Huang KK, Han SS, He LY, Yang LL, Liang BY, Zhen QY, Zhu ZB, Zhang CY, Li HY, Lin Y. Combination therapy (toripalimab and lenvatinib)-associated toxic epidermal necrolysis in a patient with metastatic liver cancer: A case report. World J Clin Cases 2022; 10(11): 3478-3484 [PMID: 35611193 DOI: 10.12998/wjcc.v10.i11.3478]
Corresponding Author of This Article
Ying Lin, MD, Chief Physician, Department of Dermatology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, No. 111 Dade Road, Yuexiu District, Guangzhou 510120, Guangdong Province, China. lin19791226@gzucm.edu.cn
Research Domain of This Article
Oncology
Article-Type of This Article
Case Report
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Kai-Kai Huang, Shan-Shan Han, Li-Ya He, Lin-Lin Yang, Bao-Ying Liang, Qing-Yu Zhen, Zi-Bo Zhu, Hong-Yi Li, Ying Lin, Department of Dermatology, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510120, Guangdong Province, China
Cai-Yun Zhang, Department of Dermatology, the Second Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou 510120, Guangdong Province, China
Ying Lin, Guangdong Provincial Key Laboratory of Chinese Medicine for Prevention and Treatment of Refractory Chronic Diseases, Guangzhou 510120, Guangdong Province, China
Author contributions: Huang KK, Han SS, and Zhang CY contributed to the treatment, literature search; Huang KK, He LY and Zhen QY contributed to manuscript writing; Lin Y, Yang LL, and Liang BY contributed to the treatment and manuscript revision; Zhu ZB and Li HY provided comments to this literature; informed consent was conducted by Huang KK; all authors have read and approved the final manuscript.
Supported byGuangdong Provincial Key Laboratory of Chinese Medicine for Prevention and Treatment of Refractory Chronic Diseases, No. 2018B030322012.
Informed consent statement: Consent was obtained from the relatives of the patient for publication of this report and any accompanying results.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ying Lin, MD, Chief Physician, Department of Dermatology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, No. 111 Dade Road, Yuexiu District, Guangzhou 510120, Guangdong Province, China. lin19791226@gzucm.edu.cn
Received: July 25, 2021 Peer-review started: July 25, 2021 First decision: December 27, 2021 Revised: January 15, 2022 Accepted: February 27, 2022 Article in press: February 27, 2022 Published online: April 16, 2022 Processing time: 256 Days and 19.5 Hours
Abstract
BACKGROUND
Both programmed cell death-1 (PD-1) inhibitors and lenvatinib, which have a synergistic effect, are promising drugs for tumor treatment. It is generally believed that combination therapy with a PD-1 inhibitor and lenvatinib is safe and effective. However, we report a case of toxic epidermal necrolysis (TEN), a grade 4 toxicity, after this combination therapy.
CASE SUMMARY
A 39-year-old male presented with erythema, blisters and erosions on the face, neck, trunk and limbs 1 wk after receiving combination therapy with lenvatinib and toripalimab, a PD-1 inhibitor. The skin injury covered more than 70% of the body surface area. He was previously diagnosed with liver cancer with cervical vertebra metastasis. Histologically, prominent necrotic keratinocytes, hyperkeratosis, liquefaction of basal cells and acantholytic bullae were observed in the epidermis. Blood vessels in the dermis were infiltrated by lymphocytes and eosinophils. Direct immunofluorescence staining was negative. Thus, the diagnosis was confirmed to be TEN (associated with combination therapy with toripalimab and lenvatinib). Full-dose and long-term corticosteroids, high-dose intravenous immunoglobulin and targeted antibiotic drugs were administered. The rashes gradually faded; however, as expected, the tumor progressed. Therefore, sorafenib and regorafenib were given in succession, and the patient was still alive at the 10-mo follow-up.
CONCLUSION
Cautious attention should be given to rashes that develop after combination therapy with PD-1 inhibitors and lenvatinib. Large-dose and long-course glucocorticoids may be crucial for the treatment of TEN associated with this combination treatment.
Core Tip: Both programmed cell death-1 (PD-1) inhibitors and lenvatinib, which exhibit a synergistic effect, are promising drugs for tumor treatment. However, we encountered a patient who presented with erythema, blisters and erosions on the face, neck, trunk and limbs 1 wk after combination therapy with lenvatinib and toripalimab, a PD-1 inhibitor. Skin biopsy was performed, and the diagnosis was confirmed as toxic epidermal necrolysis (TEN). We are the first group to report the occurrence of TEN, a grade 4 toxicity, after this combination therapy. Full-dose and long-term corticosteroids were administered, and the rashes gradually faded.
