To the Editor:

Erythema induratum, also known as nodular vasculitis, is a panniculitis that usually affects the lower extremities in middle-aged women. Classically, it has been described as a delayed-type hypersensitivity reaction to Mycobacterium tuberculosis, also known as a tuberculid.^1,2 Other infections, however, also have been implicated as causes of erythema induratum, including bacillus Calmette-Guérin (BCG), the attenuated form of Mycobacterium bovis, which commonly is used for tuberculosis vaccination. Medications also may cause erythema induratum. The characteristic distribution of the nodules on the posterior calves helps to distinguish erythema induratum from other panniculitides. A PubMed search of articles indexed for MEDLINE using the term disseminated erythema induratum revealed few case reports documenting nodules on the arms, thighs, or chest, and only 1 case report of disseminated erythema induratum.^3-8 We describe a rare combination of disseminated erythema induratum in a patient with remote exposure to tuberculosis and recent BCG exposure.

An 88-year-old woman presented for evaluation of violaceous, minimally tender, nonulcerated, subcutaneous nodules on the legs, arms, and trunk of several weeks’ duration (Figure 1). She had a remote history of tuberculosis as a child, prior to the advent of modern antituberculosis regimens. Her medical history also included hypertension, breast cancer treated with lymph node dissection, gastroesophageal reflux disease, and bladder cancer treated with intravesical BCG 10 years prior to the onset of the nodules. She reported minimal coughing and a 25-lb weight loss over the last year, but she denied night sweats, fever, or chills.

Disseminated erythema induratum, an exceptionally rare variant of panniculitis, may be seen in patients with a remote history of M tuberculosis exposure and/or recent therapeutic BCG exposure. It is imperative to rule out active tuberculosis, especially in elderly patients whose disease predated the advent of modern antituberculosis therapy. Using an IFN-γ release assay in addition to chest radiographs and other clinical stigmata allows differentiation of the etiology of erythema induratum in those patients with tuberculosis who also were treated with BCG.

To the Editor:

Erythema induratum, also known as nodular vasculitis, is a panniculitis that usually affects the lower extremities in middle-aged women. Classically, it has been described as a delayed-type hypersensitivity reaction to Mycobacterium tuberculosis, also known as a tuberculid.^1,2 Other infections, however, also have been implicated as causes of erythema induratum, including bacillus Calmette-Guérin (BCG), the attenuated form of Mycobacterium bovis, which commonly is used for tuberculosis vaccination. Medications also may cause erythema induratum. The characteristic distribution of the nodules on the posterior calves helps to distinguish erythema induratum from other panniculitides. A PubMed search of articles indexed for MEDLINE using the term disseminated erythema induratum revealed few case reports documenting nodules on the arms, thighs, or chest, and only 1 case report of disseminated erythema induratum.^3-8 We describe a rare combination of disseminated erythema induratum in a patient with remote exposure to tuberculosis and recent BCG exposure.

An 88-year-old woman presented for evaluation of violaceous, minimally tender, nonulcerated, subcutaneous nodules on the legs, arms, and trunk of several weeks’ duration (Figure 1). She had a remote history of tuberculosis as a child, prior to the advent of modern antituberculosis regimens. Her medical history also included hypertension, breast cancer treated with lymph node dissection, gastroesophageal reflux disease, and bladder cancer treated with intravesical BCG 10 years prior to the onset of the nodules. She reported minimal coughing and a 25-lb weight loss over the last year, but she denied night sweats, fever, or chills.

Disseminated erythema induratum, an exceptionally rare variant of panniculitis, may be seen in patients with a remote history of M tuberculosis exposure and/or recent therapeutic BCG exposure. It is imperative to rule out active tuberculosis, especially in elderly patients whose disease predated the advent of modern antituberculosis therapy. Using an IFN-γ release assay in addition to chest radiographs and other clinical stigmata allows differentiation of the etiology of erythema induratum in those patients with tuberculosis who also were treated with BCG.

To the Editor:

Erythema induratum, also known as nodular vasculitis, is a panniculitis that usually affects the lower extremities in middle-aged women. Classically, it has been described as a delayed-type hypersensitivity reaction to Mycobacterium tuberculosis, also known as a tuberculid.^1,2 Other infections, however, also have been implicated as causes of erythema induratum, including bacillus Calmette-Guérin (BCG), the attenuated form of Mycobacterium bovis, which commonly is used for tuberculosis vaccination. Medications also may cause erythema induratum. The characteristic distribution of the nodules on the posterior calves helps to distinguish erythema induratum from other panniculitides. A PubMed search of articles indexed for MEDLINE using the term disseminated erythema induratum revealed few case reports documenting nodules on the arms, thighs, or chest, and only 1 case report of disseminated erythema induratum.^3-8 We describe a rare combination of disseminated erythema induratum in a patient with remote exposure to tuberculosis and recent BCG exposure.

An 88-year-old woman presented for evaluation of violaceous, minimally tender, nonulcerated, subcutaneous nodules on the legs, arms, and trunk of several weeks’ duration (Figure 1). She had a remote history of tuberculosis as a child, prior to the advent of modern antituberculosis regimens. Her medical history also included hypertension, breast cancer treated with lymph node dissection, gastroesophageal reflux disease, and bladder cancer treated with intravesical BCG 10 years prior to the onset of the nodules. She reported minimal coughing and a 25-lb weight loss over the last year, but she denied night sweats, fever, or chills.

Disseminated erythema induratum, an exceptionally rare variant of panniculitis, may be seen in patients with a remote history of M tuberculosis exposure and/or recent therapeutic BCG exposure. It is imperative to rule out active tuberculosis, especially in elderly patients whose disease predated the advent of modern antituberculosis therapy. Using an IFN-γ release assay in addition to chest radiographs and other clinical stigmata allows differentiation of the etiology of erythema induratum in those patients with tuberculosis who also were treated with BCG.

Scleroderma renal crisis is often the most challenging type of scleroderma emergency to identify promptly, according to Francesco Boin, MD, professor of medicine and director of the scleroderma center at the University of California, San Francisco.

“Fortunately, it’s not a frequent event. But it’s severe enough that all rheumatologists should be aware of it,” he said at the virtual edition of the American College of Rheumatology’s 2020 State-of-the-Art Clinical Symposium.
 

Atypical presentations occur in 30%

Scleroderma renal crisis (SRC) occurs in 5%-10% of scleroderma patients. A vexing feature of this emergency is that not uncommonly it actually precedes the diagnosis of scleroderma. Indeed, 20% of patients with SRC present with sine scleroderma – that is, they have no skin disease and their renal crisis is their first symptom of scleroderma. In contrast, critical digital ischemia – the most common scleroderma emergency – is invariably preceded by worsening episodes of Raynaud’s, and impending intestinal pseudo-obstruction – also among the most common scleroderma emergencies – is heralded by an established history of dysmotility, loss of appetite, abdominal bloating, small intestinal bacterial overgrowth, and bowel distension.

While sine SRC often poses a formidable diagnostic challenge, SRC occurs most often in patients with early, rapidly progressing diffuse scleroderma skin disease. Indeed, the median duration of scleroderma when SRC strikes is just 8 months. The use of glucocorticoids at 15 mg or more per day, or at lower doses for a lengthy period, is an independent risk factor for SRC. Detection of anti–RNA polymerase III antibodies warrants increased vigilance, since 60% of patients with SRC are anti–RNA polymerase III antibody positive. Other autoantibodies are not a risk factor. Neither is preexisting hypertension nor a high baseline serum creatinine.

The classic textbook presentation of SRC is abrupt onset of blood pressures greater than 20 mm Hg above normal for that individual, along with sudden renal failure; a climbing creatinine; proteinuria; and expressions of malignant hypertension such as pulmonary edema, new-onset heart failure, encephalopathy, and/or development of a thrombotic microangiopathy.

Notably, however, 30% of individuals with SRC don’t fit this picture at all. They may present with abrupt-onset severe hypertension but no evidence of renal failure, at least early on. Or they may have sudden renal failure without a hypertensive crisis. Alternatively, they may have no signs of malignant hypertension, just an asymptomatic pericardial effusion or mild arrhythmias.

“Also, the thrombotic microangiopathy can be present without the other features of scleroderma renal crisis, so no renal failure or hypertensive emergency. Be aware of the possibility of atypical presentations, and always suspect this unfolding problem in the right individuals,” the rheumatologist urged.

Anyone with scleroderma who presents with new-onset hypertension needs to begin keeping a careful home blood pressure diary. If the blood pressure shoots up, or symptoms of malignant hypertension develop, or laboratory monitoring reveals evidence of thrombotic microangiopathy, the patient should immediately go to the ED because these events are often followed by accelerated progression to renal crisis.

Inpatient management of SRC is critical. “In the hospital we can monitor renal function in a more refined way, we can manage the malignant hypertension, and early on, hospitalization provides the opportunity to do a renal biopsy. I always consider doing this early. The pathologist often pushes back, but I think it’s relevant. It confirms the diagnosis. We’ve had patients where we were surprised: We thought it was scleroderma renal crisis, but instead they had interstitial nephritis or glomerulonephritis. Most important, biopsy has major prognostic implications: You can measure the extent of damage and therefore have a sense of whether the patient will be able to recover renal function,” Dr. Boin explained.

Prognosis and predictors

Outcome of SRC is often poor: the 1-year mortality is 20%-30%, with a 5-year mortality of 30%-50%. Normotensive SRC with renal crisis, which accounts for about 10% of all cases of SRC, is particularly serious in its implication, with a 1-year mortality of 60%. Half of patients with SRC require hemodialysis, and only one-quarter of them recover spontaneous renal function.

Predictors of worse outcome include older age at onset of SRC, male gender, a serum creatinine level above 3 mg/dL at presentation, incomplete blood pressure control within the first 3 days of the crisis, and normotensive SRC. Use of an ACE inhibitor prior to SRC is also an independent predictor of poor outcome, possibly because by keeping the blood pressure under control the medication blunts recognition of the unfolding renal crisis.

“This is why experts don’t recommend prophylactic ACE inhibitors in patients who are at risk for SRC,” according to Dr. Boin.

He reported having no financial conflicts regarding his presentation.

bjancin@mdedge.com

Scleroderma renal crisis is often the most challenging type of scleroderma emergency to identify promptly, according to Francesco Boin, MD, professor of medicine and director of the scleroderma center at the University of California, San Francisco.

“Fortunately, it’s not a frequent event. But it’s severe enough that all rheumatologists should be aware of it,” he said at the virtual edition of the American College of Rheumatology’s 2020 State-of-the-Art Clinical Symposium.
 

Atypical presentations occur in 30%

Scleroderma renal crisis (SRC) occurs in 5%-10% of scleroderma patients. A vexing feature of this emergency is that not uncommonly it actually precedes the diagnosis of scleroderma. Indeed, 20% of patients with SRC present with sine scleroderma – that is, they have no skin disease and their renal crisis is their first symptom of scleroderma. In contrast, critical digital ischemia – the most common scleroderma emergency – is invariably preceded by worsening episodes of Raynaud’s, and impending intestinal pseudo-obstruction – also among the most common scleroderma emergencies – is heralded by an established history of dysmotility, loss of appetite, abdominal bloating, small intestinal bacterial overgrowth, and bowel distension.

While sine SRC often poses a formidable diagnostic challenge, SRC occurs most often in patients with early, rapidly progressing diffuse scleroderma skin disease. Indeed, the median duration of scleroderma when SRC strikes is just 8 months. The use of glucocorticoids at 15 mg or more per day, or at lower doses for a lengthy period, is an independent risk factor for SRC. Detection of anti–RNA polymerase III antibodies warrants increased vigilance, since 60% of patients with SRC are anti–RNA polymerase III antibody positive. Other autoantibodies are not a risk factor. Neither is preexisting hypertension nor a high baseline serum creatinine.

The classic textbook presentation of SRC is abrupt onset of blood pressures greater than 20 mm Hg above normal for that individual, along with sudden renal failure; a climbing creatinine; proteinuria; and expressions of malignant hypertension such as pulmonary edema, new-onset heart failure, encephalopathy, and/or development of a thrombotic microangiopathy.

Notably, however, 30% of individuals with SRC don’t fit this picture at all. They may present with abrupt-onset severe hypertension but no evidence of renal failure, at least early on. Or they may have sudden renal failure without a hypertensive crisis. Alternatively, they may have no signs of malignant hypertension, just an asymptomatic pericardial effusion or mild arrhythmias.

“Also, the thrombotic microangiopathy can be present without the other features of scleroderma renal crisis, so no renal failure or hypertensive emergency. Be aware of the possibility of atypical presentations, and always suspect this unfolding problem in the right individuals,” the rheumatologist urged.

Anyone with scleroderma who presents with new-onset hypertension needs to begin keeping a careful home blood pressure diary. If the blood pressure shoots up, or symptoms of malignant hypertension develop, or laboratory monitoring reveals evidence of thrombotic microangiopathy, the patient should immediately go to the ED because these events are often followed by accelerated progression to renal crisis.

Inpatient management of SRC is critical. “In the hospital we can monitor renal function in a more refined way, we can manage the malignant hypertension, and early on, hospitalization provides the opportunity to do a renal biopsy. I always consider doing this early. The pathologist often pushes back, but I think it’s relevant. It confirms the diagnosis. We’ve had patients where we were surprised: We thought it was scleroderma renal crisis, but instead they had interstitial nephritis or glomerulonephritis. Most important, biopsy has major prognostic implications: You can measure the extent of damage and therefore have a sense of whether the patient will be able to recover renal function,” Dr. Boin explained.

Prognosis and predictors

Outcome of SRC is often poor: the 1-year mortality is 20%-30%, with a 5-year mortality of 30%-50%. Normotensive SRC with renal crisis, which accounts for about 10% of all cases of SRC, is particularly serious in its implication, with a 1-year mortality of 60%. Half of patients with SRC require hemodialysis, and only one-quarter of them recover spontaneous renal function.

Predictors of worse outcome include older age at onset of SRC, male gender, a serum creatinine level above 3 mg/dL at presentation, incomplete blood pressure control within the first 3 days of the crisis, and normotensive SRC. Use of an ACE inhibitor prior to SRC is also an independent predictor of poor outcome, possibly because by keeping the blood pressure under control the medication blunts recognition of the unfolding renal crisis.

“This is why experts don’t recommend prophylactic ACE inhibitors in patients who are at risk for SRC,” according to Dr. Boin.

He reported having no financial conflicts regarding his presentation.

bjancin@mdedge.com

Scleroderma renal crisis is often the most challenging type of scleroderma emergency to identify promptly, according to Francesco Boin, MD, professor of medicine and director of the scleroderma center at the University of California, San Francisco.

“Fortunately, it’s not a frequent event. But it’s severe enough that all rheumatologists should be aware of it,” he said at the virtual edition of the American College of Rheumatology’s 2020 State-of-the-Art Clinical Symposium.
 

Atypical presentations occur in 30%

Scleroderma renal crisis (SRC) occurs in 5%-10% of scleroderma patients. A vexing feature of this emergency is that not uncommonly it actually precedes the diagnosis of scleroderma. Indeed, 20% of patients with SRC present with sine scleroderma – that is, they have no skin disease and their renal crisis is their first symptom of scleroderma. In contrast, critical digital ischemia – the most common scleroderma emergency – is invariably preceded by worsening episodes of Raynaud’s, and impending intestinal pseudo-obstruction – also among the most common scleroderma emergencies – is heralded by an established history of dysmotility, loss of appetite, abdominal bloating, small intestinal bacterial overgrowth, and bowel distension.

While sine SRC often poses a formidable diagnostic challenge, SRC occurs most often in patients with early, rapidly progressing diffuse scleroderma skin disease. Indeed, the median duration of scleroderma when SRC strikes is just 8 months. The use of glucocorticoids at 15 mg or more per day, or at lower doses for a lengthy period, is an independent risk factor for SRC. Detection of anti–RNA polymerase III antibodies warrants increased vigilance, since 60% of patients with SRC are anti–RNA polymerase III antibody positive. Other autoantibodies are not a risk factor. Neither is preexisting hypertension nor a high baseline serum creatinine.

The classic textbook presentation of SRC is abrupt onset of blood pressures greater than 20 mm Hg above normal for that individual, along with sudden renal failure; a climbing creatinine; proteinuria; and expressions of malignant hypertension such as pulmonary edema, new-onset heart failure, encephalopathy, and/or development of a thrombotic microangiopathy.

Notably, however, 30% of individuals with SRC don’t fit this picture at all. They may present with abrupt-onset severe hypertension but no evidence of renal failure, at least early on. Or they may have sudden renal failure without a hypertensive crisis. Alternatively, they may have no signs of malignant hypertension, just an asymptomatic pericardial effusion or mild arrhythmias.

“Also, the thrombotic microangiopathy can be present without the other features of scleroderma renal crisis, so no renal failure or hypertensive emergency. Be aware of the possibility of atypical presentations, and always suspect this unfolding problem in the right individuals,” the rheumatologist urged.

Anyone with scleroderma who presents with new-onset hypertension needs to begin keeping a careful home blood pressure diary. If the blood pressure shoots up, or symptoms of malignant hypertension develop, or laboratory monitoring reveals evidence of thrombotic microangiopathy, the patient should immediately go to the ED because these events are often followed by accelerated progression to renal crisis.

Inpatient management of SRC is critical. “In the hospital we can monitor renal function in a more refined way, we can manage the malignant hypertension, and early on, hospitalization provides the opportunity to do a renal biopsy. I always consider doing this early. The pathologist often pushes back, but I think it’s relevant. It confirms the diagnosis. We’ve had patients where we were surprised: We thought it was scleroderma renal crisis, but instead they had interstitial nephritis or glomerulonephritis. Most important, biopsy has major prognostic implications: You can measure the extent of damage and therefore have a sense of whether the patient will be able to recover renal function,” Dr. Boin explained.

Prognosis and predictors

Outcome of SRC is often poor: the 1-year mortality is 20%-30%, with a 5-year mortality of 30%-50%. Normotensive SRC with renal crisis, which accounts for about 10% of all cases of SRC, is particularly serious in its implication, with a 1-year mortality of 60%. Half of patients with SRC require hemodialysis, and only one-quarter of them recover spontaneous renal function.

Predictors of worse outcome include older age at onset of SRC, male gender, a serum creatinine level above 3 mg/dL at presentation, incomplete blood pressure control within the first 3 days of the crisis, and normotensive SRC. Use of an ACE inhibitor prior to SRC is also an independent predictor of poor outcome, possibly because by keeping the blood pressure under control the medication blunts recognition of the unfolding renal crisis.

“This is why experts don’t recommend prophylactic ACE inhibitors in patients who are at risk for SRC,” according to Dr. Boin.

He reported having no financial conflicts regarding his presentation.

bjancin@mdedge.com

Pediatric Dermatology

• Early onset of atopic dermatitis linked to poorer control, could signify more persistent disease
• Patients with actopic dermatitis should be routinely asked about conjunctivitis
• Hope on the horizon: New cantharidin formulation alleviates molluscum contagiosum in pivotal trials 
• Patch testing in atopic dermatitis: When and how 
• Topical calcineurin inhibitors are an effective treatment option for periorificial dermatitis 
• Psychology consults for children’s skin issues can boost adherence, wellness

Read the supplement.

Pediatric Dermatology

• Early onset of atopic dermatitis linked to poorer control, could signify more persistent disease
• Patients with actopic dermatitis should be routinely asked about conjunctivitis
• Hope on the horizon: New cantharidin formulation alleviates molluscum contagiosum in pivotal trials 
• Patch testing in atopic dermatitis: When and how 
• Topical calcineurin inhibitors are an effective treatment option for periorificial dermatitis 
• Psychology consults for children’s skin issues can boost adherence, wellness

Read the supplement.

Pediatric Dermatology

• Early onset of atopic dermatitis linked to poorer control, could signify more persistent disease
• Patients with actopic dermatitis should be routinely asked about conjunctivitis
• Hope on the horizon: New cantharidin formulation alleviates molluscum contagiosum in pivotal trials 
• Patch testing in atopic dermatitis: When and how 
• Topical calcineurin inhibitors are an effective treatment option for periorificial dermatitis 
• Psychology consults for children’s skin issues can boost adherence, wellness

Read the supplement.

• Early onset of atopic dermatitis linked to poorer control, could signify more persistent disease
• Patients with actopic dermatitis should be routinely asked about conjunctivitis
• Hope on the horizon: New cantharidin formulation alleviates molluscum contagiosum in pivotal trials 
• Patch testing in atopic dermatitis: When and how 
• Topical calcineurin inhibitors are an effective treatment option for periorificial dermatitis 
• Psychology consults for children’s skin issues can boost adherence, wellness

Read the supplement.

• Early onset of atopic dermatitis linked to poorer control, could signify more persistent disease
• Patients with actopic dermatitis should be routinely asked about conjunctivitis
• Hope on the horizon: New cantharidin formulation alleviates molluscum contagiosum in pivotal trials 
• Patch testing in atopic dermatitis: When and how 
• Topical calcineurin inhibitors are an effective treatment option for periorificial dermatitis 
• Psychology consults for children’s skin issues can boost adherence, wellness

Read the supplement.

• Early onset of atopic dermatitis linked to poorer control, could signify more persistent disease
• Patients with actopic dermatitis should be routinely asked about conjunctivitis
• Hope on the horizon: New cantharidin formulation alleviates molluscum contagiosum in pivotal trials 
• Patch testing in atopic dermatitis: When and how 
• Topical calcineurin inhibitors are an effective treatment option for periorificial dermatitis 
• Psychology consults for children’s skin issues can boost adherence, wellness

Read the supplement.

The Food and Drug Administration has approved Uplizna (inebilizumab-cdon) for the treatment of adult patients with neuromyelitis optica spectrum disorder (NMOSD) who are anti-AQP4 antibody positive. Uplizna is the second approved treatment for the disorder.

Approval was based on results from the global, placebo-controlled N-MOmentum trial, which included 213 anti-AQP4 antibody–positive patients and 17 anti-AQP4 antibody–negative patients who received inebilizumab-cdon or placebo. Just under 90% of patients in the positive group remained relapse free 6 months after the initial dosing, compared with 58% of patients taking placebo. People who took inebilizumab also saw a reduction in NMOSD-related hospitalizations. There was no evidence of a benefit in patients who were anti-AQP4 antibody negative.

Inebilizumab-cdon was safe and well tolerated during the trial, with the most common adverse events being urinary tract infection (20%), nasopharyngitis (13%), infusion reaction (12%), arthralgia (11%), and headache (10%). The drug is approved as twice-yearly maintenance after initial dosing. The prescribing information for Uplizna includes a warning for infusion reactions, potential depletion of certain proteins (hypogammaglobulinemia), and potential increased risk of infection—including progressive multifocal leukoencephalopathy—and potential reactivation of hepatitis B and tuberculosis.

“NMOSD is an extremely challenging disease to treat. Patients experience unpredictable attacks that can lead to permanent disability from blindness and paralysis. In addition, each subsequent attack may result in a cumulative worsening of disability,” Bruce Cree, MD, PhD, lead investigator for the N-MOmentum trial and professor of clinical neurology at the University of California, San Francisco, said in a press release. “Uplizna is an important new treatment option that provides prescribing physicians and patients living with NMOSD a therapy with proven efficacy, a favorable safety profile and a twice-a-year maintenance dosing schedule.”

lfranki@mdedge.com

The Food and Drug Administration has approved Uplizna (inebilizumab-cdon) for the treatment of adult patients with neuromyelitis optica spectrum disorder (NMOSD) who are anti-AQP4 antibody positive. Uplizna is the second approved treatment for the disorder.

Approval was based on results from the global, placebo-controlled N-MOmentum trial, which included 213 anti-AQP4 antibody–positive patients and 17 anti-AQP4 antibody–negative patients who received inebilizumab-cdon or placebo. Just under 90% of patients in the positive group remained relapse free 6 months after the initial dosing, compared with 58% of patients taking placebo. People who took inebilizumab also saw a reduction in NMOSD-related hospitalizations. There was no evidence of a benefit in patients who were anti-AQP4 antibody negative.

Inebilizumab-cdon was safe and well tolerated during the trial, with the most common adverse events being urinary tract infection (20%), nasopharyngitis (13%), infusion reaction (12%), arthralgia (11%), and headache (10%). The drug is approved as twice-yearly maintenance after initial dosing. The prescribing information for Uplizna includes a warning for infusion reactions, potential depletion of certain proteins (hypogammaglobulinemia), and potential increased risk of infection—including progressive multifocal leukoencephalopathy—and potential reactivation of hepatitis B and tuberculosis.

“NMOSD is an extremely challenging disease to treat. Patients experience unpredictable attacks that can lead to permanent disability from blindness and paralysis. In addition, each subsequent attack may result in a cumulative worsening of disability,” Bruce Cree, MD, PhD, lead investigator for the N-MOmentum trial and professor of clinical neurology at the University of California, San Francisco, said in a press release. “Uplizna is an important new treatment option that provides prescribing physicians and patients living with NMOSD a therapy with proven efficacy, a favorable safety profile and a twice-a-year maintenance dosing schedule.”

lfranki@mdedge.com

The Food and Drug Administration has approved Uplizna (inebilizumab-cdon) for the treatment of adult patients with neuromyelitis optica spectrum disorder (NMOSD) who are anti-AQP4 antibody positive. Uplizna is the second approved treatment for the disorder.

Approval was based on results from the global, placebo-controlled N-MOmentum trial, which included 213 anti-AQP4 antibody–positive patients and 17 anti-AQP4 antibody–negative patients who received inebilizumab-cdon or placebo. Just under 90% of patients in the positive group remained relapse free 6 months after the initial dosing, compared with 58% of patients taking placebo. People who took inebilizumab also saw a reduction in NMOSD-related hospitalizations. There was no evidence of a benefit in patients who were anti-AQP4 antibody negative.

Inebilizumab-cdon was safe and well tolerated during the trial, with the most common adverse events being urinary tract infection (20%), nasopharyngitis (13%), infusion reaction (12%), arthralgia (11%), and headache (10%). The drug is approved as twice-yearly maintenance after initial dosing. The prescribing information for Uplizna includes a warning for infusion reactions, potential depletion of certain proteins (hypogammaglobulinemia), and potential increased risk of infection—including progressive multifocal leukoencephalopathy—and potential reactivation of hepatitis B and tuberculosis.

“NMOSD is an extremely challenging disease to treat. Patients experience unpredictable attacks that can lead to permanent disability from blindness and paralysis. In addition, each subsequent attack may result in a cumulative worsening of disability,” Bruce Cree, MD, PhD, lead investigator for the N-MOmentum trial and professor of clinical neurology at the University of California, San Francisco, said in a press release. “Uplizna is an important new treatment option that provides prescribing physicians and patients living with NMOSD a therapy with proven efficacy, a favorable safety profile and a twice-a-year maintenance dosing schedule.”

lfranki@mdedge.com

ANSWER

The correct answer is seborrheic keratosis (choice “a”).

DISCUSSION

Seborrheic keratosis could not be in the differential because it is, by definition, an epidermal lesion—that is, “stuck on” the surface of the skin. It creates a rough surface that can be easily scraped off. The lesion could have been an actual scar, but other factors (its continuous growth) and the history of excessive ultraviolet exposure pushed us away from including this condition in the differential.

The differential for this patient included sun-caused skin cancers: basal cell carcinoma (BCC; choice “b”), squamous cell carcinoma (SCC; choice “d”), and amelanotic melanoma (choice “c”). These conditions can have a colorless and scar-like appearance, and they also destroy surface adnexae. Therefore, the lack of hairs, pores, or skin lines in a circumscribed area should raise concern for possible skin cancer, especially in at-risk patients such as this one.

BCC (otherwise known as cicatricial basal cell carcinoma) is by far the most common of all sun-caused skin cancers, but it usually presents as an obvious papule or nodule, often with telltale features such as pearly, rolled borders and focal erosion or ulceration. But there are exceptions, and the scar-like BCC is one.

SCC can also occasionally present in this manner, as can amelanotic melanoma, which is a colorless melanoma and very easy to miss. This case perfectly illustrates the point I often make to the students and residents I teach: When skin cancer is suspected, pay at least as much attention to the owner as to the lesion. Also, when in doubt, biopsy will settle the matter.

TREATMENT

For the patient, shave biopsy confirmed the presence of BCC. She was then referred for Mohs micrographic surgery because of the lesion’s size, location, and uncertain visible margins.

ANSWER

The correct answer is seborrheic keratosis (choice “a”).

DISCUSSION

Seborrheic keratosis could not be in the differential because it is, by definition, an epidermal lesion—that is, “stuck on” the surface of the skin. It creates a rough surface that can be easily scraped off. The lesion could have been an actual scar, but other factors (its continuous growth) and the history of excessive ultraviolet exposure pushed us away from including this condition in the differential.

The differential for this patient included sun-caused skin cancers: basal cell carcinoma (BCC; choice “b”), squamous cell carcinoma (SCC; choice “d”), and amelanotic melanoma (choice “c”). These conditions can have a colorless and scar-like appearance, and they also destroy surface adnexae. Therefore, the lack of hairs, pores, or skin lines in a circumscribed area should raise concern for possible skin cancer, especially in at-risk patients such as this one.

BCC (otherwise known as cicatricial basal cell carcinoma) is by far the most common of all sun-caused skin cancers, but it usually presents as an obvious papule or nodule, often with telltale features such as pearly, rolled borders and focal erosion or ulceration. But there are exceptions, and the scar-like BCC is one.

SCC can also occasionally present in this manner, as can amelanotic melanoma, which is a colorless melanoma and very easy to miss. This case perfectly illustrates the point I often make to the students and residents I teach: When skin cancer is suspected, pay at least as much attention to the owner as to the lesion. Also, when in doubt, biopsy will settle the matter.

TREATMENT

For the patient, shave biopsy confirmed the presence of BCC. She was then referred for Mohs micrographic surgery because of the lesion’s size, location, and uncertain visible margins.

ANSWER

The correct answer is seborrheic keratosis (choice “a”).

DISCUSSION

Seborrheic keratosis could not be in the differential because it is, by definition, an epidermal lesion—that is, “stuck on” the surface of the skin. It creates a rough surface that can be easily scraped off. The lesion could have been an actual scar, but other factors (its continuous growth) and the history of excessive ultraviolet exposure pushed us away from including this condition in the differential.

The differential for this patient included sun-caused skin cancers: basal cell carcinoma (BCC; choice “b”), squamous cell carcinoma (SCC; choice “d”), and amelanotic melanoma (choice “c”). These conditions can have a colorless and scar-like appearance, and they also destroy surface adnexae. Therefore, the lack of hairs, pores, or skin lines in a circumscribed area should raise concern for possible skin cancer, especially in at-risk patients such as this one.

BCC (otherwise known as cicatricial basal cell carcinoma) is by far the most common of all sun-caused skin cancers, but it usually presents as an obvious papule or nodule, often with telltale features such as pearly, rolled borders and focal erosion or ulceration. But there are exceptions, and the scar-like BCC is one.

SCC can also occasionally present in this manner, as can amelanotic melanoma, which is a colorless melanoma and very easy to miss. This case perfectly illustrates the point I often make to the students and residents I teach: When skin cancer is suspected, pay at least as much attention to the owner as to the lesion. Also, when in doubt, biopsy will settle the matter.

TREATMENT

For the patient, shave biopsy confirmed the presence of BCC. She was then referred for Mohs micrographic surgery because of the lesion’s size, location, and uncertain visible margins.

A phone, an app, and the next generation of implanted cardiac device data signaling produced an unprecedented level of data transmission compliance in a single-arm, multicenter, pilot study with 245 patients, adding momentum to the expanding penetration of personal smart devices into cardiac electrophysiology.

During 12-month follow-up, the 245 patients who received either a medically indicated pacemaker or cardiac resynchronization therapy (CRT)–pacemaker equipped with Bluetooth remote transmission capability had successful data transfer to their clinicians for 95% of their scheduled data uploads while using a personal phone or tablet as the link between their heart implant and the Internet. This rate significantly surpassed the transmission-success rates tallied by traditional, bedside transmitters in historical control groups, Khaldoun G. Tarakji, MD, said at the annual scientific sessions of the Heart Rhythm Society, held online because of COVID-19.

A related analysis by Dr. Tarakji and colleagues of 811 patients from real-world practice who received similar implanted cardiac devices with the same remote-transmission capability showed a 93% rate of successful data transfers via smart devices.

In contrast, historical performance showed a 77% success rate in matched patients drawn from a pool of more than 69,000 people in routine care who had received a pacemaker or CRT-pacemaker that automatically transmitted to a bedside monitor. Historical transmission success among matched patients from a pool of more than 128,000 routine-care patients with similar implants who used a wand to interrogate their implants before the attached monitor transmitted their data had a 56% rate of successful transmissions.

Cardiac device signals that flow directly into a patient’s phone or pad and then relay automatically via an app to the clinic “are clearly much easier,” than the methods now used, observed Dr. Tarakji, a cardiac electrophysiologist at the Cleveland Clinic. “It is truly as seamless as possible. Patients don’t really need to do anything,” he said during a press briefing. The key is that most patients tend to keep their smart devices, especially their phones, near them all the time, which minimizes the chance that the implanted cardiac device might try to file a report when the patient is not positioned near the device that’s facilitating transmission. When patients use conventional, bedside transmitters they can forget to bring them on trips, while many fewer fail to take their phone. Another advantage is that the link between a phone and a cardiac implant can be started in the clinic once the patient downloads an app. Bedside units need home setup, and “some patients never even get theirs out of the box,” Dr. Tarakji lamented.

Another feature of handheld device transmissions that run off an app is that the app can display clinical metrics, activity, device performance, and transmission history, as well as educational information. All of these features can enhance patient engagement with their implanted device, their arrhythmia, and their health status. Bedside units often give patients little feedback, and they don’t display clinical data. “The real challenge for clinicians is what data you let patients see. That’s complicated,” Dr. Tarakji said.

“This study was designed to see whether the technology works. The next step is to study how it affects risk-factor modification” or other outcomes. “There are many opportunities” to explore with this new data transmission and processing capability, he concluded.

The BlueSync Field Evaluation study enrolled patients at 20 centers in the United States, France, Italy, and the United Kingdom during 2018, and the 245 patients who received a BlueSync device and were included in the analysis sent at least one of their scheduled data transmissions during their 12 months of follow-up. Participants were eligible if they were willing to use their own smart phone or pad that could interact with their cardiac implant, and included both first-time implant recipients as well as some patients who received replacement units.

Personal device–based data transmission from cardiac implants “will no doubt change the way we manage patients,” commented Nassir F. Marrouche, MD, a cardiac electrophysiologist and professor of medicine at Tulane University in New Orleans, and a designated discussant for the report. “Every implanted cardiac device should be able to connect with a phone, which can improve adoption and adherence,” he said.

But the study has several limitations for interpreting the implications of the findings, starting with its limited size and single-arm design, noted a second discussant, Roderick Tung, MD, director of cardiac electrophysiology at the University of Chicago. Another issue is the generalizability of the findings, which are likely biased by involving only patients who own a smart phone or tablet and may be more likely to transmit their data regardless of the means. And comparing transmission success in a prospective study with rates that occurred during real-world, routine practice could have a Hawthorne effect bias, where people under study behave differently than they do in everyday life. But that effect may be mitigated by confirmatory findings from a real-world group that also used smart-device transmission included in the report. Despite these caveats, it’s valuable to develop new ways of improving data collection from cardiac devices, Dr. Tung said.

The BlueSync Field Evaluation study was sponsored by Medtronic, the company that markets Bluetooth-enabled cardiac devices. Dr. Tarakji has been a consultant to Medtronic, and also to AliveCor, Boston Scientific, and Johnson & Johnson. Dr. Marrouche has been a consultant to Medtronic as well as to Biosense Webster, Biotronik, Cardiac Design, and Preventice, and he has received research funding from Abbott, Biosense Webster, Boston Scientific, and GE Healthcare. Dr. Tung has been a speaker on behalf of Abbott, Boston Scientific, and Biosense Webster.

mzoler@mdedge.com

SOURCE: Tarakji KG. Heart Rhythm 2020, Abstract D-LBCT04-01.

A phone, an app, and the next generation of implanted cardiac device data signaling produced an unprecedented level of data transmission compliance in a single-arm, multicenter, pilot study with 245 patients, adding momentum to the expanding penetration of personal smart devices into cardiac electrophysiology.

During 12-month follow-up, the 245 patients who received either a medically indicated pacemaker or cardiac resynchronization therapy (CRT)–pacemaker equipped with Bluetooth remote transmission capability had successful data transfer to their clinicians for 95% of their scheduled data uploads while using a personal phone or tablet as the link between their heart implant and the Internet. This rate significantly surpassed the transmission-success rates tallied by traditional, bedside transmitters in historical control groups, Khaldoun G. Tarakji, MD, said at the annual scientific sessions of the Heart Rhythm Society, held online because of COVID-19.

A related analysis by Dr. Tarakji and colleagues of 811 patients from real-world practice who received similar implanted cardiac devices with the same remote-transmission capability showed a 93% rate of successful data transfers via smart devices.

In contrast, historical performance showed a 77% success rate in matched patients drawn from a pool of more than 69,000 people in routine care who had received a pacemaker or CRT-pacemaker that automatically transmitted to a bedside monitor. Historical transmission success among matched patients from a pool of more than 128,000 routine-care patients with similar implants who used a wand to interrogate their implants before the attached monitor transmitted their data had a 56% rate of successful transmissions.

Cardiac device signals that flow directly into a patient’s phone or pad and then relay automatically via an app to the clinic “are clearly much easier,” than the methods now used, observed Dr. Tarakji, a cardiac electrophysiologist at the Cleveland Clinic. “It is truly as seamless as possible. Patients don’t really need to do anything,” he said during a press briefing. The key is that most patients tend to keep their smart devices, especially their phones, near them all the time, which minimizes the chance that the implanted cardiac device might try to file a report when the patient is not positioned near the device that’s facilitating transmission. When patients use conventional, bedside transmitters they can forget to bring them on trips, while many fewer fail to take their phone. Another advantage is that the link between a phone and a cardiac implant can be started in the clinic once the patient downloads an app. Bedside units need home setup, and “some patients never even get theirs out of the box,” Dr. Tarakji lamented.

Another feature of handheld device transmissions that run off an app is that the app can display clinical metrics, activity, device performance, and transmission history, as well as educational information. All of these features can enhance patient engagement with their implanted device, their arrhythmia, and their health status. Bedside units often give patients little feedback, and they don’t display clinical data. “The real challenge for clinicians is what data you let patients see. That’s complicated,” Dr. Tarakji said.

“This study was designed to see whether the technology works. The next step is to study how it affects risk-factor modification” or other outcomes. “There are many opportunities” to explore with this new data transmission and processing capability, he concluded.

The BlueSync Field Evaluation study enrolled patients at 20 centers in the United States, France, Italy, and the United Kingdom during 2018, and the 245 patients who received a BlueSync device and were included in the analysis sent at least one of their scheduled data transmissions during their 12 months of follow-up. Participants were eligible if they were willing to use their own smart phone or pad that could interact with their cardiac implant, and included both first-time implant recipients as well as some patients who received replacement units.

Personal device–based data transmission from cardiac implants “will no doubt change the way we manage patients,” commented Nassir F. Marrouche, MD, a cardiac electrophysiologist and professor of medicine at Tulane University in New Orleans, and a designated discussant for the report. “Every implanted cardiac device should be able to connect with a phone, which can improve adoption and adherence,” he said.

But the study has several limitations for interpreting the implications of the findings, starting with its limited size and single-arm design, noted a second discussant, Roderick Tung, MD, director of cardiac electrophysiology at the University of Chicago. Another issue is the generalizability of the findings, which are likely biased by involving only patients who own a smart phone or tablet and may be more likely to transmit their data regardless of the means. And comparing transmission success in a prospective study with rates that occurred during real-world, routine practice could have a Hawthorne effect bias, where people under study behave differently than they do in everyday life. But that effect may be mitigated by confirmatory findings from a real-world group that also used smart-device transmission included in the report. Despite these caveats, it’s valuable to develop new ways of improving data collection from cardiac devices, Dr. Tung said.

The BlueSync Field Evaluation study was sponsored by Medtronic, the company that markets Bluetooth-enabled cardiac devices. Dr. Tarakji has been a consultant to Medtronic, and also to AliveCor, Boston Scientific, and Johnson & Johnson. Dr. Marrouche has been a consultant to Medtronic as well as to Biosense Webster, Biotronik, Cardiac Design, and Preventice, and he has received research funding from Abbott, Biosense Webster, Boston Scientific, and GE Healthcare. Dr. Tung has been a speaker on behalf of Abbott, Boston Scientific, and Biosense Webster.

mzoler@mdedge.com

SOURCE: Tarakji KG. Heart Rhythm 2020, Abstract D-LBCT04-01.

A phone, an app, and the next generation of implanted cardiac device data signaling produced an unprecedented level of data transmission compliance in a single-arm, multicenter, pilot study with 245 patients, adding momentum to the expanding penetration of personal smart devices into cardiac electrophysiology.

During 12-month follow-up, the 245 patients who received either a medically indicated pacemaker or cardiac resynchronization therapy (CRT)–pacemaker equipped with Bluetooth remote transmission capability had successful data transfer to their clinicians for 95% of their scheduled data uploads while using a personal phone or tablet as the link between their heart implant and the Internet. This rate significantly surpassed the transmission-success rates tallied by traditional, bedside transmitters in historical control groups, Khaldoun G. Tarakji, MD, said at the annual scientific sessions of the Heart Rhythm Society, held online because of COVID-19.

A related analysis by Dr. Tarakji and colleagues of 811 patients from real-world practice who received similar implanted cardiac devices with the same remote-transmission capability showed a 93% rate of successful data transfers via smart devices.

In contrast, historical performance showed a 77% success rate in matched patients drawn from a pool of more than 69,000 people in routine care who had received a pacemaker or CRT-pacemaker that automatically transmitted to a bedside monitor. Historical transmission success among matched patients from a pool of more than 128,000 routine-care patients with similar implants who used a wand to interrogate their implants before the attached monitor transmitted their data had a 56% rate of successful transmissions.

Cardiac device signals that flow directly into a patient’s phone or pad and then relay automatically via an app to the clinic “are clearly much easier,” than the methods now used, observed Dr. Tarakji, a cardiac electrophysiologist at the Cleveland Clinic. “It is truly as seamless as possible. Patients don’t really need to do anything,” he said during a press briefing. The key is that most patients tend to keep their smart devices, especially their phones, near them all the time, which minimizes the chance that the implanted cardiac device might try to file a report when the patient is not positioned near the device that’s facilitating transmission. When patients use conventional, bedside transmitters they can forget to bring them on trips, while many fewer fail to take their phone. Another advantage is that the link between a phone and a cardiac implant can be started in the clinic once the patient downloads an app. Bedside units need home setup, and “some patients never even get theirs out of the box,” Dr. Tarakji lamented.

Another feature of handheld device transmissions that run off an app is that the app can display clinical metrics, activity, device performance, and transmission history, as well as educational information. All of these features can enhance patient engagement with their implanted device, their arrhythmia, and their health status. Bedside units often give patients little feedback, and they don’t display clinical data. “The real challenge for clinicians is what data you let patients see. That’s complicated,” Dr. Tarakji said.

“This study was designed to see whether the technology works. The next step is to study how it affects risk-factor modification” or other outcomes. “There are many opportunities” to explore with this new data transmission and processing capability, he concluded.

The BlueSync Field Evaluation study enrolled patients at 20 centers in the United States, France, Italy, and the United Kingdom during 2018, and the 245 patients who received a BlueSync device and were included in the analysis sent at least one of their scheduled data transmissions during their 12 months of follow-up. Participants were eligible if they were willing to use their own smart phone or pad that could interact with their cardiac implant, and included both first-time implant recipients as well as some patients who received replacement units.

Personal device–based data transmission from cardiac implants “will no doubt change the way we manage patients,” commented Nassir F. Marrouche, MD, a cardiac electrophysiologist and professor of medicine at Tulane University in New Orleans, and a designated discussant for the report. “Every implanted cardiac device should be able to connect with a phone, which can improve adoption and adherence,” he said.

But the study has several limitations for interpreting the implications of the findings, starting with its limited size and single-arm design, noted a second discussant, Roderick Tung, MD, director of cardiac electrophysiology at the University of Chicago. Another issue is the generalizability of the findings, which are likely biased by involving only patients who own a smart phone or tablet and may be more likely to transmit their data regardless of the means. And comparing transmission success in a prospective study with rates that occurred during real-world, routine practice could have a Hawthorne effect bias, where people under study behave differently than they do in everyday life. But that effect may be mitigated by confirmatory findings from a real-world group that also used smart-device transmission included in the report. Despite these caveats, it’s valuable to develop new ways of improving data collection from cardiac devices, Dr. Tung said.

The BlueSync Field Evaluation study was sponsored by Medtronic, the company that markets Bluetooth-enabled cardiac devices. Dr. Tarakji has been a consultant to Medtronic, and also to AliveCor, Boston Scientific, and Johnson & Johnson. Dr. Marrouche has been a consultant to Medtronic as well as to Biosense Webster, Biotronik, Cardiac Design, and Preventice, and he has received research funding from Abbott, Biosense Webster, Boston Scientific, and GE Healthcare. Dr. Tung has been a speaker on behalf of Abbott, Boston Scientific, and Biosense Webster.

mzoler@mdedge.com

SOURCE: Tarakji KG. Heart Rhythm 2020, Abstract D-LBCT04-01.

Combination toripalimab and axitinib produced promising early results in patients with metastatic mucosal melanoma, according to a presentation made as part of the American Society of Clinical Oncology virtual scientific program.

The combination was well tolerated and “the preliminary efficacy seems to be promising,” which warrants a phase 3 trial, said investigator Jun Guo, MD, of the Peking University Cancer Hospital and Institute in Beijing, who presented the findings.

Mucosal melanoma does not respond as well as cutaneous melanoma to standard programmed death-1 (PD-1) blockade, so investigators are looking for additional options, Dr. Guo noted. Earlier studies have shown that vascular endothelial growth factor expression correlates negatively with clinical outcome, so the combination of VEGF inhibition with PD-1 blockade might provide therapeutic opportunities.

To find out, Dr. Guo and colleagues tested the anti-PD-1 antibody toripalimab in combination with the VEGF inhibitor axitinib in a phase 1 trial. The trial was conducted in China, where mucosal melanoma accounts for up to a quarter of all melanoma cases and where toripalimab is approved to treat mucosal melanoma.

The trial enrolled 33 patients with pathologically confirmed metastatic mucosal melanoma. The esophagus and genital tract were the most common primary lesion sites (both 21.2%). The patients’ average age was 53.4 years, and 60.6% were women. Two patients (6.1%) had previously received systemic chemotherapy. Most (64.6%) were PD–ligand 1 (PD-L1) negative, and most (60.6%) were BRAF/RAS/NF1 wild type.

The patients received axitinib at 5 mg twice daily plus toripalimab at 3 mg/kg every 2 weeks until confirmed disease progression, unacceptable toxicity, or voluntary withdrawal.

As of May 2, 2020, the overall response rate was 48.5%. There were 15 partial responses and 1 complete response. The median duration of response was 13.7 months. The median progression-free survival was 7.5 months, and the median overall survival was 20.7 months.

Progression-free and overall survival were numerically higher in PD-L1-positive subjects and those with higher tumor mutation burdens. An expression profile of 12 genes related to inflammation and angiogenesis showed a significant correlation with response. This might help identify patients most likely to respond to the combination, but further validation is needed, Dr. Guo said.

A total of 32 subjects (97%) have had a treatment-related adverse event, including 13 (39.4%) with grade 3-5 events. The most common of these were proteinuria, hypertension, and neutropenia (all 9.1%).

“So does this study address the unmet need? In many ways, yes,” said Ryan Sullivan, MD, an assistant professor of hematology/oncology at Massachusetts General Hospital in Boston, and the discussant on Dr. Guo’s presentation.

“However, the data to date [don’t] mean we should be treating all of our mucosal melanoma patients with axitinib plus an anti-PD-1 antibody. There needs to be randomized data, but I would describe this data as very encouraging,” he said.

The study was funded by the maker of toripalimab, Shanghai Junshi Bioscience. Dr. Guo disclosed relationships with Shanghai Junshi Bioscience and Pfizer, maker of axitinib. Other investigators are employed by Shanghai Junshi Bioscience. Dr. Sullivan reported institutional research funding from Pfizer.

aotto@mdedge.com

SOURCE: Guo J et al. ASCO 2020, Abstract 10007.

Combination toripalimab and axitinib produced promising early results in patients with metastatic mucosal melanoma, according to a presentation made as part of the American Society of Clinical Oncology virtual scientific program.

The combination was well tolerated and “the preliminary efficacy seems to be promising,” which warrants a phase 3 trial, said investigator Jun Guo, MD, of the Peking University Cancer Hospital and Institute in Beijing, who presented the findings.

Mucosal melanoma does not respond as well as cutaneous melanoma to standard programmed death-1 (PD-1) blockade, so investigators are looking for additional options, Dr. Guo noted. Earlier studies have shown that vascular endothelial growth factor expression correlates negatively with clinical outcome, so the combination of VEGF inhibition with PD-1 blockade might provide therapeutic opportunities.

To find out, Dr. Guo and colleagues tested the anti-PD-1 antibody toripalimab in combination with the VEGF inhibitor axitinib in a phase 1 trial. The trial was conducted in China, where mucosal melanoma accounts for up to a quarter of all melanoma cases and where toripalimab is approved to treat mucosal melanoma.

The trial enrolled 33 patients with pathologically confirmed metastatic mucosal melanoma. The esophagus and genital tract were the most common primary lesion sites (both 21.2%). The patients’ average age was 53.4 years, and 60.6% were women. Two patients (6.1%) had previously received systemic chemotherapy. Most (64.6%) were PD–ligand 1 (PD-L1) negative, and most (60.6%) were BRAF/RAS/NF1 wild type.

The patients received axitinib at 5 mg twice daily plus toripalimab at 3 mg/kg every 2 weeks until confirmed disease progression, unacceptable toxicity, or voluntary withdrawal.

As of May 2, 2020, the overall response rate was 48.5%. There were 15 partial responses and 1 complete response. The median duration of response was 13.7 months. The median progression-free survival was 7.5 months, and the median overall survival was 20.7 months.

Progression-free and overall survival were numerically higher in PD-L1-positive subjects and those with higher tumor mutation burdens. An expression profile of 12 genes related to inflammation and angiogenesis showed a significant correlation with response. This might help identify patients most likely to respond to the combination, but further validation is needed, Dr. Guo said.

A total of 32 subjects (97%) have had a treatment-related adverse event, including 13 (39.4%) with grade 3-5 events. The most common of these were proteinuria, hypertension, and neutropenia (all 9.1%).

“So does this study address the unmet need? In many ways, yes,” said Ryan Sullivan, MD, an assistant professor of hematology/oncology at Massachusetts General Hospital in Boston, and the discussant on Dr. Guo’s presentation.

“However, the data to date [don’t] mean we should be treating all of our mucosal melanoma patients with axitinib plus an anti-PD-1 antibody. There needs to be randomized data, but I would describe this data as very encouraging,” he said.

The study was funded by the maker of toripalimab, Shanghai Junshi Bioscience. Dr. Guo disclosed relationships with Shanghai Junshi Bioscience and Pfizer, maker of axitinib. Other investigators are employed by Shanghai Junshi Bioscience. Dr. Sullivan reported institutional research funding from Pfizer.

aotto@mdedge.com

SOURCE: Guo J et al. ASCO 2020, Abstract 10007.

Combination toripalimab and axitinib produced promising early results in patients with metastatic mucosal melanoma, according to a presentation made as part of the American Society of Clinical Oncology virtual scientific program.

The combination was well tolerated and “the preliminary efficacy seems to be promising,” which warrants a phase 3 trial, said investigator Jun Guo, MD, of the Peking University Cancer Hospital and Institute in Beijing, who presented the findings.

Mucosal melanoma does not respond as well as cutaneous melanoma to standard programmed death-1 (PD-1) blockade, so investigators are looking for additional options, Dr. Guo noted. Earlier studies have shown that vascular endothelial growth factor expression correlates negatively with clinical outcome, so the combination of VEGF inhibition with PD-1 blockade might provide therapeutic opportunities.

To find out, Dr. Guo and colleagues tested the anti-PD-1 antibody toripalimab in combination with the VEGF inhibitor axitinib in a phase 1 trial. The trial was conducted in China, where mucosal melanoma accounts for up to a quarter of all melanoma cases and where toripalimab is approved to treat mucosal melanoma.

The trial enrolled 33 patients with pathologically confirmed metastatic mucosal melanoma. The esophagus and genital tract were the most common primary lesion sites (both 21.2%). The patients’ average age was 53.4 years, and 60.6% were women. Two patients (6.1%) had previously received systemic chemotherapy. Most (64.6%) were PD–ligand 1 (PD-L1) negative, and most (60.6%) were BRAF/RAS/NF1 wild type.

The patients received axitinib at 5 mg twice daily plus toripalimab at 3 mg/kg every 2 weeks until confirmed disease progression, unacceptable toxicity, or voluntary withdrawal.

As of May 2, 2020, the overall response rate was 48.5%. There were 15 partial responses and 1 complete response. The median duration of response was 13.7 months. The median progression-free survival was 7.5 months, and the median overall survival was 20.7 months.

Progression-free and overall survival were numerically higher in PD-L1-positive subjects and those with higher tumor mutation burdens. An expression profile of 12 genes related to inflammation and angiogenesis showed a significant correlation with response. This might help identify patients most likely to respond to the combination, but further validation is needed, Dr. Guo said.

A total of 32 subjects (97%) have had a treatment-related adverse event, including 13 (39.4%) with grade 3-5 events. The most common of these were proteinuria, hypertension, and neutropenia (all 9.1%).

“So does this study address the unmet need? In many ways, yes,” said Ryan Sullivan, MD, an assistant professor of hematology/oncology at Massachusetts General Hospital in Boston, and the discussant on Dr. Guo’s presentation.

“However, the data to date [don’t] mean we should be treating all of our mucosal melanoma patients with axitinib plus an anti-PD-1 antibody. There needs to be randomized data, but I would describe this data as very encouraging,” he said.

The study was funded by the maker of toripalimab, Shanghai Junshi Bioscience. Dr. Guo disclosed relationships with Shanghai Junshi Bioscience and Pfizer, maker of axitinib. Other investigators are employed by Shanghai Junshi Bioscience. Dr. Sullivan reported institutional research funding from Pfizer.

aotto@mdedge.com

SOURCE: Guo J et al. ASCO 2020, Abstract 10007.

In a new analysis of international registry data, renal denervation resulted in similar reduced blood pressure levels in patients with varying high-risk comorbidities and across a range of cardiovascular risk scores.

Ted Bosworth/MDedge News

At 3 years, 24-hour systolic BP was reduced by an average of –8.9 mm Hg overall, with slightly higher or lower readings seen in those with higher cardiovascular risk scores (–10.4 mm Hg) and 65 years or older (–10.2 mm Hg). Similar reductions were seen in those with resistant hypertension (–8.7 mm Hg), diabetes (–8.6 mm Hg), isolated systolic hypertension (–10.1 mm Hg), chronic kidney disease (–10.1 mm Hg), or atrial fibrillation (–10.0 mm Hg).

“In the largest international registry of its kind, the efficacy of renal denervation was similar in patients with and without baseline conditions associated with increased sympathetic activity and irrespective of ASCVD [atherosclerotic cardiovascular disease] risk,” first author Felix Mahfoud, MD, said in an interview.

Dr. Mahfoud, from University Hospital of Saarland, Homburg, Germany, and colleagues published their analysis in the Journal of the American College of Cardiology.

The article reported a post hoc analysis of data from the Global SYMPLICITY Registry (GSR), an international, Medtronic-funded effort that includes 2,652 patients with uncontrolled hypertension treated with a Symplicity denervation system. Data were obtained from 196 centers in 45 countries.

“Blood pressure reductions were durable and sustained to 3 years and the rates of new-onset, end-stage renal disease and elevation in serum creatinine levels were very low in patients at high and low [cardiovascular] risk,” reported Dr. Mahfoud.

As expected, adverse event rates were higher for patients with higher baseline cardiovascular risk. “Elevated rates were also seen in patients with [atrial fibrillation] and diabetes, identifying these subgroups who might derive even greater clinical benefit from improved BP control using renal denervation,” said Dr. Mahfoud.

Asked which patients might be optimal candidates for renal denervation, Dr. Mahfoud recommended the technology for “patients with uncontrolled hypertension on medication, patients with nonadherence, unwillingness, or intolerability to medication, and patients with combined systolic and diastolic hypertension.”
 

Analyses limited by incomplete data

Stephen C. Textor, MD, has concerns over the amount of missing data in the GSR database and its continued use as a repository of information on renal denervation.

“I am a bit lukewarm on this paper in part because of the nature of the registry data they’re using,” he added in an interview. “The problem I see is that the registry is not terribly uniform as to what information they collect on each patient, not terribly uniform in terms of how the procedure is performed, and not terribly uniform on how they follow up patients.”

Indeed, the post hoc subgroup analyses represent only a limited subset because of incomplete data, added Dr. Textor, a nephrologist at the Cleveland Clinic in Rochester, Minn.

“Remarkably, only 504 [patients] had “matched” data for office [systolic BP] levels at the time points defined in the report,” he wrote in an editorial comment accompanying the registry report (J Am Coll Cardiol. 2020 Jun 16;75[23]:2889-91).

Similarly, the researchers were able to calculate baseline atherosclerotic cardiovascular risk scores in only 1,485 patients (56% of total), primarily because of missing cholesterol measurements.

“They simply did these paired comparison that may have included a couple hundred cases, and on average, there were no differences in response, but what I would have liked to see is a multivariate analysis, where you have all the data on everybody and look at what are the factors that impact response?” Dr. Textor said in the interview.

“They really couldn’t do that because they just, they’re just too many holes in the data,” he added.

On the bright side, Dr. Textor noted that, while the impact overall on systolic BP was “modest,” the standard deviations in some cases were large, indicating that some people had large reductions of systolic BP of more than 30-40 mm Hg.

“There is a belief out there that there are some people that really benefit from this, but how to identify them has been the question,” Dr. Textor said.

Enthusiasm for renal denervation plummeted after results from the SYMPLICITY HTN-3 showed the procedure failing to meet its efficacy endpoint in resistant hypertension. The procedure was associated with a 14–mm Hg fall in systolic BP, compared with an 11–mm Hg drop in the “sham” control group (N Engl J Med. 2014 Apr 10;370:1393-401). However, post hoc analysis of the trial revealed significant shortcomings in design and execution.

No renal denervation device is approved in the United States. The Symplicity device used in this registry is approved in the European Union.

In early 2020, the Food and Drug Administration promised a rigorous review of new renal denervation trials. Subsequently, primary results from the SPYRAL HTN-OFF MED pivotal trial were presented at the annual meeting of the American College of Cardiology in March and showed promising efficacy.

SPYRAL HTN OFF-MED was designed in collaboration with the FDA to obtain meaningful evidence of whether renal denervation performed with the Symplicity Spyral multielectrode catheter (Medtronic Vascular) could reduce BP in patients not taking antihypertensive medication.

Dr. Mahfoud reported he has received speaking honoraria from Medtronic and ReCor. Two other authors are employees of Medtronic. Dr. Textor reported no relationships relevant to the contents of this paper. The Global SYMPLICITY Registry is funded by Medtronic Vascular.

SOURCE: Mahfoud F et al. J Am Coll Cardiol. 2020 June 16;75:2879-88.

This article was updated 6/16/20.

In a new analysis of international registry data, renal denervation resulted in similar reduced blood pressure levels in patients with varying high-risk comorbidities and across a range of cardiovascular risk scores.

Ted Bosworth/MDedge News

At 3 years, 24-hour systolic BP was reduced by an average of –8.9 mm Hg overall, with slightly higher or lower readings seen in those with higher cardiovascular risk scores (–10.4 mm Hg) and 65 years or older (–10.2 mm Hg). Similar reductions were seen in those with resistant hypertension (–8.7 mm Hg), diabetes (–8.6 mm Hg), isolated systolic hypertension (–10.1 mm Hg), chronic kidney disease (–10.1 mm Hg), or atrial fibrillation (–10.0 mm Hg).

“In the largest international registry of its kind, the efficacy of renal denervation was similar in patients with and without baseline conditions associated with increased sympathetic activity and irrespective of ASCVD [atherosclerotic cardiovascular disease] risk,” first author Felix Mahfoud, MD, said in an interview.

Dr. Mahfoud, from University Hospital of Saarland, Homburg, Germany, and colleagues published their analysis in the Journal of the American College of Cardiology.

The article reported a post hoc analysis of data from the Global SYMPLICITY Registry (GSR), an international, Medtronic-funded effort that includes 2,652 patients with uncontrolled hypertension treated with a Symplicity denervation system. Data were obtained from 196 centers in 45 countries.

“Blood pressure reductions were durable and sustained to 3 years and the rates of new-onset, end-stage renal disease and elevation in serum creatinine levels were very low in patients at high and low [cardiovascular] risk,” reported Dr. Mahfoud.

As expected, adverse event rates were higher for patients with higher baseline cardiovascular risk. “Elevated rates were also seen in patients with [atrial fibrillation] and diabetes, identifying these subgroups who might derive even greater clinical benefit from improved BP control using renal denervation,” said Dr. Mahfoud.

Asked which patients might be optimal candidates for renal denervation, Dr. Mahfoud recommended the technology for “patients with uncontrolled hypertension on medication, patients with nonadherence, unwillingness, or intolerability to medication, and patients with combined systolic and diastolic hypertension.”
 

Analyses limited by incomplete data

Stephen C. Textor, MD, has concerns over the amount of missing data in the GSR database and its continued use as a repository of information on renal denervation.

“I am a bit lukewarm on this paper in part because of the nature of the registry data they’re using,” he added in an interview. “The problem I see is that the registry is not terribly uniform as to what information they collect on each patient, not terribly uniform in terms of how the procedure is performed, and not terribly uniform on how they follow up patients.”

Indeed, the post hoc subgroup analyses represent only a limited subset because of incomplete data, added Dr. Textor, a nephrologist at the Cleveland Clinic in Rochester, Minn.

“Remarkably, only 504 [patients] had “matched” data for office [systolic BP] levels at the time points defined in the report,” he wrote in an editorial comment accompanying the registry report (J Am Coll Cardiol. 2020 Jun 16;75[23]:2889-91).

Similarly, the researchers were able to calculate baseline atherosclerotic cardiovascular risk scores in only 1,485 patients (56% of total), primarily because of missing cholesterol measurements.

“They simply did these paired comparison that may have included a couple hundred cases, and on average, there were no differences in response, but what I would have liked to see is a multivariate analysis, where you have all the data on everybody and look at what are the factors that impact response?” Dr. Textor said in the interview.

“They really couldn’t do that because they just, they’re just too many holes in the data,” he added.

On the bright side, Dr. Textor noted that, while the impact overall on systolic BP was “modest,” the standard deviations in some cases were large, indicating that some people had large reductions of systolic BP of more than 30-40 mm Hg.

“There is a belief out there that there are some people that really benefit from this, but how to identify them has been the question,” Dr. Textor said.

Enthusiasm for renal denervation plummeted after results from the SYMPLICITY HTN-3 showed the procedure failing to meet its efficacy endpoint in resistant hypertension. The procedure was associated with a 14–mm Hg fall in systolic BP, compared with an 11–mm Hg drop in the “sham” control group (N Engl J Med. 2014 Apr 10;370:1393-401). However, post hoc analysis of the trial revealed significant shortcomings in design and execution.

No renal denervation device is approved in the United States. The Symplicity device used in this registry is approved in the European Union.

In early 2020, the Food and Drug Administration promised a rigorous review of new renal denervation trials. Subsequently, primary results from the SPYRAL HTN-OFF MED pivotal trial were presented at the annual meeting of the American College of Cardiology in March and showed promising efficacy.

SPYRAL HTN OFF-MED was designed in collaboration with the FDA to obtain meaningful evidence of whether renal denervation performed with the Symplicity Spyral multielectrode catheter (Medtronic Vascular) could reduce BP in patients not taking antihypertensive medication.

Dr. Mahfoud reported he has received speaking honoraria from Medtronic and ReCor. Two other authors are employees of Medtronic. Dr. Textor reported no relationships relevant to the contents of this paper. The Global SYMPLICITY Registry is funded by Medtronic Vascular.

SOURCE: Mahfoud F et al. J Am Coll Cardiol. 2020 June 16;75:2879-88.

This article was updated 6/16/20.

In a new analysis of international registry data, renal denervation resulted in similar reduced blood pressure levels in patients with varying high-risk comorbidities and across a range of cardiovascular risk scores.

Ted Bosworth/MDedge News

At 3 years, 24-hour systolic BP was reduced by an average of –8.9 mm Hg overall, with slightly higher or lower readings seen in those with higher cardiovascular risk scores (–10.4 mm Hg) and 65 years or older (–10.2 mm Hg). Similar reductions were seen in those with resistant hypertension (–8.7 mm Hg), diabetes (–8.6 mm Hg), isolated systolic hypertension (–10.1 mm Hg), chronic kidney disease (–10.1 mm Hg), or atrial fibrillation (–10.0 mm Hg).

“In the largest international registry of its kind, the efficacy of renal denervation was similar in patients with and without baseline conditions associated with increased sympathetic activity and irrespective of ASCVD [atherosclerotic cardiovascular disease] risk,” first author Felix Mahfoud, MD, said in an interview.

Dr. Mahfoud, from University Hospital of Saarland, Homburg, Germany, and colleagues published their analysis in the Journal of the American College of Cardiology.

The article reported a post hoc analysis of data from the Global SYMPLICITY Registry (GSR), an international, Medtronic-funded effort that includes 2,652 patients with uncontrolled hypertension treated with a Symplicity denervation system. Data were obtained from 196 centers in 45 countries.

“Blood pressure reductions were durable and sustained to 3 years and the rates of new-onset, end-stage renal disease and elevation in serum creatinine levels were very low in patients at high and low [cardiovascular] risk,” reported Dr. Mahfoud.

As expected, adverse event rates were higher for patients with higher baseline cardiovascular risk. “Elevated rates were also seen in patients with [atrial fibrillation] and diabetes, identifying these subgroups who might derive even greater clinical benefit from improved BP control using renal denervation,” said Dr. Mahfoud.

Asked which patients might be optimal candidates for renal denervation, Dr. Mahfoud recommended the technology for “patients with uncontrolled hypertension on medication, patients with nonadherence, unwillingness, or intolerability to medication, and patients with combined systolic and diastolic hypertension.”
 

Analyses limited by incomplete data

Stephen C. Textor, MD, has concerns over the amount of missing data in the GSR database and its continued use as a repository of information on renal denervation.

“I am a bit lukewarm on this paper in part because of the nature of the registry data they’re using,” he added in an interview. “The problem I see is that the registry is not terribly uniform as to what information they collect on each patient, not terribly uniform in terms of how the procedure is performed, and not terribly uniform on how they follow up patients.”

Indeed, the post hoc subgroup analyses represent only a limited subset because of incomplete data, added Dr. Textor, a nephrologist at the Cleveland Clinic in Rochester, Minn.

“Remarkably, only 504 [patients] had “matched” data for office [systolic BP] levels at the time points defined in the report,” he wrote in an editorial comment accompanying the registry report (J Am Coll Cardiol. 2020 Jun 16;75[23]:2889-91).

Similarly, the researchers were able to calculate baseline atherosclerotic cardiovascular risk scores in only 1,485 patients (56% of total), primarily because of missing cholesterol measurements.

“They simply did these paired comparison that may have included a couple hundred cases, and on average, there were no differences in response, but what I would have liked to see is a multivariate analysis, where you have all the data on everybody and look at what are the factors that impact response?” Dr. Textor said in the interview.

“They really couldn’t do that because they just, they’re just too many holes in the data,” he added.

On the bright side, Dr. Textor noted that, while the impact overall on systolic BP was “modest,” the standard deviations in some cases were large, indicating that some people had large reductions of systolic BP of more than 30-40 mm Hg.

“There is a belief out there that there are some people that really benefit from this, but how to identify them has been the question,” Dr. Textor said.

Enthusiasm for renal denervation plummeted after results from the SYMPLICITY HTN-3 showed the procedure failing to meet its efficacy endpoint in resistant hypertension. The procedure was associated with a 14–mm Hg fall in systolic BP, compared with an 11–mm Hg drop in the “sham” control group (N Engl J Med. 2014 Apr 10;370:1393-401). However, post hoc analysis of the trial revealed significant shortcomings in design and execution.

No renal denervation device is approved in the United States. The Symplicity device used in this registry is approved in the European Union.

In early 2020, the Food and Drug Administration promised a rigorous review of new renal denervation trials. Subsequently, primary results from the SPYRAL HTN-OFF MED pivotal trial were presented at the annual meeting of the American College of Cardiology in March and showed promising efficacy.

SPYRAL HTN OFF-MED was designed in collaboration with the FDA to obtain meaningful evidence of whether renal denervation performed with the Symplicity Spyral multielectrode catheter (Medtronic Vascular) could reduce BP in patients not taking antihypertensive medication.

Dr. Mahfoud reported he has received speaking honoraria from Medtronic and ReCor. Two other authors are employees of Medtronic. Dr. Textor reported no relationships relevant to the contents of this paper. The Global SYMPLICITY Registry is funded by Medtronic Vascular.

SOURCE: Mahfoud F et al. J Am Coll Cardiol. 2020 June 16;75:2879-88.

This article was updated 6/16/20.

Immune checkpoint inhibitors are used for a variety of advanced malignancies, including melanoma, non–small cell lung cancer, urothelial cancer, and renal cell carcinoma. Anti–programmed cell death 1 (PD1) targeted therapies, such as pembrolizumab and nivolumab, are improving patient survival. This class of immunotherapy is revolutionary but is associated with autoimmune adverse effects. A rare but increasingly reported adverse effect of anti-PD1 therapy is bullous pemphigoid (BP), an autoimmune blistering disease directed against BP antigen 1 and BP antigen 2 in the basement membrane of the epidermis. Lopez et al¹ reported that development of BP leads to discontinuation of immunotherapy in more than 70% of patients.

High clinical suspicion, early diagnosis, and proper management of immunotherapy-related BP are imperative for keeping patients on life-prolonging treatment. We present 3 cases of BP secondary to anti-PD1 immunotherapy in patients with melanoma or non–small cell lung cancer to highlight the diagnosis and treatment of BP as well as emphasize the importance of the dermatologist in the care of patients with immunotherapy-related skin disease.

Case Reports

Patient 1
​​​​​​​A 72-year-old woman with metastatic BRAF-mutated melanoma from an unknown primary site presented with intensely pruritic papules on the back, chest, and extremities of 4 months’ duration. She described her symptoms as insidious in onset and refractory to clobetasol ointment, oral diphenhydramine, and over-the-counter anti-itch creams. The patient had been treated with oral dabrafenib 150 mg twice daily and trametinib 2 mg/d but was switched to pembrolizumab when the disease progressed. After 8 months, she had a complete radiologic response to pembrolizumab 2 mg/kg every 3 weeks, which was discontinued in favor of observation 3 months prior to presentation to dermatology.

At the current presentation, physical examination revealed innumerable erythematous, excoriated, 2- to 4-mm, red papules diffusely scattered on the upper back, chest, abdomen, and thighs, with one 8×4-mm vesicle on the right side of the upper back (Figure 1). Discrete areas of depigmented macules, consistent with vitiligo, coalesced into patches on the legs, thighs, arms, and back. The patient was started on a 3-week oral prednisone taper for symptom relief. A hematoxylin and eosin (H&E)–stained punch biopsy of the back revealed a subepidermal split with eosinophils and a dense eosinophilic infiltrate in the dermis (Figure 2). Direct immunofluorescence (DIF) studies from a specimen adjacent to the biopsy collected for H&E staining showed linear deposition of IgA, IgG, and C3 along the dermoepidermal junction (Figure 3). Histologic findings were consistent with BP.

The patient was started on doxycycline 100 mg twice daily and clobetasol ointment 0.05% once daily to supplement the prednisone taper. At 3-week follow-up, she reported pruritus and a few erythematous macules but no new bullae. At 12 weeks, some papules persisted; however, the patient was averse to using systemic agents and decided that symptoms were adequately controlled with clobetasol ointment and oral doxycycline.

Because the patient currently remains in clinical and radiologic remission, anti-PD1 immune checkpoint inhibitors have not been restarted but remain an option for the future if disease recurs

Six months prior to presenting to dermatology, the patient underwent immunotherapy with 4 cycles of ipilimumab 200 mg intravenous (IV) and nivolumab 240 mg IV every 2 weeks, receiving ipilimumab during the first cycle only because of a lack of availability at the pharmacy. He then received nivolumab 240 mg IV every 2 weeks as maintenance therapy. After the second dose of nivolumab maintenance therapy, however, he developed generalized bullae and pruritus. Dermatology was consulted during an oncology appointment, and his oncologist decided to hold nivolumab.

Physical examination revealed generalized tense and eroded bullae covering more than 50% of the body surface area and affecting the scalp, arms, legs, torso, and buttocks. Two punch biopsies were obtained. Hematoxylin and eosin staining revealed a subepidermal split with predominantly eosinophils and scattered neutrophils. Direct immunofluorescence studies showed linear deposition of IgG, IgA, and C3 along the dermoepidermal junction, consistent with BP.

The patient’s BP was difficult to control, requiring several hospital admissions for wound care, high-dose systemic steroids, and initiation of mycophenolate mofetil. After 4 months of waxing and waning symptoms, the BP was controlled with mycophenolate mofetil 1500 mg/d; clobetasol ointment 0.05%; and diphenhydramine for pruritus. Due to the prolonged recovery and severity of BP, the patient’s oncologist deemed that he was not a candidate for future immunotherapy.

Patient 3
A 68-year-old man with PD1-negative, metastatic, well-differentiated squamous cell carcinoma of the lung presented to dermatology with a pruritic rash of 3 weeks’ duration. He had been receiving nivolumab for 2 years after disease progressed on prior chemotherapies and experienced several grade 1 or grade 2 nivolumab-induced autoimmune reactions including thyroiditis, dermatitis, and nephritis, for which he was taking prednisone 5 mg/d for suppression.

Physical examination revealed psoriasiform pink plaques on the arms, chest, and legs. The differential diagnosis at the time favored psoriasiform dermatitis over lichenoid dermatitis. A punch biopsy revealed psoriasiform dermatitis. The patient was prescribed fluocinonide ointment 0.05% daily. His plaques improved with topical steroids.

The patient returned approximately 1 month later with a report of a new blistering rash on the legs. Physical examination revealed interval improvement of the psoriasiform plaques on the scalp, torso, and extremities, but tense bullae were seen on the thighs, with surrounding superficial erosions at sites of recent bullae. Punch biopsies of the skin for H&E staining and DIF showed BP.

Prednisone was increased to 50 mg/d for a 3-week taper. Doxycycline 100 mg twice daily was started. The patient’s skin disease continued to be difficult to control with therapy; nivolumab was held by his oncologist.

Comment

Immunotherapy with immune checkpoint blockade represents a successful application of immune recognition to treat metastatic cancers, including melanoma, non–small cell lung cancer, urothelial cancer, and renal cell carcinoma. Programmed cell death 1 downregulates T-cell immune function through blocking interaction with its ligand, programmed death ligand 1. Inhibiting this brake on the immune system permits T cells to attack malignant cells.

Anti-PD1 targeted therapies improve survival in solid and hematologic malignancies, with a response rate as high as 40% in melanoma.² Although these medications can prolong survival, many are associated with loss of self-tolerance and severe autoimmunelike events that can limit therapy.³ An exception is PD1-induced vitiligo, which patient 1 developed and has been associated with a better response to therapy.⁴

Anti-PD1–induced BP is a newly reported adverse effect. In its early stages, BP can be difficult to differentiate from eczematous or urticarial dermatitis.^5-8 Discontinuation of immunotherapy has been reported in more than 70% of patients who develop BP.¹ There are reports of successful treatment of BP with a course of a PD1 inhibitor,⁹ but 2 of our patients had severe BP that led to discontinuation of immunotherapy.

Consider Prescreening
Given that development of BP often leads to cessation of therapy, identifying patients at risk prior to starting an immune checkpoint inhibitor might have clinical utility. Biopsy with DIF is the gold standard for diagnosis, but serologic testing can be a useful adjunct because enzyme-linked immunosorbent assay for BP antigen 1 and BP antigen 2 has a reported sensitivity and specificity of 87% and 98%, respectively.¹⁰ Serologic testing prior to starting therapy with an immune checkpoint inhibitor can provide a baseline for patients. A rise in titer, in conjunction with onset of a rash, might aid in earlier diagnosis, particularly because urticarial BP can be difficult to diagnose clinically.

Further study on the utility vs cost-benefit of these screening modalities is warranted. Their predictive utility might be limited, however, and positive serologic test results might have unanticipated consequences, such as hesitation in treating patients, thus leading to a delay in therapy or access to these medications.

Conclusion

The expanding use of immune checkpoint inhibitors is increasing survival in patients with metastatic melanoma and other malignancies. Adverse effects are part of the continuum of immune system stimulation, with overstimulation resulting in dermatitis; thyroiditis; pneumonitis; and less commonly hypophysitis, vitiligo, and colitis.

Rarely, immune checkpoint inhibition induces BP. Development of BP leads to discontinuation of therapy in more than half of reported cases due to lack of adequate treatment for this skin disease and its impact on quality of life. Therefore, quick diagnosis of BP in patients on immunotherapy and successful management techniques can prevent discontinuation of these lifesaving cancer therapies. For that reason, dermatologists play an important role in the management of patients on immune checkpoint inhibitors for cancer.

Immune checkpoint inhibitors are used for a variety of advanced malignancies, including melanoma, non–small cell lung cancer, urothelial cancer, and renal cell carcinoma. Anti–programmed cell death 1 (PD1) targeted therapies, such as pembrolizumab and nivolumab, are improving patient survival. This class of immunotherapy is revolutionary but is associated with autoimmune adverse effects. A rare but increasingly reported adverse effect of anti-PD1 therapy is bullous pemphigoid (BP), an autoimmune blistering disease directed against BP antigen 1 and BP antigen 2 in the basement membrane of the epidermis. Lopez et al¹ reported that development of BP leads to discontinuation of immunotherapy in more than 70% of patients.

High clinical suspicion, early diagnosis, and proper management of immunotherapy-related BP are imperative for keeping patients on life-prolonging treatment. We present 3 cases of BP secondary to anti-PD1 immunotherapy in patients with melanoma or non–small cell lung cancer to highlight the diagnosis and treatment of BP as well as emphasize the importance of the dermatologist in the care of patients with immunotherapy-related skin disease.

Case Reports

Patient 1
​​​​​​​A 72-year-old woman with metastatic BRAF-mutated melanoma from an unknown primary site presented with intensely pruritic papules on the back, chest, and extremities of 4 months’ duration. She described her symptoms as insidious in onset and refractory to clobetasol ointment, oral diphenhydramine, and over-the-counter anti-itch creams. The patient had been treated with oral dabrafenib 150 mg twice daily and trametinib 2 mg/d but was switched to pembrolizumab when the disease progressed. After 8 months, she had a complete radiologic response to pembrolizumab 2 mg/kg every 3 weeks, which was discontinued in favor of observation 3 months prior to presentation to dermatology.

At the current presentation, physical examination revealed innumerable erythematous, excoriated, 2- to 4-mm, red papules diffusely scattered on the upper back, chest, abdomen, and thighs, with one 8×4-mm vesicle on the right side of the upper back (Figure 1). Discrete areas of depigmented macules, consistent with vitiligo, coalesced into patches on the legs, thighs, arms, and back. The patient was started on a 3-week oral prednisone taper for symptom relief. A hematoxylin and eosin (H&E)–stained punch biopsy of the back revealed a subepidermal split with eosinophils and a dense eosinophilic infiltrate in the dermis (Figure 2). Direct immunofluorescence (DIF) studies from a specimen adjacent to the biopsy collected for H&E staining showed linear deposition of IgA, IgG, and C3 along the dermoepidermal junction (Figure 3). Histologic findings were consistent with BP.

The patient was started on doxycycline 100 mg twice daily and clobetasol ointment 0.05% once daily to supplement the prednisone taper. At 3-week follow-up, she reported pruritus and a few erythematous macules but no new bullae. At 12 weeks, some papules persisted; however, the patient was averse to using systemic agents and decided that symptoms were adequately controlled with clobetasol ointment and oral doxycycline.

Because the patient currently remains in clinical and radiologic remission, anti-PD1 immune checkpoint inhibitors have not been restarted but remain an option for the future if disease recurs

Six months prior to presenting to dermatology, the patient underwent immunotherapy with 4 cycles of ipilimumab 200 mg intravenous (IV) and nivolumab 240 mg IV every 2 weeks, receiving ipilimumab during the first cycle only because of a lack of availability at the pharmacy. He then received nivolumab 240 mg IV every 2 weeks as maintenance therapy. After the second dose of nivolumab maintenance therapy, however, he developed generalized bullae and pruritus. Dermatology was consulted during an oncology appointment, and his oncologist decided to hold nivolumab.

Physical examination revealed generalized tense and eroded bullae covering more than 50% of the body surface area and affecting the scalp, arms, legs, torso, and buttocks. Two punch biopsies were obtained. Hematoxylin and eosin staining revealed a subepidermal split with predominantly eosinophils and scattered neutrophils. Direct immunofluorescence studies showed linear deposition of IgG, IgA, and C3 along the dermoepidermal junction, consistent with BP.

The patient’s BP was difficult to control, requiring several hospital admissions for wound care, high-dose systemic steroids, and initiation of mycophenolate mofetil. After 4 months of waxing and waning symptoms, the BP was controlled with mycophenolate mofetil 1500 mg/d; clobetasol ointment 0.05%; and diphenhydramine for pruritus. Due to the prolonged recovery and severity of BP, the patient’s oncologist deemed that he was not a candidate for future immunotherapy.

Patient 3
A 68-year-old man with PD1-negative, metastatic, well-differentiated squamous cell carcinoma of the lung presented to dermatology with a pruritic rash of 3 weeks’ duration. He had been receiving nivolumab for 2 years after disease progressed on prior chemotherapies and experienced several grade 1 or grade 2 nivolumab-induced autoimmune reactions including thyroiditis, dermatitis, and nephritis, for which he was taking prednisone 5 mg/d for suppression.

Physical examination revealed psoriasiform pink plaques on the arms, chest, and legs. The differential diagnosis at the time favored psoriasiform dermatitis over lichenoid dermatitis. A punch biopsy revealed psoriasiform dermatitis. The patient was prescribed fluocinonide ointment 0.05% daily. His plaques improved with topical steroids.

The patient returned approximately 1 month later with a report of a new blistering rash on the legs. Physical examination revealed interval improvement of the psoriasiform plaques on the scalp, torso, and extremities, but tense bullae were seen on the thighs, with surrounding superficial erosions at sites of recent bullae. Punch biopsies of the skin for H&E staining and DIF showed BP.

Prednisone was increased to 50 mg/d for a 3-week taper. Doxycycline 100 mg twice daily was started. The patient’s skin disease continued to be difficult to control with therapy; nivolumab was held by his oncologist.

Comment

Immunotherapy with immune checkpoint blockade represents a successful application of immune recognition to treat metastatic cancers, including melanoma, non–small cell lung cancer, urothelial cancer, and renal cell carcinoma. Programmed cell death 1 downregulates T-cell immune function through blocking interaction with its ligand, programmed death ligand 1. Inhibiting this brake on the immune system permits T cells to attack malignant cells.

Anti-PD1 targeted therapies improve survival in solid and hematologic malignancies, with a response rate as high as 40% in melanoma.² Although these medications can prolong survival, many are associated with loss of self-tolerance and severe autoimmunelike events that can limit therapy.³ An exception is PD1-induced vitiligo, which patient 1 developed and has been associated with a better response to therapy.⁴

Anti-PD1–induced BP is a newly reported adverse effect. In its early stages, BP can be difficult to differentiate from eczematous or urticarial dermatitis.^5-8 Discontinuation of immunotherapy has been reported in more than 70% of patients who develop BP.¹ There are reports of successful treatment of BP with a course of a PD1 inhibitor,⁹ but 2 of our patients had severe BP that led to discontinuation of immunotherapy.

Consider Prescreening
Given that development of BP often leads to cessation of therapy, identifying patients at risk prior to starting an immune checkpoint inhibitor might have clinical utility. Biopsy with DIF is the gold standard for diagnosis, but serologic testing can be a useful adjunct because enzyme-linked immunosorbent assay for BP antigen 1 and BP antigen 2 has a reported sensitivity and specificity of 87% and 98%, respectively.¹⁰ Serologic testing prior to starting therapy with an immune checkpoint inhibitor can provide a baseline for patients. A rise in titer, in conjunction with onset of a rash, might aid in earlier diagnosis, particularly because urticarial BP can be difficult to diagnose clinically.

Further study on the utility vs cost-benefit of these screening modalities is warranted. Their predictive utility might be limited, however, and positive serologic test results might have unanticipated consequences, such as hesitation in treating patients, thus leading to a delay in therapy or access to these medications.

Conclusion

The expanding use of immune checkpoint inhibitors is increasing survival in patients with metastatic melanoma and other malignancies. Adverse effects are part of the continuum of immune system stimulation, with overstimulation resulting in dermatitis; thyroiditis; pneumonitis; and less commonly hypophysitis, vitiligo, and colitis.

Rarely, immune checkpoint inhibition induces BP. Development of BP leads to discontinuation of therapy in more than half of reported cases due to lack of adequate treatment for this skin disease and its impact on quality of life. Therefore, quick diagnosis of BP in patients on immunotherapy and successful management techniques can prevent discontinuation of these lifesaving cancer therapies. For that reason, dermatologists play an important role in the management of patients on immune checkpoint inhibitors for cancer.

Immune checkpoint inhibitors are used for a variety of advanced malignancies, including melanoma, non–small cell lung cancer, urothelial cancer, and renal cell carcinoma. Anti–programmed cell death 1 (PD1) targeted therapies, such as pembrolizumab and nivolumab, are improving patient survival. This class of immunotherapy is revolutionary but is associated with autoimmune adverse effects. A rare but increasingly reported adverse effect of anti-PD1 therapy is bullous pemphigoid (BP), an autoimmune blistering disease directed against BP antigen 1 and BP antigen 2 in the basement membrane of the epidermis. Lopez et al¹ reported that development of BP leads to discontinuation of immunotherapy in more than 70% of patients.

High clinical suspicion, early diagnosis, and proper management of immunotherapy-related BP are imperative for keeping patients on life-prolonging treatment. We present 3 cases of BP secondary to anti-PD1 immunotherapy in patients with melanoma or non–small cell lung cancer to highlight the diagnosis and treatment of BP as well as emphasize the importance of the dermatologist in the care of patients with immunotherapy-related skin disease.

Case Reports

Patient 1
​​​​​​​A 72-year-old woman with metastatic BRAF-mutated melanoma from an unknown primary site presented with intensely pruritic papules on the back, chest, and extremities of 4 months’ duration. She described her symptoms as insidious in onset and refractory to clobetasol ointment, oral diphenhydramine, and over-the-counter anti-itch creams. The patient had been treated with oral dabrafenib 150 mg twice daily and trametinib 2 mg/d but was switched to pembrolizumab when the disease progressed. After 8 months, she had a complete radiologic response to pembrolizumab 2 mg/kg every 3 weeks, which was discontinued in favor of observation 3 months prior to presentation to dermatology.

At the current presentation, physical examination revealed innumerable erythematous, excoriated, 2- to 4-mm, red papules diffusely scattered on the upper back, chest, abdomen, and thighs, with one 8×4-mm vesicle on the right side of the upper back (Figure 1). Discrete areas of depigmented macules, consistent with vitiligo, coalesced into patches on the legs, thighs, arms, and back. The patient was started on a 3-week oral prednisone taper for symptom relief. A hematoxylin and eosin (H&E)–stained punch biopsy of the back revealed a subepidermal split with eosinophils and a dense eosinophilic infiltrate in the dermis (Figure 2). Direct immunofluorescence (DIF) studies from a specimen adjacent to the biopsy collected for H&E staining showed linear deposition of IgA, IgG, and C3 along the dermoepidermal junction (Figure 3). Histologic findings were consistent with BP.

The patient was started on doxycycline 100 mg twice daily and clobetasol ointment 0.05% once daily to supplement the prednisone taper. At 3-week follow-up, she reported pruritus and a few erythematous macules but no new bullae. At 12 weeks, some papules persisted; however, the patient was averse to using systemic agents and decided that symptoms were adequately controlled with clobetasol ointment and oral doxycycline.

Because the patient currently remains in clinical and radiologic remission, anti-PD1 immune checkpoint inhibitors have not been restarted but remain an option for the future if disease recurs

Six months prior to presenting to dermatology, the patient underwent immunotherapy with 4 cycles of ipilimumab 200 mg intravenous (IV) and nivolumab 240 mg IV every 2 weeks, receiving ipilimumab during the first cycle only because of a lack of availability at the pharmacy. He then received nivolumab 240 mg IV every 2 weeks as maintenance therapy. After the second dose of nivolumab maintenance therapy, however, he developed generalized bullae and pruritus. Dermatology was consulted during an oncology appointment, and his oncologist decided to hold nivolumab.

Physical examination revealed generalized tense and eroded bullae covering more than 50% of the body surface area and affecting the scalp, arms, legs, torso, and buttocks. Two punch biopsies were obtained. Hematoxylin and eosin staining revealed a subepidermal split with predominantly eosinophils and scattered neutrophils. Direct immunofluorescence studies showed linear deposition of IgG, IgA, and C3 along the dermoepidermal junction, consistent with BP.

The patient’s BP was difficult to control, requiring several hospital admissions for wound care, high-dose systemic steroids, and initiation of mycophenolate mofetil. After 4 months of waxing and waning symptoms, the BP was controlled with mycophenolate mofetil 1500 mg/d; clobetasol ointment 0.05%; and diphenhydramine for pruritus. Due to the prolonged recovery and severity of BP, the patient’s oncologist deemed that he was not a candidate for future immunotherapy.

Patient 3
A 68-year-old man with PD1-negative, metastatic, well-differentiated squamous cell carcinoma of the lung presented to dermatology with a pruritic rash of 3 weeks’ duration. He had been receiving nivolumab for 2 years after disease progressed on prior chemotherapies and experienced several grade 1 or grade 2 nivolumab-induced autoimmune reactions including thyroiditis, dermatitis, and nephritis, for which he was taking prednisone 5 mg/d for suppression.

Physical examination revealed psoriasiform pink plaques on the arms, chest, and legs. The differential diagnosis at the time favored psoriasiform dermatitis over lichenoid dermatitis. A punch biopsy revealed psoriasiform dermatitis. The patient was prescribed fluocinonide ointment 0.05% daily. His plaques improved with topical steroids.

The patient returned approximately 1 month later with a report of a new blistering rash on the legs. Physical examination revealed interval improvement of the psoriasiform plaques on the scalp, torso, and extremities, but tense bullae were seen on the thighs, with surrounding superficial erosions at sites of recent bullae. Punch biopsies of the skin for H&E staining and DIF showed BP.

Prednisone was increased to 50 mg/d for a 3-week taper. Doxycycline 100 mg twice daily was started. The patient’s skin disease continued to be difficult to control with therapy; nivolumab was held by his oncologist.

Comment

Immunotherapy with immune checkpoint blockade represents a successful application of immune recognition to treat metastatic cancers, including melanoma, non–small cell lung cancer, urothelial cancer, and renal cell carcinoma. Programmed cell death 1 downregulates T-cell immune function through blocking interaction with its ligand, programmed death ligand 1. Inhibiting this brake on the immune system permits T cells to attack malignant cells.

Anti-PD1 targeted therapies improve survival in solid and hematologic malignancies, with a response rate as high as 40% in melanoma.² Although these medications can prolong survival, many are associated with loss of self-tolerance and severe autoimmunelike events that can limit therapy.³ An exception is PD1-induced vitiligo, which patient 1 developed and has been associated with a better response to therapy.⁴

Anti-PD1–induced BP is a newly reported adverse effect. In its early stages, BP can be difficult to differentiate from eczematous or urticarial dermatitis.^5-8 Discontinuation of immunotherapy has been reported in more than 70% of patients who develop BP.¹ There are reports of successful treatment of BP with a course of a PD1 inhibitor,⁹ but 2 of our patients had severe BP that led to discontinuation of immunotherapy.

Consider Prescreening
Given that development of BP often leads to cessation of therapy, identifying patients at risk prior to starting an immune checkpoint inhibitor might have clinical utility. Biopsy with DIF is the gold standard for diagnosis, but serologic testing can be a useful adjunct because enzyme-linked immunosorbent assay for BP antigen 1 and BP antigen 2 has a reported sensitivity and specificity of 87% and 98%, respectively.¹⁰ Serologic testing prior to starting therapy with an immune checkpoint inhibitor can provide a baseline for patients. A rise in titer, in conjunction with onset of a rash, might aid in earlier diagnosis, particularly because urticarial BP can be difficult to diagnose clinically.

Further study on the utility vs cost-benefit of these screening modalities is warranted. Their predictive utility might be limited, however, and positive serologic test results might have unanticipated consequences, such as hesitation in treating patients, thus leading to a delay in therapy or access to these medications.

Conclusion

The expanding use of immune checkpoint inhibitors is increasing survival in patients with metastatic melanoma and other malignancies. Adverse effects are part of the continuum of immune system stimulation, with overstimulation resulting in dermatitis; thyroiditis; pneumonitis; and less commonly hypophysitis, vitiligo, and colitis.

Rarely, immune checkpoint inhibition induces BP. Development of BP leads to discontinuation of therapy in more than half of reported cases due to lack of adequate treatment for this skin disease and its impact on quality of life. Therefore, quick diagnosis of BP in patients on immunotherapy and successful management techniques can prevent discontinuation of these lifesaving cancer therapies. For that reason, dermatologists play an important role in the management of patients on immune checkpoint inhibitors for cancer.