Severe erosive gingivostomatitis in a patient treated by vedolizumab

Vedolizumab is a humanized monoclonal antibody that binds to the human a4β7 integrin and is approved for use in inflammatory bowel diseases. We describe a patient with severe, refractory erosive gingivostomatitis, which appeared a few days after the first dose of vedolizumab and resolved after discontinuation of the drug. We believe the gingivostomatitis to be a direct side effect of vedolizumab, rather than an extraintestinal manifestation of the underlying inflammatory bowel diseases. The clinicians need to be aware of this adverse event, which could be mistakenly considered as an extraintestinal manifestation of inflammatory bowel diseases.

Update of survival and cost of metastatic melanoma with new drugs: Estimations from the MelBase cohort

PURPOSE

Since 2011, significant progress was observed in metastatic melanoma (MM), with the commercialisation of seven immunotherapies or targeted therapies, which showed significant improvement in survival. In France, in 2004, the cost of MM was estimated at €1634 per patient; this cost has not been re-estimated since. This study provided an update on survival and cost in real-life clinical practice.

METHODS

Clinical and economic data (treatments, hospitalisations, radiotherapy sessions, visits, imaging and biological exams) were extracted from the prospective MelBase cohort, collecting individual data in 955 patients in 26 hospitals, from diagnosis of metastatic disease until death. Survival was estimated by the Kaplan-Meier method. Costs were calculated from the health insurance perspective using French tariffs. For live patients, survival and costs were extrapolated using a multistate model, describing the 5-year course of the disease according to patient prognostic factors and number of treatment lines.

RESULTS

Since the availability of new drugs, the mean survival time of MM patients has increased to 23.6 months (_95%confidence interval [CI] :21.2;26.6), with 58% of patients receiving a second line of treatment. Mean management costs increased to €269,682 (_95%CI:244,196;304,916) per patient. Drugs accounted for 80% of the total cost.

CONCLUSION

This study is the first that evaluated the impact of immunotherapies and targeted therapies both on survival and cost in real-life conditions. Alongside the introduction of breakthrough therapies in the first and subsequent lines, MM has been associated with a significant increase in survival but also in costs, raising the question of financial sustainability.

C-Kit non-mutated metastatic melanoma showing positive response to Nilotinib

Melanoma is an aggressive tumor with advanced disease characterized by widespread metastatic lesions and the tumor has traditionally been resistant to most forms of treatment. Indeed, metastatic melanoma has a very poor prognosis with a median survival time of 8-9 months and an estimated 3-year survival rate of less than 15%. Recent advances in our understanding of the genetic profile of melanoma cells and the molecular factors that drive malignant transformation have resulted in the identification of numerous new therapeutic targets. KIT is an established therapeutic target in cancers with activating mutations of KIT, such as gastrointestinal stromal tumors (GIST), and considerable efficacy has been achieved with various small molecule inhibitors of KIT including imatinib mesylate. Nilotinib is an inhibitor of ligand-induced PDGFRα and PDFGRβ kinase activity and autophosphorylation of constitutively activated KIT harboring exon 13 or exon 11 mutations (IC50 values of 0.2 and 0.027 μmol/L, respectively), with efficacy comparable to that of imatinib. We report a case of non-kit mutated metastatic vaginal melanoma showing impressive response to nilotinib.

What is the prognostic significance of acrometastases?

In contrast with bone metastasis, acrometastases are uncommon and are associated with advanced cancer. We report the cases of two patients with atypical lesions of the fingers in a context of cancer, in which biopsies confirmed a metastasis. Patients died rapidly before treatment was initiated. We discuss the characteristics of these atypical metastatic sites, associated with a generally poor prognosis.

Paradoxical cutaneous squamous cell proliferations in patients treated with sorafenib

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Background: The new multikinase inhibitor sorafenib is associated with multiple and usually manageable skin side effects. We report 12 patients presenting with solitary or multiple cutaneous squamous cell proliferations occurring in the months following initiation of sorafenib and we discuss the significance of this unexpected association. Results: Twelve patients treated by sorafenib for renal cell cancer or hepatocellular carcinoma presented one or several skin tumours with a typical keratoacanthoma (KA) appearance 3 to 9 months after the onset of sorafenib therapy. Some KAs had a spontaneous regression. No recurrence after surgical excision or metastatic dissemination was reported. Histologic examination of 22 lesions found classical non aggressive KAs in 16 cases and more aggressive squamous cell carcinoma-like lesions with deep dermis invasion and cellular atypias in 5 patients. Conclusions: Sorafenib treatment can be associated with cutaneous squamous cell proliferation resembling KAs. Although our observations suggest that these skin neoplasms have a low aggressive potential, these reports address the questions of the paradoxical proliferating effect of a drug that usually has an anti-proliferating effect. They also reactivate the unresolved controversy about the relationship between KA and authentic squamous cell carcinoma. More practically, although the exact frequency of this side effect is unknown, physicians should be aware of this side effect and regularly perform skin examination of their patients. Surgical excision is the treatment of choice in order to rule out authentic squamous cell carcinoma. Impact and management of these skin proliferations will have to be further evaluated, especially if sorafenib is to be tested in an adjuvant setting.

No significant financial relationships to disclose.

Management of adverse skin reactions to anticancer agents: The Gustave Roussy Institute experience

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Background: Anticancer therapies are associated with various and multiple cutaneous side effects frequently impacting patients’ quality of life and sometimes impairing treatment continuation. Some new skin syndromes and their potential relationship with drug efficacy have been the subject of hundreds of publications over the last few years. Methods: All physicians in our institution were informed by mail about the creation of a weekly consultation and the availability of an emergency call number specifically devoted to the management of adverse cutaneous reactions to anticancer agents. Patients could be referred to us from our institute or from other french institutes. All cutaneous side effects were recorded. Type, severity, and duration of symptoms were described. Imputability of the drugs was evaluated according to semiological, chronological and bibliographical criteria. Results: Over a 4 months period, 215 visits have been performed for a total of 128 patients. 169 events were reported among which 123 were considered to be imputable to the drugs. Several new cutaneous side effects were identified. Hiring a beautician and a pedicure for aesthetic complaints or hand foot skin reactions has been necessary in several cases. Causative agents were mostly targeted therapies (76.4%). Topical (n=132) or systemic treatments (n=45) were prescribed. Temporary dose reduction or treatment interruption was recommended in 18 cases (10.6%). This pilot experience was highly appreciated by both patients and physicians. It was consolidated as a permanent organization at the frontier between oncology and dermatology with the creation of an adapted case report form (CRF). Conclusions: There is a real need for dermatological management of skin side effects in a cancer institute, especially if early trials testing new agents are performed. Dedicated collaboration between oncologists and dermatologists should be promoted as well as the creation of a global skin-oriented CRF in order to facilitate international collaborations and to evaluate the impact of this dermatological management on compliance to treatment.

No significant financial relationships to disclose.

Keloids treated with postoperative Iridium 192* brachytherapy: a retrospective study

BACKGROUND

Post-excisional brachytherapy with Iridium 192 is a treatment of keloids scars (KS). Its indications and its parameters are not subject to any consensus.

OBJECTIVE

We wanted to assess the effectiveness and satisfaction of patients treated in our centre.

PATIENTS AND METHODS

This was a retrospective study conducted from November 2006 to November 2007. Patients with clinically and histologically proven KS treated between 1990 and 2005, were convened in consultation between September and October 2007. Clinical data and parameters of the brachytherapy have been collected.

RESULTS

Eighty-seven patients (138 KS) were treated. Eighty-two KS (46 patients) met the criteria for inclusion. Thirty-two patients (55 KS) have been seen in consultation. The average time between the onset of KS and treatment was 63.5 months. The brachytherapy has begun after a maximum of 7 hours posterior to surgery for all KS. The average dose was 17.9 Gy calculated at 5 mm. We observed 23.6% of recurrence after treatment. Seventy-nine per cent of itching and 87.5% of pain have totally disappeared. The phototypes 5 and 6 had an increased risk of recurrence.

DISCUSSION

This is the most important series of KS treated with Post-excisional brachytherapy presented so far. The technique is efficient in preventing keloid recurrence and in treating the functional signs, but at the expense of an unaesthetic result, of which patient must be warned about. A follow-up of at least two years after treatment is recommended.