Sarcoidosis in the setting of combination ipilimumab and nivolumab immunotherapy: a case report & review of the literature

Abstract

BackgroundWe report a case of sarcoidosis in a patient with metastatic melanoma managed with combination ipilimumab/nivolumab. Sarcoid development has been linked with single agent immunotherapy but, to our knowledge, it has not been reported with combination ipilimumab/nivolumab treatment. This case raises unique management challenges for both the melanoma and the immunotherapy-related toxicity.Case presentationA 46 year old Caucasian female with M1c-metastatic melanoma was managed with ipilimumab/nivolumab combination. Patient experienced response in baseline lesions but developed new clinical and radiographic findings. Biopsy of new lesions at two different sites both demonstrated tumefactive sarcoidosis. Staining of the biopsy tissue for PD-L1 expression demonstrated strong PD-L1 staining of the histiocytes and lymphocytes within the granulomas. Monotherapy nivolumab was continued without progression of sarcoid findings or clinical deterioration.ConclusionsTissue biopsy for evaluation of new lesions on immunotherapy is an important step to help guide decision making, as non-melanoma lesions can mimic disease progression.

EBUS-TBNA Can Distinguish Sarcoid-Like Side Effect of Nivolumab Treatment from Tumor Progression in Non-Small Cell Lung Cancer

“…This reaction has been well documented in melanoma [3][4][5][6][7][8] but on rare occasion also in lung carcinoma. Concerning the few cases of lung cancer, none of them showed clear lymph node progression with sarcoid-like reaction, but rather a cutaneous form or unclear diagnosis [15,16].…”

“…These adverse effects are found in patients treated for early-stage lung cancer. This case illustrates pseudoprogression by lymph node sarcoid-like reaction [4][5][6][7][8]. This form prompts further explorations not to disregard any cancer evolution.…”

Sarcoidosis, Malignancy and Immune Checkpoint Blockade

“…For example, cases of sarcoid-like reactions have been reported following treatment of melanoma with interferon, vemurafenib, vaccine therapy, ipilimumab and nivolumab [9][10][11][12][13][14]. In our institutional experience, we have seen patients with concurrent melanoma and sarcoidosis both identified at the diagnosis of malignancy, and the development of sarcoid-like reactions, both symptomatic and asymptomatic from ICPI therapy [15].…”

Immune-Related Adverse Events: Pneumonitis

“…Sarcoid-like reactions have been observed with ipilimumab [91,104,105] and with PD-1 inhibition [106,107]. Sarcoid-like reactions are rare irAEs, and the manifestations vary from case to case.…”