Hand-foot skin reaction in patients treated with sorafenib: a clinicopathological study of cutaneous manifestations due to multitargeted kinase inhibitor therapy.

BACKGROUND: Hand-foot skin reaction is a distinctive cutaneous side-effect of antineoplastic kinase inhibitor-targeted therapy. Severe hand-foot skin reaction requires postponement of treatment or dose reduction. Histopathological studies of skin toxicity associated with kinase inhibitors are currently unavailable. OBJECTIVES: To report the clinical and histopathological findings of hand-foot skin reaction produced by the multikinase inhibitor sorafenib. METHODS: Nine patients with metastatic carcinoma-seven with renal cell carcinoma (RCC), one with melanoma and one with hepatocellular carcinoma (HCC)-received continuous, oral sorafenib 400 mg twice daily. Hand-foot skin reaction was defined and graded according to National Cancer Institute Common Toxicity Criteria 3.0. Biopsies from lesions of erythematous scaly or blistering skin were obtained from five cases (four RCC and one HCC). RESULTS: Seven of the nine (78%) patients developed hand-foot skin reaction characterized by well-demarcated, tender, erythematous papules and plaques with greyish blisters or hyperkeratotic, callus-like formations on palmoplantar surfaces and distal phalanges. Skin biopsy of hand-foot skin reaction lesions revealed epidermal acanthosis, papillomatosis, parakeratosis, dispersed dyskeratotic cells and keratinocyte vacuolar degeneration. Other skin toxicities included angular cheilitis, seborrhoeic dermatitis and perianal dermatitis. CONCLUSIONS: The clinical manifestations and histopathological features of sorafenib-induced skin reactions are unique. The most relevant histopathological findings of hand-foot skin reaction include keratinocyte vacuolar degeneration, the presence of intracytoplasmic eosinophilic bodies, and intraepidermal blisters in the stratum malpighii. Further studies are warranted to elucidate the mechanisms of this novel multitargeted kinase inhibitor-associated skin reaction.

Primary aleukemic myeloid leukemia cutis treated successfully with combination chemotherapy: report of a case and review of the literature.

Aleukemic myeloid leukemia cutis is extremely rare and is usually associated with early marrow relapse and poor treatment outcome. We report a 39-year-old man presenting with generalized cutaneous nodules. The initial diagnosis was cutaneous malignant lymphoma. New skin lesions and a nasopharyngeal mass developed during phototherapy. Biopsy of the cutaneous and nasopharyngeal lesions revealed monotonous blast cell infiltration. Cytochemical stain and immunophenotypic analysis of the fresh cell suspension made from another skin biopsy specimen identified that the neoplastic cells belonged to the monocytic lineage. A diagnosis of primary aleukemic leukemia cutis was established. The leukemic cells expressed CD56 but did not carry AML-1/ETO, CBFbeta/MYH11, or common MLL fusion transcripts. He received standard induction therapy for acute myeloid leukemia, followed by high-dose postremission chemotherapy and has been disease-free for more than 30 months. To the best of our knowledge, the current case has the longest disease-free survival among those reported.