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Melanoma is one of the deadliest type of skin cancer, with a dismal 5-year survival rate for patients with metastatic melanoma. However, in the last decade, the development of novel immune therapy and targeted therapy has significantly improved overall survival in patients with advanced melanoma, and these therapies have replaced cytotoxic chemotherapy as the mainstay of systemic treatment. Checkpoint inhibitors, such as anti CTLA-4 and anti–PD-1 antibodies, have shown durable tumor control among responders and have emerged as the front-line therapies in the treatment of metastatic melanoma.  The co-inhibitory checkpoint receptor molecule PD-1 is highly expressed on T lymphocytes. When PD-1 binds to its ligands (PD-L1 and PD-L2), it inhibits T-cell activation and proliferation in the tumor microenvironment.1 Therefore, PD-1 binding to its ligands ultimately results in immune suppression against cancer cells. Nivolumab is an anti–PD-1 antibody that disrupts the binding of PD-1 to its ligands and restores T-cell activation and the body's immunologic response to cancer cells. It has demonstrated superior clinical efficacy, including significant improvements in overall survival and progression-free survival over anti–CTLA-4 antibody and cytotoxic chemotherapy drugs.2, 3 Common side effects associated with nivolumab include fatigue, nausea, and diarrhea but, more importantly, immune-related adverse events such as dermatitis, colitis, hepatitis, and endocrinopathies.2 Here we describe a case of granulomatous panniculitis mimicking disease progression in a patient with metastatic melanoma who was treated with nivolumab.

Diffuse granulomatous panniculitis associated with anti PD-1 antibody therapy