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Disease stabilization with pembrolizumab for metastatic acral melanoma in the setting of autoimmune bullous pemphigoid.

Beck KM, Dong J, Geskin LJ, Beltrani VP, Phelps RG, Carvajal RD, Schwartz G, Saenger YM, Gartrell RD - J Immunother Cancer (2016)

Bottom Line: We describe the first case of a patient with metastatic cKIT mutated acral melanoma, brain metastasis, and pre-existing severe autoimmune bullous pemphigoid (BP) with stable and asymptomatic disease 10 months after treatment with pembrolizumab.The patient experienced severe BP exacerbation after therapy with ipilimumab requiring systemic immune suppression, but nonetheless pembrolizumab was administered on further disease progression.This case suggests that pembrolizumab may confer more benefit than risk even in patients with known severe autoimmune conditions who require intermittent systemic immunosuppression.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY USA ; Department of Dermatology, Columbia University College of Physicians and Surgeons, New York, NY USA.

ABSTRACT

Background: To date, patients with pre-existing autoimmune conditions have been excluded from immunotherapy trials out of concern for severe autoimmune exacerbations.

Case presentation: We describe the first case of a patient with metastatic cKIT mutated acral melanoma, brain metastasis, and pre-existing severe autoimmune bullous pemphigoid (BP) with stable and asymptomatic disease 10 months after treatment with pembrolizumab. The patient experienced severe BP exacerbation after therapy with ipilimumab requiring systemic immune suppression, but nonetheless pembrolizumab was administered on further disease progression.

Conclusions: This case suggests that pembrolizumab may confer more benefit than risk even in patients with known severe autoimmune conditions who require intermittent systemic immunosuppression.

No MeSH data available.


Related in: MedlinePlus

Biopsy of the patient’s skin lesions. Haematoxylin and eosin stain reveals subepidermal bulla as well as fibrin net, numerous eosinophils, perivascular mixed infiltrate, and well-preserved dermal papillae within the bulla cavity
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Fig1: Biopsy of the patient’s skin lesions. Haematoxylin and eosin stain reveals subepidermal bulla as well as fibrin net, numerous eosinophils, perivascular mixed infiltrate, and well-preserved dermal papillae within the bulla cavity

Mentions: In 2010, the patient presented with multiple bullae on the back. The diagnosis of BP was made by a skin biopsy and clinical and pathological correlation [Fig. 1]. Disease activity was managed with high dose oral prednisone with eventual taper and disease remission after one year. In 2011, the patient noticed a new lump in his right axilla. Pathology confirmed malignant melanoma with a cKIT mutation (L576P in exon 11) completely replacing a lymph node. Positron-emission tomography (PET) revealed lung nodules, suspicious for metastatic disease. The patient declined a recommended lung biopsy and, after discussion of the risk of BP flare, therapy was initiated with ipilimumab at 3 mg/kg. Several days after the second dose, he experienced severe exacerbation of his BP with mucous membrane involvement for which he was hospitalized and treated with a 9-week course of 60 mg of prednisone. He subsequently maintained control of BP with 15 mg of prednisone daily.Fig. 1


Disease stabilization with pembrolizumab for metastatic acral melanoma in the setting of autoimmune bullous pemphigoid.

Beck KM, Dong J, Geskin LJ, Beltrani VP, Phelps RG, Carvajal RD, Schwartz G, Saenger YM, Gartrell RD - J Immunother Cancer (2016)

Biopsy of the patient’s skin lesions. Haematoxylin and eosin stain reveals subepidermal bulla as well as fibrin net, numerous eosinophils, perivascular mixed infiltrate, and well-preserved dermal papillae within the bulla cavity
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4835882&req=5

Fig1: Biopsy of the patient’s skin lesions. Haematoxylin and eosin stain reveals subepidermal bulla as well as fibrin net, numerous eosinophils, perivascular mixed infiltrate, and well-preserved dermal papillae within the bulla cavity
Mentions: In 2010, the patient presented with multiple bullae on the back. The diagnosis of BP was made by a skin biopsy and clinical and pathological correlation [Fig. 1]. Disease activity was managed with high dose oral prednisone with eventual taper and disease remission after one year. In 2011, the patient noticed a new lump in his right axilla. Pathology confirmed malignant melanoma with a cKIT mutation (L576P in exon 11) completely replacing a lymph node. Positron-emission tomography (PET) revealed lung nodules, suspicious for metastatic disease. The patient declined a recommended lung biopsy and, after discussion of the risk of BP flare, therapy was initiated with ipilimumab at 3 mg/kg. Several days after the second dose, he experienced severe exacerbation of his BP with mucous membrane involvement for which he was hospitalized and treated with a 9-week course of 60 mg of prednisone. He subsequently maintained control of BP with 15 mg of prednisone daily.Fig. 1

Bottom Line: We describe the first case of a patient with metastatic cKIT mutated acral melanoma, brain metastasis, and pre-existing severe autoimmune bullous pemphigoid (BP) with stable and asymptomatic disease 10 months after treatment with pembrolizumab.The patient experienced severe BP exacerbation after therapy with ipilimumab requiring systemic immune suppression, but nonetheless pembrolizumab was administered on further disease progression.This case suggests that pembrolizumab may confer more benefit than risk even in patients with known severe autoimmune conditions who require intermittent systemic immunosuppression.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY USA ; Department of Dermatology, Columbia University College of Physicians and Surgeons, New York, NY USA.

ABSTRACT

Background: To date, patients with pre-existing autoimmune conditions have been excluded from immunotherapy trials out of concern for severe autoimmune exacerbations.

Case presentation: We describe the first case of a patient with metastatic cKIT mutated acral melanoma, brain metastasis, and pre-existing severe autoimmune bullous pemphigoid (BP) with stable and asymptomatic disease 10 months after treatment with pembrolizumab. The patient experienced severe BP exacerbation after therapy with ipilimumab requiring systemic immune suppression, but nonetheless pembrolizumab was administered on further disease progression.

Conclusions: This case suggests that pembrolizumab may confer more benefit than risk even in patients with known severe autoimmune conditions who require intermittent systemic immunosuppression.

No MeSH data available.


Related in: MedlinePlus