Abstract
Ipilimumab is a first-in-class immunological checkpoint blockade agent and monoclonal antibody against Cytotoxic T-Lymphocyte Antigen 4 (CTLA-4) that has demonstrated survival benefit and durable responses in patients with metastatic melanoma. To date, solid organ transplant recipients have been excluded from clinical trials with cancer immunotherapies on the basis of their concurrent treatment with immunosuppressive agents. We present the first case to our knowledge of a patient with advanced cutaneous melanoma receiving ipilimumab status post orthotopic liver transplantation with a partial response. Transaminitis was observed 4 months after administration of ipilimumab that resolved with close observation. No evidence of graft rejection has been observed to date. This case advocates for further investigation of the safety and efficacy of cancer immunotherapies in solid organ transplant recipients.
Highlights
Patients presenting with melanoma after solid organ transplantation present unique challenges to oncologists
There are several important considerations in this setting, including the risk of injury to the allograft with the administration of anticancer therapy and the scarcity of published data regarding the clinical management of advanced melanoma in organ transplant recipients
This is especially relevant given the recent development of immunomodulatory therapies for the treatment of metastatic melanoma
Summary
Patients presenting with melanoma after solid organ transplantation present unique challenges to oncologists. Explant pathology revealed established cirrhosis with a 2.5 cm moderately differentiated HCC with evidence of microvascular invasion After transplantation, he maintained stable liver function on an immunosuppressive regimen of tacrolimus and mycophenolate mofetil. His rapamycin was reduced from 3 mg to 1 mg daily and mycophenolate mofetil was discontinued, given prior clinical reports documenting tumor regression with reduction of immunosuppression [5,6] He completed 5 cycles of chemotherapy as well as 14 of 20 planned fractions of palliative radiotherapy to the hip before experiencing multifocal disease progression in April 2014, with increasing disease burden in the lungs, mediastinal lymph nodes, liver and spleen. Given the increased risk of graft rejection, the treatment plan included weekly monitoring of liver function tests The patient received his four induction doses of ipilimumab 3 mg/kg between April 2014 and July 2014. The patient continues to feel well and is undergoing continued close monitoring for both his liver function and disease status
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