Drug-Related Pneumonitis in Cancer Treatment during the COVID-19 Era

Strategies for mitigating adverse events related to selective RET inhibitors in patients with RET-altered cancers

The US Food and Drug Administration (FDA) approval of the selective RET inhibitors selpercatinib and pralsetinib has led to a paradigm change in the treatment of RET-altered lung and thyroid cancers through a higher response rate and a more tolerable safety and toxicity profile than multi-kinase inhibitors. Recently, selpercatinib has received a tissue-agnostic FDA approval for all RET-fusion-positive cancers, and pralsetinib has shown pan-cancer activity as well. Given the anticipated increase in the use of both drugs across multiple tumor types, it is crucial to recognize the possible side effects and approaches for their optimal management in order to maximize the clinical benefit for treated patients. In this review, we underscore potential toxicities associated with selective RET inhibitors and discuss strategies to mitigate them.

Navigating the Rapidly Evolving Advanced Urothelial Carcinoma Treatment Landscape: Insights from Italian Experts

PURPOSE OF REVIEW

To discuss recent advances in the treatment of advanced urothelial carcinoma (UC) and how best to incorporate new therapies into clinical practice.

RECENT FINDINGS

There have been several recent practice-changing phase 2 and 3 trials of immune checkpoint inhibitors (ICIs), antibody-drug conjugates (ADCs), and targeted agents in advanced UC. Based on data from these trials, ICIs can be used as first-line maintenance therapy in patients who do not progress on platinum-based chemotherapy, second-line therapy for those with progression, and first-line therapy in cisplatin-ineligible patients with PD-L1 expression; ADCs and targeted agents provide later-line treatment options. Despite substantial progress in the treatment of advanced UC, there are still many uncertainties, including the optimal treatment sequence for novel agents, and reliable predictive biomarkers to aid in treatment selection. There is also an unmet need for effective treatment options in patients unfit for any platinum-based chemotherapy.

Alpelisib induced interstitial lung disease in a patient with advanced breast cancer

BACKGROUND

Interstitial lung disease interstitial lung disease is a group of respiratory diseases that causes progressive fibrosis. Many of the recently approved oncology drugs are associated with the development of interstitial lung disease as an adverse event. We report an alpelisib-induced interstitial lung disease in a patient with advanced breast cancer.

CASE REPORT

A 65-year-old breast cancer patient who had multiple bone metastases and had been previously treated with letrozole and ribociclib, started alpelisib and fulvestrant combination upon the development of liver metastases. Her past medical history was not significant except the history of hypertension. She developed fatigue and progressive dyspnea 3, 5 months after starting alpelisib and was hospitalized due to rapidly deteriorating hypoxia within 2-3 days.

MANAGEMENT AND OUTCOME

Naranjo Algorithm calculated score was 4 (probable Adverse Drug Reaction). Her thoracic computed tomography and angiography scan were consistent with interstitial infiltrate ground-glass appearance. She had no fever. Her workup for COVID-19 (coronavirus disease), other respiratory infectious agents, and pulmonary embolism was negative. There was a rapid clinical and radiologic response to corticosteroid therapy within one week. She was discharged from the hospital with a tapered steroid dose and complete resolution of her lung infiltrations. Alpelisib was discontinued despite radiological partial response in her liver metastases and a decline in her tumor marker.

DISCUSSION

Drug-induced interstitial lung disease is usually a diagnosis of exclusion, difficult to identify particularly during the COVID-19 pandemic for patients with cancer. Differential diagnosis includes infectious pneumonia, radiation pneumonitis, diffuse alveolar hemorrhage, pulmonary edema, and pulmonary lymphangitic metastasis.

Clinical best practices in optimal monitoring, early diagnosis, and effective management of antibody-drug conjugate-induced interstitial lung disease or pneumonitis: a multidisciplinary team approach in Singapore

INTRODUCTION

Interstitial lung disease (ILD) or pneumonitis remains an important adverse event identified with treatment with antibody-drug conjugates (ADCs). Drug-induced ILD (DILD) accounts for 3%-5% of common ILD cases and is a significant problem in clinical practice. Hence, with the anticipation of the widespread use of ADCs, it will be important for guidelines and recommendations to be established to direct and standardize the management of DILD by a multidisciplinary team (MDT).

AREAS COVERED

A thorough literature search was conducted using PubMed to identify relevant articles related to ADCs published between 1 January 2010 and 31 November 2022. Based on the review of the literature combined with expert opinions, this review article offers an overview of incidences of ILDs associated with the use of newer anticancer therapies, specifically ADCs, and discusses local-regional best practices in optimal monitoring, early diagnosis, and management of DILD involving an MDT.

EXPERT OPINION

Multidisciplinary input and consensus are crucial in the accurate diagnosis of DILD. The core group of essential attendees in the MDT are oncologists, pulmonologists, thoracic radiologists, and pathologists. This allows for the integration of expertise from different specialists to achieve a 'best fit' diagnosis and management.

Multidisciplinary clinical guidance on trastuzumab deruxtecan (T-DXd)-related interstitial lung disease/pneumonitis-Focus on proactive monitoring, diagnosis, and management

Trastuzumab deruxtecan (T-DXd; DS-8201) is an antibody-drug conjugate targeting human epidermal growth factor receptor 2. Interstitial lung disease (ILD)/pneumonitis is an adverse event associated with T-DXd; in most cases, it is low grade (grade ≤ 2) and can be treated effectively but may develop to be fatal in some instances. It is important to increase patient and provider understanding of T-DXd-related ILD/pneumonitis to improve patient outcomes. Drug-related ILD/pneumonitis is a diagnosis of exclusion; other possible causes of lung injury/imaging findings must be ruled out for an accurate diagnosis. Symptoms can be nonspecific, and identifying early symptoms is challenging; therefore, diagnosis is often delayed. We reviewed characteristics of patients who developed T-DXd-related ILD/pneumonitis and its patterns, produced multidisciplinary guidelines on diagnosis and management, and described areas for future investigation. Ongoing studies are collecting data on T-DXd-related ILD/pneumonitis to further our understanding of its clinical patterns and mechanisms. SEARCH STRATEGY AND SELECTION CRITERIA: References were identified based on the guidelines used by the authors in treating interstitial lung disease and pneumonitis. Searches of the authors' own files were also completed. A search of PubMed with the search terms (trastuzumab deruxtecan) AND (interstitial lung disease) AND (guidelines) was conducted on November 1, 2021, with no restrictions based on publication date, and the two articles yielded by the search were included.