Gemcitabine-induced acute lipodermatosclerosis-like reaction

Chemotherapy-Induced Pseudocellulitis Without Prior Radiation Exposure: A Systematic Review

Importance

Chemotherapy-induced pseudocellulitis is an ill-defined term for a poorly understood phenomenon. Encompassing a myriad of cellulitis-mimicking oncologic adverse cutaneous drug reactions (ACDRs), pseudocellulitis may be difficult to diagnosis, and the lack of treatment guidance may mean unnecessary antibiotic exposure and interruptions to oncologic care.

Objectives

To use case reports to characterize the various cellulitis-mimicking reactions caused by chemotherapeutic medications, to understand how these reactions affect patient care (ie, antibiotic exposure and interruptions to oncologic treatment), and to make recommendations for improved diagnosis and care of patients with chemotherapy-induced pseudocellulitis.

Evidence Review

A systematic review of case reports of patients with pseudocellulitis was performed. Reports were identified through database searches using PubMed and Embase, with subsequent reference searches. Included publications described at least 1 case of chemotherapy-induced ACDR and used the term pseudocellulitis or showed evidence of cellulitis mimicry. Cases of radiation recall dermatitis were excluded. Data were extracted from a total of 32 publications representing 81 patients diagnosed with pseudocellulitis.

Findings

Of the 81 cases (median [range] age, 67 [36-80] years; 44 [54%] male patients), most were associated with gemcitabine use; pemetrexed use was reported less frequently. Only 39 were considered to be true chemotherapy-induced pseudocellulitis. These cases resembled infectious cellulitis and did not meet diagnostic criteria for any known diagnoses; therefore, these were described solely as pseudocellulitis. Of this group, 26 patients (67%) had been administered antibiotics before the correct diagnosis was made, and 14 patients (36%) experienced interruptions to their oncologic treatment plans.

Conclusions and Relevance

This systematic review found a variety of chemotherapy-induced ACDRs that mimic infectious cellulitis, including a group of reactions termed pseudocellulitis that do not meet criteria for other diagnoses. A more universally accepted definition and clinical research on chemotherapy-induced pseudocellulitis would allow for more accurate diagnosis, effective treatment, antibiotic stewardship, and continuation of oncologic treatment.

Drug-induced scleroderma-like lesion

Drug-induced scleroderma-like lesion is a condition in which administration of a drug induces skin sclerotic lesions similar to systemic sclerosis or morphea. The clinical manifestations of drug-induced scleroderma-like lesion can be divided into two types: scleroderma-like lesions and morphea-like plaques. A wide variety of drugs can cause drug-induced scleroderma-like lesion. Bleomycin, _L-tryptophan, vinyl chloride, and phytonadione (vitamin K₁) have been reported, but in recent years, cases due to chemotherapeutic agents, such as taxane-based agents, gemcitabine, and tegafur-uracil, and immune checkpoint inhibitors have increased. Drug-induced scleroderma-like lesion differs from systemic sclerosis in that it does not include Raynaud's phenomenon, nail-fold capillary abnormality, organ involvement, such as reflux esophagitis, interstitial pneumonia, renal crisis, or anti-nuclear Abs. On the other hand, there are reports of cases in which Raynaud's phenomenon, positive conversion of anti-nuclear Abs, and development of skin sclerosis from the fingers developed after initiation of the drug. Whether the skin sclerosis improves after discontinuation of the drug depends on the patient. In patients with severe skin sclerosis, functional impairment, such as flexion contracture of the fingers, may occur, and systemic therapy, such as steroids, may be necessary. When treating patients with skin sclerosis, it is important to keep in mind the possibility that the sclerotic lesion may be induced by a drug.

Case Report: Chemotherapy-Associated Systemic Sclerosis: Is DNA Damage to Blame?

Systemic sclerosis, also known as scleroderma, is an autoimmune disease characterized by cutaneous and visceral fibrosis, immune dysregulation, and vasculopathy. Generally, the degree of skin fibrosis is associated with an increased likelihood of visceral organ involvement. Its pathogenesis is poorly understood; however, it is clear that changes in both the innate and adaptive immune responses are associated with fibroblast dysfunction and vascular damage. Further, DNA damage has been postulated as one of the triggering factors in systemic sclerosis, although the association of DNA damage with the progression of this disease is more poorly established. Recently, abnormal DNA damage response repair pathways have also been identified in patients with systemic sclerosis, suggesting that cells from patients with this disease may be more susceptible to DNA damaging agents. Chemotherapeutic drugs and other DNA damaging agents have been associated with the development of systemic sclerosis, as these agents may provide additional "hits" that promote abnormal DNA damage responses and subsequent inflammatory changes. Herein, we present the case of a 39-year-old female who developed scleroderma after the treatment of her breast cancer with chemotherapeutic agents. Her scleroderma was subsequently successfully treated with autologous hematopoietic stem cell transplantation. We also completed a literature review for previously published cases of chemotherapy associated with systemic sclerosis and highlighted a role of DNA damage in promoting the disease. Our case is the first case of chemotherapy associated with systemic sclerosis treated with hematopoietic stem cell transplantation.

Skin Necrosis Due to the Extravasation of Irritant Anticancer Agents

A 70-year-old man with malignant lymphoma was subjected to a fourth course of chemotherapy using gemcitabine and cisplatin. During the intravenous infusion of anticancer agents, pain and redness was observed at the site of insertion. The patient was subsequently treated with the strongest topical steroids and topical cooling agents. However, 2 weeks later, the affected area turned yellow, and the histopathological findings revealed skin necrosis of the entire dermis layer. It took two and a half months to cure the lesion. Close attention should be paid to the development of skin necrosis even when irritant anticancer agents such as gemcitabine and cisplatin are administered.

Chemotherapy reaction induced by ixabepilone, a microtubule stabilizing agent, mimicking extramammary Paget's disease in a patient with breast carcinoma

The histopathologic characteristics of reactions caused by the many novel anticancer agents are under-recognized. We report a case of a 67-year-old female with locally advanced metastatic breast cancer, who initially presented with an extensive reticulated erythematous patch on the trunk caused by intravascular metastases confirmed by a skin biopsy. Owing to disease progression, she was started on ixabepilone, a mitotic inhibitor. While receiving ixabepilone, another skin biopsy was obtained and initially interpreted as extramammary Paget's disease. However, the biopsy showed metaphase arrest of numerous keratinocytes in the basilar and suprabasilar epidermis. Atypical epithelial cells were only present in the intravascular spaces similar to the initial biopsy. Given the temporal association between the initiation of ixabepilone therapy and the epidermal mitotic arrest, a diagnosis of chemotherapy reaction to ixabepilone was rendered. Ixabepilone is an analog of epothilone, a microtubule stabilizer causing mitotic arrest of the cell cycle approved for the treatment of metastatic and locally advanced treatment-resistant breast cancer. The demonstration of epidermal mitotic arrest caused by ixabepilone is without precedent. The case emphasizes the importance of considering a chemotherapy reaction in the histologic differential diagnosis of epidermal mitotic arrest in a cancer patient receiving chemotherapy.

Cutaneous reactions to chemotherapeutic drugs and targeted therapies for cancer: part I. Conventional chemotherapeutic drugs

Conventional chemotherapy continues to be an important part of cancer management, but may cause various cutaneous reactions because it disturbs specific cell cycle phases. The alkylating agents cyclophosphamide, ifosfamide, and thiotepa can produce hyperpigmentation, while hypersensitivity reactions can be seen with platinum alkylating agents. Antimetabolites vary in reactions from exanthematous to bullous skin lesions. 5-fluorouracil and its derivatives and liposomal doxorubicin and daunorubicin are characteristically known to cause hand-foot syndrome, while bleomycin can cause fibrosis and flagellate dermatitis. Several hypersensitivity reactions may also occur from mitotic inhibitors and topoisomerase inhibitors. These different characteristic presentations are important to dermatologists in identifying the correct diagnosis and management for the cancer patient.

Gemcitabine-induced extensive skin necrosis

An 82-year-old woman presented with oedema and extensive necrotic ulcerative lesions on the back side of her lower limbs, emerging after the second cycle of chemotherapy consisting of Gemcitabine for metastatic pancreatic cancer. The absence of any convincing argument in favor of cardiovascular or autoimmune disease led us to attribute the onset of skin necrosis to chemotherapy administration. Although skin ischemia has also been described as a paraneoplastic syndrome, in this case we could observe a temporal and causal relationship to Gemcitabine infusion. Recently, this drug has been associated with important vascular side effects; its vascular toxicity is in fact higher than previously estimated. To our knowledge, careful attention should be reserved to neoplastic patients candidated to Gemcitabine administration, especially if previously affected by arterial vascular disease, venous thromboembolism, or collagenoses.

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.

Bullous dermatosis associated with gemcitabine therapy for non-small-cell lung carcinoma

Gemcitabine considered is to be a well-tolerated cytostatic drug with little known side effects. Cutaneous reactions are well known but still rarely reported. We report the case of a 75-year-old man with stage IV non-small-cell lung carcinoma treated with combination of gemcitabine 1000 mg/m2 and cisplatin 75 mg/m2 repeated every 28 days, who developed bilateral cutaneous bullous lesions of lower limbs following gemcitabine administration. Histopathologic examination did not show any toxidermy aspect and there was not any sign of immunoglobulin deposit in direct immunofluorescence test. Chemotherapy was stopped and lesions disappeared without any treatment. Even delayed with regard to gemcitabine administration, the causal relationship of gemcitabine treatment with skin reaction is possible according to the Naranjo probability scale. Pathologists should be aware of this kind of side effect in managing chemotherapy drugs and report any dermatologic reactions in order to identify the cause of toxicity and avoid a misdiagnosis.