Effets secondaires cutanés des nouvelles molécules anticancéreuses : focus sur les molécules ciblant les récepteurs tyrosine kinase et le récepteur à l’EGF

Cutaneous adverse drug reactions

Cutaneous adverse drug reactions (ADRs) represent a heterogeneous field including various clinical patterns without specific features suggesting drug causality. Maculopapular exanthema and urticaria are the most common types of cutaneous ADR. Serious cutaneous ADRs, which may cause permanent sequelae or have fatal outcome, may represent 2% of all cutaneous ADR and must be quickly identified to guide their management. These serious reactions include bullous manifestations (epidermal necrolysis i.e. Stevens-Johnson syndrome and toxic epidermal necrolysis), drug reaction with eosinophilia and systemic symptoms (DRESS) and acute generalized exanthematous pustulosis (AGEP). Some risk factors for developing cutaneous ADRs have been identified, including immunosuppression, autoimmunity or genetic variants. All drugs can cause cutaneous ADRs, the most commonly implicated being antibiotics (especially aminopenicillins and sulfonamides), anticonvulsants, allopurinol, antineoplastic drugs, non-steroidal anti-inflammatory drugs and iodinated contrast media. Pathophysiology is related to immediate or delayed "idiosyncratic" immunologic mechanisms, i.e., usually not related to dose, and pharmacologic/toxic mechanisms, commonly dose-dependent and/or time-dependent. If an immuno-allergic mechanism is suspected, allergological explorations (including epicutaneous patch testing and/or intradermal test) are often possible to clarify drug causality, however these have a variable sensitivity according to the drug and to the ADR type. No in vivo or in vitro test can consistently confirm the drug causality. To determine the origin of a rash, a logical approach based on clinical characteristics, chronologic factors and elimination of differential diagnosis (especially infectious etiologies) is required, completed with a literature search. Reporting to pharmacovigilance system is therefore essential both to analyze drug causality at individual level, and to contribute to knowledge of the drug at population level, especially for serious cutaneous ADRs or in cases involving newly marketed drugs.

[Cutaneous drug reactions]

Cutaneous drug reactions are a common reason for calls and visits. This term chiefly refers to hypersensitivity reactions ranging from benign rash without contraindication of treatment to severe life-threatening clinical pictures, such as anaphylactic shock and epidermal necrolysis. They should be carefully managed from the outset. Indeed, history taking and precise semiological description of the lesions are crucial to the formulation of recommendations for the patient. Allergological investigation of such reactions has developed greatly in recent decades and must now be carried out much more extensively. The arrival of new drug families such as biotherapies and the development of drug habituation protocols constitute the challenges of tomorrow for cutaneous drug reactions.

Impact of Skin Toxicities Associated with Targeted Cancer Therapies on Body Image: A Prospective Study

BACKGROUND AND OBJECTIVE

Body-image issues associated with dermatological side effects induced by anticancer-targeted therapies have not been specifically explored until now despite growing literature about their impact on quality of life. Prospective and longitudinal investigations were needed. The aim of our study was to describe body-image changes occurring with cutaneous toxicities and their psychosocial impact on patients.

PATIENTS AND METHODS

Thirty-three patients were evaluated four times during the first 3 months of targeted therapy in terms of body satisfaction, physical attitudes and depression with validated and ad hoc questionnaires. The NCI-CTCAE V4.0 was used to grade adverse dermatological events. Descriptive and inferential analyses were conducted with SPSS 14.0 software.

RESULTS

Ninety-four per cent of the patients developed skin toxicities. Body satisfaction remained stable and slightly better than average over this period. About one-third of the patients reported body-image issues at baseline. Body satisfaction and depression levels at baseline appeared to be significantly associated with body-image issues after 3 months of therapy.

CONCLUSION

In the framework of regular dermatological monitoring, skin toxicities did not appear to be associated with body-image issues. Body satisfaction and depressive symptoms at the beginning of targeted therapy emerged as critical factors that practitioners should consider in order to prevent deterioration of body image that could impact on quality of life and compromise compliance.

NSK-01105, a novel sorafenib derivative, inhibits human prostate tumor growth via suppression of VEGFR2/EGFR-mediated angiogenesis

The purpose of this study is to investigate the anti-angiogenic activities of NSK-01105, a novel sorafenib derivative, in in vitro, ex vivo and in vivo models, and explore the potential mechanisms. NSK-01105 significantly inhibited vascular endothelial growth factor (VEGF)-induced migration and tube formation of human umbilical vein endothelial cells at non-cytotoxic concentrations as shown by wound-healing, transwell migration and endothelial cell tube formation assays, respectively. Cell viability and invasion of LNCaP and PC-3 cells were significantly inhibited by cytotoxicity assay and matrigel invasion assay. Furthermore, NSK-01105 also inhibited ex vivo angiogenesis in matrigel plug assay. Western blot analysis showed that NSK-01105 down-regulated VEGF-induced phosphorylation of VEGF receptor 2 (VEGFR2) and the activation of epidermal growth factor receptor (EGFR). Tumor volumes were significantly reduced by NSK-01105 at 60 mg/kg/day in both xenograft models. Immunohistochemical staining demonstrated a close association between inhibition of tumor growth and neovascularization. Collectively, our results suggest a role of NSK-01105 in treatment for human prostate tumors, and one of the potential mechanisms may be attributed to anti-angiogenic activities.

[Impact of cutaneous toxicities associated with targeted therapies on quality of life. Results of a longitudinal exploratory study]

Targeted therapies represent a promising option in cancer treatment, which have shown tumor control and patients survival benefits. But these drugs have systemic side effects, in particular frequent and various cutaneous effects. Few data have been published about the impact of these symptoms on patients' quality of life, particularly for psychological and social aspects. That is why we wished to evaluate this impact in order to propose a preventive management and optimize patients' care. Twenty-seven patients participated in both evaluation times of a longitudinal quantitative pilot study. They completed the same set of psychological questionnaires before taking treatment and 30 days after. Patients were mainly men with a metastatic lung, digestive or cutaneous cancer. Analyses showed that dermatological symptoms in 22 patients were associated for a majority of them with a decrease of quality of life, characterized by difficulties in houseworks and leisure activities, and a social functioning impairment. Adverse skin events did not seem to affect emotional state. These results must be confirmed by further investigations in a larger-scale prospective research.

SC-1, a sorafenib derivative, shows anti-tumor effects in osteogenic sarcoma cells

Despite significant advances in the treatment of osteosarcoma (OS), overall survival rate of OS patients has remained relatively constant for over two decades and novel approaches are needed to further improve prognosis. Here, we report the anti-tumor effect of SC-1, a novel sorafenib derivative that closely resembles sorafenib structurally but is devoid of kinase inhibitory activity, on OS cells through mediation of signal transducer and activator of transcription 3 (STAT3). SC-1 showed similar effects to sorafenib on growth inhibition and apoptosis, and downregulated phospho-STAT3 (p-STAT3) at tyrosine 705 in all tested OS cell lines (U2OS, HOS, and 143B). Expression of STAT3-driven genes, including cylcin D1 and c-myc, were also repressed by SC-1. Ectopic expression of STAT3 in 143B cells abolished apoptosis in SC-1-treated cells. Inhibition of SHP-1 decreased SC-1-induced apoptosis. SC-1 upregulated the activity of SHP-1 in tested OS cell lines in a dose-dependent manner. Finally, SC-1 reduced 143B tumor growth significantly in vivo, which was associated with downregulation of p-STAT3 and upregulation of SHP-1 activity. These data demonstrate that SC-1 has clinical potential for the treatment of OS patients.

[Successive cutaneous adverse reactions to nilotinib and imatinib in a single patient]

BACKGROUND

Since the advent of targeted molecules, the treatment and prognosis of many cancers, especially chronic myeloid leukemia (CML), have been substantially modified through the introduction of first- and second-generation tyrosine kinase inhibitors. Skin effects constitute the most common adverse effects of these new substances. Although such skin changes are not life-threatening, they can have extensive clinical impact, in some cases leading to discontinuation of treatment.

PATIENTS AND METHODS

A 47-year-old woman with no past medical history was followed for chronic phase CML since 26/11/2010 with the presence of the t(9; 22) karyotype. Imatinib (IM) was started at a dose of 400mg/day and haematological response was good. After 4 months of treatment with IM the patient presented with erythematous plaques on both upper limbs and on the oral and vaginal mucosa. These lesions disappeared after discontinuation of IM. The patient was then put on nilotinib 400mg/d and skin lesions reappeared after 3 weeks in the more serious form of erythema multiform with acral distribution, but with no involvement of the mucosa, resulting in immediate cessation of nilotinib. Skin biopsy was consistent with a drug-induced eruption. The lesions disappeared after discontinuation of nilotinib.

DISCUSSION

In case of intolerance to IM, a second-generation ITK (dasatinib or nilotinib) may be substituted, and while cross-sensitivities seem infrequent, therapy is problematic in these patients presenting potentially curable blood dyscrasias.

Cetuximab-associated elongation of the eyelashes: case report and review of eyelash trichomegaly secondary to epidermal growth factor receptor inhibitors

Eyelash trichomegaly is an uncommon drug-associated sequelae experienced during treatment with epidermal growth factor receptor (EGFR) inhibitors. Elongation of the eyelashes induced by these agents has predominantly been observed in oncology patients with either colorectal or lung cancer. It is most frequently associated with cetuximab and erlotinib; however, it has also been described in individuals treated with gefitinib or panitumumab. We describe cetuximab-associated eyelash trichomegaly in a woman with metastatic rectal carcinoma. We review the clinical presentation, adverse effects, and management of EGFR inhibitor-related eyelash trichomegaly. The long eyelashes are not a drug-limiting adverse effect and some patients consider the change to be cosmetically enhancing. Trimming the lashes with scissors can usually ameliorate local symptoms. The eyelashes often return to their original length at variable time periods after EGFR inhibitor therapy is discontinued.

[Squamous cell carcinoma in a patient receiving sorafenib]

BACKGROUND

Sorafenib is a multikinase inhibitor approved for the treatment of renal cell carcinoma and hepatocellular carcinoma. Associated short-term cutaneous adverse events are well known. Regarding long-term adverse events, keratoacanthoma has been reported more recently and, more rarely, invasive squamous cell carcinoma.

PATIENTS AND METHODS

A 56-year-old man was treated with sorafenib in December 2008 for renal cell carcinoma with cutaneous metastases. The patient had a skin phototype IV and no history of intense sun exposure. Within five months of starting sorafenib, he developed deeply invasive well-differentiated retroauricular squamous cell carcinoma.

DISCUSSION

Sorafenib modifies the immunostimulatory capacity of dendritic cells by reducing cytokine secretion and CD1a expression. Blockade of autocrine vascular endothelial growth factor (VEGF) signalling in keratinocytes can also select tumoural clones with increased oncogenic Ras mutation, increased activation of phospholipase D and modulation of the Ras/Raf/MAP kinase signalling pathway involved in cutaneous squamous cell carcinogenesis.

CONCLUSION

Cases of keratoacanthomas and deeply invasive squamous cell carcinomas reported in patients on sorafenib emphasise the need for multidisciplinary follow-up of this population and the important role of dermatologists in managing the short and long-term adverse effects of multitarget tyrosine inhibitors.

[Unilateral acneiform rash in facial palsy]

BACKGROUND

Cetuximab is a chimeric monoclonal antibody selective for epidermal growth factor receptor (EGFR). It is increasingly used in epithelial cancer, often in combination with radiotherapy or chemotherapeutic agents, since it induces a broad range of cellular responses that enhance tumour sensitivity to these therapies. However, it can cause numerous adverse effects, the most common being acneiform eruption on the face and trunk, which is generally bilateral and symmetric.

PATIENTS AND METHODS

Herein we present the first case of unilateral cetuximab-induced acneiform eruption in facial palsy.

DISCUSSION

To our knowledge the medical literature contains no other such cases. Our hypothesis is that lymphoedema associated with facial palsy reduces lymphatic drainage, promoting the deposition of cetuximab on EGFR and persistence of local signs.

Sorafenib-induced hand-foot skin reaction: a Koebner phenomenon?

Sorafenib is a tyrosine kinase inhibitor prescribed primarily for the management of metastatic kidney cancer. It exhibits a good safety profile, but is the cause of a number of dermatological adverse effects. The most common and often the most troublesome is a specific hand-foot skin reaction (HFSR) affecting at least 30% of patients. It occurs predominantly on hyperkeratotic areas of the hands and feet that are subject to chronic pressure, suggesting the role played by repeated subclinical traumas in its pathophysiological mechanism. We report here two new cases of sorafenib-induced HFSR, but associated with identical lesions occurring on specific areas of friction (scar, elbows) and suggestive of a Koebner phenomenon. This provides information about the origin of the palmar and plantar lesions observed with sorafenib.

Rational use of cetuximab in the treatment of advanced non-small cell lung cancer

Lung cancer is the leading cause of mortality in the United States. Non-small cell lung cancer (NSCLC) accounts for approximately 85% of all lung cancers. Most NSCLC patients present with loco-regionally advanced or metastatic disease where response rates are low and median overall survival approximates 8 to 10 months. Chemotherapy is the mainstay of treatment for NSCLC patients with metastatic disease. Epidermal growth factor receptor (EGFR) and family of receptors play a critical role in lung cancer tumorigenesis. Cetuximab, a monoclonal antibody that binds the EGFR, has demonstrated preclinical and clinical activity against NSCLC. This review focuses on the use of cetuximab in NSCLC.