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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

Clinical picture of ruptured bullae, erosions, and crusts of mild bullous pemphigoid exacerbation on low-dose corticosteroid treatment
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Fig3: Clinical picture of ruptured bullae, erosions, and crusts of mild bullous pemphigoid exacerbation on low-dose corticosteroid treatment

Mentions: In 2014, he developed new osseous metastases to the thoracic vertebrae. Nilotinib was discontinued and he received palliative radiation to the spine for local disease control. At this time the patient completed prednisone taper without flare of his BP. The patient then received pembrolizumab, at a dose of 2 mg/kg given every three weeks. The first 3 doses of pembrolizumab were well tolerated with minimal bullous eruption, which was controlled with clobetasol 0.05 % topical cream. Imaging after 10 weeks of treatment showed essentially stable disease, and a cutaneous metastasis on his wrist flattened and regressed [Fig. 2]. However, following the fourth cycle, the patient developed a severe BP flare resulting in discontinuation of pembrolizumab and the start of oral prednisone at 60 mg a day. Over the next three months, the patient’s BP lesions had resolved and prednisone was tapered off, allowing for a fifth cycle of pembrolizumab [Fig. 3]. The patient again developed a flare of BP requiring patient to stop anti-PD1 and again start prednisone at the same dose. He had improvement of skin lesions but was unable to taper below 15 mg without worsening symptoms. One year following initial treatment with pembrolizumab, scans show stable disease with unchanged brain, pulmonary, and osseous metastases. Clinically, the patient feels well and denies symptoms related to his metastases. He is undergoing continued monitoring of both his metastatic melanoma and his BP.


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)

Clinical picture of ruptured bullae, erosions, and crusts of mild bullous pemphigoid exacerbation on low-dose corticosteroid treatment
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

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

Fig3: Clinical picture of ruptured bullae, erosions, and crusts of mild bullous pemphigoid exacerbation on low-dose corticosteroid treatment
Mentions: In 2014, he developed new osseous metastases to the thoracic vertebrae. Nilotinib was discontinued and he received palliative radiation to the spine for local disease control. At this time the patient completed prednisone taper without flare of his BP. The patient then received pembrolizumab, at a dose of 2 mg/kg given every three weeks. The first 3 doses of pembrolizumab were well tolerated with minimal bullous eruption, which was controlled with clobetasol 0.05 % topical cream. Imaging after 10 weeks of treatment showed essentially stable disease, and a cutaneous metastasis on his wrist flattened and regressed [Fig. 2]. However, following the fourth cycle, the patient developed a severe BP flare resulting in discontinuation of pembrolizumab and the start of oral prednisone at 60 mg a day. Over the next three months, the patient’s BP lesions had resolved and prednisone was tapered off, allowing for a fifth cycle of pembrolizumab [Fig. 3]. The patient again developed a flare of BP requiring patient to stop anti-PD1 and again start prednisone at the same dose. He had improvement of skin lesions but was unable to taper below 15 mg without worsening symptoms. One year following initial treatment with pembrolizumab, scans show stable disease with unchanged brain, pulmonary, and osseous metastases. Clinically, the patient feels well and denies symptoms related to his metastases. He is undergoing continued monitoring of both his metastatic melanoma and his BP.

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