Clinical photographs of skin lesions associated with anti–cytotoxic T-lymphocyte antigen 4 therapy. A, Pink-red papules coalescing into thin plaques on posterior elbow and arm of patient 2, with evidence of Koebner phenomenon (arrow). B, Bright red papules coalesce to form thin plaques with fine scale on the upper arm of patient 3. C, Close-up view of red papules on the back of patient 6. D, Generalized alopecia affecting the scalp (shown), chest, back, pubic area, and facial hair of patient 1.
Histologic features of dermatitis associated with anti–cytotoxic T- lymphocyte antigen 4. A, Superficial perivascular mononuclear infiltrate with mild spongiosis and minimal exocytosis of T cells into the epidermis in patient 3. No vacuolar change was noted (hematoxylin-eosin, original magnification ×10). B, A higher-power view of part A shows abundant eosinophils (arrows) in the dermis. C-E, Immunostaining of skin sections from patient 3 show CD3+ (C); CD4+ (D); and CD8+ (E).
Skin eruption in patient 9 after treatment with anti–cytotoxic T- lymphocyte antigen 4 followed by hydrochlorothiazide and other medications. A, A confluent red rash is seen on the back. B, Close-up of individual papular lesions. C, Right upper arm lesion demonstrates vacuolar changes (hematoxylin-eosin, original magnification ×20). D, Anti-CD8 staining demonstrates extensive exocytosis in the epidermis (original magnification ×20).
Peripheral eosinophilia in patients treated with anti–cytotoxic T-lymphocyte antigen 4 (anti–CTLA-4) who developed skin eruptions. A, Eosinophil count is shown as a percentage of the total white blood cell count (WBC) in patients who developed dermatitis while receiving anti–CTLA-4 treatment and those who were treated with anti-CTLA-4, but who had not developed known autoimmune toxic side effects in the first 6 weeks of treatment. Eosinophil counts were evaluated before initiation of anti–CTLA-4 treatment in both groups of patients. For patients who developed dermatitis, blood was evaluated when patients underwent the first evaluation for their rashes. For those with no toxic effect, blood was evaluated approximately 6 weeks after at least 2 anti–CTLA-4 treatments. The pretreatment and posttreatment P values from each group of patients were statistically compared using paired, 2-sided t tests (n = 8). Because patient 9's skin eruption was not thought to be due primarily to anti-CTLA-4, his peripheral eosinophil values were not included in this analysis. B, Peripheral leukocyte subsets as a percentage of the total WBC count in relation to initial dermatitis and exacerbation of the skin reaction in patient 5. The left y-axis indicates percentages for the following leukocyte subsets: neutrophils, lymphocytes, monocytes. The right y-axis indicates percentage of eosinophils.
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Jaber SH, Cowen EW, Haworth LR, et al. Skin Reactions in a Subset of Patients With Stage IV Melanoma Treated With Anti–Cytotoxic T-Lymphocyte Antigen 4 Monoclonal Antibody as a Single Agent. Arch Dermatol. 2006;142(2):166–172. doi:10.1001/archderm.142.2.166
To describe the clinical and histologic manifestations of skin reactions incidentally noted in patients with stage IV melanoma who were treated with up to 9 mg/kg of a humanized monoclonal antibody reactive against human cytotoxic T-lymphocyte antigen 4 (anti–CTLA-4) as a single agent every 3 weeks.
Single-institution prospective study.
Patients treated with anti–CTLA-4 as a sole agent were prospectively referred for clinicopathologic characterization of skin reactions occurring during treatment.
Main Outcome Measures
Specific clinicopathologic features were determined by means of a detailed history, a physical examination, conventional histologic analysis, antibody staining, and complete blood cell counts.
Nine (14%) of 63 consecutive patients treated with anti–CTLA-4 as a sole agent developed skin eruptions that were attributed to anti–CTLA-4 in 8 of them. Skin lesions consisted primarily of discrete, pruritic, erythematous, minimally scaly papules that typically coalesced into thin plaques on the trunk and extensor surfaces of the extremities. Extensive alopecia was also noted in 1 patient. Histologically, a superficial, perivascular CD4+-predominant T-cell infiltrate with eosinophils in the dermis, rare dyskeratotic cells, and mild epidermal spongiosis were present. An increase (compared with pretreatment values) in the peripheral blood eosinophil frequency was observed in patients at the time of skin eruptions (P = .006).
Specific features of the skin eruption dermatitis with increased tissue and peripheral blood eosinophil levels in a subset of treated patients. Specific features of skin eruption associated with anti–CTLA-4 resemble those described for maculopapular reactions to medications.
Overcoming tolerance of self-antigens significantly limits the use of vaccine therapy for the treatment of cancer.1 Despite multiple trials demonstrating that tumor vaccination results in the development of enhanced immunity, objective responses are infrequent. Because most known tumor antigens are normal “self-proteins,” immune regulatory mechanisms that prevent autoimmunity also prevent robust immune responses to cancer and peptide vaccines.
Cytotoxic T-lymphocyte antigen 4 (CTLA-4) is an important costimulatory molecule expressed by activated T cells and a subset of regulatory T cells.2 Engagement of CTLA-4 inhibits T-cell activation by blocking production of interleukin 2 and interleukin 2 receptor expression, leading to arrest of T cells at the G1 phase of the cell cycle.3 In CTLA-4 knockout mice, a rapid, fatal lymphoproliferative disorder develops,4 suggesting that CTLA-4 is also integral to the maintenance of tolerance and prevention of autoimmunity. Moreover, CTLA-4 appears to be critical in regulating TH2 vs TH1 differentiation in helper T (TH) cells, because activated CTLA-4–deficient T cells are strongly biased toward TH2 differentiation.5,6
Given the integral role of CTLA-4 in the maintenance of tolerance, there has been considerable interest in overcoming tolerance in the treatment of cancer by blockade of CTLA-4 function. As monotherapy in animal models, anti–CTLA-4 monoclonal antibodies have been most effective in treating immunogenic tumors, with minimal effects on large established tumors or weakly immunogenic tumors.2,7 Combining anti–CTLA-4 therapy with concurrent vaccination with tumor cells that secrete granulocyte-macrophage colony-stimulating factor substantially enhanced efficacy against poorly immunogenic tumors such as B16 melanoma.8
Recently, results of 3 clinical trials involving the use of anti–CTLA-4 in combination with peptide vaccine for the treatment of cancer have been reported.9-11 In total, 40 patients with metastatic melanoma and 2 patients with metastatic ovarian cancer were treated with anti–CTLA-4 therapy in combination with or after peptide vaccine therapy. In one of these trials, a single administration of anti–CTLA-4 in patients for whom previous vaccine therapy had failed yielded histopathologic evidence of tumor cell death and lymphocytic invasion within some tumors but no objective clinical responses.10 In the other 2 trials in which repeated doses of anti–CTLA-4 were given in combination with peptide vaccine, a subset of patients with metastatic melanoma demonstrated major tumor regression with long tumor-free intervals.9,11
Administration of anti–CTLA-4 was associated with multiple autoimmune toxic effects, including enterocolitis, hypophysitis, hepatitis, uveitis,12 vitiligo, increased antinuclear antibody levels, elevated rheumatoid factor levels, and rashes.9-11 Recent experience at the National Cancer Institute (NCI) Clinical Center showed that 14 (25%) of 56 patients with stage IV melanoma treated with anti–CTLA-4 and vaccinated with HLA-A*0201–restricted gp100 peptides experienced grades III to IV autoimmune reactions (ie, reversible [grade III] or irreversible/progressive [grade IV] toxic effects involving function of a major organ and requiring immunosuppressive treatment13), including rashes.14 Autoimmune manifestations were more pronounced in patients with more dramatic objective disease responses,9,14 suggesting that effective anticancer responses may be correlated with autoimmunity to self-antigens other than tumor antigens.
Rashes have been common adverse effects in recipients of anti–CTLA-4 therapy administered after or in conjunction with vaccination. Phan et al9 observed that rashes developed in 4 (29%) of 14 patients, with 3 of the 4 patients experiencing grades III to IV rashes based on common toxic effects criteria version 2.0 (Table 1).13 Histologically, these showed epidermal spongiosis, papillary dermal edema, and a perivascular lymphocytic infiltrate with eosinophils. Hodi et al10 reported that all patients (7/7) with metastatic melanoma and 1 of 2 with ovarian cancer developed a skin eruption (grade I) after anti–CTLA-4 therapy. Last, Sanderson et al11 reported that 7 (37%) of 19 patients developed a grade I to II rash.
Although it has been documented that dermatitis develops in a significant percentage of patients treated with anti–CTLA-4 therapy in combination with or after vaccine therapy, the clinical and histologic features of this skin eruption have not been systematically studied. We herein describe the clinicopathologic features of skin eruptions that developed in previously unvaccinated patients with melanoma who received anti–CTLA-4 treatment as a single agent, thus removing the potential effects that vaccination might have had on the development of autoimmunity in previous studies. Of interest, the features of anti–CTLA-4 dermatitis bear clinical and histologic similarities to those reported for maculopapular drug exanthems (MPEs),15 which are the most common cutaneous adverse effects of widely used medications such as aminopenicillins and sulfonamide antimicrobial drugs.
All patients gave informed consent in an institutional review board–approved protocol in the Surgery Branch of the NCI, Bethesda, Md. Anti–CTLA-4 (MDX-010; Medarex, Princeton, NJ),9 is a fully humanized antibody reactive with CTLA-4. The major inclusion criteria for patients entering this study for experimental melanoma treatment included being 16 years or older; having a life expectancy 6 months or longer, an Eastern Cooperative Oncology Group performance status of 2 or less, and a diagnosis of stage IV melanoma (except mucosal or ocular melanoma) that is clinically evaluable and measurable; and being postmenopausal (>1 year) or using reliable contraception (if female) or willing to use male contraception during the time of participation in the trial (if male). Major exclusion criteria included a history of malignancy within the previous 5 years (with exceptions for certain in situ cancers and basal and/or squamous cell carcinoma of the skin); presence of autoimmune disease, active infection, or concurrent medical condition requiring use of systemic or topical corticosteroids or immunosuppressive agents; being pregnant or nursing; prior treatment with anti–CTLA-4, or a history of systemic hypersensitivity to 1 of the investigational agents used in the trial.
Patients were enrolled in an experimental immunotherapy protocol that contained the following 3 treatment arms: (1) patients who were seronegative for human leukocyte antigen (HLA)-A*0201 were treated with anti–CTLA-4 alone; (2) patients who were seropositive for HLA-A*0201 were randomized to receive melanoma-associated peptides in conjunction with anti–CTLA-4; and (3) patients who were seropositive for HLA-A*0201 were randomized to receive anti–CTLA-4 alone. Herein, only patients in the first and third treatment arms (those receiving only anti–CTLA-4) were considered for this report. As of this writing, enrollment for the trial has not yet been completed. A detailed report detailing the complete inclusion/exclusion criteria, treatment end points, clinical efficacy of anti–CTLA-4, and other autoimmune manifestations of treatment will be forthcoming once enrollment and further analyses are completed.
Anti–CTLA-4 was administered intravenously at a starting dosage of 3 or 5 mg/kg (maximum, ≤9 mg/kg) every 3 weeks, with intrapatient dose escalation at every other dose. Treatment was held for autoimmune toxic effects and stabilizing disease. At each treatment visit, patients were questioned and examined for the development of adverse effects by physicians from the NCI Surgery Branch. Patients with visible skin eruptions were referred to the NCI dermatology consultation clinic, where a detailed history and photographs were obtained and skin examination was performed. Four-millimeter punch biopsy specimens of representative skin lesions were obtained while the patient was under local anesthesia for conventional histologic examination and immunostaining for T- and B-cell markers. Biopsy specimens were reviewed by a dermatopathologist for histologic diagnosis and by a pathologist (D.M.B.) for scoring of specific histologic features.
All patients received anti–CTLA-4 as experimental therapy for stage IV melanoma. Of the first 63 consecutive patients receiving anti–CTLA-4 treatment alone in this clinical trial, 9 (14%; 7 men and 2 women) were examined by NCI dermatologists (E.W.C. and S.T.H.) after referral for evaluation of skin eruptions detected by the primary surgical oncology team. As shown in Table 2, patients ranged in age from 34 to 67 years, and skin-related reactions developed from 3 to 67 days after initial anti–CTLA-4 treatment. Skin reactions developed in 4 of the 9 after their first anti–CTLA-4 injections. Notably, none of the patients had a history of atopic dermatitis or psoriasis. Three of the 9 patients were taking no concurrent medications at the time of the skin reaction. Except for patient 9, concurrent therapies had been initiated before anti–CTLA-4 therapy and were deemed unlikely to have caused the rashes. Unless specifically noted, descriptions of the gross and microscopic features refer to the 8 patients in whom rashes were attributed to anti–CTLA-4 therapy. Four of 9 patients had a history of cutaneous reactions to a variety of substances, including chemotherapy agents (cisplatin), promethazine hydrochloride, shellfish and iodine dye, and interferon alfa (Table 2).
Except patient 9, in whom colitis developed early during his course of anti–CTLA-4 therapy, patients were not aware of fever or systemic illness (eg, diarrhea) that accompanied the development of their rashes. Patients were ambulatory and not acutely ill at the time of skin examination. Most patients reported variable degrees of pruritus ranging from mild to severe, and 3 patients described a painful, burning sensation (Table 3).
As shown in Figure 1, a typical primary skin lesion was a dome-shaped, pink to bright red papule that ranged from 2 to 4 mm in diameter (Figure 1A-C). Lesions typically started out as discrete papules (Figure 1B and C) that could coalesce to form thin plaques (Figure 1A). External trauma (scratching) occasionally led to the formation of new lesions (ie, Koebner phenomenon, Figure 1A [arrow]). Although older lesions showed some evidence of fine white scale, scaling was not a prominent feature. The proximal extensor surfaces of the limbs were most often involved, followed by the trunk and distal extremities. The palms and soles were generally spared. The face and head were involved in 3 patients. Patient 1 (in addition to a mild papular eruption on the trunk and arms) developed striking, nonscarring alopecia of the scalp (Figure 1D), eyebrows, face, pubic region, and trunk after anti–CTLA-4 treatment. Patient 2 developed a symmetric skin eruption that appeared to be photodistributed. Patients 2 and 9 developed the only rashes that appeared to be exacerbated by light. Discontinuation of anti–CTLA-4 therapy for several weeks resulted in marked improvement of rashes. During this period, patients used only bland emollients (no topical steroids) and oral diphenhydramine hydrochloride for relief of pruritus. Two months after his last dose of anti–CTLA-4, the alopecia experienced by patient 1 had not improved.
Skin biopsy specimens were obtained from representative, nontreated lesions and submitted for pathologic examination. The histologic features of the dermatitis are depicted in Figure 2A and B and summarized in Table 3. These biopsy results showed moderate-to-dense mononuclear lymphocytic infiltrates around the superficial vascular plexi and in the papillary dermis. In some patients, deeper blood vessels and hair follicles were also involved. Lichenoid aggregation of lymphocytes and large numbers of dyskeratotic keratinocytes at the dermoepidermal interface with vacuolar changes were not observed except in the biopsy specimen of patient 9, whose clinical history suggested that a drug other than anti–CTLA-4 was responsible for his skin eruption. Epidermal spongiosis and T-cell exocytosis, features of contact dermatitis, were absent or minimal. In 6 (75%) of the 8 patients whose skin reactions were attributed to anti–CTLA-4, eosinophils were observed in the superficial and deep dermis. Results of immunohistochemistry revealed that the mononuclear infiltrate observed by hematoxylin-eosin examination consisted almost entirely of CD3+ T cells (Figure 2C) (with no or few B cells), of which more than 80% were typically CD4+ (Figure 2D) and less than 20% were CD8+ (Figure 2E) except as noted for patient 9. A scalp skin biopsy specimen taken from the patient with near total alopecia of the scalp and other body regions (patient 1) was histologically consistent with alopecia areata and contained predominantly CD4+ T cells and only scant CD8+ T cells, which was consistent with idiopathic alopecia areata.16
Patient 9, who was treated with his second dose of anti–CTLA-4 5 weeks before referral, developed a pruritic, papular eruption of the trunk with photoaccentuated lesions on the sun-exposed skin of his face and back of the neck (Figure 3A and B). At the time of the skin eruption, he was being treated with low-dose prednisone for autoimmune colitis related to anti–CTLA-4. In contrast to biopsy specimens from other patients, a lesional skin biopsy specimen showed moderate vacuolar change (Figure 3C), extensive exocytosis of CD8+ T cells in the epidermis (Figure 3D), a greater proportion of CD8+ to CD4+ T cells in the dermis and epidermis, and no dermal eosinophils. Because the patient had just started hydrochlorothiazide therapy for hypertension approximately 3 weeks before referral and showed evidence of the lichenoid photosensitive dermatitis observed with thiazide diuretics,17 the most likely cause of his skin eruption was deemed to be hydrochlorothiazide. We could not rule out, however, that his other concurrent medications and/or prior treatment with anti–CTLA-4 may have caused or exacerbated his skin eruption.
Complete blood cell counts were performed at 3-week intervals according to protocol in coordination with scheduled anti–CTLA-4 treatments. These values were within reference limits, except for notable increases in peripheral eosinophil frequencies. As shown for 8 of 9 patients with rashes attributed to anti–CTLA-4 and illustrated in detail for patient 5 (Figure 4), the eosinophil frequencies (obtained after development of rashes) were significantly increased relative to values obtained before anti–CTLA-4 treatment. Only 3 patients had peripheral eosinophil frequencies of more than 9% (the upper limit of the reference range in our clinical laboratory) at the time they underwent evaluation for their skin findings. Patients demonstrated 2.7- to 16-fold increases from their baseline values (mean values before vs after anti–CTLA-4 treatment, 1.73% vs 8.38%; P = .006 by paired t test) after development of skin reactions. By contrast, no statistically significant increase in the frequency of eosinophils (P = .19) was noted in the blood (Figure 4A) of 8 patients who did not develop autoimmune toxic effects or rashes during comparable time periods.
We herein describe 9 patients with stage IV melanoma who developed skin eruptions after treatment with anti–CTLA-4 as a single agent for immunotherapy of metastatic disease. In 8 of the 9 patients, anti–CTLA-4 was believed to be the primary cause of the rash. The frequency of dermatitis observed in this study (9 [14%] of 63 patients) was less than that reported for patients receiving anti–CTLA-4 therapy in conjunction with vaccination, suggesting that vaccination increases the risk of skin reactions during treatment with anti–CTLA-4. Besides the papular eruption described in our cohort of patients, striking near-total alopecia developed in patient 1 after administration of anti–CTLA-4, and a CD8+ T-cell–predominant dermatitis developed in patient 9 (most likely secondary to hydrochlorothiazide therapy) with vacuolar change. The use of anti–CTLA-4 alone in our patients allows us a rare opportunity to document the effects of CTLA-4 blockade in the regulation of human cutaneous immunity.
The most consistent clinicopathologic features observed were the predominance of CD4+ T cells and eosinophils in the dermis and increases in peripheral blood eosinophil frequencies, suggesting possible skewing toward a TH2-type immune response. These observations show similarities to the striking activation of TH2-type CD4+ T cells5 and marked infiltration of internal organs with such TH2 cells in mice lacking CTLA-4.4
The antigen or antigens driving the accumulation or proliferation of CD4+ T cells found in dermatitis associated with anti–CTLA-4 are unknown. Because cytolytic T cells specific for melanoma-associated antigens such as tyrosinase or MART-1 (melanoma antigen recognized by T cells 1) are found frequently in the peripheral circulation in patients with melanoma,18 we hypothesize that CD4+ T cells within the inflamed skin of our patients may be triggered by antigen-presenting cells in the skin that potentially display melanocyte-associated antigens in conjunction with major histocompatibility complex class II under steady-state conditions. Indeed, Hodi et al10 noted the presence of CD4+ and CD8+ T cells adjacent to cells they described as melanocytes in skin reactions after anti–CTLA-4 treatment in previously vaccinated patients with melanoma.
The clinical and histopathologic findings in our cohort of patients have some, but not all, features of what has commonly been termed maculopapular drug exanthem and has been observed with many drugs such as penicillins or sulfa-based drugs.15 The MPEs likely represent most of all drug-induced skin reactions19 and typically occur 1 to 2 weeks after the first ingestion of a drug. Histologically, MPE and dermatitis associated with anti–CTLA-4 show a preponderance of CD4+ T cells and eosinophils in the dermis along with mild epidermal spongiosis and little exocytosis. Histologically, however, MPEs often show evidence of vacuolar alteration of the basal keratinocytes.15,20 However, because MPEs seldom undergo biopsy by dermatologists unless they evolve into more serious conditions, vacuolar alteration may reflect a bias in the reporting of more advanced skin reactions.
Vacuolar changes are more common in destructive (blistering) reactions to drugs, including severe erythema multiforme (ie, Stevens-Johnson syndrome) and toxic epidermal necrolysis, which both exhibit increased numbers of CD8+ T cells at the dermal-epidermal interface and in the epidermis.21,22 A biopsy specimen from patient 9 (from a rash attributed to hydrochlorothiazide) demonstrated large numbers of CD8+ T cells in the epidermis and vacuolar changes that were consistent with erythema multiforme. Prior anti–CTLA-4 therapy may have contributed to the development and/or severity of this rash.
Highly specific biologic agents such as anti–CTLA-4, efalizumab (for psoriasis), etanercept (for psoriasis and rheumatoid arthritis), bevacizumab (for cancer), and rituximab (for cancer) promise to improve outcomes in inflammatory and neoplastic diseases, but unwanted adverse effects, which are distinct from those reported herein for anti–CTLA-4, are becoming apparent as these agents enter wide use.23-26 With anti–CTLA-4, previous reports suggest that inhibition of CTLA-4 in conjunction with vaccination strategies may be an important adjuvant in mediating objective cancer regression, but at the cost of an increased incidence of autoimmune reactions such as colitis, hypophysitis, and dermatitis. The cutaneous eruptions described in our patients after administration of antibodies that block the function of CTLA-4 clinically and histopathologically resemble the MPEs commonly observed in patients after administration of many medications, raising the intriguing possibility that inhibition of CTLA-4 function may play a role in the pathogenesis of 1 of the most common toxic effects associated with administration of pharmaceutical agents.
Correspondence: Sam T. Hwang, MD, PhD, Dermatology Branch, Bldg 10, Room 12N238, 10 Center Dr, Bethesda, MD 20892-1908 (email@example.com).
Financial Disclosure: None.
Accepted for Publication: July 25, 2005.
Author Contributions:Study concept and design: Jaber, Cowen, and Hwang. Acquisition of data: Jaber, Cowen, Haworth, Booher, Berman, and Hwang. Analysis and interpretation of data: Jaber, Cowen, Rosenberg, and Hwang. Drafting of the manuscript: Jaber, Cowen, and Hwang. Critical revision of the manuscript for important intellectual content: Jaber, Cowen, Haworth, Booher, Berman, Rosenberg, and Hwang. Statistical analysis: Jaber and Hwang. Administrative, technical, and material support: Jaber, Haworth, Booher, Berman, Rosenberg, and Hwang. Study supervision: Hwang.
Funding/Support: This study was supported by the National Institutes of Health/Pfizer Clinical Research Training Program, Bethesda, Md (Dr Jaber).
Acknowledgment: We thank Mark C. Udey, MD, PhD, and Maria L. Turner, MD (Dermatology Branch, National Cancer Institute [NCI], Bethesda, Md), for many helpful comments and Tamika Allen, RN, and Catherine Levy, RN (Surgery Branch, NCI), for their aid in accumulating patient statistics.
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