Honeycomb buccal mucosa lesions induced by checkpoint inhibitors

Moreno-Vílchez, Carlos; Servitje, Octavio; Marcoval, Joaquim

doi:10.1016/j.medcli.2021.07.022

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We report 3 consecutive cases treated with checkpoint inhibitors for advanced solid tumors in whom muco-cutaneous lichenoid lesions developed. We emphasize in the clinical features of the oral manifestations.A 66-year-old man presented with a 1-month history of asymptomatic reticular streaks affecting the lip and buccal mucosa (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Physical examination also revealed multiple polygonal erythematous papules on the wrists. The patient had a history of metastatic cutaneous melanoma and was included two years ago in a phase III clinical trial with pembrolizumab–levatinib vs pembrolizumab alone. The mucocutaneous manifestations started between cycles 25 and 26 of treatment. The clinical findings were consistent with lichen planus-like drug eruption possibly secondary to anti-PD-1 treatment. The treatment with pembrolizumab was interrupted temporally and after one month in treatment with oral corticoids the lesions disappeared.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>A 74-year-old man, with metastatic clear cell renal carcinoma on treatment with nivolumab, presented with a 3-month history of erythematous polygonal papules with fine desquamation involving the wrists and upper legs. Asymptomatic reticular confluent lesions were present in lip and buccal mucosa. The lesions developed after his second cycle of nivolumab. A lichenoid reaction to nivolumab was suspected and a biopsy of a papular lesion of the wrist was performed, confirming the diagnosis. After two months with topical corticosteroids the improvement was remarkable.A 57-year-old woman, with a stage IV lung adenocarcinoma received nivolumab during 8 months until disease progression, was referred for pruritic palmo-plantar erythematous papules. Examination also revealed confluent reticular lesions in the buccal mucosa. She received the last cycle of nivolumab 2 months before the lesions appeared. The diagnosis of lichenoid drug reaction due to anti-PD1 therapy was confirmed by a cutaneous biopsy. Treatment with topical corticosteroids was established resolving the lesions after 2 months of treatment.Pembrolizumab and nivolumab are anti-PD-1 antibodies approved for the treatment of the advanced stages of a wide variety of tumors. Cutaneous adverse events have been reported in about 8.7–42% of these patients. In this context, lichenoid drug eruptions are showing an incidence of 1.2–11%.<a class="elsevierStyleCrossRef" href="#bib0025">2</a> These 3 cases, presented with a confluent and well-defined honeycomb oral pattern, were indistinguishable from idiopathic oral lichen planus lesions. In contrast with the idiopathic form of the disease, anti-PD-1 oral lichenoid reactions reported in these patients tend to have an abrupt onset and a more limited duration. Treatment of this complication includes topical and systemic corticosteroids.<a class="elsevierStyleCrossRef" href="#bib0020">1</a> Temporally or permanent interruption of anti-PD-1 therapy only appears to be necessary in severe cases.<a class="elsevierStyleCrossRef" href="#bib0030">3</a> Early recognition and appropriate management becomes increasingly important as the number of patients on these treatments continues growing." 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Dika" 1 => "M. Lambertini" 2 => "B. Gouveia" 3 => "M. Mussi" 4 => "E. Marcelli" 5 => "E. Campione" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "J Clin Med" "fecha" => "2021" "volumen" => "101" "paginaInicial" => "1283" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0025" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lichen planus-like drug eruption on anti-PD-1 therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Kratzsch" 1 => "J.C. Simon" 2 => "M. Ziemer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/ddg.13370" "Revista" => array:6 [ "tituloSerie" => "J Dtsch Dermatol Ges" "fecha" => "2017" "volumen" => "15" "paginaInicial" => "1238" "paginaFinal" => "1240" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29211335" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0030" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous adverse reactions to anti-PD-1 treatment – a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.B. Simonsen" 1 => "J. Kaae" 2 => "E. Ellebaek" 3 => "I.M. Svane" 4 => "C. Zachariae" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2020.04.058" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2020" "volumen" => "83" "paginaInicial" => "1415" "paginaFinal" => "1424" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32320766" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00257753/0000015800000009/v1_202205040537/S0025775321005303/v1_202205040537/en/main.assets" "Apartado" => array:4 [ "identificador" => "66430" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas al Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00257753/0000015800000009/v1_202205040537/S0025775321005303/v1_202205040537/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775321005303?idApp=UINPBA00004N"]

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