Melanoma occurring during treatment with fingolimod for multiple sclerosis: a case report

[Multiple sclerosis and melanoma]

Multiple sclerosis (MS) is a chronic autoimmune progressive demyelinating disease of the central nervous system, mainly in young people. The clinical picture of MS has a variety of neurological symptoms, which manifests itself during periods of exacerbation or progression and stabilizes at the moments of remission. The widespread introduction of new drugs with immunosuppressive and immunomodulatory mechanisms of action has led to the development of special risk management plans for monitoring patients during therapy and preventing adverse events and new comorbid conditions. This article presents a review of the literature and a case report on the combination of MS and melanoma in patients. Melanoma can rarely develop in patients treated with DMD, so it is necessary to introduce such a specialist in dermatology and venereology into a multidisciplinary team.

Multiple sclerosis and breast cancer risk: a meta-analysis of observational and Mendelian randomization studies

Background

Several observational studies have explored the relationships between multiple sclerosis (MS) and breast cancer; however, whether an association exists remains unknown.

Methods

We conducted a meta-analysis of observational studies and Mendelian randomization (MR) based on genetic variants to identify the relationship between MS and breast cancer. The observational studies were searched from PubMed, Embase, Web of Science, and Scopus to assess the relationship between MS and breast cancer from inception to 07 Nov 2022. Moreover, we explored the association between genetically pre-disposed MS and breast cancer risk based on an MR study. The summary analysis for MS from two separate databases [International Multiple Sclerosis Genetics Consortium (IMSGC), FinnGen] and the summary analysis for breast cancer from Breast Cancer Association Consortium.

Results

Fifteen cohort studies involving 173,565 female MS patients were included in this meta-analysis. The correlation between MS and breast cancer was not statistically significant [relative ratio (RR) = 1.08, 95% confidence interval (CI) = 0.99-1.17]. In the MR analysis, we did not observe causal associations of genetically determined MS with breast cancer and its subtypes from both the IMSGC and FinnGen datasets.

Conclusion

The meta-analysis of observational and MR based on genetic variants does not support the correlation between MS and breast cancer.

Sphingosine-1 Phosphate Receptor Modulators Increase In Vitro Melanoma Cell Line Proliferation at Therapeutic Doses Used in Patients with Multiple Sclerosis

INTRODUCTION

S1P₁ receptor modulators (S1P₁-RM) are oral disease-modifying therapies (DMTs) for multiple sclerosis (MS). Several authorities have raised doubts that S1P₁-RM are responsible for an increased risk of melanoma in patients with MS. We studied the in vitro effects of S1P₁-RM on different melanoma cell lines to compare the effect of available S1P₁-RM on the proliferation of human melanoma cells.

METHODS

Four S1P₁-RM were studied which are currently approved for managing MS, namely fingolimod (Gilenya^®), siponimod (Mayzent^®), ozanimod (Zeposia^®), and ponesimod (Ponvory^®). We tested these four drugs at different concentrations, including therapeutic doses (0.5, 1.6, 5.5, 18, and 60 µM), on human melanoma cell lines (501Mel cells, 1205LU cells, and M249R cells) to analyze in vitro cell proliferation monitored with the IncuCyte ZOOM live cell microscope (Essen Bioscience).

RESULTS

At therapeutic doses, median confluence increased overall for all lineages: + 122% for ozanimod (p < 0.001), + 71% for ponesimod (p < 0.001), + 67% for siponimod (NS), and + 41% for fingolimod (p = 0.094). Ozanimod- and ponesimod-treated cells increased confluency in 501Mel, 1205LU, and M249R cell lines (p < 0.001).

CONCLUSION

These data suggest an increased proliferation of various melanoma cell lines with S1P₁-RM treatments used at therapeutic concentrations for patients with MS and should raise the question of increased dermatologic surveillance.

Breast Carcinoma After Ocrelizumab Therapy in Multiple Sclerosis Patients: A Case Series and Literature Review

Ocrelizumab is a humanized CD20 monoclonal antibody which was approved for management of Relapsing Remitting Multiple Sclerosis (RRMS) and Primary Progressive Multiple Sclerosis (PPMS) in 2017. We present 2 patients, a 67-year-old woman with history of PPMS and a 42-year-old woman with RRMS, who were started on ocrelizumab and were diagnosed with invasive ductal cell breast carcinoma after 2 years of ocrelizumab infusion followed by discontinuation of the drug. Large trials conducted for ocrelizumab showed malignancies in a total of 4 cases with RRMS in OPERA 1 trial conducted over 2 years from 2011 to 2013 (breast cancer, renal cell carcinoma, and melanomas) and in 11 cases with PPMS seen in ORATORIO trial conducted in 2017. There are currently no other published case reports of breast cancer in setting of ocrelizumab use for MS outside of large trials on literature review.

Skin care advice to patients with multiple sclerosis on Fingolimod treatment at increased risk of skin malignancy-room for improvement?

Fingolimod is used to treat relapsing-remitting multiple sclerosis. It has an immunosuppressive effect that predisposes to skin malignancies. The Summary of Product Characteristics recommends that persons receiving Fingolimod be educated regarding photoprotection and vigilance of skin lesions and should undergo a dermatological evaluation at initiation of treatment and 6-12 monthly thereafter. The incidence of keratinocytic carcinomas in those on long-term immunosuppression following solid organ transplantation is declining. This trend coincided with temporal changes in immunosuppressive protocols and the introduction of skin cancer prevention programmes suggesting that the risk of developing these malignancies may be mitigated by the provision of education to patients amongst other measures. The aim of our study was to assess if health care professionals are explaining skin advice and documenting the discussion when prescribing Fingolimod in a University Hospital outpatient setting. Clinical records of consecutive patients on Fingolimod were reviewed. Data on demographics, documented provision of advice on skin protection and who provided the advice was collected. Fifty patients with multiple sclerosis were identified. Median age was 40.5 years (range 25-63). Forty-two were female (42/50, 84%). Provision of advice regarding skin protection was documented in 20% (10/50). This was provided by nurse specialists in 14% (7/50), doctors in 10% (5/50) and both in 4% (2/50). The risk of developing skin cancers can be reduced by the adoption of simple preventative measures; patients on Fingolimod are at an increased risk of developing these cancers. This study demonstrates a need for improvement in the documentation of advice around skin protection.

Exacerbation of Multiple Sclerosis by BRAF/MEK Treatment for Malignant Melanoma: The Central Vein Sign to Distinguish Demyelinating Lesions From Metastases

The emergence of immunomodulators as effective cancer treatments has been an important advance in cancer therapy. The combination therapy of BRAF/MEK inhibition with or without anti-CTLA-4 treatment causes an immunostimulatory effect that has greatly reduced death from melanoma. In this article, we present the case of a patient with prior multiple sclerosis (MS) and who later developed metastatic malignant melanoma, had a marked increase of magnetic resonance imaging (MRI) findings after treatment with the combination of trametinib (MEK) and dabrafenib (BRAF), diagnostic question of metastatic disease versus new MS lesions without brain biopsy is discussed. A healthy 49-year-old man was diagnosed with MS in October 2012. He was stable with an oral disease modifying drug until March of 2016 when the patient discovered a lump in his right groin. Biopsy was positive for S100 and BRAF V600 mutation. Combination MEK/BRAF was given and after immunotherapy an MRI showed 25 new gadolinium-enhancing lesions thought to be metastases. A brain biopsy was recommended but neurology and neuroimaging consultation showed that the MRI was consistent with demyelination (oval/ovoid, homogeneous and open-ring enhancement, and predominance of the central vein sign within lesions) rather than metastasis. Treatment for MS has been successful and there has been no return of his melanoma in 4 years. New immunotherapies are lifesaving but the modulation of the immune system can cause unpredictable events such are markedly increased MS activity. The awareness of the diagnostic value of the central vein sign provided a better outcome for this patient and could be a model in the future for others.

Primary mediastinal large B-cell lymphoma in a patient on Fingolimod for relapsing-remitting multiple sclerosis

BACKGROUND

There are multiple case reports in the literature describing an association between fingolimod and cutaneous neoplasms.

OBJECTIVE

Investigate and report a case of a primary mediastinal large B-cell lymphoma in a patient on fingolimod for Relapsing-Remitting Multiple Sclerosis (RRMS).

METHODS

Case Report.

RESULTS

The patient developed a primary mediastinal large B-cell lymphoma after seven years of treatment with fingolimod. The patient is currently in complete remission after cessation of treatment, surgical resection, chemotherapy, and radiation therapy.

CONCLUSION

This case report highlights the first primary mediastinal large B-cell lymphoma associated with fingolimod treatment. It should be considered a rare, but potential adverse effect of fingolimod.

Sphingosine-1-Phosphate: Its Pharmacological Regulation and the Treatment of Multiple Sclerosis: A Review Article

Sphingosine-1-phosphate (S1P), via its G-protein-coupled receptors, is a signaling molecule with important regulatory properties on numerous, widely varied cell types. Five S1P receptors (S1PR1-5) have been identified, each with effects determined by their unique G-protein-driven downstream pathways. The discovery that lymphocyte egress from peripheral lymphoid organs is promoted by S1P via S1PR-1 stimulation led to the development of pharmacological agents which are S1PR antagonists. These agents promote lymphocyte sequestration and reduce lymphocyte-driven inflammatory damage of the central nervous system (CNS) in animal models, encouraging their examination of efficacy in the treatment of multiple sclerosis (MS). Preclinical research has also demonstrated direct protective effects of S1PR antagonists within the CNS, by modulation of S1PRs, particularly S1PR-1 and S1PR-5, and possibly S1PR-2, independent of effects upon lymphocytes. Three of these agents, fingolimod, siponimod and ozanimod have been approved, and ponesimod has been submitted for regulatory approval. In patients with MS, these agents reduce relapse risk, sustained disability progression, magnetic resonance imaging markers of disease activity, and whole brain and/or cortical and deep gray matter atrophy. Future opportunities in the development of more selective and intracellular S1PR-driven downstream pathway modulators may expand the breadth of agents to treat MS.

Multiple Sclerosis Treatment and Melanoma Development

Therapy of multiple sclerosis (MS) with disease-modifying agents such as natalizumab or fingolimod has been associated with the development of cutaneous melanoma. Here we briefly revise literature data and report of a case of a 48-year old woman who developed a melanoma and several atypical naevi after sub sequential treatment with natalizumab (1 year) and fingolimod (7 years). By immunohistochemistry we observed the presence of T cells and leukocyte infiltration as well as of vascular endothelial growth factor (VEGF)-A expression in the patient melanoma biopsy. Then, we analyzed proliferation, migration and VEGF-A expression in three melanoma cell lines and found out that both natalizumab and fingolimod inhibited tumor cell proliferation but promoted or blocked cell migration depending on the cell line examined. VEGF-A secretion was augmented in one melanoma cell line only after fingolimod treatment. In conclusion, our in vitro data do not support the hypothesis of a direct action of natalizumab or fingolimod on melanoma progression but acting on the tumor microenvironment these treatments could indirectly favor melanoma evolution.

Detection of a new melanoma in a patient treated with fingolimod

In addition to the TRANSFORMS, FREEDOMS, INFORMS studies, very few publications have identified new cases of skin cancer in patients treated with fingolimod. Here, we present the case of a 52-year-old Caucasian patient with relapsing remitting multiple sclerosis for 19 years, with a phototype II with blue eyes, light brown hair, no personal or family history of melanoma and a low number of naevi (<10). She did not experience intense sun exposure in childhood as well as severe sunburn and did not practise sessions in ultraviolet cabins. This case is distinguished from other published cases, usually superficial spreading malignant melanoma by its unclassifiable histological character. The occurrence of skin cancers in patients with multiple sclerosis remains exceptional, but new cases have recently emerged requiring the strengthening of dermatological follow-up of such patients.

Synergistic effects of vemurafenib and fingolimod (FTY720) in vemurafenib‑resistant melanoma cell lines

Vemurafenib, a selective inhibitor of mutated BRAF, is used to treat late‑stage melanoma. However, resistance to vemurafenib is urgently required as it can have fatal consequences. Fingolimod (FTY720), a sphingosine‑1‑phosphate receptor modulator, has been used for the treatment of several malignant neoplasms in clinical trials. The present study investigated the effects of FTY720 and vemurafenib combination treatment on cell death induction, and defined the molecular mechanisms in vemurafenib‑resistant melanoma cells. The combination treatment with FTY720 and vemurafenib reduced cell viability, and the expression of apoptosis‑associated cleaved poly (adenosine diphosphate‑ribose) polymerase (PARP) was increased when compared with treatment with vemurafenib alone in WM‑115 cells, a vemurafenib‑resistant human melanoma cell line. In addition, the protein expression of phosphorylated extracellular signal‑related kinase (ERK) in WM‑115 cells was decreased by this combination treatment. Vemurafenib‑resistant SK‑Mel‑28 cells (R‑SK‑Mel) were established by culturing SK‑Mel‑28 cells, which are the most sensitive to vemurafenib, in the presence of vemurafenib. Similar to WM‑155 cells, the viability of R‑SK‑Mel cells was reduced and the expression of cleaved PARP was increased by the combination treatment with FTY720 and vemurafenib. In addition, the expression of phosphorylated ERK and Akt was also reduced by this treatment. These results suggested that FTY720 and vemurafenib synergistically induced cell death by downregulating proliferation and survival signalling pathways in vemurafenib‑resistant melanoma cells.

A multicentric pharmacovigilance study: collection and analysis of adverse drug reactions in relapsing-remitting multiple sclerosis patients

Purpose

We performed a pharmacovigilance study of 10 drugs used in patients with relapsing-remitting multiple sclerosis (RR-MS). Our aim was to provide an overview of the safety of these drugs by the evaluation of reported expected and unexpected adverse reactions.

Patients and methods

We collected and analyzed adverse drug reactions from RR-MS patients belonging to four hospitals in three Italian regions, for a period of 24 months.

Results

We received a total of 411 adverse reactions, of which 84.18% were expected and only 15.82% were unexpected. We found no correlation between the number of reported adverse reactions and the route of administration (injectable/intravenous drugs N=224, oral drugs N=187). However, oral agents have caused a greater number of unexpected moderate-to-severe adverse reactions while, in injectable and infusion therapies, they have been evaluated as mild–moderate adverse reactions.

Conclusion

Our results underscore the importance of monitoring the safety profile of multiple sclerosis therapies, with particular attention to oral agents that have been introduced later in the clinical practice.

The protumorigenic potential of FTY720 by promoting extramedullary hematopoiesis and MDSC accumulation

FTY720 (also called fingolimod) is recognized as an immunosuppressant and has been approved by the Food and Drug Administration to treat refractory multiple sclerosis. However, long-term administration of FTY720 potentially increases the risk for cancer in recipients. The underlying mechanisms remain poorly understood. Herein, we provided evidence that FTY720 administration potentiated tumor growth. Mechanistically, FTY720 enhanced extramedullary hematopoiesis and massive accumulation of myeloid-derived suppressor cells (MDSCs), which actively suppressed antitumor immune responses. Granulocyte-macrophage colony-stimulating factor (GM-CSF), mainly produced by MDSCs, was identified as a key factor to mediate these effects of FTY720 in tumor microenvironment. Furthermore, we showed that FTY720 triggers MDSCs to release GM-CSF via S1P receptor 3 (S1pr3) through Rho kinase and extracellular signal-regulated kinase-dependent pathway. Thus, our findings provide mechanistic explanation for the protumorigenic potentials of FTY720 and suggest that targeting S1pr3 simultaneously may be beneficial for the patients receiving FTY720 treatment.

Fingolimod (Gilenya) and melanoma

The Food and Drug Administration (FDA) had approved fingolimod usage for multiple sclerosis in 2010. Melanoma after the usage of fingolimod immunomodulation was reported rarely in clinical trials, and only two case reports exist in the published literature, both occurring in Europe. Most of the incidences reported in clinical trials were in-situ, whereas both case reports were of malignant melanoma. Fingolimod has been found to inhibit metastatic melanoma growth in a mouse model that depends on vascular endothelial growth factor (VEGF)-induced angiogenesis for metastasis. However, there are numerous pathways of angiogenesis and tumour growth found in vivo by which melanoma can expand that do not mandate VEGF. We report a case of superficial spreading malignant melanoma occurring after fingolimod therapy in the USA.

Development of a primary cutaneous CD30(+) anaplastic large-cell T-cell lymphoma during treatment of multiple sclerosis with fingolimod

Background:

The appearance of solid tumors und lymphomas during treatment with fingolimod was observed in studies and has been described in case reports.

Objective:

To report a case of primary cutaneous CD30(+) anaplastic large-cell T-cell lymphoma during treatment of multiple sclerosis (MS) with fingolimod.

Methods:

Case study.

Results:

Our patient developed a lymphoma a few weeks after initialization of therapy with fingolimod; 5 weeks after discontinuation of treatment the lesions resolved.

Conclusion:

Causality of fingolimod is indicated by the fact that the skin lesions appeared after commencement of treatment and resolved after discontinuation of therapy. This case serves as a reminder of the potential side effects of fingolimod.

Cutaneous Adverse Effects of Neurologic Medications

Life-threatening and benign drug reactions occur frequently in the skin, affecting 8 % of the general population and 2-3 % of all hospitalized patients, emphasizing the need for physicians to effectively recognize and manage patients with drug-induced eruptions. Neurologic medications represent a vast array of drug classes with cutaneous side effects. Approximately 7 % of the United States (US) adult population is affected by adult-onset neurological disorders, reflecting a large number of patients on neurologic drug therapies. This review elucidates the cutaneous reactions associated with medications approved by the US Food and Drug Administration (FDA) to treat the following neurologic pathologies: Alzheimer disease, amyotrophic lateral sclerosis, epilepsy, Huntington disease, migraine, multiple sclerosis, Parkinson disease, and pseudobulbar affect. A search of the literature was performed using the specific FDA-approved drug or drug classes in combination with the terms 'dermatologic,' 'cutaneous,' 'skin,' or 'rash.' Both PubMed and the Cochrane Database of Systematic Reviews were utilized, with side effects ranging from those cited in randomized controlled trials to case reports. It behooves neurologists, dermatologists, and primary care physicians to be aware of the recorded cutaneous adverse reactions and their severity for proper management and potential need to withdraw the offending medication.

Risk Mitigation Strategies for Adverse Reactions Associated with the Disease-Modifying Drugs in Multiple Sclerosis

Over the past several years, the number of disease-modifying therapies (DMTs) for the treatment of multiple sclerosis (MS) has doubled in number. The 13 approved agents have shown a wide range of efficacy and safety in their clinical trials and post-marketing experience. While the availability of the newer agents allows for a wider selection of therapy for clinicians and patients, there is a need for careful understanding of the benefits and risks of each agent. Several factors such as the medication efficacy, side-effect profile, patient's preference, and co-morbidities need to be considered. An individualized treatment approach is thus imperative. In this review, risk stratification and mitigation strategies of the various disease-modifying agents are discussed.

The antineoplastic properties of FTY720: evidence for the repurposing of fingolimod

Almost all drugs approved for use in humans possess potentially beneficial 'off-target' effects in addition to their principal activity. In some cases this has allowed for the relatively rapid repurposing of drugs for other indications. In this review we focus on the potential for re-purposing FTY720 (also known as fingolimod, Gilenya(™)), an immunomodulatory drug recently approved for the treatment of multiple sclerosis (MS). The therapeutic benefit of FTY720 in MS is largely attributed to the immunosuppressive effects that result from its modulation of sphingosine 1-phosphate receptor signalling. However, this drug has also been shown to inhibit other cancer-associated signal transduction pathways in part because of its structural similarity to sphingosine, and consequently shows efficacy as an anti-cancer agent both in vitro and in vivo. Here, we review the effects of FTY720 on signal transduction pathways and cancer-related cellular processes, and discuss its potential use as an anti-cancer drug.

Overview and safety of fingolimod hydrochloride use in patients with multiple sclerosis

INTRODUCTION

Fingolimod (Gilenya®, FTY720) is an oral sphingosine-1-phosphate analogue that was approved by the FDA in 2010 for the treatment of relapsing forms of multiple sclerosis (MS). Fingolimod's mechanism of action is primarily related to lymphocyte sequestration in primary and secondary lymphoid tissues. Phase III trials demonstrated a reduction in annualized relapse rate and MRI progression in fingolimod-treated subjects compared with both placebo and IFN-β-treated subjects. Frequent adverse effects include fatigue, gastrointestinal disturbance, headache and upper respiratory tract infection. More serious, but rare, adverse events associated with fingolimod include atrioventricular block, symptomatic bradycardia, herpetic viral infections and macular edema.

AREAS COVERED

We discuss the mechanism of action, pharmacokinetics, clinical efficacy and safety profile of fingolimod in patients with relapsing MS.

EXPERT OPINION

Fingolimod is an effective treatment for relapsing MS and its oral route of administration may be preferred by some. Fingolimod is generally well tolerated but requires diligence in patient selection and monitoring. Additional information is needed regarding risk of infection, malignancy and rebound disease with long-term use of fingolimod.

Patient experience and practice trends in multiple sclerosis - clinical utility of fingolimod

Targeting sphingosine-1-phosphate pathway with orally available immune-modulatory fingolimod (Gilenya™) therapy ameliorates relapsing-remitting multiple sclerosis (RRMS) by decreasing relapse rate as shown in FREEDOMS and TRANSFORMS. Fingolimod has also been shown to be superior to interferon-beta therapy as evidenced by TRANSFORMS. Albeit multiple benefits in treatment of multiple sclerosis including high efficacy and ease of administration, potential untoward effects such as cardiotoxicity, risk of infection, and cancer exist, thus mandating careful screening and frequent monitoring of patients undergoing treatment with fingolimod. This review outlines mechanism of action, observations, side effects, and practice guidelines on use of fingolimod in treatment of RRMS.