10.5826/dpc.1303a178
text/xml
2160-9381
2908
en
Concetta Potenza
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Efficacy of Cemiplimab in a Patient Affected by Cutaneous Squamous Cell Carcinoma and Myelodysplastic Syndrome
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Letter to the Editor
2023-07-31
2022-10-13
2023-07-31
2023-08-24
e2023178
Dermatol Pract Concept
Concetta Potenza
2023/07/31
10.5826/dpc.1303a178
e2023178
a:1:{s:5:"en_US";s:27:"Sapienza University of Rome";}
2160-9381
en
e2023178
Jelinek T, Mihalyova J, Kascak M, et al. PD-1/PD-L1 inhibitors in haematological malignancies: update 2017. Immunology. 2017 Nov;152(3):357-371
Efficacy of Cemiplimab in a Patient Affected by Cutaneous Squamous Cell Carcinoma and Myelodysplastic Syndrome
https://dpcj.org/index.php/dpc/article/download/2908/2217
          Efficacy of Cemiplimab in a Patient Affected
            by Cutaneous Squamous Cell Carcinoma
                 and Myelodysplastic Syndrome
                 Ilaria Proietti1, Ersilia Tolino1, Nicoletta Bernardini1, Marco Di Fraia1,
                                     Nevena Skroza1, Concetta Potenza1


1 Department of Medico-Surgical Sciences and Biotechnologies, Polo Pontino, Sapienza University of Rome, Italy



Citation: Proietti I, Tolino E, Bernardini N, Di Fraia M, Skroza N, Potenza C. Efficacy of Cemiplimab in a Patient Affected by Cutaneous
Squamous Cell Carcinoma and Myelodysplastic Syndrome. Dermatol Pract Concept. 2023;13(3):e2023178.
DOI: https://doi.org/10.5826/dpc.1303a178
Accepted: February 28, 2023; Published: July 2023
Copyright: ©2023 Proietti et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Di Fraia Marco, MD, Department of Medico-Surgical Sciences and Biotechnologies, Polo Pontino,
Sapienza University of Rome, Corso della Repubblica, 79, 04100, Latina (LT), Italy. E-mail: marco.difraia@uniroma1.it




Dear Editor,                                                             patients with cSCC is still under study, for this population is
                                                                         often excluded from clinical trials [3].
We have read with interest the article by Michela Lai et al                   Herein we present the case of a hematologic patient af-
entitled “Cutaneous squamous cell carcinoma in patients                  fected by cSCC treated with cemiplimab.
with chronic lymphocytic leukemia: a systematic review of                     A 73-year-old man showed a painful, ulcerated firm
the literature” [1].                                                     nodule of the lower left hemilip (Figure 1A) and a nodular
    Cutaneous squamous cell carcinoma (cSCC) is the sec-                 ulcerated lesion in the submental region (Figure 1B). The pa-
ond most common malignant neoplasm of the skin. Immu-                    tient also complained about remarkable fatigue. He has been
nosuppressed patients can develop cSCC more frequently                   suffering from myelodysplastic syndrome (MDS) for around
than average population, and these cancers seem to behave                two years. A diagnosis of a type 2 Refractory Anemia with
more aggressively with a lower degree of differentiation [2].            Excess of Blasts (RAEB-2) was made after bone marrow as-
Naturally, hematologic patients have an immunosuppressed                 piration (2016 WHO classification). The patient was under
status due to their disease and to its treatment.                        treatment with systemic antibiotics and 5-azacytidine.
    Immunotherapy (IT) is assuming an important role in the                   Excisional (free margins) skin biopsy of the labial lesion
treatment of cSCC: cemiplimab, an inhibitor of Programmed                revealed a G3 cSCC, with skeletal muscle and bone inva-
Death receptor-1 (PD-1) has been approved for patients af-               sion (pT3 according to AJCC staging system). No biopsy
fected by cSCC, not eligible to curative surgery and radio-              was performed for the ulcerated lesion of the submental re-
therapy. However, the use of immunotherapy in hematologic                gion. The patient underwent a positron emission computed




Letter to the Editor | Dermatol Pract Concept. 2023;13(3):e2023178                                                                         1
tomography (PET/CT) with 18-fluorodeoxyglucose that                   Table 1. Results of laboratory tests performed
showed two areas of pathologic tracer uptake in the lower               before starting cemiplimab (W0) and after
left hemilip, extended to the jaw, and in the submental re-                     15 weeks (W15) of therapy.
gion. In addition, the exam documented mildly increased
                                                                                                     W0                   W15
tracer uptake in the humeral and femoral diaphyses, refer-
                                                                         Hemoglobin              8.6 g/dl              10.7 g/dl
able to the MDS, and some pathologic cervical adenopathies.                                                 3
                                                                         Neutrophils             0.4 x10 /µl           0.5 x103/µl
    Thus, the patient started treatment with cemiplimab, 350
                                                                         Lymphocytes             0.2 x103/µl           0.7 x103/µl.
mg every three weeks. After five administrations, marked                                                  3
                                                                         Platelets               50 x10 /µl             74 x 103/µl
clinical improvement of the submental region was observed
(Figure 2) while there was no local relapse in the labial re-
gion. Moreover, the patient reported notable pain and fa-
tigue reduction.
                                                                        The PD-1/PD-L1 axis is involved in the pathogenesis of
    Results of laboratory tests performed before starting
                                                                    many hematological malignancies. For this reason, anti-PD1
cemiplimab and after 15 weeks of therapy are reported in
                                                                    drugs might have a promising role for their treatment. In
Table 1.
                                                                    chronic lymphocytic leukemia (CLL), PD-1 is expressed on
                                                                    CD4+ and CD8+ T cells, and proliferation of these cells
                                                                    is associated with a negative prognosis. In fact, patients
                                                                    with advanced CLL stage have an increased number of
                                                                    PD1+ CD4+ T cells in the peripheral blood. PD-1 blockade
                                                                    has also shown a significant benefit in CLL patients with
                                                                    Richter syndrome [3].
                                                                        Concerning MDS pathogenesis, pathological medullary
                                                                    progenitor cells (CD34+), show an increased expression of
                                                                    checkpoint molecules, including PD1, which interfere with an
                                                                    effective T-cell-receptor (TCR) signaling and correct presenta-
                                                                    tion of the antigens to T-lymphocytes. Because of this, the use
                                                                    of immunotherapy is suggested in association with demethyl-
                                                                    ating agents, such as azacytidine [4]. These agents increase the
                                                                    expression of molecules such as cancer/testis antigens, which
                                                                    are highly immunogenic. This synergistic effect might elicit an
                                                                    increased immune response against the pathologically altered
                                                                    bone marrow progenitor cells of MDS. Phase 2 trials regard-
                                                                    ing the association of demethylating agents with various types
                                                                    of immunotherapies, including nivolumab (an anti-PD-1) are
                                                                    ongoing, and preliminary results seem promising [5].
                                                                        In our case, cemiplimab was successful for cSCC treat-
Figure 1. (A) Lower left hemilip lesion before excisional biopsy.   ment, as expected. Moreover, we suppose that cemiplimab
(B) Submental lesion.                                               in combination with 5-azacytidine improved MDS control.


                                                                    References
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2                                                                   Letter to the Editor | Dermatol Pract Concept. 2023;13(3):e2023178
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Letter to the Editor | Dermatol Pract Concept. 2023;13(3):e2023178                                                                  3
