corrections
1 year ago, positron-emission tomography revealed a new hypermetabolic subcutaneous nodule, which was excised and found to be melanoma with three BRAF mutations (L597Q, K601W, and S602T). Five months ago, she had another subcutaneous nodule removed, this time under her left breast. However, there was persistent disease, and when she presented to our institution, a large pedunculated necrotic mass under the left breast was evident (Fig. 1A and 1B). A computed tomographic (CT) scan also revealed left internal mammary lymphadenopathy, which was presumed to represent metastatic disease. The patient received the first treatment of ipilimumab (3 mg per kilogram of body weight) and nivolu mab (1 mg per kilogram), without substantial adverse effects. When she returned 3 weeks later for the next treatment, she reported that the tumor had “disappeared.” She was left with a cavity, as shown in Figure 1C; there was no evidence of tumor. Because of a rash, treatment was delayed for one cycle. Gentle scrapings of the cavity base were negative on cytologic examination. Six weeks after the first treatment, a repeat CT scan showed resolution of the chest-wall mass (Fig. 1D) and a decrease in size of the left internal mammary lymphadenopathy. The patient has resumed treatment. This patient had a rapid eradication of a large tumor mass after a single treatment with combination immunotherapy. We wish to bring this to the attention of our colleagues, not only as an example of the potential of immunotherapy to mediate dramatic and rapid antitumor effects, but also to point out a potential safety concern. Such an antitumor effect occurring in a transmural metastasis in the small bowel or myocardium, common sites of metastatic melanoma, could have grave consequences. It is ironic that we are now concerned about the possibility of overly vigorous antimelanoma responses. Paul B. Chapman, M.D. Sandra P. D’Angelo, M.D. Jedd D. Wolchok, M.D., Ph.D. Memorial Sloan Kettering Cancer Center New York, NY [email protected] Supported by Bristol-Myers Squibb. Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org. This letter was published on April 20, 2015, at NEJM.org. 1. Hodi FS, O’Day SJ, McDermott DF, et al. Improved survival
with ipilimumab in patients with metastatic melanoma. N Engl J Med 2010;363:711-23. [Erratum, N Engl J Med 2010;363:1290.]
2074
2. Robert C, Long GV, Brady B, et al. Nivolumab in previously
untreated melanoma without BRAF mutation. N Engl J Med 2015; 372:320-30. 3. Wolchok JD, Kluger H, Callahan MK, et al. Nivolumab plus ipilimumab in advanced melanoma. N Engl J Med 2013;369:122-33. DOI: 10.1056/NEJMc1501894 Correspondence Copyright © 2015 Massachusetts Medical Society.
instructions for letters to the editor
Letters to the Editor are considered for publication, subject to editing and abridgment, provided they do not contain material that has been submitted or published elsewhere. Please note the following: • Letters in reference to a Journal article must not exceed 175 words (excluding references) and must be received within 3 weeks after publication of the article. • Letters not related to a Journal article must not exceed 400 words. • A letter can have no more than five references and one figure or table. • A letter can be signed by no more than three authors. • Financial associations or other possible conflicts of interest must be disclosed. Disclosures will be published with the letters. (For authors of Journal articles who are responding to letters, we will only publish new relevant relationships that have developed since publication of the article.) • Include your full mailing address, telephone number, fax number, and e-mail address with your letter. • All letters must be submitted at authors.NEJM.org. Letters that do not adhere to these instructions will not be considered. We will notify you when we have made a decision about possible publication. Letters regarding a recent Journal article may be shared with the authors of that article. We are unable to provide prepublication proofs. Submission of a letter constitutes permission for the Massachusetts Medical Society, its licensees, and its assignees to use it in the Journal’s various print and electronic publications and in collections, revisions, and any other form or medium.
corrections Case 38-2014: An 87-Year-Old Man with Sore Throat, Hoarseness, Fatigue, and Dyspnea (December 11, 2014;371:2321-7). In the Cancer subsection of Differential Diagnosis (page 2324), the incidence ratios given in the second paragraph were transposed; they should have been 2.0 and 6.2, rather than 6.2 and 2.0. The article is correct at NEJM.org. Natalizumab Induction and Maintenance Therapy for Crohn’s Disease (November 3, 2005;353:1912-25). In Figure 3D (page 1920), the P values (left to right) should have been P = 0.01 and P = 0.001, rather than P = 0.003 and P
1 year ago, positron-emission tomography revealed a new hypermetabolic subcutaneous nodule, which was excised and found to be melanoma with three BRAF mutations (L597Q, K601W, and S602T). Five months ago, she had another subcutaneous nodule removed, this time under her left breast. However, there was persistent disease, and when she presented to our institution, a large pedunculated necrotic mass under the left breast was evident (Fig. 1A and 1B). A computed tomographic (CT) scan also revealed left internal mammary lymphadenopathy, which was presumed to represent metastatic disease. The patient received the first treatment of ipilimumab (3 mg per kilogram of body weight) and nivolu mab (1 mg per kilogram), without substantial adverse effects. When she returned 3 weeks later for the next treatment, she reported that the tumor had “disappeared.” She was left with a cavity, as shown in Figure 1C; there was no evidence of tumor. Because of a rash, treatment was delayed for one cycle. Gentle scrapings of the cavity base were negative on cytologic examination. Six weeks after the first treatment, a repeat CT scan showed resolution of the chest-wall mass (Fig. 1D) and a decrease in size of the left internal mammary lymphadenopathy. The patient has resumed treatment. This patient had a rapid eradication of a large tumor mass after a single treatment with combination immunotherapy. We wish to bring this to the attention of our colleagues, not only as an example of the potential of immunotherapy to mediate dramatic and rapid antitumor effects, but also to point out a potential safety concern. Such an antitumor effect occurring in a transmural metastasis in the small bowel or myocardium, common sites of metastatic melanoma, could have grave consequences. It is ironic that we are now concerned about the possibility of overly vigorous antimelanoma responses. Paul B. Chapman, M.D. Sandra P. D’Angelo, M.D. Jedd D. Wolchok, M.D., Ph.D. Memorial Sloan Kettering Cancer Center New York, NY [email protected] Supported by Bristol-Myers Squibb. Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org. This letter was published on April 20, 2015, at NEJM.org. 1. Hodi FS, O’Day SJ, McDermott DF, et al. Improved survival
with ipilimumab in patients with metastatic melanoma. N Engl J Med 2010;363:711-23. [Erratum, N Engl J Med 2010;363:1290.]
2074
2. Robert C, Long GV, Brady B, et al. Nivolumab in previously
untreated melanoma without BRAF mutation. N Engl J Med 2015; 372:320-30. 3. Wolchok JD, Kluger H, Callahan MK, et al. Nivolumab plus ipilimumab in advanced melanoma. N Engl J Med 2013;369:122-33. DOI: 10.1056/NEJMc1501894 Correspondence Copyright © 2015 Massachusetts Medical Society.
instructions for letters to the editor
Letters to the Editor are considered for publication, subject to editing and abridgment, provided they do not contain material that has been submitted or published elsewhere. Please note the following: • Letters in reference to a Journal article must not exceed 175 words (excluding references) and must be received within 3 weeks after publication of the article. • Letters not related to a Journal article must not exceed 400 words. • A letter can have no more than five references and one figure or table. • A letter can be signed by no more than three authors. • Financial associations or other possible conflicts of interest must be disclosed. Disclosures will be published with the letters. (For authors of Journal articles who are responding to letters, we will only publish new relevant relationships that have developed since publication of the article.) • Include your full mailing address, telephone number, fax number, and e-mail address with your letter. • All letters must be submitted at authors.NEJM.org. Letters that do not adhere to these instructions will not be considered. We will notify you when we have made a decision about possible publication. Letters regarding a recent Journal article may be shared with the authors of that article. We are unable to provide prepublication proofs. Submission of a letter constitutes permission for the Massachusetts Medical Society, its licensees, and its assignees to use it in the Journal’s various print and electronic publications and in collections, revisions, and any other form or medium.
corrections Case 38-2014: An 87-Year-Old Man with Sore Throat, Hoarseness, Fatigue, and Dyspnea (December 11, 2014;371:2321-7). In the Cancer subsection of Differential Diagnosis (page 2324), the incidence ratios given in the second paragraph were transposed; they should have been 2.0 and 6.2, rather than 6.2 and 2.0. The article is correct at NEJM.org. Natalizumab Induction and Maintenance Therapy for Crohn’s Disease (November 3, 2005;353:1912-25). In Figure 3D (page 1920), the P values (left to right) should have been P = 0.01 and P = 0.001, rather than P = 0.003 and P
