A 63-year-old male with a 20-year history of a chronic, recurrent sacrococcygeal pilonidal cyst was referred to our outpatient clinic. He had received multiple surgical resections in the past with benign pathology. He presented with a verrucous wart-like midline mass on the superior gluteal cleft that had grown since his last resection. The patient subsequently underwent resection of the mass with bilateral gluteal rotational flaps. Pathology showed squamous cell carcinoma with tumor-free margins, and further imaging showed no evidence of metastatic disease. It is believed chronic inflammation with subsequent genetic and impaired DNA repair mechanisms is the leading cause of malignancy. The treatment of choice for pilonidal carcinoma is surgical resection with free margins. Reconstruction methods can be utilized to repair the tissue defect. Pilonidal carcinoma has high mortality risk with surgical treatment yielding a disease-free 5-year survival rate of 55% of patients and a high recurrence rate of 50%. The role of chemoradiotherapy is currently unclear.
:Merkel cell carcinoma (MCC) is a rare and aggressive cutaneous neoplasm that is almost always intradermal. Immunosuppression increases the risk of MCC, which is believed to be due to increased susceptibility to Merkel cell polyomavirus (MCPyV). Intraepidermal MCC, or MCC in situ (MCCis), is extremely rare and usually associated with other cutaneous lesions. Here, we describe a case of MCPyV-negative MCCis arising in an immunocompromised patient. This case adds to only 9 previously reported cases of MCCis without a coexisting neoplasm and suggests that immunosuppression can lead to MCCis by mechanisms other than MCPyV. Although previously reported cases of MCCis demonstrated excellent prognosis, local recurrence and metastasis are still possible. Prognostication, treatment, and follow-up of MCCis should be similar to MCC.
Bullous pemphigoid is a rare and severe adverse reaction to immune-checkpoint inhibitors that can be life-threatening. Here, we present two cases of bullous pemphigoid secondary to nivolumab and ipilimumab+nivolumab therapy, respectively. Both cases presented months after discontinuation of immunotherapy. Our first case highlights the life-threatening nature of bullous pemphigoid due to its potential to cause laryngeal oedema. Our second case illustrates that cytotoxic T-lymphocyte-associated protein-4 inhibitors can rarely lead to bullous pemphigoid, in addition to programmed cell death-1 (PD-1) and programmed cell death ligand-1 (PD-L1) inhibitors. Both cases emphasise the importance of skin examinations and dermatological follow-up for patients during and even after discontinuation of immunotherapy.
Sarcoid-like reactions (SLRs) are rare, granulomatous inflammatory reactions to immune checkpoint inhibitors (ICIs) that can involve any organ but frequently affect the lungs, mediastinal lymph nodes and skin. We present a rare case of an exclusively cutaneous SLR due to pembrolizumab that clinically resembled dermatomyositis. A literature review yielded only 12 previously reported cases of ICI-induced cutaneous SLR without any systemic involvement. Our case highlights the diversity of presentations of cutaneous SLR and emphasises the importance of histological evaluation of new cutaneous eruptions.
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