Audiovestibular dysfunction associated with adoptive cell immunotherapy for melanoma

OBJECTIVE

To understand the audiologic and vestibular toxicities associated with adoptive cell immunotherapy (ACI) targeting pigment-pathway antigens on melanoma and to investigate the use of intratympanic steroid injections in the treatment of these toxicities.

STUDY DESIGN

Prospective nonrandomized study.

SETTING

Tertiary clinical research center.

METHODS

Thirty-two patients with progressive metastatic melanoma who failed conventional therapy underwent ACI with T cells genetically modified to target MART-1 (n = 18) or gp100 (n = 14). All patients received serial audiometric testing. Vestibular testing was performed on patients with vestibular complaints. Patients with significant deficits received intratympanic steroid injections.

RESULTS

Of 32 patients, 15 had no hearing change, 9 had mild hearing loss, and 8 had moderate hearing loss following treatment. Ten patients received intratympanic steroid injections for mild (n = 2) or moderate (n = 7) hearing loss or for significant imbalance (n = 1). Of those with mild hearing loss (n = 9), all but 1 recovered to pretreatment hearing levels. Four of 8 patients with moderate hearing loss recovered to baseline hearing levels, and 4 had partial recovery. All 7 patients with posttreatment vestibular complaints had demonstrable vestibular dysfunction. Three of these patients demonstrated recovery to normal vestibular function. The number of modified T cells infused for therapy correlated with the degree of audiovestibular deficit.

CONCLUSION

Adoptive cell immunotherapy targeting pigment-pathway cell proteins, a novel therapy for melanoma, can induce hearing loss and vestibular dysfunction. The presumed mechanism of autoimmune attack on normal melanocytes in the cochlear stria vascularis and in the vestibular organs demonstrates the importance of melanocytes in normal inner ear function.

Fibula Flap Donor Site Wound Healing with Compression Stockings

Objective: Investigate the efficacy of graduated compression stockings (GCSs) at improving donor site skin graft take after fibula free flap (FFF).

Method: Retrospective review of 12 patients (13 donor sites) that underwent FFF for mandibular reconstruction over a 1-year period. One-third of the patients were instructed to use graduated compression stockings after removal of the initial wound-vac dressing. Wound healing was followed closely for all patients. Operative and comorbid factors were reviewed.

Results: Two patients reported regular GCS use and 2 were non-compliant. Both patients with regular use had excellent wound healing and 90% to 100% skin graft take. Of the remaining 11 donor sites, 3 had no wound complications, 4 had minor wound complications, 3 had major wound complications, and 1 was lost to follow-up. Skin graft area varied with an average of 25 cm2 for GCS patients and 60 cm2 for non-GCS. Cardiovascular disease, alcohol use, and smoking were more common among the non-GCS group with strong tendency toward patients with major wound complications. Other operative and comorbid factors were similar between groups.

Conclusion: Graduated compression stocking use demonstrates some promise for use in fibula free flap donor site healing. Patients wearing GCSs had excellent wound healing and no morbidities related to their use. Further studies are warranted to determine if improvement in fibular donor site wound healing occurs with GCS use.

Audiovestibular Dysfunction Associated with Adoptive Cell Therapy for Melanoma

Objective: 1) Understand the audiologic and vestibular toxicity associated with Adoptive Cell Therapy (ACT) for melanoma, which utilizes T-cells engineered with receptors to target the tumor-associated antigens MART-1 and gp100. 2) Investigate the use of intratympanic steroid injections in the treatment of audiovestibular dysfunction associated with ACT for melanoma.

Method: Retrospective review of 33 patients with metastatic melanoma nonresponsive to conventional therapy who underwent ACT with modified T-cells targeting MART-1 (n = 19) or gp100 (n = 14) from 2007 to 2008. All patients received serial audiometric testing. Vestibular testing was performed on patients with vestibular complaints. Patients with significant hearing loss received intratympanic steroid injections.

Results: Out of 33 patients, 16 had no hearing loss, 9 had mild hearing loss, and 8 had moderate hearing loss posttreatment. Ten patients received intratympanic steroid injections for mild (n = 3) or moderate (n = 7) hearing loss. Of those with mild hearing loss all but one recovered fully. Five of 8 patients with moderate hearing loss recovered to baseline hearing levels and 3 had partial recovery. There was vestibular dysfunction in 7 patients who underwent vestibular testing, one recovered fully, and the others showed partial recovery or no recovery. The number of modified T-cells infused for therapy correlated with the degree of audiovestibular deficit.

Conclusion: ACT targeting pigmented cell antigens is a novel therapy for melanoma that is associated with hearing loss and vestibular dysfunction. The presumed mechanism of autoimmune attack on normal melanocytes in the stria vascularis of the cochlea and vestibular organs demonstrates the importance of melanocytes in normal inner ear function.