Fulminant Hepatic Failure after Chemosaturation withPercutaneous Hepatic Perfusion and Nivolumab in a Patient withMetastatic Uveal Melanoma

Immune checkpoint inhibitors, such as nivolumab, a programmed death receptor-1 (PD-1) inhibitor, have dramatically improvedthe treatment of advanced melanomas. Chemosaturation with percutaneous hepatic perfusion (PHP) delivers chemotherapy inhigh doses directly to the liver and is a potentially effective treatment modality in metastatic uveal melanoma with livermetastases. Its safety and effectiveness have not been studied in patients also receiving immunotherapy. A 46-year-old male witha history of uveal melanoma of the right eye was found to have liver metastases. He was treated with PHP using high-dosemelphalan for 6 months with a partial response followed by progression. Two months after his last PHP treatment, the patientwas started on nivolumab. After two doses of nivolumab, the patient developed severe hepatitis that progressed to fulminanthepatic failure and death despite treatment with high-dose corticosteroids and mycophenolate mofetil. Nivolumab and otherimmune checkpoint inhibitors have been effective in treating advanced melanoma and extending life. However, there are seriousimmune adverse events that can occur. While hepatitis after taking nivolumab has been documented, fulminant hepatic failureis rare. We believe that prior PHP treatment contributed to the severity of the hepatitis and, ultimately, fulminant hepaticfailure. To our knowledge, this is the only case of fulminant hepatic failure secondary to a checkpoint inhibitor with precedingPHP. Specific precautions should be made in patients who have been exposed to PHP in the past, and further studies should bedone to assess the safety of using checkpoint inhibitors after PHP.