Anna Skripnik Lucas

Autoimmune Bullous Skin Disorders with Immune Checkpoint Inhibitors Targeting PD-1 and PD-L1

Bullous pemphigoid is a rare immune-related adverse event after anti–PD-1/PD-L1 immune checkpoint treatment and may be mediated by both T-cell and B-cell responses. Early referral to dermatology for accurate diagnosis and management is recommended. Monoclonal antibodies (mAb) targeting immune checkpoint pathways such as cytotoxic T-lymphocyte–associated protein 4 (CTLA-4) and programmed death 1 (PD-1) may confer durable disease control in several malignancies. In some patients, immune checkpoint mAbs cause cutaneous immune-related adverse events. Although the most commonly reported cutaneous toxicities are mild, a subset may persist despite therapy and can lead to severe or life-threatening toxicity. Autoimmune blistering disorders are not commonly associated with immune checkpoint mAb therapy. We report a case series of patients who developed bullous pemphigoid (BP), an autoimmune process classically attributed to pathologic autoantibody formation and complement deposition. Three patients were identified. Two patients developed BP while receiving the anti–PD-1 mAb nivolumab, and one while receiving the anti–PD-L1 mAb durvalumab. The clinicopathologic features of each patient and rash, and corresponding radiologic findings at the development of the rash and after its treatment, are described. Patients receiving an anti–PD-1/PD-L1 mAb may develop immune-related BP. This may be related to both T-cell– and B-cell–mediated responses. Referral to a dermatologist for accurate diagnosis and management is recommended. Cancer Immunol Res; 4(5); 383–9. ©2016 AACR.

Primary cutaneous marginal zone B-cell lymphoma: Response to treatment and disease-free survival in a series of 137 patients

BACKGROUND Primary cutaneous marginal zone B-cell lymphomas are low-grade lymphomas running an indolent course. Skin relapses have been frequently reported but little information about disease-free survival (DFS) is available. OBJECTIVE We sought to evaluate relapse rate and DFS in patients with primary cutaneous marginal zone B-cell lymphomas. METHODS Clinical features, European Organization for Research and Treatment of Cancer/International Society for Cutaneous Lymphomas stage, light chain restriction, clonality, treatments, skin relapses, DFS, stage progression, extracutaneous disease, and outcome are analyzed in a series of 137 patients. RESULTS Patients were classified as solitary lesion (T1) (n = 70; 51%), regional skin involvement (T2) (n = 40; 29%), and generalized skin lesions (T3) (n = 27; 20%). Surgical excision, local radiotherapy, or a combination were the initial treatment in 118 patients (86%). In 121 of 137 patients (88%) a complete remission was observed after initial treatment, including 99 of 106 patients (93%) with solitary or localized disease and 22 of 31 patients (71%) with multifocal lesions. Cutaneous relapses were observed in 53 patients (44%). Median DFS was 47 months. Patients with multifocal lesions or T3 disease showed higher relapse rate and shorter DFS. No significant differences were observed between surgery and radiotherapy, but surgery alone was associated with more recurrences at initial site. Overall survival at 5 and 10 years was 93%. Six patients (4%) developed extracutaneous disease during follow-up. LIMITATIONS This was a case series retrospective study. CONCLUSION Our results support long-term follow-up in patients with primary cutaneous marginal zone B-cell lymphomas. Disseminated skin lesions have higher relapse rate and shorter DFS suggesting further investigation on systemic therapies in such a group of patients.

Long-term follow-up and management of small and medium-sized CD4(+) T cell lymphoma and CD8(+) lymphoid proliferations of acral sites: a multicenter experience.

Primary cutaneous CD4+ small–medium pleomorphic T cell lymphoma (SMPTCL) is a low‐grade cutaneous T cell lymphoma. Its clinical and histopathologic features are comparable with those of CD8+ lymphoid proliferations (LPs) of the ear and acral sites.

Clinical Outcome and Prognosis of Young Patients with Mycosis Fungoides

Mycosis fungoides (MF) in young patients is rare and may have atypical presentations. There are limited data in these patients. The objective was to determine the clinical outcome and prognosis of young patients with MF.

Inflammatory dermatoses, infections, and drug eruptions are the most common skin conditions in hospitalized cancer patients

Background: Dermatologic conditions cause morbidity and mortality among hospitalized cancer patients. An improved understanding is critical for implementing clinical and research programs in inpatient oncodermatology. Objective: To characterize inpatient dermatology consultations at a large comprehensive cancer center. Methods: Retrospective database query of new admissions and medical record review of initial inpatient dermatology consultations comparing inpatients consulted and not consulted during January‐December 2015. Results: In total, 412 of 11,533 inpatients received 471 dermatology consultations (54% male, median age 59.5 years). Patients with hematologic cancers were 6 times more likely to receive dermatologic consultations compared with nonhematologic cancers (odds ratio 6.56, 95% confidence interval 5.35–8.05, P < .0001). Patients consulted by a dermatologist had a significantly longer length of stay than inpatients not consulted by dermatology (median 11 vs 5 days, P < .0001). Among the 645 dermatologic conditions diagnosed, the most common categories were inflammatory diseases, infections, and drug reactions; the most frequent conditions were contact dermatitis, herpes zoster, and chemotherapy‐induced drug eruptions. Limitations: The studys retrospective nature and single‐institution setting are potential limitations. Conclusion: Hematologic malignancies are a significant risk factor for dermatology inpatient consultations. A significantly longer length of stay was associated with dermatology consultations, suggesting high comorbidities in these patients. Increased dermatologic care of these inpatients might improve quality of life, dermatologic health, and ability to receive anticancer agents.

The Role of Oncodermatology in the Care of Patients Receiving Cancer Therapy

OBJECTIVE To review the emerging sub-specialty of oncodermatology and the role of oncodermatology nurses as facilitators of interprofessional collaboration between the oncology team and the dermatology team. DATA SOURCES Journal articles indexed on the National Library of Medicine database. CONCLUSION The complexity of cancer care with new cancer therapies and their associated dermatologic adverse events profiles benefit from a collaborative, interprofessional approach between dermatology and oncology in the care of the patient with cancer. IMPLICATIONS FOR NURSING PRACTICE Oncodermatology nurses are in roles that can facilitate interprofessional collaboration, optimizing the care of patients with cancer.

Checkpoint Inhibitors: Common Immune-Related Adverse Events and Their Management

BACKGROUND: Immunotherapy, specifically the use of checkpoint inhibitors, offers patients with cancer an alternative to chemotherapy, targeting different pathways to destroy cancer cells. The side effects of immunotherapies, as well as their impact on normal tissue, need to be assessed and managed based on their mechanisms of action. OBJECTIVES: This article presents an overview of immune‐related adverse events (AEs). METHODS: Common immune‐related toxicities, as well as rare and refractory toxicities, are reviewed. FINDINGS: Immunotherapy treatment is an option for many patients with cancer, and nurses must understand the distinct side effect profile of these agents. Prompt identification and expert management are the cornerstones of success when dealing with immune‐related AEs, and oncology nurses play a key role in improving patient care.

Nursing Best Practice Referral Algorithm for the Early Detection of Mycosis Fungoides

Background Mycosis fungoides is the most common type of cutaneous T-cell lymphoma (CTCL), yet is frequently misdiagnosed and perplexing to those who may not be familiar with the disease process and management. Therefore, nursing involvement in the interdisciplinary referral process from a generalist to a specialist is key to improving patient outcomes in the early detection of mycosis fungoides. Purpose of Study/Inquiry This manuscript elucidates the nursing role in the referral process of patients with CTCL, the importance of clinical grasp in the interdisciplinary approach for referrals, and factors to consider when customizing patient care plans. Methodology/Methods and Analytical Approach In effort to elucidate the nursing role in the obscure referral process in this unique patient population, an evidence-based approach is utilized to create a standardized method of care coordination to improve patient outcomes. Harvesting this method improves clinical care coordination and can result in a powerful tool to streamline the referral process. Findings/Implications An evidence-based standardized algorithm has been created for the nurse in the generalist office referring to patients with cutaneous lymphoma to dermatology specialists. Furthermore, this manuscript will strengthen nursing clinical knowledge, define the referral process, and improve patient outcomes in the transfer of care for patients with CTCL.