Anti-TNF agents in patients with inflammatory bowel disease and malignant melanoma--challenges in management.

Abstract

The inflammatory bowel diseases (IBD) are chronic immune-mediated inflammatory diseases of the gut that occur in genetically predisposed individuals exposed to environmental triggers. Several immunosuppressive agents have been successfully used for induction and maintenance treatment in inflammatory bowel disease. These include steroids, thiopurines, methotrexate, anti-tumor necrosis factor (anti-TNF) alpha agents, anti-alpha 4 integrins, and anti-IL-12/23 agent to name a few. There are also limited data on novel approaches including thalidomide and stem cell transplant. In spite of the significant successes associated with these agents, numerous malignancies have been associated with their use. Lymphomas including hepatosplenic T cell lymphomas, non-melanoma skin cancers and, more recently, melanoma have been described, specifically with anti-TNF. We reviewed the available published literature on melanoma in IBD, melanoma associated with anti-TNF, and the data on other treatment options in patients with IBD. In addition, we also reviewed the limited data on the gut specific integrin-vedolizumab. This may provide an additional option in the management of the subset of patients with IBD and melanoma. Options for treatment of IBD should be based on the stage of melanoma, control of IBD, and patient preferences. It should involve shared decision-making and close interdisciplinary follow-up between the IBD physician and the dermatologist, preferably with expertise in the management of melanoma. Treatment choices in patients with IBD and melanoma are challenging. There is very limited data providing guidance in this subset of patients. As such, treatment and follow-up should be individualized, extensively discussed with patients and their families as appropriate, and done in conjunction with a close follow-up by gastroenterologist and dermatologist.