Acta Dermato-Venereologica 99-10CompleteContent | Page 22
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SHORT COMMUNICATION
Vitiligo Repigmentation with Melanoma Progression During Pembrolizumab Treatment
Charlée NARDIN, Fabien PELLETIER, Eve PUZENAT and François AUBIN
Department of Dermatology, University of Franche-Comte, EA-3181, Teaching Hospital, 3 Bd Fleming, FR-25030 Besancon cedex, France.
E-mail: [email protected]
Accepted Apr 16, 2019; E-published Apr 16, 2019
Vitiligo is an autoimmune skin disorder characterized by
hypopigmented skin lesions, originating from the loss
of functional melanocytes in the epidermis. Vitiligo can
occur in patients suffering from melanoma and has long
been recognized as an independent favourable prognostic
factor for melanoma patients, correlating with impro-
ved overall and tumour-free survival rates (1). Vitiligo
has been reported in patients suffering from advanced
melanoma, treated with immune checkpoint inhibitors
(ICI) (2, 3). Furthermore, the onset of vitiligo in patients
treated with the anti-PD-1 (programmed cell death 1
protein) antibody for advanced melanoma is associated
with improved response and better outcomes (4–8). Here,
we report a case of vitiligo re-pigmentation, which was
associated with disease progression in a patient treated
with pembrolizumab for metastatic melanoma.
CASE REPORT
A 50-year-old woman presented to our hospital with metastatic
melanoma. She had a past medical history of left uveal melanoma,
treated with surgery one year earlier. Molecular analysis of the
metastatic liver lesion revealed a GNAQ mutation. She had no
medical and family history of autoimmune diseases. A computed
tomography (CT) scan showed liver, lung, brain, lymph nodes,
subcutaneous, medullar and bone metastases with spinal cord
compression. Pembrolizumab was initiated (2 mg/kg, every 3
weeks) simultaneously with radiation therapy for vertebral me-
tastases. Paracetamol was prescribed for back pain. One month
after pembrolizumab initiation, she developed extensive vitiligo
(Fig. 1A). In addition, she developed hypothyroidism, without
thyroid antibodies, and was treated with thyroid hormone therapy.
At 3 months follow-up, CT scan showed stable disease (Fig. 1B).
However, after 16 infusions of pembrolizumab (46 weeks of
treatment), partial vitiligo re-pigmentation was observed on the
face only. Of note, this occurred in the winter without any specific
treatment or sun exposure (Fig. 1C). Lactate dehydrogenase (LDH)
levels increased concomitantly (Fig. 2). CT scan was performed,
and revealed disease progression (Fig. 1D).
Fig. 1. Vitiligo re-pigmentation associated with melanoma
progression during pembrolizumab treatment. (a) Extensive vitiligo
in a patient treated with pembrolizumab for metastatic melanoma. (b)
Axial CT section demonstrating stable disease with thoracic metastasis
associated with extensive vitiligo. (c) Partial re-pigmentation of vitiligo
after 16 infusions of pembrolizumab. (d) Axial CT section demonstrating
disease progression with an increase in thoracic metastasis associated
with vitiligo re-pigmentation.
DISCUSSION
Vitiligo is one of the most frequent dermatologic adverse
events of the anti-PD-1 therapy in cancer immuno
therapy (2). In a meta-analysis, the incidence of all-grade
vitiligo was around 8% with immunotherapy (2). The
incidence of vitiligo in melanoma patients, treated with
pembrolizumab, has been reported to be up to 25% (4).
As compared to patients under chemotherapy, vitiligo
is reported to be more frequent in patients treated with
nivolumab or pembrolizumab (2). In the literature,
Fig. 2. Kinetics of serum biomarkers over time. Lactate dehydrogenase
(LDH) rate only seemed to decrease with vitiligo and disease control while
rising at the time of vitiligo re-pigmentation and disease progression.
This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta
Journal Compilation © 2019 Acta Dermato-Venereologica.
doi: 10.2340/00015555-3199
Acta Derm Venereol 2019; 99: 913–914