Kaposi's varicelliform eruption in a patient with metastatic melanoma and primary cutaneous anaplastic large cell lymphoma treated with talimogene laherparepvec and nivolumab

Abstract

Background: Immune-directed therapies have become front-line therapy for melanoma and are transforming the management of advanced disease. In refractory cases, multi-modal immunoncology (IO) approaches are being utilized, including combining immune checkpoint blockade (ICB) with oncolytic herpes viruses. Talimogene laherparepvec (T-VEC) is the first genetically modified oncolytic viral therapy (OVT) approved for the treatment of recurrent and unresectable melanoma. The use of IO in patients with concomitant malignancies and/or compromised immune systems is limited due to systematic exclusion from clinical trials. For example, a single case report of a solid organ transplant patient successfully treated with T-VEC for metastatic melanoma has been reported. Furthermore, the use of ICB in T-cell malignancies is limited and paradoxical worsening has been described. To our knowledge, this is the first report of dual ICB/T-VEC being administered to a patient with concurrent primary cutaneous anaplastic large cell lymphoma (pcALCL) and melanoma.

Case presentation: Here we present the case of a patient with concomitant primary cutaneous ALCL and metastatic melanoma, progressing on anti-programmed death (PD)-1 therapy, who developed Kaposi's varicelliform eruption after receiving the first dose of Talimogene laherparepvec.

Conclusion: This case highlights the complexities of care of patients with coexistent cancers, demonstrates rapid progression of primary cutaneous ALCL on nivolumab and introduces a novel adverse effect of Talimogene laherparepvec.

Keywords: Anaplastic large cell lymphoma; Immunocompromised; Kaposi varicelliform eruption; Melanoma; Talimogene laherparepvec; eczema TVECium.

Fig. 1

Timeline of the patient’s clinical course. A time reference has been included, with Day 0 referring to the day of the diagnosis of pcALCL. C1D1, cycle 1 day 1; c/f, concerning for; Dx:, diagnosis; Gy, gray; Hosp adm, hospital admission; KVE, kaposi’s varicelliform eruption; pcALCL, primary cutaneous anaplastic large cell lymphoma; R-Benda, rituximab-bendamustine; T-VEC, Talimogene laherparepvec; WBC, white blood cell count; WLE, wide-local excision; XRT, radiotherapy

Fig. 2

Progression of the patient’s primary cutaneous anaplastic large cell lymphoma. The patient’s lesions prior to nivolumab treatment (a-c); on treatment (d-h), with corresponding cycle days denoted in the white box on the bottom of each insert

Fig. 3

Kaposi’s varicelliform eruption. Scattered 2–3 mm eroded and crusted papules on the bilateral upper arms and trunk. Lesions are concentrated on the right upper arm and trunk

Fig. 4

Tzanck smear from a vesicle on the right arm. Under medium power, multinucleated giant cells with viral cytopathic effects, including nuclear molding, are seen