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- Presentation
Dermatopathology of Toxic Erythema of Chemotherapy and Its Differentiation from GVHD and SJS/TEN
Description
The talk reviewed the dermatopathology of toxic erythema of chemotherapy (TEC) and how to distinguish it from graft-versus-host disease (GVHD) and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). The most useful histologic clues for TEC are eccrine syringosquamous metaplasia, epidermal dismaturation, and neutrophilic eccrine hidradenitis; these are relatively specific compared with GVHD, which more often shows keratinocyte apoptosis and vacuolar change. Follicular involvement and acantholysis can also occur in TEC, especially in some chemotherapy-related eruptions, so they do not exclude the diagnosis. In contrast, SJS/TEN-like presentations may show epidermal necrosis and blistering, but immunohistochemistry can help: a high CD8-to-CD4 ratio supports SJS/TEN, while a lower ratio favors GVHD or TEC. The speaker emphasized that clinical context, tissue culture when infection is possible, and close clinicopathologic correlation are essential, and that more studies are needed to refine immunostains and reaction-pattern recognition across different chemotherapies.
View moreConclusions
- Epidermal dysmaturation, eccrine syringometaplasia, and neutrophilic eccrine hidradenitis are the most useful histologic clues favoring toxic erythema of chemotherapy over graft-versus-host disease.
- Acantholysis and follicular involvement can occur in toxic erythema of chemotherapy, so they should not automatically exclude that diagnosis or be assumed to indicate only Grover-like disease or SJS/TEN.
- Because toxic erythema of chemotherapy can closely mimic stage IV GVHD or SJS/TEN clinically and histologically, diagnosis requires careful correlation of timing, distribution, and biopsy findings.
- In enfortumab vedotin-associated eruptions, the pattern is often more consistent with a SJS/TEN-like toxic reaction than with classic immune-mediated SJS/TEN.
- Immunohistochemistry may help in difficult cases, with a CD8:CD4 ratio greater than 4:1 supporting SJS/TEN-like disease, while a lower ratio leans toward GVHD or TEC.
- Current evidence suggests follicular involvement is more common in TEC than earlier studies implied, so it should be considered a supportive but not exclusive feature.
- Overall, the presentation concludes that TEC has a recognizable but overlapping dermatopathologic spectrum, and better studies are still needed to refine immune profiling and improve distinction from mimics.
- Bolognia JL, Cooper DL, Glusac EJ. Toxic erythema of chemotherapy: a useful clinical term. J Am Acad Dermatol. 2008 Sep;59(3):524-9. doi:10.1016/j.jaad.2008.05.018.#10.1016/j.jaad.2008.05.018
- Clinical and histopathological spectrum of toxic erythema of chemotherapy in patients who have undergone allogeneic hematopoietic cell transplantation. Hematol Oncol Stem Cell Ther. 2019.#10.1016/j.hemonc.2018.09.001
- Clinical and Histopathologic Spectrum of Toxic Erythema of Chemotherapy: A Series of 56 Cases From a Single Institution. Am J Dermatopathol. 2024 Jun 1;46(6):337-345. doi:10.1097/DAD.0000000000002450.#10.1097/DAD.0000000000002450
- Combination chemotherapy with 5-fluorouracil, folinic acid, and alpha-interferon producing histologic features of graft-versus-host disease.#10.1016/0190-9622(93)70187-x
- Clinicopathological spectrum of chemotherapy induced Grover's disease. J Eur Acad Dermatol Venereol. 2007 Sep;21(8):1145-7. doi:10.1111/j.1468-3083.2006.02130.x.#10.1111/j.1468-3083.2006.02130.x
- A rare presentation of enfortumab vedotin-induced toxic epidermal necrolysis. JAAD Case Rep. 2020.#10.1016/j.jdcr.2020.10.020
- Challita P, et al. Cancer Research. 2016;76(10).
- Naik H. J Cutan Pathol. 2017;44(10):857-86.
- Enfortumab vedotin toxic epidermal necrolysis-like blistering dermatosis: A case series and review of the literature.#10.1016/j.jdcr.2023.10.025
- Khanjar B, et al. JAAD Case Rep. 2023;43:40-50.
- Multiomic single-cell sequencing defines tissue-specific responses in Stevens-Johnson Syndrome and Toxic epidermal necrolysis. bioRxiv.#10.1101/2023.11.26.568771
- Case Report: Enfortumab Vedotin for Metastatic Urothelial Carcinoma: A Case Series on the Clinical and Histopathologic Spectrum of Adverse Cutaneous Reactions From Fatal Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis to Dermal Hypersensitivity Reaction.#10.3389/fonc.2021.621591