Immune privilege: failure of immunotherapy in controlling metastatic cutaneous melanoma to the eye

VITREOUS SEEDING OF RENAL CELL CARCINOMA IN A PATIENT RECEIVING CHECKPOINT INHIBITORS

PURPOSE

To describe a case of vitreous seeding with tractional retinal detachment as a result of metastatic renal cell carcinoma in a patient on systemic checkpoint inhibitors.

METHODS

Case report.

RESULTS

A 44-year-old Hispanic woman with a history of renal cell carcinoma with metastases to the lungs, adrenal glands, hilar lymph nodes, and peritoneum presented with a complaint of severe floaters and blurry vision of the right eye for two months. She was found to have dense, web-like vitreous opacities and a peripheral tractional retinal detachment of the right eye. Pars plana vitrectomy, membrane peeling, endolaser, air-fluid exchange, gas injection, and vitreous biopsy were performed. The vitreous and membranes were sent for cytology with stains, including AE1/AE3, PAX-8, CK-7, CA-IX, AMACR, and S-100. Cytology revealed crowded groups of glandular cells, some in papillary-like formations. Positive stains included AE1/AE3, PAX-8, CK-7, CA-IX, and AMACR.

CONCLUSION

Cytology and pathology demonstrated that vitreous seeding of metastatic renal cell carcinoma without an ocular mass lesion. It is hypothesized that the use of checkpoint inhibitors played a role in allowing for the atypical and previously unreported seeding of renal cell carcinoma to the vitreous.

Type II Collagen-Specific B Cells Induce Immune Tolerance in Th1-Skewed, Th2-Skewed, and Arthritis-Prone Strains of Mice

Antigen-specific regulatory T cells play key immune suppressive roles in autoimmune disease models and regulate the peripheral tolerance achieved via anterior chamber-associated immune deviation (ACAID). Articular cartilage has type II collagen (CII), which is a potent autoantigen protein in arthritis. There has not been much research on the clinical importance of CII-associated diseases. Moreover, the capability of CII to induce immune tolerance has not been previously assessed. We reported that delivery of CII either directly into the eye or via intravenous injection of CII-specific ACAID antigen presenting cells (APCs) can induce ACAID. Here, we hypothesized that peripheral tolerance can be induced following adoptive transfer of in vitro generated CII-specific ACAID B cells to naive mice. Delayed hypersensitivity (DTH) assays were used to assess the suppressive ability of adoptively transferred B cells. Immune responses of ACAID B cell-injected mice were significantly suppressed following challenges with CII as compared to positive controls. This effect was replicated in three different strains of mice (C57BL/6, BALB/c, and DBA/1). Thus, CII-specific ACAID B cells were able to induce immune tolerance in Th1-skewed, Th2-skewed, and arthritis-prone mice. ACAID B cell-mediated tolerance induced by CII could have therapeutic implications for the treatment of CII-mediated autoimmune diseases.

Immunotherapy-Resistant Vitreoretinal Metastatic Melanoma

Purpose

To describe 2 cases of vitreoretinal metastases in patients treated with immunotherapy for metastatic melanoma.

Methods

Retrospective case series.

Results

We pre-sent 2 patients with metastatic melanoma treated with systemic immunotherapy with subsequent development of ocular vitreoretinal metastasis. The first patient was a male with metastatic melanoma from a site of unknown origin that was in complete remission following a course of ipilimumab and nivolumab therapy. He presented to an outside provider for evaluation of vitritis and a pigmented lesion in the right eye that was presumed secondary to toxoplasmosis. After failing initial management with oral antibiotics, he underwent diagnostic pars plana vitrectomy, and vitreous biopsy was consistent with metastatic melanoma to the vitreous. He was additionally found to have an elevated pigmented retinal mass consistent with a retinal metastasis from melanoma that initially failed treatment with plaque brachytherapy and ultimately required enucleation. The second case was a monocular male with metastatic melanoma from cutaneous melanoma with decreased vision 3 months after the initiation of nivolumab therapy. He presented with dense vitreous debris in his seeing eye and was thought to have nivolumab-associated inflammation. He was initially treated with difluprednate with improved vision and decrease in vitreous debris, but developed dense pigment deposition in the affected eye later in the treatment course. Diagnostic pars plana vitrectomy was performed, and vitreous biopsy was positive for malignant melanoma cells. His systemic disease was in remission at the time of diagnosis of ocular metastasis. External beam radiation was recommended given his monocular status.

Conclusion

Vitreoretinal metastasis can develop despite favorable systemic response to immunotherapy in patients with metastatic cutaneous melanoma. Lack of ocular penetration and extension of life span with immunotherapeutic agents may be the underlying mechanism for vitreoretinal metastasis.

Intravitreous Cutaneous Metastatic Melanoma in the Era of Checkpoint Inhibition: Unmasking and Masquerading

PURPOSE

Cutaneous melanoma metastatic to the vitreous is very rare. This study investigated the clinical findings, treatment, and outcome of patients with metastatic cutaneous melanoma to the vitreous. Most patients received checkpoint inhibition for the treatment of systemic disease, and the significance of this was explored.

DESIGN

Multicenter, retrospective cohort study.

PARTICIPANTS

Fourteen eyes of 11 patients with metastatic cutaneous melanoma to the vitreous.

METHODS

Clinical records, including fundus photography and ultrasound results, were reviewed retrospectively, and relevant data were recorded for each patient eye.

MAIN OUTCOME MEASURES

Clinical features at presentation, ophthalmic and systemic treatments, and outcomes.

RESULTS

The median age at presentation of ophthalmic disease was 66 years (range, 23-88 years), and the median follow-up from diagnosis of ophthalmic disease was 23 months. Ten of 11 patients were treated with immune checkpoint inhibition at some point in the treatment course. The median time from starting immunotherapy to ocular symptoms was 17 months (range, 4.5-38 months). Half of eyes demonstrated amelanotic vitreous debris. Five eyes demonstrated elevated intraocular pressure, and 4 eyes demonstrated a retinal detachment. Six patients showed metastatic disease in the central nervous system. Ophthalmic treatment included external beam radiation (30-40 Gy) in 6 eyes, intravitreous melphalan (10-20 μg) in 4 eyes, enucleation of 1 eye, and local observation while receiving systemic treatment in 2 eyes. Three eyes received intravitreous bevacizumab for neovascularization. The final Snellen visual acuity ranged from 20/20 to no light perception.

CONCLUSIONS

The differential diagnosis of vitreous debris in the context of metastatic cutaneous melanoma includes intravitreal metastasis, and this seems to be particularly apparent during this era of treatment with checkpoint inhibition. External beam radiation, intravitreous melphalan, and systemic checkpoint inhibition can be used in the treatment of ophthalmic disease. Neovascular glaucoma and retinal detachments may occur, and most eyes show poor visual potential. Approximately one quarter of patients demonstrated ocular disease that preceded central nervous system metastasis. Patients with visual symptoms or vitreous debris in the context of metastatic cutaneous melanoma would benefit from evaluation by an ophthalmic oncologist.

Stereotactic Radiotherapy for Oligometastasis

Oligometastatic disease is defined as “a condition with a few metastases arising from tumors that have not acquired a potential for widespread metastases.” Its behavior suggests a transitional malignant state somewhere between localized and metastatic cancer. Treatment of oligometastatic disease is expected to achieve long-term local control and to improve survival. Historically, patients with oligometastases have often undergone surgical resection since it was anecdotally believed that surgical resection could result in progression-free or overall survival benefits. To date, no prospective randomized trials have demonstrated surgery-related survival benefits. Short courses of highly focused, extremely high-dose radiotherapies (e.g., stereotactic radiosurgery and stereotactic ablative body radiotherapy (SABR)) have frequently been used as alternatives to surgery for treatment of oligometastasis. A randomized study has demonstrated the overall survival benefits of stereotactic radiosurgery for solitary brain metastasis. Following the success of stereotactic radiosurgery, SABR has been widely accepted for treating extracranial metastases, considering its efficacy and minimum invasiveness. In this review, we discuss the history of and rationale for the local treatment of oligometastases and probe into the implementation of SABR for oligometastatic disease.