Sequential treatment with secukinumab and ustekinumab in a patient with severe psoriasis and recent history of cerebral malignant melanoma metastasis

Abstract

This report of a 53‐year‐old woman with severe psoriasis treated with biologic therapy despite recent history of malignant melanoma with cerebral metastasis suggests that biologic therapy for chronic inflammatory diseases may be an option for selected patients with recent cancer.

1. INTRODUCTION

Studies have indicated increased risk of skin cancer in patients with severe psoriasis1 and after treatment with biologic therapy2 but it is unclear whether biologic therapy is associated with recurrence or spread of synchronous cancer in patients with psoriasis. Therefore, biologic therapy is not widely used in patients with known oncologic conditions. A recent case study reported use of ustekinumab in a male patient with severe psoriasis and history of malignant melanoma (MM).3 The European guidelines do not prohibit use of biologic therapy in patients with recent cancer; however, biologic therapy should be used with caution and after consulting an oncologist.4 Patients with severe psoriasis and history of cancer therefore constitute a group of special concern.

2. CASE

We describe a 53‐year‐old woman with severe psoriasis and psoriatic arthritis treated with sequential biologic therapy despite recent history of MM with cerebral metastasis. Since 1987, the patient has been treated for extended periods with methotrexate (MTX) and cyclosporine, which was eventually discontinued due to lack of response and adverse effects. In 2003, the patient began treatment with infliximab 4‐5 mg/kg every eighth week and 5 mg MTX once weekly. The patient experienced complete resolution of symptoms of this treatment. In 2009, while the patient was still receiving infliximab she conceived her second child; however, she decided to continue infliximab treatment after being thoroughly informed about the possible risks and side effects. She continued infliximab until gestational week 32. She had a normal pregnancy and gave birth to a healthy boy. After delivery, she resumed treatment with infliximab.

In September 2016, the patient was diagnosed with a cerebral MM metastasis for which she received neurosurgery but not radiation therapy, targeted cancer immunotherapy, or chemotherapy. The metastasis was located in the basal ganglia/frontal lobe in close proximity to the right ventricle and measured 5.3 × 6.2 cm including the surrounding region of hemorrhage. It was not possible to locate the primary tumor. Infliximab was discontinued, and she was treated with 10 mg prednisolone due to increased intracranial pressure and to prevent flare of psoriatic arthritis. After having discontinued infliximab during treatment for cancer, the patient returned to our department with worsening of psoriasis and had a psoriasis area and severity index (PASI) score of 7.8. We speculate that flare of psoriasis was due to a combination of discontinuation of infliximab and prescription, and subsequently discontinuation, of prednisolone. She was treated with 10 mg MTX once per week, which was increased to 15 mg and then to 25 mg due to lack of response. The PASI score increased to 16 and further to 25, and she experienced adverse effects of MTX. Due to the lack of control of her symptoms, it was investigated whether the patient could be treated with secukinumab despite her history of MM aided by the local medicine committee at the hospital. The patient was thoroughly informed about potential side effects of biologic treatment including cancer and relapse of previous cancer. In April 2017, treatment with secukinumab 300 mg weekly in the first 4 weeks and thereafter every month was initiated. Before initiating treatment with secukinumab, the patient had a PASI score of 25 and a dermatology life quality index (DLQI) score of 20. After 3 months of treatment, her lesions had fully resolved (PASI = 0) and quality of life had improved significantly (DLQI = 0). The patient continued with 300 mg secukinumab every month with good response. At 6 months follow‐up, the patient reported only minor flare‐ups and quality of life was not affected (DLQI = 0). After 10 months of treatment with secukinumab, the patient experienced severe worsening of psoriasis with a PASI score of 18.2, and in March 2018, she discontinued secukinumab and initiated treatment with ustekinumab 90 mg every 3 months. Ustekinumab was well tolerated and with sustained effectiveness, despite a short‐term guttate flare‐up in December 2018 with PASI 5 and DLQI 1, until April 2019. No relapse of MM has been suspected. She is currently treated with ustekinumab.

3. COMMENT

In this case of a 53‐year‐old woman with recent history of cerebral MM metastasis sequential biologic therapy with secukinumab and ustekinumab for almost 2 years was well tolerated and apparently not associated with relapse of cancer or any other adverse events. Still, every case of severe psoriasis and oncologic co‐conditions should be evaluated individually before initiating biologic therapy.1 Because severe psoriasis has a great impact on patients’ quality of life, biologic therapy may be a treatment option for selected patients with recent cancer.

CONFLICT OF INTEREST

None declared.

AUTHOR CONTRIBUTIONS

MNG: wrote the article, intellectual input and revision. TK and PLD: involved in patient care, intellectual input and revision. SFT: conceived and wrote the article.

Ghazanfar MN, Karlsmark T, Danielsen PL, Thomsen SF. Sequential treatment with secukinumab and ustekinumab in a patient with severe psoriasis and recent history of cerebral malignant melanoma metastasis. Clin Case Rep. 2019;7:1350–1351. 10.1002/ccr3.2225