What are the considerations for using neoadjuvant therapy in a patient with a history of giant cell arteritis (GCA) and currently being treated with tocilizumab (interleukin-6 receptor inhibitor) for melanoma?

Neoadjuvant Therapy in Melanoma with Active GCA on Tocilizumab

In a patient with GCA currently treated with tocilizumab who requires neoadjuvant therapy for melanoma, you must first document complete GCA remission with current vascular imaging (MRA/CTA) before initiating immune checkpoint inhibitors, as active vascular inflammation substantially increases the risk of catastrophic complications. 1

Critical Pre-Treatment Assessment

Document current GCA disease status before any melanoma treatment:

• Obtain MRA or CTA of large vessels to distinguish active inflammation from stable/healed vascular changes 1
• Do not rely on ESR/CRP levels—tocilizumab suppresses these markers and can mask ongoing inflammation while vascular damage progresses 2, 3
• Clinical vascular examination including four-extremity blood pressures, pulse examination, and auscultation for bruits 3
• Assess for any new symptoms: headache, visual changes, jaw claudication, or limb claudication 1

Decision Algorithm Based on GCA Status

If GCA shows sustained remission on imaging:

• Checkpoint inhibitors can be considered, as melanoma mortality risk must be weighed against the risk of reactivating controlled autoimmune disease 1
• The history of GCA treated with tocilizumab is not an absolute contraindication to checkpoint inhibitor therapy 1

If GCA shows active inflammation on imaging:

• Do not initiate checkpoint inhibitors—this substantially increases risk of catastrophic vascular complications 1
• Optimize GCA control first by escalating immunosuppressive therapy 4
• Consider adding high-dose glucocorticoids (40-60 mg prednisone daily) or increasing tocilizumab dose 1

Intensive Monitoring Protocol During Checkpoint Inhibitor Therapy

Implement the following surveillance regimen:

• Clinical vascular examination at each oncology visit 1
• Four-extremity blood pressures at each visit 1
• Serial vascular imaging (MRA/CTA) every 3-6 months during early checkpoint inhibitor therapy 1
• Maintain low threshold for obtaining urgent vascular imaging if any new symptoms develop 1

Management of GCA Reactivation During Checkpoint Inhibitors

If GCA flares during melanoma treatment:

• Immediately increase glucocorticoids to 40-60 mg prednisone daily 1
• Consider adding or increasing tocilizumab dose if not already optimized 1
• The ACR recommends adding a non-glucocorticoid immunosuppressive agent when GCA relapses with cranial ischemia symptoms 4

Critical Pitfalls to Avoid

Do not delay melanoma treatment indefinitely waiting for "perfect" GCA control—melanoma mortality must be factored into the risk-benefit equation, particularly for stage III/IV disease 1. However, this does not mean proceeding with active vascular inflammation present on imaging.

Do not assume normal inflammatory markers indicate inactive GCA in a patient on tocilizumab—clinical symptoms and imaging are paramount for disease assessment 1, 2. Tocilizumab suppresses ESR/CRP, potentially masking ongoing inflammation 2, 3.

Do not use checkpoint inhibitors during active GCA with ongoing inflammation on imaging—this creates unacceptable risk of vascular catastrophe including vision loss, stroke, or limb ischemia 1.

Glucocorticoid Management Considerations

If initiating or escalating glucocorticoids for GCA control before melanoma treatment, use high-dose oral glucocorticoids (typically 40-60 mg prednisone daily) to achieve rapid disease control 4. For patients with threatened vision loss, IV pulse glucocorticoids should be considered over high-dose oral glucocorticoids 4.

The combination of tocilizumab with glucocorticoids is conditionally recommended over glucocorticoids alone for newly diagnosed or relapsing GCA 4, which supports continuing tocilizumab throughout melanoma treatment if GCA remains controlled.