Skin Reactions in a Subset of Patients with Stage IV Melanoma Treated with Anti–Cytotoxic T-Lymphocyte Antigen 4 Monoclonal Antibody As a Single Agent

STUDY Skin Reactions in a Subset of Patients With Stage IV Melanoma Treated With Anti–Cytotoxic T-Lymphocyte Antigen 4 Monoclonal Antibody as a Single Agent

Samer H. Jaber, BS; Edward W. Cowen, MD; Leah R. Haworth, RN; Susan L. Booher, RN, MS; David M. Berman, MD, PhD; Steven A. Rosenberg, MD, PhD; Sam T. Hwang, MD, PhD

Objective: To describe the clinical and histologic mani- tions that were attributed to anti–CTLA-4 in 8 of them. festations of skin reactions incidentally noted in pa- Skin lesions consisted primarily of discrete, pruritic, ery- tients with stage IV melanoma who were treated with up thematous, minimally scaly papules that typically coa- to 9 mg/kg of a humanized monoclonal antibody reac- lesced into thin plaques on the trunk and extensor sur- tive against human cytotoxic T-lymphocyte antigen 4 faces of the extremities. Extensive alopecia was also noted (anti–CTLA-4) as a single agent every 3 weeks. in 1 patient. Histologically, a superficial, perivascular CD4ϩ-predominant T-cell infiltrate with eosinophils in Setting: Single-institution prospective study. the dermis, rare dyskeratotic cells, and mild epidermal spongiosis were present. An increase (compared with pre- Design: Patients treated with anti–CTLA-4 as a sole agent treatment values) in the peripheral blood eosinophil were prospectively referred for clinicopathologic charac- frequency was observed in patients at the time of skin terization of skin reactions occurring during treatment. eruptions (P=.006).

Main Outcome Measures: Specific clinicopatho- Conclusions: Specific features of the skin eruption der- logic features were determined by means of a detailed his- matitis with increased tissue and peripheral blood eo- tory, a physical examination, conventional histologic sinophil levels in a subset of treated patients. Specific fea- analysis, antibody staining, and complete blood cell tures of skin eruption associated with anti–CTLA-4 counts. resemble those described for maculopapular reactions to medications. Results: Nine (14%) of 63 consecutive patients treated with anti–CTLA-4 as a sole agent developed skin erup- Arch Dermatol. 2006;142:166-172

VERCOMING TOLERANCE to arrest of T cells at the G1 phase of the of self-antigens signifi- cell cycle.3 In CTLA-4 knockout mice, a cantly limits the use of rapid, fatal lymphoproliferative disorder de- vaccine therapy for the velops,4 suggesting that CTLA-4 is also in- treatment of cancer.1 De- tegral to the maintenance of tolerance and spiteO multiple trials demonstrating that tu- prevention of autoimmunity. Moreover, mor vaccination results in the develop- CTLA-4 appears to be critical in regulat- ment of enhanced immunity, objective ing TH2vsTH1 differentiation in helper T responses are infrequent. Because most (TH) cells, because activated CTLA-4– known tumor antigens are normal “self- deficient T cells are strongly biased to- 5,6 proteins,” immune regulatory mecha- ward TH2 differentiation. nisms that prevent autoimmunity also pre- Given the integral role of CTLA-4 in the vent robust immune responses to cancer maintenance of tolerance, there has been and peptide vaccines. considerable interest in overcoming tolerance in the treatment of cancer by block- Author Affiliations: See also page 175 ade of CTLA-4 function. As monotherapy Dermatology (Mr Jaber, in animal models, anti–CTLA-4 monoclo- Drs Cowen and Hwang, and Cytotoxic T-lymphocyte antigen 4 nal antibodies have been most effective in Ms Booher) and Surgery (CTLA-4) is an important costimulatory treating immunogenic tumors, with mini- Branches (Ms Haworth and molecule expressed by activated T cells and mal effects on large established tumors or Dr Rosenberg) and Laboratory 2 2,7 of Pathology (Dr Berman), a subset of regulatory T cells. Engage- weakly immunogenic tumors. Combin- Center for Cancer Research, ment of CTLA-4 inhibits T-cell activation ing anti–CTLA-4 therapy with concurrent National Cancer Institute, by blocking production of interleukin 2 and vaccination with tumor cells that secrete Bethesda, Md. interleukin 2 receptor expression, leading granulocyte-macrophagecolony-stimulating

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©2006 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 factor substantially enhanced efficacy against poorly immunogenic tumors such as B16 melanoma.8 Table 1. Common Toxic Effects Criteria Version 2.0 Recently, results of 3 clinical trials involving the for Desquamation/Rash* use of anti–CTLA-4 in combination with peptide vaccine for the treatment of cancer have been reported.9-11 Grade Description In total, 40 patients with metastatic melanoma and 2 I Macular or papular eruption or erythema without associated patients with metastatic ovarian cancer were treated symptoms II As grade I but with pruritus or other associated symptoms with anti–CTLA-4 therapy in combination with or covering Ͻ50% of body surface area or localized after peptide vaccine therapy. In one of these trials, a desquamation or other lesions covering Ͻ50% single administration of anti–CTLA-4 in patients for of body surface area whom previous vaccine therapy had failed yielded his- III Symptomatic generalized erythroderma or macular, papular, Ն topathologic evidence of tumor cell death and lym- or vesicular eruption or desquamation covering 50% of body surface area phocytic invasion within some tumors but no objec- IV Generalized exfoliative dermatitis or ulcerative dermatitis tive clinical responses.10 In the other 2 trials in which repeated doses of anti–CTLA-4 were given in combi- *Toxic effects grading system described in Trotti et al.13 nation with peptide vaccine, a subset of patients with metastatic melanoma demonstrated major tumor regression with long tumor-free intervals.9,11 matitis bear clinical and histologic similarities to those Administration of anti–CTLA-4 was associated with reported for maculopapular drug exanthems (MPEs),15 multiple autoimmune toxic effects, including enteroco- which are the most common cutaneous adverse effects litis, hypophysitis, hepatitis, uveitis,12 vitiligo, in- of widely used medications such as aminopenicillins creased antinuclear antibody levels, elevated rheuma- and sulfonamide antimicrobial drugs. toid factor levels, and rashes.9-11 Recent experience at the National Cancer Institute (NCI) Clinical Center showed METHODS that 14 (25%) of 56 patients with stage IV melanoma treated with anti–CTLA-4 and vaccinated with HLA- A*0201–restricted gp100 peptides experienced grades III All patients gave informed consent in an institutional review board–approved protocol in the Surgery Branch of the NCI, to IV autoimmune reactions (ie, reversible [grade III] or Bethesda, Md. Anti–CTLA-4 (MDX-010; Medarex, Prince- irreversible/progressive [grade IV] toxic effects involv- ton, NJ),9 is a fully humanized antibody reactive with ing function of a major organ and requiring immuno- CTLA-4. The major inclusion criteria for patients entering suppressive treatment13), including rashes.14 Autoim- this study for experimental melanoma treatment included mune manifestations were more pronounced in patients being 16 years or older; having a life expectancy 6 months or with more dramatic objective disease responses,9,14 sug- longer, an Eastern Cooperative Oncology Group perfor- gesting that effective anticancer responses may be cor- mance status of 2 or less, and a diagnosis of stage IV melanoma (except mucosal or ocular melanoma) that is clinically related with autoimmunity to self-antigens other than tu- Ͼ mor antigens. evaluable and measurable; and being postmenopausal ( 1 Rashes have been common adverse effects in recipi- year) or using reliable contraception (if female) or willing to use male contraception during the time of participation in ents of anti–CTLA-4 therapy administered after or in 9 the trial (if male). Major exclusion criteria included a history conjunction with vaccination. Phan et al observed that of malignancy within the previous 5 years (with exceptions rashes developed in 4 (29%) of 14 patients, with 3 of the for certain in situ cancers and basal and/or squamous cell 4 patients experiencing grades III to IV rashes based on carcinoma of the skin); presence of autoimmune disease, common toxic effects criteria version 2.0 (Table 1).13 active infection, or concurrent medical condition requiring Histologically, these showed epidermal spongiosis, use of systemic or topical corticosteroids or immunosup- papillary dermal edema, and a perivascular lympho- pressive agents; being pregnant or nursing; prior treatment cytic infiltrate with eosinophils. Hodi et al10 reported with anti–CTLA-4, or a history of systemic hypersensitivity that all patients (7/7) with metastatic melanoma and 1 to 1 of the investigational agents used in the trial. of 2 with ovarian cancer developed a skin eruption Patients were enrolled in an experimental immunotherapy protocol that contained the following 3 treatment arms: (1) patients (grade I) after anti–CTLA-4 therapy. Last, Sanderson et 11 who were seronegative for human leukocyte antigen (HLA)- al reported that 7 (37%) of 19 patients developed a A*0201 were treated with anti–CTLA-4 alone; (2) patients grade I to II rash. who were seropositive for HLA-A*0201 were randomized to re- Although it has been documented that dermatitis ceive melanoma-associated peptides in conjunction with develops in a significant percentage of patients treated anti–CTLA-4; and (3) patients who were seropositive for HLA- with anti–CTLA-4 therapy in combination with or A*0201 were randomized to receive anti–CTLA-4 alone. Herein, after vaccine therapy, the clinical and histologic fea- only patients in the first and third treatment arms (those receiv- tures of this skin eruption have not been systemati- ing only anti–CTLA-4) were considered for this report. As of this cally studied. We herein describe the clinicopathologic writing, enrollment for the trial has not yet been completed. A features of skin eruptions that developed in previously detailed report detailing the complete inclusion/exclusion criteria, treatment end points, clinical efficacy of anti–CTLA-4, and unvaccinated patients with melanoma who received other autoimmune manifestations of treatment will be forthcom- anti–CTLA-4 treatment as a single agent, thus remov- ing once enrollment and further analyses are completed. ing the potential effects that vaccination might have Anti–CTLA-4 was administered intravenously at a starting had on the development of autoimmunity in previous dosage of 3 or 5 mg/kg (maximum, Յ9 mg/kg) every 3 weeks, studies. Of interest, the features of anti–CTLA-4 der- with intrapatient dose escalation at every other dose. Treat-

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Onset of Rash Dose No./ HLA-A* Anti–CTLA-4 After First Dose at Which Patient No./ 0201 Starting Dose, Anti–CTLA-4 Rash Began, Sex/Age, y Status mg/kg Treatment, d mg/kg Concurrent Drug Use Allergies 1/M/34 − 3 49 3/5 Levothyroxine sodium None 2/M/35 ϩ 3 14 1/3 None None 3/F/56 − 3 7 1/3 Diltiazem hydrochloride Iodine dye– and shellfish-associated rash and aspirin 4/M/50 ϩ 3 47 3/5 Bupropion hydrochloride None 5/M/43 − 3 30 2/3 None Promethazine hydrochloride–associated facial swelling 6/M/55 − 5 10 1/5 Citalopram, fenofibrate, alprazolam, Interferon alfa–associated rash; vitiligo trazodone hydrochloride, and multivitamins 7/F/67 ϩ 5 3 1/5 Risedronate sodium Cisplatin-associated rash and esomeprazole 8/M/57 − 5 31 2/5 None None 9/M/49 − 5 67 2/5 Hydrochlorothiazide, amlodipine None besylate, lisinopril, alprazolam, prednisone, esomeprazole

Abbreviations: anti–CTLA-4, anti–cytotoxic T-lymphocyte antigen 4; HLA-A*0201, human, leukocyte antigen A*0201; −, negative; ϩ, positive.

ment was held for autoimmune toxic effects and stabilizing dis- chemotherapy agents (cisplatin), promethazine hydro- ease. At each treatment visit, patients were questioned and ex- chloride, shellfish and iodine dye, and interferon alfa amined for the development of adverse effects by physicians (Table 2). from the NCI Surgery Branch. Patients with visible skin eruptions were referred to the NCI dermatology consultation clinic, where a detailed history and photographs were obtained and PHYSICAL SIGNS AND SYMPTOMS skin examination was performed. Four-millimeter punch bi- OF DERMATITIS ASSOCIATED opsy specimens of representative skin lesions were obtained WITH ANTI–CTLA-4 while the patient was under local anesthesia for conventional histologic examination and immunostaining for T- and B-cell Except patient 9, in whom colitis developed early dur- markers. Biopsy specimens were reviewed by a dermatopa- ing his course of anti–CTLA-4 therapy, patients were not thologist for histologic diagnosis and by a pathologist (D.M.B.) aware of fever or systemic illness (eg, diarrhea) that ac- for scoring of specific histologic features. companied the development of their rashes. Patients were ambulatory and not acutely ill at the time of skin exami- RESULTS nation. Most patients reported variable degrees of pruritus ranging from mild to severe, and 3 patients de- PATIENT POPULATION scribed a painful, burning sensation (Table 3). As shown in Figure 1, a typical primary skin lesion All patients received anti–CTLA-4 as experimental therapy was a dome-shaped, pink to bright red papule that ranged for stage IV melanoma. Of the first 63 consecutive pa- from 2 to 4 mm in diameter (Figure 1A-C). Lesions typi- tients receiving anti–CTLA-4 treatment alone in this clinically started out as discrete papules (Figure 1B and C) cal trial, 9 (14%; 7 men and 2 women) were examined that could coalesce to form thin plaques (Figure 1A). Ex- by NCI dermatologists (E.W.C. and S.T.H.) after re- ternal trauma (scratching) occasionally led to the for- ferral for evaluation of skin eruptions detected by the mation of new lesions (ie, Koebner phenomenon, primary surgical oncology team. As shown in Table 2, Figure 1A [arrow]). Although older lesions showed some patients ranged in age from 34 to 67 years, and skin- evidence of fine white scale, scaling was not a promi- related reactions developed from 3 to 67 days after ini- nent feature. The proximal extensor surfaces of the limbs tial anti–CTLA-4 treatment. Skin reactions developed in were most often involved, followed by the trunk and dis- 4 of the 9 after their first anti–CTLA-4 injections. Nota- tal extremities. The palms and soles were generally spared. bly, none of the patients had a history of atopic derma- The face and head were involved in 3 patients. Patient 1 titis or psoriasis. Three of the 9 patients were taking no (in addition to a mild papular eruption on the trunk and concurrent medications at the time of the skin reaction. arms) developed striking, nonscarring alopecia of the scalp Except for patient 9, concurrent therapies had been ini- (Figure 1D), eyebrows, face, pubic region, and trunk af- tiated before anti–CTLA-4 therapy and were deemed un- ter anti–CTLA-4 treatment. Patient 2 developed a sym- likely to have caused the rashes. Unless specifically noted, metric skin eruption that appeared to be photodistrib- descriptions of the gross and microscopic features refer uted. Patients 2 and 9 developed the only rashes that to the 8 patients in whom rashes were attributed to anti– appeared to be exacerbated by light. Discontinuation of CTLA-4 therapy. Four of 9 patients had a history of cu- anti–CTLA-4 therapy for several weeks resulted in marked taneous reactions to a variety of substances, including improvement of rashes. During this period, patients used

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Patient Dyskeratotic No. Distribution Symptoms Spongiosis Exocytosis Eosinophils Cells 1 Bilateral arms, chest, and back; progressive, Mild pruritus worse with heat, 00ϩ 0 total alopecia of scalp, face, pubic region, sweating, and exercise and trunk also developed 2 Consistent with photodistribution; Mild pruritus 0 0 0 0 Koebner phenomenon noted with linear excoriations on posterior upper arm 3 Inframammary region, shins, arms, thighs, Severe pruritus with burning ϩ ϩ ϩϩ ϩ and back with accentuation of rash on extensor surfaces 4 Forearms and upper back with mild erythema Mild pruritus 0 ϩϩ ϩ of anterior thighs 5 Generally distributed, with sparing of the buttocks Mild pruritus ϩϩϩ 0 and upper chest above the nipple line 6 Anterior thighs, lower back, rear shoulders, Severe pruritus with burning ϩ 0 ϩϩ 0 and axilla; vitiligo on neck; accentuation of rash on extensor surfaces 7 Forearms, arms, legs, chest, back, Severe pruritus ϩϩϩ 00 and buttocks 8 Initial lesions on trunk; worsened significantly Mild pruritus ϩ 0 ϩ 0 after fourth treatment, with involvement of trunk, arms, and legs 9 Back, anterior chest, and sun-exposed sites Mild pruritus with mild burning ϩ ϩϩϩ 0 ϩ of forehead, back of neck, and ears

*Formalin-fixed sections were stained with hematoxylin-eosin and assessed for the following histologic features: (1) dyskeratotic epidermal cells: positive (ϩ), if 1 or more dyskeratotic cells were seen per high-power field, otherwise negative (0); (2) spongiosis: little or none: 0; moderate to severe: ϩ; (3) eosinophils: the number of eosinophils per ϫ40 field in the dermis was counted and stratified as follows: none detected, 0; 1 to 5, ϩ; and more than 5, ϩϩ; and (4) exocytosis: the number of mononuclear cells (presumably T cells) observed in the epidermis per section was classified as follows: none detected, 0; 1 to 5 cells, ϩ; more than 5 but less than 10 cells, ϩϩ; and 10 cells or more, ϩϩϩ. Skin sections were also stained with antibodies reactive with CD20, CD3, CD4, and CD8.

only bland emollients (no topical steroids) and oral di- (Figure 2C) (with no or few B cells), of which more phenhydramine hydrochloride for relief of pruritus. Two than 80% were typically CD4ϩ (Figure 2D) and less months after his last dose of anti–CTLA-4, the alopecia than 20% were CD8ϩ (Figure 2E) except as noted for experienced by patient 1 had not improved. patient 9. A scalp skin biopsy specimen taken from the patient with near total alopecia of the scalp and other HISTOLOGIC AND IMMUNOHISTOLOGIC body regions (patient 1) was histologically consistent EXAMINATION with alopecia areata and contained predominantly CD4ϩ T cells and only scant CD8ϩ T cells, which was Skin biopsy specimens were obtained from representa- consistent with idiopathic alopecia areata.16 tive, nontreated lesions and submitted for pathologic Patient 9, who was treated with his second dose of anti– examination. The histologic features of the dermatitis CTLA-4 5 weeks before referral, developed a pruritic, are depicted in Figure 2A and B and summarized in papular eruption of the trunk with photoaccentuated le- Table 3. These biopsy results showed moderate-to- sions on the sun-exposed skin of his face and back of the dense mononuclear lymphocytic infiltrates around the neck (Figure 3A and B). At the time of the skin erup- superficial vascular plexi and in the papillary dermis. tion, he was being treated with low-dose prednisone for In some patients, deeper blood vessels and hair fol- autoimmune colitis related to anti–CTLA-4. In contrast licles were also involved. Lichenoid aggregation of to biopsy specimens from other patients, a lesional skin lymphocytes and large numbers of dyskeratotic kera- biopsy specimen showed moderate vacuolar change tinocytes at the dermoepidermal interface with vacu- (Figure 3C), extensive exocytosis of CD8ϩ T cells in the olar changes were not observed except in the biopsy epidermis (Figure 3D), a greater proportion of CD8ϩ to specimen of patient 9, whose clinical history suggested CD4ϩ T cells in the dermis and epidermis, and no der- that a drug other than anti–CTLA-4 was responsible mal eosinophils. Because the patient had just started hy- for his skin eruption. Epidermal spongiosis and T-cell drochlorothiazide therapy for hypertension approxi- exocytosis, features of contact dermatitis, were absent mately 3 weeks before referral and showed evidence of or minimal. In 6 (75%) of the 8 patients whose skin the lichenoid photosensitive dermatitis observed with thia- reactions were attributed to anti–CTLA-4, eosinophils zide diuretics,17 the most likely cause of his skin erup- were observed in the superficial and deep dermis. tion was deemed to be hydrochlorothiazide. We could Results of immunohistochemistry revealed that the not rule out, however, that his other concurrent medi- mononuclear infiltrate observed by hematoxylin-eosin cations and/or prior treatment with anti–CTLA-4 may examination consisted almost entirely of CD3ϩ T cells have caused or exacerbated his skin eruption.

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Figure 1. Clinical photographs of skin lesions associated with anti–cytotoxic T-lymphocyte antigen 4 therapy. A, Pink-red papules coalescing into thin plaques on posterior elbow and arm of patient 2, with evidence of Koebner phenomenon (arrow). B, Bright red papules coalesce to form thin plaques with fine scale on the upper arm of patient 3. C, Close-up view of red papules on the back of patient 6. D, Generalized alopecia affecting the scalp (shown), chest, back, pubic area, and facial hair of patient 1.

Complete blood cell counts were performed at 3-week cination, suggesting that vaccination increases the risk intervals according to protocol in coordination with sched- of skin reactions during treatment with anti–CTLA-4. Be- uled anti–CTLA-4 treatments. These values were within sides the papular eruption described in our cohort of pa- reference limits, except for notable increases in periph- tients, striking near-total alopecia developed in patient eral eosinophil frequencies. As shown for 8 of 9 patients 1 after administration of anti–CTLA-4, and a CD8ϩ T-cell– with rashes attributed to anti–CTLA-4 and illustrated in predominant dermatitis developed in patient 9 (most likely detail for patient 5 (Figure 4), the eosinophil frequen- secondary to hydrochlorothiazide therapy) with vacu- cies (obtained after development of rashes) were signifi- olar change. The use of anti–CTLA-4 alone in our pa- cantly increased relative to values obtained before anti– tients allows us a rare opportunity to document the ef- CTLA-4 treatment. Only 3 patients had peripheral fects of CTLA-4 blockade in the regulation of human eosinophil frequencies of more than 9% (the upper limit cutaneous immunity. of the reference range in our clinical laboratory) at the time The most consistent clinicopathologic features ob- they underwent evaluation for their skin findings. Pa- served were the predominance of CD4ϩ T cells and eo- tients demonstrated 2.7- to 16-fold increases from their sinophils in the dermis and increases in peripheral blood baseline values (mean values before vs after anti–CTLA-4 eosinophil frequencies, suggesting possible skewing to- treatment, 1.73% vs 8.38%; P=.006 by paired t test) after ward a TH2-type immune response. These observations development of skin reactions. By contrast, no statisti- show similarities to the striking activation of TH2-type cally significant increase in the frequency of eosinophils CD4ϩ T cells5 and marked infiltration of internal organs (P=.19) was noted in the blood (Figure 4A) of 8 patients 4 with such TH2 cells in mice lacking CTLA-4. who did not develop autoimmune toxic effects or rashes The antigen or antigens driving the accumulation or during comparable time periods. proliferation of CD4ϩ T cells found in dermatitis associated with anti–CTLA-4 are unknown. Because cyto- COMMENT lytic T cells specific for melanoma-associated antigens such as tyrosinase or MART-1 (melanoma antigen recog- We herein describe 9 patients with stage IV melanoma nized by T cells 1) are found frequently in the periph- who developed skin eruptions after treatment with anti– eral circulation in patients with melanoma,18 we hypoth- CTLA-4 as a single agent for immunotherapy of meta- esize that CD4ϩ T cells within the inflamed skin of our static disease. In 8 of the 9 patients, anti–CTLA-4 was patients may be triggered by antigen-presenting cells in believed to be the primary cause of the rash. The fre- the skin that potentially display melanocyte-associated quency of dermatitis observed in this study (9 [14%] of antigens in conjunction with major histocompatibility 63 patients) was less than that reported for patients re- complex class II under steady-state conditions. Indeed, ceiving anti–CTLA-4 therapy in conjunction with vac- Hodi et al10 noted the presence of CD4ϩ and CD8ϩ T cells

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E Figure 3. Skin eruption in patient 9 after treatment with anti–cytotoxic T- lymphocyte antigen 4 followed by hydrochlorothiazide and other medications. A, A confluent red rash is seen on the back. B, Close-up of individual papular lesions. C, Right upper arm lesion demonstrates vacuolar changes (hematoxylin-eosin, original magnification ϫ20). D, Anti-CD8 staining demonstrates extensive exocytosis in the epidermis (original magnification ϫ20). Figure 2. Histologic features of dermatitis associated with anti–cytotoxic T- lymphocyte antigen 4. A, Superficial perivascular mononuclear infiltrate with mild spongiosis and minimal exocytosis of T cells into the epidermis in Highly specific biologic agents such as anti–CTLA-4, patient 3. No vacuolar change was noted (hematoxylin-eosin, original efalizumab (for psoriasis), etanercept (for psoriasis and magnification ϫ10). B, A higher-power view of part A shows abundant eosinophils (arrows) in the dermis. C-E, Immunostaining of skin sections rheumatoid arthritis), bevacizumab (for cancer), and ri- from patient 3 show CD3ϩ (C); CD4ϩ (D); and CD8ϩ (E). tuximab (for cancer) promise to improve outcomes in inflammatory and neoplastic diseases, but unwanted adverse effects, which are distinct from those reported adjacent to cells they described as melanocytes in skin herein for anti–CTLA-4, are becoming apparent as reactions after anti–CTLA-4 treatment in previously vac- these agents enter wide use.23-26 With anti–CTLA-4, cinated patients with melanoma. previous reports suggest that inhibition of CTLA-4 in The clinical and histopathologic findings in our cohort conjunction with vaccination strategies may be an im- of patients have some, but not all, features of what has com- portant adjuvant in mediating objective cancer regres- monly been termed maculopapular drug exanthem and has sion, but at the cost of an increased incidence of auto- been observed with many drugs such as penicillins or sulfa- immune reactions such as colitis, hypophysitis, and based drugs.15 The MPEs likely represent most of all drug- dermatitis. The cutaneous eruptions described in our induced skin reactions19 and typically occur 1 to 2 weeks patients after administration of antibodies that block after the first ingestion of a drug. Histologically, MPE and the function of CTLA-4 clinically and histopathologi- dermatitis associated with anti–CTLA-4 show a prepon- cally resemble the MPEs commonly observed in pa- derance of CD4ϩ T cells and eosinophils in the dermis along tients after administration of many medications, raising with mild epidermal spongiosis and little exocytosis. His- the intriguing possibility that inhibition of CTLA-4 tologically, however, MPEs often show evidence of vacu- function may play a role in the pathogenesis of 1 of the olar alteration of the basal keratinocytes.15,20 However, be- most common toxic effects associated with administra- cause MPEs seldom undergo biopsy by dermatologists tion of pharmaceutical agents. unless they evolve into more serious conditions, vacuolar alteration may reflect a bias in the reporting of more ad- Accepted for Publication: July 25, 2005. vanced skin reactions. Correspondence: Sam T. Hwang, MD, PhD, Dermatol- Vacuolar changes are more common in destructive ogy Branch, Bldg 10, Room 12N238, 10 Center Dr, (blistering) reactions to drugs, including severe erythema Bethesda, MD 20892-1908 ([email protected]). multiforme (ie, Stevens-Johnson syndrome) and toxic epi- Author Contributions: Study concept and design: Jaber, dermal necrolysis, which both exhibit increased numbers Cowen, and Hwang. Acquisition of data: Jaber, Cowen, of CD8ϩ T cells at the dermal-epidermal interface and in the Haworth, Booher, Berman, and Hwang. Analysis and in- epidermis.21,22 A biopsy specimen from patient 9 (from a rash terpretation of data: Jaber, Cowen, Rosenberg, and Hwang. attributed to hydrochlorothiazide) demonstrated large num- Drafting of the manuscript: Jaber, Cowen, and Hwang. Criti- bers of CD8ϩ T cells in the epidermis and vacuolar changes cal revision of the manuscript for important intellectual con- that were consistent with erythema multiforme. Prior anti– tent: Jaber, Cowen, Haworth, Booher, Berman, Rosen- CTLA-4 therapy may have contributed to the development berg, and Hwang. Statistical analysis: Jaber and Hwang. and/or severity of this rash. Administrative, technical, and material support: Jaber,

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Common toxicity criteria: version 2.0 an improved reference for grading the acute effects of cancer treatment: impact on Figure 4. Peripheral eosinophilia in patients treated with anti–cytotoxic radiotherapy. Int J Radiat Oncol Biol Phys. 2000;47:13-47. T-lymphocyte antigen 4 (anti–CTLA-4) who developed skin eruptions. 14. Attia P, Phan GO, Maker AV, et al. Autoimmunity correlates with tumor regres- A, Eosinophil count is shown as a percentage of the total white blood cell sion in patients with metastatic melanoma treated with anti-cytotoxic T- count (WBC) in patients who developed dermatitis while receiving lymphocyte antigen-4. J Clin Oncol. 2005;23:6043-6053. anti–CTLA-4 treatment and those who were treated with anti-CTLA-4, but 15. Pichler WJ, Yawalkar N, Britschgi M, et al. Cellular and molecular pathophysi- who had not developed known autoimmune toxic side effects in the first 6 ology of cutaneous drug reactions. Am J Clin Dermatol. 2002;3:229-238. weeks of treatment. Eosinophil counts were evaluated before initiation of 16. Todes-Taylor N, Turner R, Wood GS, Stratte PT, Morhenn VB. T cell subpopu- anti–CTLA-4 treatment in both groups of patients. For patients who lations in alopecia areata. J Am Acad Dermatol. 1984;11:216-223. developed dermatitis, blood was evaluated when patients underwent the first 17. Burckhardt W, Sutter T. Photoallergic drug exanthema caused by hydrochloro- evaluation for their rashes. For those with no toxic effect, blood was thiazide [in German]. Z Haut Geschlechtskr. 1963;34:105-108. evaluated approximately 6 weeks after at least 2 anti–CTLA-4 treatments. The 18. Lee PP, Yee C, Savage PA, et al. Characterization of circulating T cells specific pretreatment and posttreatment P values from each group of patients were for tumor-associated antigens in melanoma patients. Nat Med. 1999;5: statistically compared using paired, 2-sided t tests (n=8). Because patient 9’s skin eruption was not thought to be due primarily to anti-CTLA-4, his peripheral 677-685. eosinophil values were not included in this analysis. B, Peripheral leukocyte 19. Bigby M. Rates of cutaneous reactions to drugs. Arch Dermatol. 2001;137: subsets as a percentage of the total WBC count in relation to initial dermatitis 765-770. and exacerbation of the skin reaction in patient 5. The left y-axis indicates 20. Yawalkar N, Pichler WJ. Immunohistology of drug-induced exanthema: clues to percentages for the following leukocyte subsets: neutrophils, lymphocytes, pathogenesis. Curr Opin Allergy Clin Immunol. 2001;1:299-303. monocytes. The right y-axis indicates percentage of eosinophils. 21. Hertl M, Bohlen H, Jugert F, Boecker C, Knaup R, Merk HF. Predominance of epidermal CD8ϩ T lymphocytes in bullous cutaneous reactions caused by beta- lactam antibiotics. J Invest Dermatol. 1993;101:794-799. Haworth, Booher, Berman, Rosenberg, and Hwang. Study 22. Hertl M, Jugert F, Merk HF. CD8ϩ dermal T cells from a sulphamethoxazole- supervision: Hwang. induced bullous exanthem proliferate in response to drug-modified liver Financial Disclosure: None. microsomes. Br J Dermatol. 1995;132:215-220. Funding/Support: This study was supported by the Na- 23. Gaylor ML, Duvic M. Generalized pustular psoriasis following withdrawal of tional Institutes of Health/Pfizer Clinical Research Train- efalizumab. J Drugs Dermatol. 2004;3:77-79. 24. Scheinfeld N. A comprehensive review and evaluation of the side effects of the ing Program, Bethesda, Md (Dr Jaber). tumor necrosis factor alpha blockers etanercept, infliximab and adalimumab. Acknowledgment: We thank Mark C. Udey, MD, PhD, J Dermatolog Treat. 2004;15:280-294. and Maria L. Turner, MD (Dermatology Branch, Na- 25. Zeltser R, Valle L, Tanck C, Holyst MM, Ritchlin C, Gaspari AA. Clinical, histo- tional Cancer Institute [NCI], Bethesda, Md), for many logical, and immunophenotypic characteristics of injection site reactions associated with etanercept: a recombinant tumor necrosis factor ␣ receptor: Fc fu- helpful comments and Tamika Allen, RN, and Cather- sion protein. Arch Dermatol. 2001;137:893-899. ine Levy, RN (Surgery Branch, NCI), for their aid in ac- 26. Lowndes S, Darby A, Mead G, Lister A. Stevens-Johnson syndrome after treat- cumulating patient statistics. ment with rituximab. Ann Oncol. 2002;13:1948-1950.

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