Ipilimumab and Nivolumab for Treatment of Eyelid Spindle Cell Melanoma

Abstract

A 70-year-old man presented with recurrent left upper eyelid spindle cell melanoma. He was initially diagnosed with eyelid spindle cell melanoma three years prior and underwent excision with negative sentinel lymph node biopsy. He refused radiation and was observed without evidence of local or systemic disease. Seventeen months later, he developed a biopsy-proven local recurrence and presented for additional evaluation. Exam demonstrated a large, firm, amelanotic lesion encasing the entire left upper eyelid from the medial to lateral canthus and attaching to the brow tissues and frontal bone (A). Due to the extensive surgery required for complete excision, he opted for checkpoint inhibitor immunotherapy. He received ipilimumab 1 mg/kg and nivolumab 3 mg/kg intravenously every three weeks for 4 cycles. He had pseudoprogression after the first cycle within one week after receiving the first cycle (B) but demonstrated dramatic clinical improvement after his fourth cycle (C) that remained evident three months after he received his last cycle of combined ipilimumab and nivolumab (D). He continues to undergo treatment with intravenous nivolumab with plan for 3 additional cycles of nivolumab monotherapy given his improvement. Ipilimumab and nivolumab are checkpoint inhibitors that provide effective noninvasive treatment for malignant melanoma, especially in locations such as the periorbital region where Mohs surgery with possible extensive excision and subsequent reconstruction would result in high morbidity, including cicatricial lagophthalmos, ectropion, exposure keratopathy, or restrictive strabismus. In patients with extensive disease, including our patient, checkpoint inhibitor immunotherapy may reduce the need for orbital exenteration. Awareness that immunotherapy may lead to pseudoprogression, increased tumor size after immune cell infiltration of the tumor due to effective treatment response, is important to avoid premature cessation of efficacious immunotherapeutic agents.