Successful treatment with Ipilimumab and Interleukin-2 in two patients with metastatic melanoma and systemic autoimmune disease

Abstract

Two patients were treated with immunotherapy for metastatic malignant melanoma (MM) despite suffering from systemic autoimmune disease, i.e., ulcerative colitis (UC) and Behcets disease (BD), respectively. Both patients benefitted from the treatment. The patient with UC achieved partial remission of all measurable parameters after treatment with Ipilimumab, while the patient with BD achieved a complete remission of MM after treatment with Interleukin-2 (IL-2) and Interferon-α (IFN-α). Moreover, no aggravation of symptoms related to the autoimmune diseases was seen during treatment, in contrast, clinical indications of improvement were observed. These two cases illustrate that the presence of autoimmune disease does not necessarily predict increased autoimmune toxicity in connection with immunotherapy. They also raise the question of whether autoimmune disease should continue to be an absolute exclusion criterion for treatment of MM with immunotherapy. Consequently, given the poor prognosis of refractory MM, immunotherapies need to be taken into consideration even in cases of autoimmune comorbidity due to the potential long-term benefit that these therapies offer to MM patients.

Introduction

Treatment of metastatic malignant melanoma (MM) using promising new therapeutics is undergoing rapid development. Presently, the main treatment modality is immune therapy comprising the immune regulatory antibody, Ipilimumab, directed against the cytotoxic T-lymphocyte antigen 4 (anti-CTLA4 mAb) and new antibodies targeting the immune regulatory molecules PD1 and PD-L1 [1]. Furthermore, high-dose recombinant Interleukin-2 (IL-2) is used as standard of care for MM in the United States and in selected European countries including Denmark. IL-2 is also as part of the highly effective experimental adoptive cell therapy using autologous tumor-infiltrating lymphocytes [2]. In addition to immune therapy, MM patients with V600 mutation in the proto-oncogene BRAF can be offered treatment with a BRAF or MEK inhibitor [3].

IL-2 is an immune stimulatory cytokine which is naturally produced by the T cells upon activation of the T-cell receptor by an antigen. IL-2 stimulates the proliferation and differentiation of naïve T cells into antigen-specific effector T cells, triggering the release of other immune-stimulating cytokines like Interferon-γ, Tumor Necrosis Factor-α and IL-6 [4]. Interferon-α (IFN-α), also part of the natural immune response, has an anti-proliferative effect and upregulates expression of major histocompatibility complex class I on tumor cells, increasing the killing of tumor cells mediated by cytolytic T lymphocytes [5]. IL-2 was approved by the FDA in 1998 based on the induction of durable complete responses in 6–8 % of patients with metastatic melanoma, with response rates generally ranging from 10 to 20 % [6]. IL-2 therapy schedule and dosing differs; in Denmark, the decrescendo IL-2 regimen is standard; which includes the combination of IL-2 and IFN-α based on a proposed synergistic effect which has been demonstrated in preclinical as well as phase I and II studies [7].

Treatment with Ipilimumab relies on preventing the down-regulation of T cell activity following activation resulting in a potentiation of the antitumor immune responses mediated by CD4+ and CD8+ T cells. Activation requires both stimulation and co-stimulation with binding of B7 to CD28 on the T cell. After T cell activation, surface CTLA4 is up-regulated and competes with CD28 for B7 binding, thereby removing the co-stimulatory signal. Ipilimumab has a higher affinity than the naturally occurring B7, which normally binds to CTLA4 causing inhibition of T cell activation through the prevention of CTLA4-B7 binding [8, 9]. Ipilimumab induces objective responses in about 10 % of patients and clinical benefit in 20–30 % of patients. Even more importantly, treatment using Ipilimumab significantly improves survival [10], with most recent data showing that 20 % of the patients live more than 5 years after treatment [11].

Currently, comorbidity, in terms of significant autoimmune disease, excludes patients from treatment with both high-dose IL-2 and Ipilimumab based on the risk of potentially severe immune-related adverse effects which can be anticipated due to the enhancement of autoimmune reactivity. In two exceptional cases we treated two MM patients with active ulcerative colitis (UC) and Behcets disease (BD) with Ipilimumab and IL-2, respectively.

Ulcerative colitis is an idiopathic inflammatory bowel disease characterized by diffuse, continuous, and superficial involvement of the colorectum with chronic inflammation and crypt abnormalities and the absence of non-cryptolytic granulomas [12, 13]. UC is a chronic disorder presumed to be caused by an inappropriate immune response to environmental stimuli. UC is treated with oral or topical 5-Aminosalicylate or topical Glucocorticosteroid, in mild to moderate cases, while systemic Glucocorticosteroid, Cyclosporine or biological agents are used in more severe cases [13]. Intolerance to treatment or lack of response to medical treatment may ultimately leave surgery as a final treatment option.

Behcets disease is characterized by systemic vasculitis, mainly affecting the small blood vessels; both veins and arteries display nonspecific inflammation due to exogenous triggering of the immune system in a genetically susceptible host. The syndrome encompasses a wide range of manifestations including oral and/or genital aphthous ulcers, skin lesions, thrombophlebitis, uveitis, arthritis, arthralgia, thrombosis, gastrointestinal involvement, or involvement of the central nervous system [14, 15]. Treatment ranges from Corticosteroid, Colchicine, Azathioprine, Cyclosporine, TNF-α inhibitor, Etanercept, IFN-α to Cyclophosphamide, and Methotrexate, depending upon the severity of symptoms and organ involvement [15].

The courses of treatment for the two patient cases and the developments of their conditions are summarized below.

Case 1: Patient with ulcerative colitis

A 58-year old man was diagnosed with a primary melanoma on his back in 2010 (nodular melanoma; thickness of 0.7 mm; Clark’s level 4). The patient had a congenital nevus on 11–13 % of the body and had been treated for UC since 2009 with limited success. Previous medical treatment of the UC had included Prednisolone, Azathoprine, Mesalazine, and Infliximab. However, in July 2010, a colectomy with ileostomy was performed due to progressive colitis (Fig. 1). In October 2012, recurrence of the melanoma with metastatic disease localized in the liver and retroperitoneum was confirmed. The patient was initially not considered suitable for immune therapy due to his medical history of UC and persistent symptoms arising from the rectum remaining after surgery, which included daily passage of mucus and blood despite treatment with steroid suppositories. As the melanoma turned out to be BRAF mutation negative, the patient was treated with 1st line Temozolomide; after three series of treatment, CT scan showed progression of the known lesions and a new tumor conglomerate adjacent to the spine at Th12/L1 level (Fig. 2a). The patient had a strong desire for further treatment and insisted on starting Ipilimumab treatment despite the potential risk of worsening the UC. Before starting treatment with Ipilimumab, he received local radiotherapy (25 Gray in 5 fractions) targeting the tumor near to the spine due to the risk of neural invasion. In April 2013, the patient began treatment with four series of Ipilimumab (3 mg/kg i.v.); Karnofsky scoring was 70–80 % based on symptoms from the disease in the form of tiredness, loss of appetite and weight, fluctuating fever, and the need for opiate pain control. Prior to the second course of treatment, the patient was hospitalized due to a high fever and treated with antibiotics without verification of an infectious focus. Already at the time of the third treatment, performance status improved with disappearance of disease related symptoms. In addition, the patient no longer had secretion of mucus and blood from the rectum. After the fourth course of treatments, CT evaluation showed partial remission of all measurable parameters (Fig. 2b) which lasted for 7 months. Ipilimumab therapy was reintroduced in March 2014 due to minor regrowth of a few liver metastases. Again, the patient achieved partial remission after four series without the reappearance of UC symptoms.

Fig. 1.

Biopsy from the sigmoid colon before colectomy showing active chronic inflammatory bowel disease with crypt abscesses, gland destruction, and stromal inflammatory infiltrate. HE staining, scale bar 100 μm

Fig. 2.

a (top row): CT scan before Ipilimumab showing baseline measurable lesions (arrows): i Liver metastasis (3.1 cm), ii Liver metastasis (3.6 cm), iii Retroperitoneal lymph node (3.0 cm). In total; 9.7 cm. b (lower row): CT scan after four series of Ipilimumab showing reduction in measurable lesions (arrows): i Liver metastasis (1.8 cm), ii Liver metastasis (2.1 cm), iii Retroperitoneal lymph node (2.6 cm). In total; 6.5 cm

Case 2: Patient with Behcet’s disease

A 48-year old woman was diagnosed in 2011 with three primary melanomas: on her arm (superficial spreading melanoma; thickness of 1.06 mm; Clark’s level 4), on her back (superficial spreading melanoma, thickness of 0.54 mm; Clark’s level 2), and on her shoulder (superficial spreading melanoma; thickness of 0.4 mm; Clark’s level 2). The patient had a medical history of Castleman’s disease, which had been histologically verified in 2001. In 2008, the patient was diagnosed with BD based on serological tests and chronic symptoms including oral and genital ulcers, deep vein thrombosis, personality change (depression), flu-like symptoms, pain, and tiredness. Treatment with Methotrexate and Hydroxychloroquine was initiated following the diagnosis. In May 2012, it was established that the patient had recurrent melanoma with metastases localized in the left breast and in multiple lymph nodes close to the clavicle/sternum, the left axillary region, and close to the spine (Fig. 3a). At the time of referral, the patient had symptoms of BD with oral ulcers and flu-like symptoms including fever, pain, and tiredness. The patient was informed of treatment with decrescendo IL-2 (intravenous IL-2 regimen with continuous infusions of 18 million units per m² over 6, 12, and 24 h followed by 4.5 million units per m² over 24 h for 3 days) and IFN-α (s.c. injection of 300 μg one week before each series of IL-2) and of the potential risk of severe aggravation of the ongoing BD. The patient insisted on receiving immunotherapy. Treatment with Methotrexate was therefore discontinued, and IL-2 treatment was initiated in June 2012. At that time, the left breast was red, hard and very painfully swollen due to diffuse metastatic infiltration which clinically resembled inflammatory breast cancer. After two series of well-tolerated treatments, a CT scan in August 2012 showed partial remission of all measurable parameters (Fig. 3b). The third and fourth series of treatment were both terminated prematurely due to mental strain on the patient. In September 2012, a CT scan showed complete remission with disappearance of all lesions and normalization of the breast (Fig. 3c). Simultaneously, the patient reported disappearance of symptoms related to Behcet’s disease including generalized symptoms and blisters. Treatment was, however, permanently stopped due to mental strain on the patient.

Fig. 3.

a (top row): CT scan before IL-2 showing baseline measurable lesions (arrows): i Supraclavicular lymph node (2.0 cm), ii Retroclavicular lymph node (3.3 cm), iii Left axillary lymph node (2.0 cm); in total = 7.3 cm. b (middle row): CT scan after 2 series of IL-2 showing reduction in measurable lesions (arrows): i Supraclavicular lymph node (1.0 cm), ii Retroclavicular lymph node (1.5 cm), iii Left axillary lymph node (0.8 cm); in total = 3.3 cm. c (lower row): CT scan after 4 series of IL-2 showing further reduction in measurable lesions (arrows): i Supraclavicular lymph node (undetectable), ii Retroclavicular lymph node (undetectable), iii Left axillary lymph node (undetectable); in total = 0.0 cm

Unfortunately, complete remission was temporary and the patient experienced localized axillary disease progression after 3 months. Local surgery was performed. However, in February 2013, a new axillary metastatic lesion was found on PET–CT and was subsequently surgically removed. At the same time, the patient experienced reoccurrence of oral mucosal ulcers. Later that month, the patient developed further disease dissemination including a brain metastasis. The patient was treated with surgery and stereotactic radiotherapy, and in June 2013, Ipilimumab (3 mg/kg i.v.) was initiated. Four series of Ipilimumab treatment were given without side effects except for itching of the skin; however, the disease progressed during therapy and the patient died October 2013.

Discussion

In the presented cases, MM patients also suffering with autoimmune diseases experienced response to immunotherapy with partial or complete remission of the MM and without aggravation of the symptoms related to their autoimmune conditions. In contrast, clinical indications of an improvement of the autoimmune symptoms were observed during immune therapy. This is a surprising observation, as it would be expected that treatment activating the immune system would cause an exacerbation of the symptoms related to the autoimmune conditions. These single case observations raise the question as to whether autoimmune disease should continue to be an absolute exclusion criterion for treatment with immunotherapy.

One of the MM patient treated with Ipilimumab also suffered from UC and as such, it was anticipated that there could be an increased risk of the development of autoimmune toxicity, which is known to potentially involve the gastrointestinal tract [16]. However, in the current case, significant clinical response to Ipilimumab treatment was not associated with increased UC activity. In contrast, the symptoms arising from the rectum remitted during Ipilimumab therapy. Based on this single case, it is of course not possible to judge whether or not this observation was a coincidence. However, this observation challenges the general exclusion of UC patients from Ipilimumab treatment. Thus, in certain MM patients with more localized colitis, especially in remission, or after colectomy due to pancolitis, Ipilimumab therapy might still be considered as a relevant and safe treatment option.

Ulcerative colitis and Ipilimumab-induced colitis seem to have several immune pathological characteristics in common and both conditions respond well to therapy with a TNF-α inhibitor [17]. The mechanism by which Ipilimumab might reduce the symptoms of colitis is not evident, but may include Ipilimumab-induced alterations of intestinal immunity and thereby effect the inflammatory reactions involved in UC. CTLA4 is constitutively expressed by regulatory T cells (Tregs), but the involvement of CTLA4 in mediating the suppressive function of Tregs is still under debate [18]. As Tregs are known to accumulate in the colonic mucosa of patients with active UC [19], it could be speculated that Ipilimumab treatment maybe lead to a local increased Treg suppressive function, which has the potential to attenuate mucosal autoimmune reactivity.

To this end, no prognostic relevance of circulating Tregs in melanoma patients was found in a study recently published by Weide et al. [20]. On the other hand, it was recently demonstrated that a decrease in circulating Tregs during Ipilimumab treatment is associated with disease control and improved survival [21].

In the case involving BD, the patient had substantial ongoing autoimmune symptoms and it was considered necessary to discontinue her chronic immunosuppressive treatment with Methotrexate in order to begin immunotherapy. Subsequently, she was treated with high doses of IL-2, which is known to play a major role in T-cell-mediated pathogenesis of BD [22] and could therefore potentially increase BD activity. However, the patient did not experience any aggravation of BD symptoms; in contrast, all chronic symptoms disappeared during IL-2 therapy. Again, this observation should be interpreted with caution; however, several possible explanations could be suggested. Firstly, that the patient was also treated with low-dose IFN-α, and although IFN-α level may be upregulated in patients with BD, treatment of BD patients with IFN-α2a has proved successful in smaller studies [23]. Therefore, the IFN-α component in this treatment regimen may, in fact, have contributed to the observed reduction in BD symptoms. Secondly, the ability of IL-2 to induce Tregs might also be involved in the observed improvement in autoimmune symptoms. Tregs are characterized by a high expression of the IL-2 receptor alpha chain, CD25, and studies indicate that IL-2 is able to increase Treg level and function [24]. To this end, a clinical trial investigating induction of regulatory T cells by low-dose IL-2 in autoimmune and inflammatory diseases is currently ongoing (www.clinicaltrials.gov), where UC and BD are among the autoimmune diseases being investigated. Results from this trial might correlate our observations.

The cases presented illustrate that the presence of autoimmune diseases such as localized UC and BD is not necessarily predictive for increased autoimmune toxicity in connection with immunotherapy. Immune activating therapies for MM should, however, still be used with caution in patients with preexisting autoimmune diseases, and the potential risks hereof should be explained to the patients. On the other hand, given the poor prognosis of refractory MM, immunotherapies need be taken into consideration also in case of autoimmune comorbidity due to the potential long-term benefit that these therapies offer to MM patients.

Abbreviations

anti-CTLA4

mAbAnti-cytotoxic T-lymphocyte antigen 4 monoclonal antibody

BD

Behcets disease

IL-2

Interleukin-2

IFN-α

Interferon-α

MM

Malignant melanoma

UC

Ulcerative colitis