P-012 Metastatic Melanoma in an Ulcerative Colitis Patient on Infliximab 9 Years After Surgical Resection of an Early Stage Primary Melanoma

Abstract

BACKGROUND: Localized stage I and II primary melanoma have a cumulative recurrence risk of 2%-5% between 5 and 20 years after complete resection and eradication. There has been speculation that immunosuppressant therapy may increase the risk of recurrence. However, recent data has suggested that immunosuppressants may not increase the recurrence risk of early stage, completely resected melanoma. Nevertheless, concern about the association of immunosuppressants and malignancy recurrence persists. This is a case of a patient with ulcerative colitis and a history of completely resected stage 1B primary melanoma who developed metastatic melanoma within 8 months of initiating infliximab therapy. METHODS: A 41 year old male presented to the gastroenterology clinic with bloody diarrhea and was found to have ulcerative colitis. His medical history was significant for a primary left shoulder melanoma stage IB (T1bN0M0, 0.80 mm depth, non-ulcerated, mitotic rate of 4 of 10 per high power field) diagnosed and completely resected 7 years prior. He was started on and initially responded to mesalamine. However, subsequent flares were not controlled with mesalamine and tapering courses of prednisone. Infliximab therapy was subsequently initiated. Eight months later, he presented with significant weight loss. CT imaging showed new lesions in the right lower lobe of the lung and body of the sternum, which were confirmed by PET scan to be malignant metastatic lesions. He underwent right nodule resection, with pathology showing pleomorphism and spindle cell morphology and negative surgical margins. He was started on vemurafenib chemotherapy. Repeat PET showed regression of sternal metastasis, but new metastases to the spine, femur, and brain. Despite aggressive radiation therapy, the patient died within 8 weeks. RESULTS: It has been speculated that there is an association between anti- TNF-alpha agents and development of melanoma. Metastatic melanoma in individuals with psoriasis, rheumatoid arthritis and solid organ transplants treated with anti-TNF-alpha has been reported. However, recent studies suggest that the association between anti-TNF-alpha agents and recurrence of an early stage melanoma that has been surgically treated is unclear. This is an unusual case of aggressive, ultimately fatal, metastatic melanoma occurring 8 months after initiation of infliximab in an individual who had completely resected early stage melanoma 9 years earlier. It is possible that infliximab increased the susceptibility for recurrent disease. Alternatively, the short duration of infliximab treatment raises the possibility that unrecognized recurrent melanoma was present prior to starting infliximab therapy. CONCLUSIONS: There are presently no guidelines for use of anti-TNF-alpha agents in individuals with a history of early stage melanoma. However performance of PET CT imaging, in addition to clinical examination, may be considered in the rare circumstance in which an individual with previously treated early stage melanoma requires administration of an anti-TNF-alpha agents. Continued attention to this matter is necessary to ensure optimal therapy to individuals with a history of melanoma and inflammatory bowel disease.