for 4-6 h on d 1-5 in control group. Cisplatin and oxaliplatin were administered in the same way to both the groups: cisplatin 60-80 mg/m² by hyperthermic intraperitoneal administration, and oxaliplatin 130 mg/m² intravenously for 2 h on d 1. All the drugs were recycled every 21 d, with at least two cycles. Pyridoxine 50 mg was given t.i.d. orally for prophylaxis of the hand-foot syndrome (HFS). Then the effect, adverse events, cost-effectiveness and DI of the two groups were evaluated.

RESULTS: Hundred and fourteen cases (87.0%) finished more than two chemotherapy cycles. The overall response rate of them was 52.5% (X group) and 42.4% (control group) respectively. Tumor progression time (TTP) was 7.35 mo vs 5.95 mo, and 1-year survival rate was 53.1% vs 44.5%. There was a remarkable statistical significance of TTP and 1-year survival between the two groups. The main Xeloda-related adverse events were myelosuppression, gastrointestinal toxicity, neurotoxicity and HFS, which were mild and well tolerable. Therefore, no patients withdrew from the study due to side effects before two chemotherapy cycles were finished. Both groups finished pre-arranged DI and the relative DI was nearly 1.0. The average cost for 1 patient in one cycle was ￥9 137.35 (X group) and ￥8 961.72 (control group), or US $1 100.89 in X group and $1 079.73 in control group. To add 1% to the response rate costs ￥161.44 vs￥210.37 respectively (US $19.45 vs $25.35). One-month prolongation of TTP costs ￥1 243.18 vs ￥1 506.17 (US $149.78 vs$181.47). Escalation of 1% of 1-year survival costs ￥172.74 vs ￥201.64 (US $20.75 vs $24.29).

CONCLUSION: Oral Xeloda combined with bi-platinu two-way combination chemotherapy is efficient and tolerable for patients with advanced gastrointestinal malignancies; meanwhile the expenditure is similar to that of CF/5-FU combined with bi-platinu chemotherapy, and will be cheaper if we are concerned about the increase of the response rate, TTP or 1-year-survival rate pharmacoeconomically.

Chemotherapy of metastatic colorectal cancer

Over the past decade, metastatic colorectal cancer has evolved from a relatively resistant disease to one that is sensitive to a variety of chemotherapeutic drugs and combinations of drugs. During the same period, the median survival of patients with metastatic colorectal cancer increased from approximately 14 months to almost 20 months. First-line chemotherapy prolongs survival and delays the appearance of symptoms and should be considered in patients who are still asymptomatic. Patients with metastatic colorectal cancer and adequate performance status should be treated with a combination of fluorouracil (5-FU) and either oxaliplatin or irinotecan. Bevacizumab, the monoclonal antibody against the vascular endothelial growth factor, has been shown to prolong survival with acceptable toxicity and may be added when available. When the disease recurs, second-line chemotherapy may also prolong survival in appropriately selected patients. Typically, treatment includes 5-FU and one of the drugs not used in the first-line therapy (oxaliplatin or irinotecan). Several oral prodrugs of 5-FU are currently available. Capecitabine, approved in the United States, may be safely substituted for 5-FU in the majority of settings and combinations. Cetuximab is a monoclonal antibody against the epidermal growth factor receptor and is approved both as a single agent and in combination with irinotecan for patients with recurrent disease. This treatment may represent a second-line or third-line option in selected patients. Treatment of patients with isolated liver metastases may also include surgical or other ablative procedures. In carefully selected patients, these modalities add to the efficacy of chemotherapy and may be used with potentially curative intent. However, for the vast majority of patients with metastatic colorectal cancer treatment is palliative.

Hand-foot syndrome in patients treated with capecitabine-containing combination chemotherapy

Clinical characteristics and risk factors of hand-foot syndrome were investigated in patients who received capecitabine-containing chemotherapy. Toxicity data were analyzed from 179 patients in 4 prospective clinical trials testing docetaxel/capecitabine/cisplatin in stomach cancer, capecitabine/cisplatin in biliary or stomach cancer, and vinorelbine/capecitabine in breast cancer. Hand-foot syndrome was reported in 116/179 (64.8%) of patients, with grade 3 hand-foot syndrome in 8/179 (4.5%). Hand-foot syndrome first developed within the first 3 chemotherapy cycles in 100/116 (86.2%) patients, with the median onset for all 3 treatment regimens occurring during cycle 2. Because severe reactions were rare, hand-foot syndrome was not a major factor influencing treatment schedule. Risk factor analyses showed that combined use of docetaxel and preceding chemotherapy-related stomatitis were significant risk factors for the development of hand-foot syndrome. Our results suggest that a combined treatment agent and a patient's susceptibility to chemotherapy-related toxicity may increase the risk of capecitabine-induced hand-foot syndrome.

Management of hand-foot syndrome in patients treated with capecitabine (Xeloda)

Comparative trials of capecitabine (Xeloda) versus 5-FU/LV in metastatic colorectal cancer have shown that hand-foot syndrome (HFS) was the only clinical adverse event occurring more frequently with capecitabine. Most patients with HFS present with dysesthesia, usually with a tingling sensation in the palms and soles of the hands and feet. This can progress in 3-4 days to burning pain plus well-defined symmetric swelling and erythema. The hands tend to be more commonly affected than the feet, and might even be the only area affected in some patients. HFS can interfere with the general activities of daily living, especially when blistering, moist desquamation, severe pain or ulceration occurs. While HFS is manageable, if ignored it can progress rapidly. However, dose interruption and reduction of capecitabine usually leads to a rapid reversal of signs and symptoms without long-term consequences. Nurses play a key role in educating patients how to recognise HFS, when to interrupt treatment and how to adjust the dose to maintain effective therapy with capecitabine over the long term. It is particularly important that patients and nurses are aware that dose interruption/reduction does not affect the overall antitumour efficacy of capecitabine.

Hand-foot Syndrome in a Patient with Multiple Fire Ant Stings

The case is reported of an elderly patient with known previous exposure to fire ant stings, and who presented with hand-foot syndrome (HFS) in the setting of multiple fire ant stings to the lower extremities. Both hands and both feet were red, swollen, and mildly tender. Treatment was with fluocinonide cream, and all symptoms resolved as the classic fire ant skin lesions regressed. HFS was initially reported in association with acute crisis in sickle cell anemia and thalassemia and more recently as a common toxicity of chemotherapy administration. This is the first report of its occurrence in the setting of fire ant envenomization. Although recent literature may indicate a potential therapeutic benefit from COX-2 antagonists, the process appears to be self-limited, and requires only conservative treatment.

Pharmacokinetics of S-1, an oral formulation of ftorafur, oxonic acid and 5-chloro-2,4-dihydroxypyridine (molar ratio 1:0.4:1) in patients with solid tumors

S-1 is an oral formulation of ftorafur (FT), oxonic acid and 5-chloro-2,4-dihydroxypyridine (CDHP) at a molar ratio of 1:0.4:1. FT is a 5-fluorouracil (5-FU) prodrug, CDHP is a dihydropyrimidine dehydrogenase (DPD) inhibitor and oxonic acid is an inhibitor of 5-FU phosphoribosylation in the gastrointestinal mucosa and was included to prevent gastrointestinal toxicity. We determined the pharmacokinetics of S-1 in 28 patients at doses of 25, 35, 40 and 45 mg/m(2). The plasma C(max) values of FT, 5-FU, oxonic acid and CDHP increased dose-dependently and after 1-2 h were in the ranges 5.8-13 microM, 0.4-2.4 microM, 0.026-1.337 microM, and 1.1-3.6 microM, respectively. Uracil levels, indicative of DPD inhibition, also increased dose-dependently from basal levels of 0.03-0.25 microM to 3.6-9.4 microM after 2-4 h, and 0.09-0.9 microM was still present after 24 h. The pharmacokinetics of CDHP and uracil were linear over the dose range. The areas under the plasma concentration curves (AUC) for CDHP and uracil were in the ranges 418-1735 and 2281-8627 micromol x min/l, respectively. The t(1/2) values were in the ranges 213-692 and 216-354 min, respectively. Cumulative urinary excretion of FT was predominantly as 5-FU and was 2.2-11.9%; the urinary excretion of both fluoro-beta-alanine and uracil was generally maximal between 6 and 18 h. During 28-day courses with twice-daily S-1 administration, 5-FU and uracil generally increased. Before each intake of S-1, 5-FU varied between 0.5 and 1 microM and uracil was in the micromolar range (up to 7 microM), indicating that effective DPD inhibition was maintained during the course. In a biopsy of an esophageal adenocarcinoma metastasis that had regressed, thymidylate synthase, the target of 5-FU, was inhibited 50%, but increased four- to tenfold after relapse in subsequent biopsies. In conclusion, oral S-1 administration resulted in prolonged exposure to micromolar 5-FU concentrations due to DPD inhibition, and the decrease in uracil levels after 6 h followed the pattern of CDHP and indicates reversible DPD inhibition.