New Yellow Plaques in a Patient Taking Pembrolizumab

Abstract

A woman in her 70s presented with a new 4-cm left upper lobe lung mass with hilar lymphadenopathy. Biopsy results demonstrated a squamous cell carcinoma (SCC) of the lung, and chemoradiotherapy with carboplatin and paclitaxel for stage 3A disease was initiated. An allergic reaction prompted a change to cisplatin-etoposide, which continued as adjuvant chemotherapy after the radiation was complete. At first restaging, a recurrence of disease in the lung was detected, which was treated with cisplatin and gemcitabine for 4 months before she enrolled in a clinical trial (NCT02009449) in which she received combination therapy with pembrolizumab, 2 mg/kg intravenously for 21 days, and an investigational agent, AM0010 (pegylated recombinant human interleukin-10), 10 μg/kg subcutaneously on days 1 through 14 of the 21-day cycle. Three months into treatment, she developed multiple thick, mildly pruritic, yellow hyperkeratotic plaques on her lower extremities (Figure , A). A referral to a dermatology expert was initiated. Clinical image A Histopathologic image B Histopathologic image C Figure. A, Clinical image showing representative plaque on left leg of patient on initial presentation. B, Shave biopsy of skin (hematoxylin-eosin; original magnification ×10). C, Deeper biopsy demonstrating bandlike lymphocytic infiltration (hematoxylin-eosin; original magnification ×20). WHAT IS YOUR DIAGNOSIS? A. Squamous cell carcinoma B. Plaque psoriasis C. Hypertrophic lichen planus D. Keratoacanthoma Clinical Review & Education

An Atypical Presentation of Lichen Planus-Like Reaction from Pembrolizumab

“…In terms of specifically for lichenoid reactions the main management includes topical and systemic corticosteroids [22]. The majority are able to be maintained on their anti-PD1 therapy (81%) and it was concluded that treatment can still be continued [23].…”

Hypertrophic Lichen Planus with Histological Features of Squamous Cell Carcinoma Associated with Immune Checkpoint Blockade Therapy

“…The consistency of the clinical findings with HLP in the setting of ICB therapy led to the use of topical steroids as appropriate treatment for this condition, with complete resolution of the cutaneous lesions in both patients (Table 1). ICB therapy is associated with irAEs, such as dermatologic toxicities [5][6][7], caused by possible antigen "unmasking" in which PD-1 pathway blockade allows for the body to mount an immune response to the uncovered antigens [8]. Lichenoid reactions observed in the context of anti-PD-1 therapy support the possible role of the PD-1 pathway in lichen planus [6,7,9].…”

“…ICB therapy is associated with irAEs, such as dermatologic toxicities [5][6][7], caused by possible antigen "unmasking" in which PD-1 pathway blockade allows for the body to mount an immune response to the uncovered antigens [8]. Lichenoid reactions observed in the context of anti-PD-1 therapy support the possible role of the PD-1 pathway in lichen planus [6,7,9]. One study of approximately 80 patients receiving either pembrolizumab or nivolumab noted a lichenoid eruption in nearly one-fifth of patients [10].…”

“…Although several reports have evaluated LP reactions to ICB therapy, only a few previous reports have described a hypertrophic lichen planus mimicking SCC in this setting [3,6,7]. Characteristics in favor of HLP over SCC are hyperkeratotic raised lesions on the distal extremities and absence of actinic damage or other risk factors for development of simultaneous SCCs.…”

“…ICB therapies targeting the programmed cell death pathway play a critical role in the treatment of metastatic cancers including cutaneous SCC, metastatic melanoma, non-small cell lung cancer, and Merkel cell carcinoma. ICB is associated with several dermatologic immune-related adverse events (irAEs), including pruritus, morbilliform drug eruption, lichen planus (LP), atopic dermatitis, bullous disorders, and vitiligo [5][6][7]. We report a case duet of HLP associated with ICB therapy that were diagnosed as SCC on biopsy.…”