PD-1 inhibitor use for skin malignancies in patients with solid organ and bone marrow transplants: Graft rejection, treatment responses, and survival

Importance

Solid organ transplant recipients face a markedly increased risk of aggressive skin cancers. Programmed cell death protein-1 (PD-1) inhibitors have significantly improved outcomes for advanced melanoma, squamous cell carcinoma (SCC), and Merkel cell carcinoma (MCC), but their use in transplant patients is limited by the risk of graft rejection. Data in this population remain scarce.

Objective

To evaluate rates of graft rejection, treatment responses, and survival among transplant recipients treated with PD-1 inhibitors for advanced skin malignancies.

Methods

We identified 16 solid organ transplants patients (14 kidney, 2 liver) and 5 allogeneic bone marrow transplant patients. Skin cancer types included 14 squamous cell carcinomas, 2 melanomas, and 5 Merkel cell carcinomas.

Results

Among 16 solid organ transplant recipients (14 kidney, 2 liver), 4 developed graft rejection. Three occurred prior to PD-1 initiation, leaving only one rejection attributable to therapy. Median survival following PD-1 initiation was longer in patients with rejection (8.3 months) compared with those who died of cancer progression (3.0 months). No bone marrow transplant recipients experienced rejection.

Conclusions and relevance

In our data (the largest reported cohort to date), most transplant recipients tolerated PD-1 inhibitors without graft rejection. Although rejection remains a serious risk, these findings suggest that PD-1 immunotherapy may be considered as a salvage option for carefully selected patients with advanced skin cancer.