Ocular side effects in chronic myeloid leukemia patients treated with imatinib

Side Effects of Novel Anticancer Drugs on the Posterior Segment of the Eye: A Review of the Literature

Currently, common treatment approaches for neoplastic diseases include surgery, radiation, and/or anticancer drugs (chemotherapy, hormone medications, and targeted therapies). In particular, anticancer medicines destroy cancerous cells by blocking certain pathways that aid in the disease's initiation and progression. These pharmaceutical drugs' capacity to inhibit malignant cells has made them indispensable in the treatment of neoplastic disorders. Nonetheless, considering their cyto- and neurotoxicity, as well as their inflammatory responses, these medications may also have unfavorable systemic and ocular side effects. In fact, it is well known that ocular posterior segment side effects, including retinal and vascular complications, have a negative influence on the patient's eyesight and quality of life. However, the underlying mechanisms contributing to the development of these side effects remain incompletely recognized, especially in the case of newly available anticancer drugs. The purpose of this literature review is to analyze the possible side effects of new anticancer drugs on the posterior segment of the eye, trying to better understand the involved pharmacological mechanisms and offer helpful guidance on their appropriate management.

Viewing Pulmonary Arterial Hypertension Pathogenesis and Opportunities for Disease-Modifying Therapy Through the Lens of Biomass

Fibroproliferative remodeling of distal pulmonary arterioles is a cornerstone characteristic of pulmonary arterial hypertension (PAH). Data from contemporary quantitative imaging suggest that anabolic synthesis of macromolecular substrate, defined here as biomass, is the proximate event that causes vascular remodeling via pathogenic changes to DNA, collagen, cytoskeleton, and lipid membranes. Modifying biomass is achievable but requires tilting the balance in favor of endogenous degradation over synthetic pathways in order to advance the first-ever disease-modifying PAH pharmacotherapy. Viewing PAH pathobiology through the lens of biomass represents an opportunity to decipher novel determinants of disease inception and inform interventions that induce reverse remodeling.

Neuro-ophthalmic complications of modern anti-cancer drugs

PURPOSE

Targeted cancer therapies have been responsible for a dramatic shift in treatment strategies for cancer, and the number of drugs, classes, and indications are continually growing. Neuro-ophthalmic complications of these medications are an uncommon but important subset of adverse events which profoundly impact vision. This review aims to collate studies and reports of known neuro-ophthalmic complications of targeted therapies and describe their management.

METHODS

The anti-cancer drugs included in the review were any drugs targeting specific molecules involved in the cancer disease process. PubMed, EMBASE, and Web of Science were searched using the generic names of each drug and keywords of neuro-ophthalmic conditions. The prescribing information published by the US Food and Drug Administration (FDA) for each drug was also reviewed.

RESULTS

Several classes of targeted anti-cancer drugs were found to cause neuro-ophthalmic adverse effects. Immune checkpoint inhibitors are responsible for a raft of immune-related adverse events such as optic neuritis, ischemic optic neuropathy, PRES, and myasthenia gravis. Therapies with anti-VEGF activity can provoke posterior reversible leukoencephalopathy, which commonly presents with visual loss and can be fatal if not treated promptly. Inhibitors of BCR-ABL1, VEGF, ALK, and proteasomes have all been linked to optic nerve disorders which can have debilitating consequences for vision.

CONCLUSION

The neuro-ophthalmic complications of modern anti-cancer drugs can limit or necessitate the withdrawal of these life-prolonging medications. Ophthalmologists should be alert for neuro-ophthalmic complications in these medications to facilitate prompt diagnosis and treatment and reduce the risk of severe and permanent consequences.

Assessment of ocular manifestation frequency and quality of life in chronic myeloproliferative disorders

Chronic myeloproliferative disorders (CMPD) include hemoblastoses with abnormal proliferation of myeloid lineages and concomitant alterations in the peripheral blood indicators. The aim of this study was to assess the frequency and structure of ophthalmic complications as a quality of life factor in patients with CMPD. A group of patients with hemoblastoses of this type (n = 41) were surveyed using National Eye Institute Visual Function Questionnaire-25 along with a comprehensive examination by noninvasive ophthalmological techniques. The patients typically reported impaired visual acuity, visual discomfort and foreign body sensation in the eyes. Though many of the patients assessed their general health and vision as satisfactory, the vast majority (68.3%) expressed serious concerns about their visual abilities. The ophthalmological examination revealed various defects including refractive errors (61%), corkscrew dilation and tortuosity of conjunctival and retinal vessels (77.9%), recurrent subconjunctival hemorrhages (39%) and dilated optic nerve sheaths (36.6%). The survey data indicate that visual impairments significantly affect quality of life in patients with CMPD. Overall, the results underscore the importance of interdisciplinary approach in the management of patients with CMPD to enable early diagnosis and feasible correction of the ophthalmic component.

Adverse outcomes in chronic myeloid leukemia patients treated with tyrosine kinase inhibitors: Follow-up of patients diagnosed 2002-2017 in a complete coverage and nationwide agnostic register study

Tyrosine kinase inhibitors (TKIs) have profoundly improved the clinical outcome for patients with chronic myeloid leukemia (CML), but their overall survival is still subnormal and the treatment is associated with adverse events. In a large cohort-study, we assessed the morbidity in 1328 Swedish CML chronic phase patients diagnosed 2002-2017 and treated with TKIs, as compared to that in carefully matched control individuals. Several Swedish patient registers with near-complete nationwide coverage were utilized for data acquisition. Median follow-up was 6 (IQR, 3-10) years with a total follow-up of 8510 person-years for the full cohort. Among 670 analyzed disease categories, the patient cohort showed a significantly increased risk in 142 while, strikingly, no category was more common in controls. Increased incidence rate ratios/IRR (95% CI) for more severe events among patients included acute myocardial infarction (AMI) 2.0 (1.5-2.6), heart failure 2.6 (2.2-3.2), pneumonia 2.8 (2.3-3.5), and unspecified sepsis 3.5 (2.6-4.7). When comparing patients on 2nd generation TKIs vs. imatinib in a within-cohort analysis, nilotinib generated elevated IRRs for AMI (2.9; 1.5-5.6) and chronic ischemic heart disease (2.2; 1.2-3.9), dasatinib for pleural effusion (11.6; 7.6-17.7) and infectious complications, for example, acute upper respiratory infections (3.0; 1.4-6.0). Our extensive real-world data reveal significant risk increases of severe morbidity in TKI-treated CML patients, as compared to matched controls, particularly for 2nd generation TKIs. Whether this increased morbidity may also translate into increased mortality, thus preventing CML patients to achieve a normalized overall survival, needs to be further explored.

Vitreous hemorrhage: A rare ophthalmic adverse effect due to imatinib treatment

INTRODUCTION

Imatinib is generally well tolerated by patients. The most common ophthalmic side effects are eyelid edema and periorbital edema. Other side effects which occur at rates of <1% include blepharitis, blurred vision, conjunctival hemorrhage, conjunctivitis, retinal hemorrhage, etc. An uncommon case is here reported of a 51-year-old male with chronic myeloid leukemia who developed vitreous hemorrhage due to imatinib after 9 months of treatment.

CASE REPORT

A 51-year-old male with leukocytosis detected in the blood test examination was referred to the Hematology Department. The bone marrow biopsy result was compatible with chronic myeloid leukemia. Imatinib treatment (400 mg/day) was started. In the ninth month of imatinib treatment, the patient complained of a sudden decrease in vision. Vitreous hemorrhage was detected in the left eye and the patient underwent surgery. Vitreous hemorrhage recurred 1 month after the operation. On the fourth day after the discontinuation of imatinib treatment, the patient's ophthalmic complaints improved significantly. The Naranjo algorithm was applied and a score of 9 was detected. The vitreous hemorrhage of the patient was attributed to imatinib, and so the treatment of the patient was switched to bosutinib.

DISCUSSION

Imatinib is an oral signal inhibitor that targets tyrosine kinase for BCR/ABL, platelet-derived growth factor, stem cell factor, and c-kit (CD117). The conjunctiva and sclera have a large amount of c-kit positive mast cells which are inhibited by imatinib. The inhibition of c-kit positive mast cells by imatinib may be responsible for further exposure of the conjunctival mucosa to injuries.

Ocular Toxicity of Targeted Anticancer Agents

The proliferation of targeted anticancer agents over the last two decades has revolutionized cancer treatment and improved survival in many previously refractory malignancies. However, many agents are associated with characteristic ophthalmic adverse effects. It is important that ophthalmologists recognize and maintain a high index of suspicion for these side effects in patients on targeted therapy. Most ophthalmic adverse effects can be treated with specific ocular therapy without discontinuation of cancer treatment, although it is important to be aware of the life-threatening and vision-threatening circumstances that would require therapy cessation in conjunction with the patient's oncologist. This review aims to summarize the ophthalmic adverse effects of targeted and hormonal anticancer agents and briefly describe their management.

Targeted Cancer Therapy and Its Ophthalmic Side Effects: A Review

Targeted cancer therapy agents are the latest development in cancer therapeutics. Although the spectrum of their use continues to expand, ocular side effects are frequently encountered with the use of cancer therapeutics. This review describes the ocular side effects of targeted cancer therapy agents.

Recent advances in the combination delivery of drug for leukemia and other cancers

Introduction: Combination therapy has been explored for its potential to reduce or eliminate multidrug resistance in treating different types of cancer including leukemia. Nutraceutical, small molecular drugs, and small interfering ribonucleic acid (siRNA) are some of the effective drugs. In order to avoid off-site targeting, reduce the dosage required, and increase the half-life of the drug in the circulation system, drug delivery vehicles, such as nanoparticles and microfibers have been explored.Areas covered: This review summarizes various therapies utilized in treating leukemia based on their effectiveness in inducing protein inhibition and/or apoptosis. In particular, treatment effectiveness using combination therapy using various devices is addressed. Recently explored drug delivery methods are reviewed, providing examples and their applications in cancer treatment. The drug listing, delivery systems classifications, along with the general modeling approach in this review, provide, to a full extent, a basis for cancer drug delivery future studies.Expert opinion: The reviewer's opinion tackles the potential of using a multi-delivery system to deliver multiple drugs, providing better control upon drug release and targeting. Both local and systemic delivery are considered and explored for their potential targets. Researchers are advised to pre-consider all aspects associated with their desired delivery method.

Cranial nerve palsies in patients with hematological malignancies: a case series

Objectives: Cranial neuropathies (CNs) can be due to a wide spectrum of causes, and the differential diagnosis is particularly challenging in patients with positive history of hematological malignancies, when neoplastic meningitis (NM) must be excluded.Patients and Methods: We retrospectively selected a series of twelve haematological patients with isolated cranial neuropathies (ICNs) or multiple cranial neuropathies (MCNs). among 71 patients that developed neurologic symptoms during different stages of the cancer, between 1 January, 2010 and 31 December, 2017. Brain and cauda equina magnetic resonance imaging (MRI) with gadolinium, cerebrospinal fluid (CSF) analysis, including flow cytometry for cell immunophenotyping and microbiological exams were performed in all patients.Results: Patients developed signs and symptoms of involvement of isolated (n = 11) or multiple (n = 1) cranial nerves, at different stages of the primary disease, and, in 5 of these cases in complete remission after hematopoietic stem cell transplantation. Among the 5 cases that eventually were diagnosed as having NM, cerebrospinal fluid was positive for neoplastic cells in 3, and MRI gadolinium-enhancement was present in 3. The other episodes were attributed to heterogeneous pathologies that were unrelated to meningeal infiltration by neoplastic cells.Conclusions: Our observations confirm that NM in haematological malignancies can yield insidious isolated signs of cranial nerves. Only a multidisciplinary approach allows prompt recognition of these conditions through a challenging process of differential diagnosis, and proper therapies.

Uncontrolled neovascular glaucoma - an alarming manifestation of chronic myeloid leukemia on imatinib therapy - a case report and review of literature

A 45-year-old diabetic male, with diabetic retinopathy and medically uncontrolled neovascular glaucoma (NVG) underwent intracameral bevacizumab followed by trabeculectomy, with controlled intraocular pressures (IOP) post-operatively, OD: 12 mmHg; OS: 14 mmHg. Patient was referred to hematology, where he was diagnosed as chronic myeloid leukemia (CML) and started on imatinib mesylate. Thereafter, he presented with recurrence of neovascularization and vascularization of the bleb along with OS vitreous hemorrhage at 6 weeks follow-up. While he was planned for OS vitreo-retinal surgery, he presented with OD spontaneous hyphema with raised IOP (OD: 38 mmHg, OS: 16 mmHg). He had maintained a tight glycemic control. Following imatinib therapy, there was a rapid progression and recurrence of neovascularization, eventually leading to failure of trabeculectomy OD and bilateral severe loss of vision. Imatinib may be implicated in the worsening of NVG in CML patients, especially with co-existing diabetes and thus, such patients should receive regular thorough ophthalmic evaluation as long as imatinib continues.

Vogt-Koyanagi-Harada disease like presentation in patients with chronic myeloid leukemia

Purpose

To report two rare cases of chronic myeloid leukemia (CML) on tyrosine kinase inhibitors presenting as bilateral serous retinal detachment and ocular inflammation, simulating Vogt-Koyanagi-Harada (VKH) disease.

Methods

Case series and review of literature.

Result

Two young patients (one male and one female) with CML on treatment with tyrosine kinase inhibitors (imatinib and dasatanib) under remission presented with bilateral sudden vision loss. One patient had bilateral multiple pockets of serous retinal fluid while the other had panuveitis with exudative retinal detachment. There was neither prodromal symptoms nor systemic signs and symptoms suggestive of VKH in both cases. They responded well to systemic steroid therapy without recurrences with complete visual recovery.

Conclusion and importance

CML patients can have features similar to VKH even during stable hematological phase and may be possibly associated with the use of tyrosine kinase inhibitors. Hence it is important not to misdiagnose and treat such patients with long term immunomodulators.

Neuro-ophthalmic side effects of molecularly targeted cancer drugs

The past two decades has been an amazing time in the advancement of cancer treatment. Molecularly targeted therapy is a concept in which specific cellular molecules (overexpressed, mutationally activated, or selectively expressed proteins) are manipulated in an advantageous manner to decrease the transformation, proliferation, and/or survival of cancer cells. In addition, increased knowledge of the role of the immune system in carcinogenesis has led to the development of immune checkpoint inhibitors to restore and enhance cellular-mediated antitumor immunity. The United States Food and Drug Administration approval of the chimeric monoclonal antibody (mAb) rituximab in 1997 for the treatment of B cell non-Hodgkin lymphoma ushered in a new era of targeted therapy for cancer. A year later, trastuzumab, a humanized mAb, was approved for patients with breast cancer. In 2001, imatinib was the first small-molecule kinase inhibitor approved. The approval of ipilimumab-the first in class immune checkpoint inhibitor-in 2011 serves as a landmark period of time in the resurgence of immunotherapy for cancer. Despite the notion that increased tumor specificity results in decreased complications, toxicity remains a major hurdle in the development and implementation of many of the targeted anticancer drugs. This article will provide an overview of the current cellular and immunological understanding of cancer pathogenesis-the foundation upon which molecularly targeted therapies were developed-and a description of the ocular and neuro-ophthalmic toxicity profile of mAbs, immune checkpoint inhibitors, and small-molecule kinase inhibitors.

Vogt-Koyanagi-Harada disease in a patient of chronic myeloid leukemia

This case report describes the concurrent development of Vogt–Koyanagi–Harada (VKH) disease in a 39 year old male patient of chronic myeloid leukemia (CML). The patient being reported was a known case of CML in remission with history of painless sudden loss of vision in both eyes. Cases of leukemia can present with visual loss due to multiple ocular manifestations of leukemia itself or side effects of modern drugs used for its treatment. Clinical examination and multimodal imaging of our patient were suggestive of concurrent development of VKH. The patient was started on oral steroids, to which he showed a good response. Thus, the cases of CML may rarely develop concurrent ocular disorders not related to leukemia. These associated ocular disorders need to be distinguished from the ocular manifestations of leukemia itself. Our case highlights the concurrent development of VKH as the etiology of visual loss in a case of CML.

Managing Cutaneous Side Effects From Targeted Molecular Inhibitors for Melanoma and Nonmelanoma Skin Cancer

BACKGROUND

Targeted anticancer therapies can cause cutaneous adverse events different from classical chemotherapeutic toxicities.

OBJECTIVE

To review the literature on dermatologic adverse events (DAEs) of targeted molecular inhibitors for melanoma and nonmelanoma skin cancers with a focus on management options.

MATERIALS AND METHODS

A comprehensive literature search related to the side effects and management of these side effects from vemurafenib, dabrafenib, trametinib (BRAF inhibitors), pembrolizumab (antiprogrammed-death-receptor-1 antibody), imatinib (tyrosine kinase inhibitor), ipilimumab (anticytotoxic T-lymphocyte antigen-4 antibody), cetuximab (epidermal growth factor receptor inhibitor), sorafenib (multikinase inhibitor), and vismodegib (smoothened receptor inhibitor).

RESULTS

No large controlled studies specifically examining the management of DAEs of targeted molecular inhibitors exist, although there are case report-based recommendations and algorithms developed by expert panels to manage these adverse events.

CONCLUSION

Many options for managing the cutaneous side effects of targeted molecular inhibitors are similar to those used in general dermatology practice. When used effectively, drug dosing and patient quality of life may be optimized.

Optic neuropathy secondary to dasatinib in the treatment of a chronic myeloid leukemia case

The drug dasatinib is a new therapeutic option for patients with chronic myeloid leukemia (CML) as well as acute lymphocytic lymphoblastic leukemia (ALL). However, the scientific literature has not reached a consensus regarding the types of secondary ophthalmologic effects that this drug may have. In this study, we present the case of a 36-year-old male patient who was treated with dasatinib. Two and a half months later, this patient began to experience progressive visual loss in the superior visual field of both eyes.

After ruling out various diagnostic options and performing extensive complementary tests, the suspected diagnosis was compatible with optic neuropathy secondary to dasatinib. The patient partially improved after stopping this medication and receiving oral corticosteroid treatment.

Although secondary ophthalmological effects related to dasatinib are practically non-existent, our case is the first to report optic neuropathy secondary to this drug.

Retinal toxicities of cancer therapy drugs: biologics, small molecule inhibitors, and chemotherapies

PURPOSE

To review reported retinal side effects from current cancer therapy drugs.

METHODS

Retinal toxicities from ophthalmologic or oncologic case reports, case series, and clinical trials were identified by a systematic literature search using Lexicomp and PubMed.

RESULTS

Four biologics, 8 small molecule inhibitors, and 17 traditional chemotherapy agents had reported retinal side effects. For biologics, interferon alpha 2b was associated with retinopathy, denileukin diftitiox with pigmentary retinopathy, ipilimumab with a Vogt-Koyanagi-Harada-like syndrome, and trastuzumab with retinal ischemia. For small molecule inhibitors, v-raf murine sarcoma viral oncogene homolog B (BRAF) inhibitors were associated with uveitis, mitogen-activated protein kinase/extracellular signal-regulated kinase inhibitors with pigment epithelium detachments, and tyrosine kinase inhibitors with macular edema. Steroid antagonists were associated with crystalline retinopathy and macular edema. Nitrosoureas, platinum analogs, and cytosine arabinoside were associated with retinal vascular occlusions. Antimicrotubular agents were associated with cystoid macular edema but without fluorescein leakage. Retinoic acid derivatives were associated with impaired night vision, and mitotane was associated with a pigmentary retinopathy and papilledema.

CONCLUSION

Certain agents used in the treatment of systemic cancer are associated with ocular complications. Awareness of these complications will allow early detections and maybe reversal of some of the ocular problems.

Ocular side effects of biological agents in oncology: what should the clinician be aware of?

During the last 20 years, biologicals have become increasingly relevant in oncologic therapy. Depending on the medication used, there are different profiles of ocular side effects. Although these can be present in up to 70% of patients, they are generally underreported in the literature. Therefore, the pathophysiological details of their development are often poorly understood. Herein we attempt to identify groups of biologicals to which a specific side effect profile can be assigned. We also tried to capture all relevant side effects and therefore conducted several database investigation including Medline, Cochrane library, and the drugs section of the US Food and Drug Administration (FDA), using the following search strings: “name of biological agent (both generic and commercial names)” AND “eye” OR “ocular”. If we found a side effect that has been associated with a drug, we researched Medline using the following search string: “name of biological agent” (both generic and commercial names) AND “term for the specific side effect”. Due to the wealth of material we report only the drugs that are approved by the FDA.

Bilateral papilledema on sunitinib therapy for advanced renal cell carcinoma

We report the case of a 59-year-old man with advanced renal cell carcinoma who developed bilateral papilledema while on therapy with sunitinib, a multi-targeted tyrosine kinase inhibitor (TKI). While papilledema has been reported in association with another TKI (imatinib), the association between sunitinib and papilledema has not previously been reported in the literature.

Ocular side effects associated with imatinib mesylate and perifosine for gastrointestinal stromal tumor

Imatinib mesylate and perifosine are two relatively new drugs that have improved outcomes for patients with gastrointestinal stromal tumors in recent years. The ocular side effects of these two drugs are discussed in this chapter. The most common ocular side effect associated with imatinib mesylate is periorbital edema. Perifosine has been associated with a ring-shaped perilimbal corneal ulceration that can be treated with topical steroids and topical antibiotics.