Melanoma occurrence under long-term etanercept treatment for psoriasis: a case report

Abstract

Melanoma occurrence during treatment with anti-tumor necrosis factor is considered an incidental event, although very recent studies suggest a risk. Etanercept is a fusion protein that binds the tumor necrosis factor receptor and is included among TNF inhibitors, approved for the treatment of several autoimmune diseases, such as psoriasis.We described a 79-year-old man with psoriasis, being treated with etanercept, who presented with a new brown to black macule on his right shoulder; this was immediately surgically excised. Histology showed a superficial spreading melanoma, 1.2 mm Breslow thickness, one mitosis/hpf, with no vascular or neural invasion (stage T2b). Sentinel lymph node biopsy was negative. There were no apparent melanoma risk factors: normal total nevus count, photo type IV, no childhood sunburns, no family history of melanoma, and no previous immune suppressive drugs and/or phototherapies. Etanercept 50 mg/week had been administered continuously for 5 years before the melanoma occurrence. After etanercept withdrawal his psoriasis slowly, but progressively relapsed. ConclusionsThis is the first melanoma case reported in a psoriasis patient, among a cohort of 216 patients since 2008 treated with anti-TNF, living in Sardinia, an Italian region considered at low risk for melanoma. This case supports the role of drug-induced immune surveillance compromise, in the absence of other personal and environmental confounding factors for melanoma. The possible anti-tumor necrosis factor association with melanoma is a controversial issue. Questions remain about the validity of this association, recommendations about preventative measures, and timing of skin screening efforts. In addition, the best choice for psoriasis treatment after melanoma detection has not been thoroughly studied.