Sustained complete response of metastatic cutaneous squamous cell carcinoma by immune checkpoint inhibition in a renal transplant patient: a case report

Case report: Fatal overwhelming post-splenectomy infection in a patient with metastatic angiosarcoma treated with immunotherapy

A patient in his 40s with splenic angiosarcoma metastatic to the liver underwent splenectomy, chemotherapy, and partial hepatectomy before being treated on a clinical trial with CTLA4 and PD1 inhibitors. He had received pneumococcal and meningococcal vaccines post-splenectomy. On week 10, he developed grade 3 immune-related colitis, successfully treated with the anti-tumor necrosis factor-alpha inhibitor infliximab and steroids. After 4 cycles of treatment, scans showed partial response. He resumed anti-PD1 therapy, and 6 hours after the second dose of anti-PD1 he presented to the emergency room with hematemesis, hematochezia, hypotension, fever, and oxygen desaturation. Laboratory tests demonstrated acute renal failure and septicemia (Streptococcus pneumoniae). He died 12 hours after the anti-PD1 infusion from overwhelming post-splenectomy infection (OPSI). Autopsy demonstrated non-viable liver tumors among other findings. In conclusion, patients undergoing immunotherapy and with prior history of asplenia should be monitored closely for OPSI as they may be at increased risk.

Systematic Review of Programmed Cell Death-1 Inhibitor Therapy for Advanced-Stage Cutaneous Squamous Cell Carcinoma in Solid-organ Transplant Recipients

BACKGROUND

Programmed cell death-1 (PD-1) inhibitors represent an effective treatment option for advanced cutaneous squamous cell carcinoma (cSCC). However, solid organ transplant (SOT) recipients with cSCC have traditionally been excluded from clinical trials.

OBJECTIVE

To assess the safety and efficacy of PD-1 inhibitors for stage III-IV cSCC in SOT recipients.

MATERIALS & METHODS

A systematic review was performed using the PubMed, EMBASE, and Scopus databases.

RESULTS

We identified 21 articles describing 33 SOT recipients (26 kidney, four liver, two lung, and one heart) with stage III-IV cSCC treated with PD-1 inhibitors. Eleven patients (33.3%) experienced allograft rejection. Of the 25 cases with iRECIST scores, twelve patients (48.0%) had a complete response (CR), eight (32.0%) showed a partial response (PR), three (12.0%) progressive disease, and two (8.0%) stable disease (SD). Including patients without available iRECIST scores, 21 patients (63.6%) showed tumor response. Eleven patients died, with six (50.0%) due to tumor progression and one (11.1%) due to allograft rejection after foregoing dialysis.

CONCLUSION

PD-1 inhibitors demonstrate efficacy for advanced cSCC and confer a risk of allograft rejection in SOT recipients, requiring careful assessment of risks and benefits. If anti-PD-1 therapy is pursued, use of mTOR inhibitors, prophylactic steroids, and donor-derived cell-free DNA monitoring may mitigate the risk of rejection.