Some oncologists refrain from prescribing checkpoint immunotherapy in patients with Kaposi sarcoma who also have psoriasis or other skin conditions. A new case report says the therapy can be successfully completed while still controlling the skin condition.
Patients with HIV-negative Kaposi sarcoma (KS) can be successfully treated with immunotherapy even if they also have psoriasis or other skin conditions, according to a new case report.
The paper documents the case of a 78-year-old man who had a history of psoriasis, bullous pemphigoid, and 8 years of HIV-negative KS. Writing in the journal JAAD Case Reports, a team of investigators including Lisa C. Zaba, MD, PhD, and Nam Q. Bui, MD, both of the Stanford University School of Medicine, say their patient was able to manage his skin conditions while also responding well to immunotherapy.
KS is an angioproliferative neoplasm linked with the human herpes virus 8 (HHV-8). It is most commonly associated with people with HIV; in fact, antiretroviral therapy for HIV sometimes leads to regression of KS, the authors note. However, the cancer can also occur in patients who are HIV negative, as was the case with this patient. In such cases, checkpoint inhibitors have increasingly been seen as a viable treatment option.
The patient in the case report arrived at the clinic after his KS progressed to include metastases to the lung and soft tissue.
His doctors believed the progression was secondary to immunosuppression for the patient’s psoriasis; he had been treated with methotrexate and a tumor necrosis factor inhibitor, both of which were stopped after his KS progressed. He was diagnosed with KS of the skin and stomach, and underwent chemotherapy and radiation therapy. He also had his left foot amputated below the knee as a result of a refractory ulcerative KS mass.
Despite some response to the therapy, the patient eventually had new enlarging metastases on his lung and left leg.
At that point, physicians started the patient on ipilimumab (1 mg/kg) and nivolumab (3 mg/kg), which showed significant results within the first month. After 4 cycles of the treatment, the patient has remained on monthly nivolumab maintenance. He has seen continuing resolution of the metastases and no new lesions.
Notably, the patient was able to manage his dermatological conditions without the need for oral steroids throughout the immunotherapy treatment. A psoriasis flare, for instance, was treated with sulfasalazine, acitretin, and triamcinolone ointment.
Zaba, a supportive onco-dermatologist, told The American Journal of Managed Care® in an email that despite the apparent benefits of immunotherapy, some physicians are hesitant to use it in patients with psoriasis or other skin conditions because they fear it will worsen the skin problems.
“Although immunotherapy can worsen skin conditions like psoriasis, supportive onco-dermatologists can usually manage the skin condition with minimally immunosuppressive oral and topical medications such that the patient can successfully be treated with immunotherapy,” she said.
Bui, the oncologist with whom Zaba partnered, said he strongly recommends physicians consider ipilimumab/nivolumab for HIV-negative KS patients who are refractory to chemotherapy.
“Since immunotherapy has led to durable remissions in other types of cancers (melanoma, non-small-cell lung cancer), it is conceivable that this is a better option than chemotherapy, as patients cannot continue on chemotherapy indefinitely and the Kaposi’s usually relapses after stopping chemotherapy,” he said.
Bui cautioned, though, that these findings would need to be verified in a longer-term study.
Tabata MM, Novoa RA, Bui NQ, Zaba LC. Successful treatment of HIV-negative Kaposi sarcoma with ipilimumab and nivolumab and concurrent management of baseline psoriasis and bullous pemphigoid. JAAD Case Reports. 2020;6(5):447-449.