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      Clinical practice guidelines for the prevention and treatment of EGFR inhibitor-associated dermatologic toxicities

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          Abstract

          Background

          Epidermal growth factor receptor inhibitors (EGFRI) produce various dermatologic side effects in the majority of patients, and guidelines are crucial for the prevention and treatment of these untoward events. The purpose of this panel was to develop evidence-based recommendations for EGFRI-associated dermatologic toxicities.

          Methods

          A multinational, interdisciplinary panel of experts in supportive care in cancer reviewed pertinent studies using established criteria in order to develop first-generation recommendations for EGFRI-associated dermatologic toxicities.

          Results

          Prophylactic and reactive recommendations for papulopustular (acneiform) rash, hair changes, radiation dermatitis, pruritus, mucositis, xerosis/fissures, and paronychia are presented, as well as general dermatologic recommendations when possible.

          Conclusion

          Prevention and management of EGFRI-related dermatologic toxicities is critical to maintain patients’ health-related quality of life and dose intensity of antineoplastic regimens. More rigorous investigation of these toxicities is warranted to improve preventive and treatment strategies.

          Electronic supplementary material

          The online version of this article (doi:10.1007/s00520-011-1197-6) contains supplementary material, which is available to authorized users.

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          Most cited references92

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          KRAS mutations as an independent prognostic factor in patients with advanced colorectal cancer treated with cetuximab.

          Cetuximab is efficient in advanced colorectal cancer (CRC). We previously showed that KRAS mutations were associated with resistance to cetuximab in 30 CRC patients. The aim of this study was to validate, in an independent larger series of 89 patients, the prognostic value of KRAS mutations on response to cetuximab and survival. Eighty-nine metastatic CRC patients treated with cetuximab after treatment failure with irinotecan-based chemotherapy were analyzed for KRAS mutation by allelic discrimination on tumor DNA. The association between KRAS mutations and tumor response, skin toxicity, progression-free survival (PFS) and overall survival (OS) was analyzed. A KRAS mutation was present in 27% of the patients and was associated with resistance to cetuximab (0% v 40% of responders among the 24 mutated and 65 nonmutated patients, respectively; P < .001) and a poorer survival (median PFS: 10.1 v 31.4 weeks in patients without mutation; P = .0001; median OS: 10.1 v 14.3 months in patients without mutation; P = .026). When we pooled these 89 patients with patients from our previous study, the multivariate analysis showed that KRAS status was an independent prognostic factor associated with OS and PFS, whereas skin toxicity was only associated with OS. In a combined analysis, median OS times of patients with two, one, or no favorable prognostic factors (severe skin toxicity and no KRAS mutation) was of 15.6, 10.7, and 5.6 months, respectively. These results confirm the high prognostic value of KRAS mutations on response to cetuximab and survival in metastatic CRC patients treated with cetuximab.
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            Open-label, uncontrolled, multicenter phase II study to evaluate the efficacy and toxicity of cetuximab as a single agent in patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck who failed to respond to platinum-based therapy.

            To evaluate the efficacy and safety of the epidermal growth factor receptor-directed monoclonal antibody cetuximab administered as a single agent in patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck (SCCHN) who experience disease progression on platinum therapy. An open-label multicenter study in which patients with disease progression on two to six cycles of platinum therapy received single-agent cetuximab (initial dose 400 mg/m2 followed by subsequent weekly doses of 250 mg/m2) for > or = 6 weeks (single-agent phase). Patients who experienced disease progression could receive salvage therapy with cetuximab plus platinum (combination-therapy phase). From June 2001 to December 2002, 103 patients were enrolled and treated with cetuximab, 53 of whom subsequently received combination therapy. In the single-agent phase, response rate was 13%, disease control rate (complete response/partial response/stable disease) was 46%, and median time to progression (TTP) was 70 days. During the combination-therapy phase, the objective response rate was zero, disease control rate was 26%, and TTP was 50 days. Median overall survival was 178 days. Treatment was well tolerated. The most common cetuximab-related adverse events in the single-agent phase were skin reactions, particularly rash (49% of patients, mainly grade 1 or 2). There was one treatment-related death due to an infusion-related reaction. Single-agent cetuximab was active and generally well tolerated in the treatment of recurrent and/or metastatic SCCHN that progressed on platinum therapy. Response was comparable to that seen with cetuximab plus platinum combination regimens in the same setting.
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              Mechanisms of cutaneous toxicities to EGFR inhibitors.

              The increased target specificity of epidermal growth factor receptor (EGFR) inhibitors (EGFRIs) is associated with the reduction or abolition of nonspecific and haematopoietic side effects. However, coincident inhibition of receptor activity in tissues that depend on EGFR signalling for normal function has undesirable consequences. Because of the key role of EGFR signalling in skin, dermatological toxicities have frequently been described with EGFRIs. The resultant significant physical and psycho-social discomfort might lead to interruption or dose modification of anticancer agents. There is an urgent need for an improved understanding of these toxicities to develop adequate staging systems and mechanistically driven therapies, and to ensure quality of life and consistent antineoplastic therapy.
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                Author and article information

                Contributors
                +1-212-6100079 , +1-212-3080739 , lacoutuM@mskcc.org
                Journal
                Support Care Cancer
                Supportive Care in Cancer
                Springer-Verlag (Berlin/Heidelberg )
                0941-4355
                1433-7339
                1 June 2011
                1 June 2011
                August 2011
                : 19
                : 8
                : 1079-1095
                Affiliations
                [1 ]Dermatology Service, Department of Medicine, Memorial Sloan–Kettering Cancer Center, Rockefeller Outpatient Pavilion Suite 228, 160 East 53rd Street, New York, NY 10022 USA
                [2 ]Washington University School of Medicine, St. Louis, MO USA
                [3 ]Centre Hospitalier Universitaire de Poitiers, Poitiers Cedex, France
                [4 ]Istituto Nazionale dei Tumori, Naples, Italy
                [5 ]National University of Singapore, Singapore, Singapore
                [6 ]University of Illinois at Chicago, Chicago, IL USA
                [7 ]University of Pennsylvania, Philadelphia, PA USA
                [8 ]Vanderbilt University Medical Center, Nashville, TN USA
                Article
                1197
                10.1007/s00520-011-1197-6
                3128700
                21630130
                915d7863-645b-4a1a-aef0-ba806db59045
                © Springer-Verlag 2011
                History
                : 14 February 2011
                : 17 May 2011
                Categories
                Review Article
                Custom metadata
                © Springer-Verlag 2011

                Oncology & Radiotherapy
                paronychia,xerosis,rash,pruritus,recommendations,mucositis,egfr inhibitors,radiation dermatitis

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