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Hypopigmentation Associated With an Adenovirus-Mediated gp100/MART-1–Transduced Dendritic Cell Vaccine for Metastatic Melanoma
Hensin Tsao, MD, PhD;
Peri Millman, MD;
Gerald P. Linette, MD, PhD;
F. Stephen Hodi, MD;
Arthur J. Sober, MD;
Mark A. Goldberg, MD;
Frank G. Haluska, MD, PhD
Arch Dermatol. 2002;138:799-802.
ABSTRACT
Background Reports of vitiligo associated with metastases and rare cases of spontaneous
regression of disease have fueled enthusiasm for immunologic approaches to
the treatment of advanced melanoma. More recent strategies have focused on
using antigen-presenting dendritic cells as vaccines.
Observations We observed 3 cases of leukoderma associated with a novel adenovirus-mediated
gp100/MART-1–transduced dendritic cell (MART indicates melanoma antigen
recognized by T cells). All 3 patients had advanced metastatic melanoma. Despite
the development of this leukodermic response, all patients experienced disease
progression while under treatment.
Conclusion We provide the initial evidence for effective induction of a leukodermic
response with a gp100/MART-1–transduced dendritic cell vaccine.
INTRODUCTION
BECAUSE OF the lack of effective therapies, the prognosis is poor for
patients with advanced metastatic disease. Recently, as evidence from the
literature points to a critical role for the immune system in tumor surveillance
and destruction, much attention has been devoted to immunologically based
therapies.
Patients with melanoma have been reported to develop vitiligolike changes
called melanoma-associated hypopigmentation (MAH).1-2
One hypothesis is that MAH occurs as an adverse effect of the immunologic
destruction of tumor (ie, normal melanocytes are destroyed as a bystander
effect). This is consistent with several case series that suggest a better-than-expected
outcome for patients with cutaneous melanoma who develop MAH.1-4
However, since the effect is dramatic and the number of known cases is small,
these MAH series are susceptible to reporting bias; furthermore, survival
rates reported in these studies were based on historic rather than contemporaneous
controls.
In addition to the descriptive studies of MAH, vitiligolike changes
have also been reported in clinical trials for metastatic melanoma, especially
those using immunotherapy. Rosenberg and White5
reported vitiligo in 26% of patients with melanoma who responded to high-dose
interleukin 2; all patients with vitiligo had objective responses: none of
the nonresponders or patients with renal cell carcinoma who received interleukin
2 developed vitiligo. Furthermore, using vaccination approaches, Trefzer et
al6 and Jager et al7
reported vitiligo in patients who had stable disease6
or regression of metastases.7 One possibility
for these observations is that the vitiligo results from sensitization to
antigens shared by melanocytes and melanoma cells.
In contrast to biotherapy with interleukin 2, more recent strategies
have focused on using dendritic cells (DCs) as vaccines to enhance antigen-specific
immunity. Dendritic cells are theoretically advantageous in a vaccination
paradigm since they combine specificity and potency in the activation of antitumor
cytolytic T lymphocytes. Although there is general agreement as to the potential
benefits of DC therapy, there is a lack of consensus regarding the best vaccination
protocols. Several DC trials for metastatic melanoma have been recently published.
Nestle et al8 observed objective responses
in 5 of 16 patients (2 complete and 3 partial responses) when DCs were loaded
with peptides derived from tyrosinase, MART-1, gp100, MAGE-1, and MAGE-3 and
injected directly into the lymph nodes (MART indicates melanoma antigen recognized
by T cells; MAGE, melanoma-associated antigen). Using a similar panel of peptides
but intravenous vaccination, Mackensen et al9
reported a partial clinical response in 1 of 14 patients. Finally, when Thurner
et al10 loaded DCs with a single MAGE-3A1 peptide
and vaccinated patients by intradermal and intravenous routes,10
they observed partial regression in 6 of 11 patients. In terms of cutaneous
immunologic responses, Nestle et al8 observed
regression of a single melanocytic nevus in 1 patient, and Mackensen et al9 reported the development of generalized vitiligo in
1 patient of 14. In both cases, the patients' disease progressed despite their
having undergone the vaccination.
PATIENTS, MATERIALS, AND METHODS
We adopted a novel vaccination approach using adenovirus-mediated transduction
of melanocyte-specific antigens gp100 and MART-1 into DCs.11
Since the exogenously introduced gene is processed by the DC's natural antigen-presenting
machinery, the entire spectrum of gp100 and MART-1 peptide epitopes are theoretically
available for cytolytic T-lymphocyte activation. In our phase 1 vaccine trial
of gp100/MART-1–transduced DCs for metastatic melanoma, we found that
3 of 12 patients who underwent vaccination developed leukoderma. However,
all 3 patients also experienced disease progression while under this treatment;
therefore, the response was not associated with tumor eradication.
This trial was approved by the Massachusetts General Hospital Institutional
Review Board and the Food and Drug Administration. All patients provided written
informed consent. Vaccinations were performed every 2 to 3 weeks. Although
patient peripheral blood samples were collected for final analysis, immunologic
end points for this phase 1 trial are not available.
REPORT OF CASES
CASE 1
A 42-year-old man presented with a 1.2-mm-thick level IV melanoma on
the right flank in July 1996. Three years later, the patient developed adenopathy
in the right axilla, and a dissection revealed 9 of 18 lymph nodes with metastatic
deposits. The patient was treated with interferon alfa-2a for 6 months, but
his disease eventually progressed with a tracheal node metastasis.
The patient was then enrolled in our gp100/MART-1 adenovirus–transduced
DC vaccine trial. In June 1999, the patient received an injection of 7.5 x
106 DCs in his back. Within 3 days, he developed new areas of leukoderma
over the dorsa of both hands and his left forearm (Figure 1). A Wood light examination of the affected areas showed
chalky white pigment loss consistent with total depigmentation. Confirmatory
biopsy specimens of normal and leukodermic areas under MART-1 (Figure 2) and hematoxylin-eosin (data not shown) staining demonstrated
a complete absence of MART-1–positive melanocytes in a leukodermic area
(data not shown).
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Figure 1. Irregular areas of leukoderma
on the forearm of patient 1. Wood light examination of the left forearm showed
chalky white areas clinically suggestive of a complete loss of melanocytes.
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Figure 2. Case 1. A, Biopsy specimen of
normal skin stained with melanocyte-specific anti–MART-1 antibody showing
junctional immunostaining of melanocytes but no intraepidermal immunostaining
of Langerhans cells (original magnification x100). B, Biopsy specimen
of a hypopigmented area stained with anti–MART-1 showing complete absence
of vacuolated melanocytes and immunostaining along the dermoepidermal junction
(original magnification x400).
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Despite the apparent leukodermic response, computed tomographic scans
2 months later showed further growth of paratracheal and anterior mediastinal
nodal deposits along with development of new subdiaphragmatic, pararenal,
and splenic metastases. By the end of his fifth and final vaccine dose, the
patient's leukoderma had generalized to involve the trunk, neck, and upper
extremities. With progressive thoracic, cutaneous, and bony disease, the patient
began dacarbazine and palliative radiation therapy to the mediastinum in April
2000.
CASE 2
In June 1996, a 65-year-old man presented with left axillary lymphadenopathy
that revealed metastatic melanoma. The patient had no history of cutaneous
melanoma, and no primary tumor was found on skin examination. The patient
began a year of high-dose interferon alfa-2a therapy but subsequently developed
left supraclavicular and pectoral nodal disease.
In February 1999, the patient developed pulmonary disease and was enrolled
in the gp100/MART-1 adenovirus–transduced DC vaccine trial. He initially
received a dose of 7.5 x 106 DCs. Two weeks after his first
vaccination, the patient's disease progressed to adrenal and liver involvement.
By his third vaccination, the patient experienced progression of pulmonary
and abdominal disease and recurrence of his axillary disease.
One week prior to the fourth vaccine dose in June 1999, the patient
noted the appearance of leukoderma that was confluent on his distal fingers
(Figure 3) and scattered as small
irregularly shaped macules on his upper chest and back. With his fifth vaccination,
the patient had partial regression of a supraclavicular node. Furthermore,
with his final vaccination, the patient's leukoderma lesions increased in
number and size to involve his forehead, shoulders, and both hands, including
the wrists. Despite the widespread pigmentary involvement, the patient developed
ulcerating gastric metastases and died.
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Figure 3. Loss of pigmentation along the
distal fingertips of patient 2. Small 1- to 2-mm circular macules of pigmentation
can be seen on the fingers. Delineation of the leukoderma is most clear at
the metacarpal joint.
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CASE 3
A 74-year-old woman with no history of cutaneous melanoma presented
with right axillary metastasis in April 1998. Initially, palliative radiation
therapy for chest wall disease and a nodal dissection was performed. A year
later, however, the patient developed bilateral lung metastases and was enrolled
in a gp100/MART-1 adenovirus–transduced DC vaccine trial in September
1999. The patient initially received a dose of 7.5 x 106
cells along with low-dose interleukin 2 treatment (0.9 x 106
U/m2 per day on days 4-19 of each cycle).
After the third vaccine dose in November 1999, the patient developed
islands of leukoderma extending from the shoulder blades up to the nape of
the neck posteriorly and to the midchest anteriorly. A restaging computed
tomographic scan at the onset of the pigment loss demonstrated a dramatic
increase in the number of pulmonary nodules and liver lesions suggestive of
metastasis. The patient's leukoderma stabilized after the initial onset.
One month after her final vaccine dose, the patient's melanoma rapidly
progressed with increased bony destruction, new liver lesions, and widespread
pulmonary infiltration. No further treatments were given, and the patient
died in March 2000.
COMMENT
Three patients with stage IV melanoma participating in the adenovirus-mediated
gp100/MART-1–transduced DC vaccine trial developed leukoderma during
the trial. Since the prevalence of spontaneous MAH among patients with melanoma
is 3% to 6%,3, 12-13
the leukoderma seen in our patients is unlikely to represent a chance association
between our vaccine trial and MAH. A further link between the cutaneous response
and vaccination is supported by the temporal relationship between initiation
of treatment and subsequent loss of pigmentation. Since the mechanism underlying
leukodermic responses in melanoma is still largely speculative, we propose
that the term vaccine-associated leukoderma be used
to distinguish our observations from spontaneous MAH.
Biopsy specimens of the lesional and normal skin in 1 patient (case
1) showed an apparent absence of melanocytes consistent with melanocyte destruction.
In studies of MAH, Koh et al2 described 2 distinct
patterns: (1) an absence of melanocytes and (2) macromelanocytes of reduced
density with decreased numbers of melanosomes or increased numbers of premelanosomes.2 One possibility is that the macromelanocytes observed
in spontaneous MAH represent immunologically targeted melanocytes undergoing
destruction since these macromelanocytes have been found in active borders
of vitiligo.14
In our patients, the occurrence of leukoderma was not accompanied by
any beneficial clinical response. Several possibilities exist to explain our
findings. First, melanoma cells may use mechanisms such as down-regulation
of major histocompatibility class I molecules15
to evade immune destruction. Alternatively, the vaccine may place selective
pressure on residual tumors to lose specific gp100 and MART-1 epitopes that
are targeted by the vaccine. This immunoselection has been demonstrated in
one MAGE-3A1 pulsed-DC vaccine trial in which excised metastases at the study
entry were MAGE-3 positive, and all samples removed after vaccination were
MAGE-3 negative.10 Finally, since the adenovirus-transduced
DCs present a variety of epitopes, cytolytic T lymphocytes with different
specificities may be responsible for antimelanocyte and antimelanoma effects.
In murine models using B16 melanomas, vaccination with tyrosinase-related
protein 1 leads to tumor eradication with vitiligo while vaccination with
tyrosinase-related protein 2 results in tumor clearance without skin depigmentation.16-17
Although our case series is too limited to afford prognostic information,
the presence of a minor response (case 2) among our patients with vaccine-associated
leukoderma is consistent with results from other DC vaccine trials8-9 but in direct contrast to published
results for other immunotherapeutic trials. Rosenberg and White5
reported in their study that all patients with melanoma who developed vitiligo
also had an objective response to interleukin 2. Vitiligo has also been described
in patients with melanoma vaccinated with melanoma cell lines engineered to
produce interleukin 2.18-19 In
these trials, the few patients with vitiligo also experienced stabilization
of disease. Trefzer et al6 vaccinated 16 patients
with stage IV melanoma with fused tumor/antigen-presenting cell hybrids and
described 2 patients with regionally restricted vitiligo after vaccination.
In both cases, the patients had stable disease for more than 24 months. Finally,
Jager et al7 reported progressive hypopigmentation
in 1 patient who experienced continued regression of metastatic disease under
long-term immunization with MART-1, tyrosinase, and gp100-derived peptides.
The fact that peripheral cytolytic T lymphocytes can be targeted to the skin
has been shown in a single patient with melanoma who received an infusion
of a MART-1–specific CD8+ T-cell clone and subsequently developed
inflammatory skin lesions that harbored MART-1–specific CD8+
T cells with consequent loss of MART-1–staining melanocytes.20 Although these vaccine and immunotherapy trials support
a close association between favorable outcome, we did not observe this relationship.
Moreover, since patients with vitiligo can develop cutaneous melanomas,12 the autoimmune aggression seen in vitiligo must be
distinct from potent antitumor immunity.
In summary, we describe a leukodermic response with a gp100/MART-1–transduced
DC vaccine. Although this vaccination strategy represents a novel approach
to overcome immune tolerance, eventual clinical success will require further
studies to optimize antigen presentation, to better define epitope specificity,
and to elucidate mechanisms that allow tumors to escape immunologic killing.
AUTHOR INFORMATION
Accepted for publication October 1, 2001.
This work was supported in part by Clinical Research Training Grant
CRTG-99-249-01 CCE from the American Cancer Society, Atlanta, Ga (Dr Tsao);
a K23 award from the National Institutes of Health, Bethesda, Md (Dr Linette);
and grants from the Cancer Research Institute, New York, NY, and Genzyme Corporation
Pharmaceuticals, Framingham, Mass (Dr Haluska).
We would like to thank Pat Boustedt, Any Bock, Sharon Fee, Amy Cheung,
and Rochele Henry for their assistance.
Corresponding author and reprints: Hensin Tsao, MD, PhD, Department
of Dermatology, Bartlett 622, 48 Blossom St, Massachusetts General Hospital,
Boston, MA 02114 (e-mail: htsao{at}partners.org).
From the Department of Dermatology (Drs Tsao and Sober), the Wellman
Laboratories of Photomedicine (Dr Tsao), the Melanoma Center (Drs Tsao, Sober,
and Haluska), and the Division of Oncology (Dr Haluska), Massachusetts General
Hospital, and the Department of Adult Oncology, Dana Farber Cancer Institute
(Dr Hodi), Boston, Mass; the Department of Pediatrics, Albert Einstein College
of Medicine, New York (Bronx), NY (Dr Millman); the Department of Medicine,
Washington University, St Louis, Mo (Dr Linette); and Genzyme Molecular Oncology,
Framingham, Mass (Dr Goldberg). Dr Goldberg is an employee of, and owns stock
in, Genzyme Corporation Pharmaceuticals, Framingham.
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