Case Study Highlights Uncommon Skin Rash as Possible Sign of Lung Cancer Recurrence

Nicholas C. Rohs, MD

Case studies in lung cancer allow for clinicians to gather feedback and discuss the nuances of different situations, according to Nicholas C. Rohs, MD. During the 18th Annual New York Lung Cancers Symposium®, Rohs shared a case study of a patient who had a lung cancer relapse detected following a referral to a dermatologist due to pityriasis rubra pilaris, an uncommon skin rash.

“It's valuable to have these interesting case sessions at New York Lung because we sometimes have cases that just have no right answer. It's good to present these cases to [a larger] group so we can get feedback and understand the nuances of these cases,” Rohs said in an interview with OncLive^® during the meeting.

In the interview, Rohs delved into the details of the case study, highlighting how the relapse was detected and how he approached treatment decisions and the management of toxicities experienced by this patient. Rohs is an assistant professor of medicine, hematology, and medical oncology at Mount Sinai, in New York, New York.

OncLive: Could you expand on the details of this case study on the patient who experienced a relapse of lung cancer after presenting with pityriasis rubra pilaris?

Rohs: [I picked the] case I presented because I thought it was interesting as far as how [the patient] presented with her relapse. She originally presented with an early-stage lung adenocarcinoma. It was found to have a high immune expression and a couple of unimpactful genetic changes. She was treated with surgery, and we were hoping that she was cured at that point.

However, she presented back with an [uncommon] skin rash, something called pityriasis rubra pilaris. To a thoracic oncologist, this is like speaking a different language. However, the dermatologist did a great job in identifying this as an atypical finding and sending her back to me. This was actually the first sign of her cancer recurring. There have been a couple of case reports showing that this skin rash is related to lung cancer. Therefore, that was the trigger to allow me to get a PET scan that unfortunately did confirm her relapse.

Given her [tumor’s] high immune expression, I started her on immunotherapy. However, there was a question [of how to proceed with treatment], because she had a history of psoriasis and eczema, and she had the skin rash. I was hoping that she wasn't going to have any immune-related adverse effects [irAEs]; unfortunately, she did start having some irAEs. [Notably], she was on some dermatology drugs. [Which drugs were causing the irAEs?] How do you best care for that patient? She was having some disease response. Should I continue the therapy, treat the irAEs, or do both at the same time?

There are nuances of how we pair these therapies. Do we stop them or give steroids? This is challenging in daily clinical practice, so it was great to present that case and get everybody's feedback and hear how they would approach it.

What feedback did you receive on this case? What was the back and forth regarding this study?

The interesting thing is everybody was surprised by [pityriasis rubra pilaris]. A lot of people learned about this rash being associated with lung cancer. The most valuable thing was to teach everybody that pityriasis rubra pilaris may be a sign of lung cancer recurrence.

One of the more challenging decision points was that while these [irAEs] were happening, she was on acitretin [Soriatane] and pembrolizumab [Keytruda], [creating uncertainty] about which drug was causing her skin reactions. This patient was having oral ulcers, skin rash, and digital ulcerations. We didn't know which drug was causing it. However, her dermatologist was insistent on continuing her acitretin. I stopped her immunotherapy and started her on steroids, and that did seem to help. It was nice to hear the back and forth talk about how different people would have approached that situation. We did get some varying responses, which shows that there can be a bunch of different answers to these challenging questions.

Looking at the New York Lung Cancer Symposium as a whole, what else were you excited to see during other presentations?

These meetings are so important because of the pace of thoracic oncology right now. Every meeting, we're having impactful data coming out that we need to sit down and talk about, and we need to understand the state of the science at that moment.

[It’s important to have] meetings like this with all these amazing lung cancer experts together sharing this knowledge, and each of us seems to have a little niche where we have a particular expertise within lung cancer. Learning from each other and collaborating on cases is valuable. We can look at advances in targeted therapies, particularly the EGFR space with all these new drugs coming out and combination therapies, as well as immunotherapies and combinations. Furthermore, with all these new antibody-drug conjugates and other drugs that we haven't historically used in lung cancer, we're learning more and more together.

Reference

Gralla RJ, Doroshow D, Haigentz Jr. M, Shum E, Rohs NC. Putting the data into practice: challenging cases in lung cancers. Presented at: 18th Annual New York Lung Cancers Symposium; November 11, 2023; New York, NY.