Combined Nivolumab and Ipilimumab or Monotherapy in Untreated Melanoma

Immune checkpoint inhibitor therapy is associated with a decreased risk of developing melanoma brain metastases

BACKGROUND

Despite recent advancements in metastatic melanoma treatment, the emergence of melanoma brain metastases (MBM) continues to pose a challenge. This study aimed to explore factors associated with MBM development.

METHODS

This retrospective study included patients diagnosed with advanced melanoma (unresectable stages III and IV [M1a-c]) between 2013 and 2019 at Sahlgrenska University Hospital, Gothenburg, Sweden. Differences in baseline and primary tumor characteristics, mutational status, biomarker levels, and first-line treatment between patients who developed MBM (BM+) and patients who did not develop MBM (BM-) were analyzed using univariable and multivariable Cox proportional hazard regression.

RESULT

Of 395 patients, 91 subsequently developed MBM. Patients who received immune checkpoint inhibitors (ICI) as first-line treatment had a reduced risk of MBM development (p ≤ 0.001). None of the eleven patients who received CTLA-4 inhibitors as monotherapy or in combination with PD-1 inhibitors as first-line treatment developed brain metastases. Elevated plasma levels of S100B (p = 0.021) and higher metastatic stage (p = 0.047) were also associated with an increased risk of MBM development.

CONCLUSION

ICI treatment is associated with a decreased risk of MBM development, suggesting a protective role. Elevated S100B levels and stage IV disease at advanced melanoma diagnosis might indicate an increased risk of MBM development.

Immune microenvironment of tumor-draining lymph nodes: insights for immunotherapy

Tumor-draining lymph nodes (TDLNs) play a crucial role in modulating tumor immune responses and influencing the efficacy of immunotherapy. However, our current understanding of the microenvironment within these lymph nodes remains limited. Tumors not only impair the anti-tumor activity of CD8+ T cells by creating an immunosuppressive microenvironment, but they also facilitate immune evasion and promote metastasis by altering the structure and function of TDLNs. Research has shown that tumor-specific memory CD8+ T cells (TTSM) within TDLNs are essential for the efficacy of immune checkpoint inhibitors, such as PD-1/PD-L1 blockers. Moreover, the abnormal structure of TDLNs, along with the presence of immunosuppressive cells-such as regulatory T cells (Tregs), regulatory B cells (Bregs), and immunosuppressive dendritic cells (DCs)-contributes to tumor-mediated immune evasion. Therefore, gaining a deeper understanding of the immune microenvironment within TDLNs is essential for improving the effectiveness of immunotherapies and developing novel therapeutic strategies. This review explores various TDLN-based therapeutic strategies, addressing the controversies surrounding lymph node dissection, the use of TDLNs as a source of tumor-infiltrating lymphocytes (TILs) for therapy, targeting immunosuppressive cells within TDLNs, and methods to reverse the structural abnormalities of TDLNs. These strategies offer valuable insights and potential directions for advancing tumor immunotherapy.

Abscopal Effects and Immunomodulation in Skin Cancer Therapy

Radiation therapy (RT) is a crucial modality in cancer treatment, functioning through direct DNA damage and immune stimulation. However, RT's effects extend beyond targeted cells, influencing neighboring cells through the bystander effect (ByE) and distant sites via the abscopal effect (AbE). The AbE, first described by Mole in 1953, encompasses biological reactions at sites distant from the irradiation field. While RT can enhance antitumor immune responses, it may also contribute to an immunosuppressive microenvironment. To address this limitation, combining RT with immune checkpoint inhibitors (ICIs) has gained renewed interest, aiming to amplify antitumor immune responses. Evidence of AbEs has been observed in various metastatic or advanced cutaneous cancers, including melanoma, basal cell carcinoma, cutaneous lymphoma, Merkel cell carcinoma, and cutaneous squamous cell carcinoma. Clinical studies suggest combining RT with ICIs targeting CTLA-4 and PD-1/PD-L1 may enhance AbE incidence in these cancers. This review primarily explores the current understanding of AbEs in skin cancers, briefly acknowledging the ByE focusing on combining RT with immunomodulation. It focuses on proposed mechanisms, preclinical and clinical evidence, challenges in clinical translation, and future directions for harnessing AbEs in managing advanced skin malignancies. Alternative modalities for inducing abscopal-like responses are also explored. While promising, challenges remain in consistently reproducing AbEs in clinical practice, necessitating further research to optimize treatment combinations, timing, and patient selection.

Exhaled breath analysis with the use of an electronic nose to predict response to immune checkpoint inhibitors in patients with metastatic melanoma: melaNose trial

Introduction

Immune checkpoint inhibitors (ICIs) have significantly improved the overall survival for patients with different solid tumors. However, there is an urgent need for predictive biomarkers to identify patients with metastatic melanoma who do not benefit from treatment with ICIs, to prevent unnecessary immune related adverse events (irAEs). Electronic noses (eNoses) showed promising results in the detection of cancer as well as the prediction of response outcome in patients with cancer. In this feasibility study, we aimed to investigate whether the breath pattern measured using eNose can be used as a simple biomarker to predict clinical benefit to first-line treatment with ICIs in patients with metastatic melanoma.

Methods

In this prospective, observational single-center feasibility study, patients with metastatic melanoma performed a breath test using Aeonose™ before start of first-line treatment with ICIs. The detected exhaled breath pattern of volatile organic compounds (VOC) was used for machine learning in a training set to develop a model to identify patients who do not benefit from treatment with ICIs. Lack of clinical benefit was defined as progressive disease according to best tumor response using RECIST v1.1. Primary outcome measures were sensitivity, specificity and accuracy.

Results

The eNose showed a distinct breath pattern between patients with and without clinical benefit from ICIs. To identify patients who do not benefit from first-line ICIs treatment, breath pattern analysis using the eNose resulted in a sensitivity of 88%, specificity of 79%, and accuracy of 85%.

Conclusion

Exhaled breath analysis using eNose can identify patients with metastatic melanoma who will not benefit from first-line treatment with ICIs and guide treatment strategies. When validated in an external cohort, eNose could be a useful tool to select these patients for alternative treatment strategies in clinical practice.

The Problem with Syngeneic Mouse Tumor Models

The advent of syngeneic mouse tumor models provided the scientific foundation for cancer immunotherapies now in widespread use. However, in many respects, these models do not faithfully recapitulate the interactions between cancer cells and the immune systems of human patients who have solid tumors because they represent a very early stage in the immune response to the newly transplanted cancer cells compared with the relatively mature stage found in human patients at the time of treatment. The lack of translatability of syngeneic models is probably responsible for many failed clinical trials conducted at considerable expense, involving far too many patients with cancer who received no benefit. Better mouse models would substantially accelerate the pace of discovery of new immunotherapies. Until these models emerge, a better understanding of the differences between the existing syngeneic models and human cancers may provide a more efficient path for moving experimental drugs into clinical development. To accomplish this, we must consider mice transplanted with syngeneic tumor cells to be in vivo assays, potentially useful for understanding the mechanism of action of immunotherapies rather than disease models.

Immune Checkpoint Molecules: A Review on Pathways and Immunotherapy Implications

BACKGROUND

Today, treating cancer patients with monoclonal antibodies (mAbs), by targeting immune checkpoints, is one of the most outstanding immunotherapeutic methods. Immune checkpoints are special molecules having regulatory role in immune system responses. Once these molecules are presented on cancer cells, these cells will be capable of evading the immune system through their own specific pathways. This Evasion can be prevented by counterbalancing immune system responses with immune checkpoints related antibodies.

AIMS

The current study aimed to highlight immunotherapy and its methods, describe the immune checkpoints pathways, outline the immune checkpoint inhibitors (ICIs), and recent advances in this field, and sketch an outlook on the best treatment options for the most prevalent cancers.

MATERIALS & METHODS

This research implemented a narrative review method. A comprehensive literature review on the history, molecular and cellular biology, and the clinical aspects of immune checkpoint molecules was performed to illustrate the pathways involved in various cancers. Also, currently-available and future potential immunotherapies targeting these pathways were extracted from the searched studies.

RESULTS

The immune checkpoint family consists of many molecules, including CTLA-4, PD-1, PD-L1, LAG-3, TIM-3, and TIGIT. Attempts to modify these molecules in cancer treatment led to the development of therapeutic monoclonal antibodies. Most of these antibodies have entered clinical studies and some of them have been approved by the Food and Drug Administration (FDA) to be used in cancer patients' treatment plans.

DISCUSSION

With these novel treatments and the combination therapies they offer, there is also hope for better treatment outcomes for the previously untreatable metastatic cancers. In spite of the beneficial aspects of immune checkpoint therapy, similar to other treatments, they may cause side effects in some patients. Therefore, more studies are needed to reduce the probable side effects and uncover their underlying mechanism.

CONCLUSION

Based on the data shown in this review, there is still a lack of knowledge about the complete properties of ICIs and the possible combination therapies that we may be able to implement to achieve a better treatment response in cancer patients.

Development of a Predictive Model for Classifying Immune Checkpoint Inhibitor-Induced Liver Injury Types

Aims

Immune checkpoint inhibitors (ICIs) have transformed cancer therapy; however, they are associated with ICI-induced liver injury (ICI-LI), which manifests as hepatocellular, mixed, or cholestatic patterns with variable treatment responses. This study aimed to develop and validate a predictive model to identify ICI-LI type using clinical data available at ICI initiation.

Methods

A retrospective analysis of 297 patients with ICI-LI was conducted. Baseline clinical data were analyzed using univariate and multivariate logistic regression to predict ICI-LI types in the training and validation cohorts. A predictive model was developed and validated using receiver operating characteristic (ROC) curve analysis.

Results

Multivariate analysis in the training cohort identified male sex (odds ratio [OR]: 3.33, 95% confidence interval [CI]: 1.57-7.06, p = 0.002), serum albumin levels (OR: 0.42, 95% CI: 0.19-0.91, p = 0.027), and serum alanine aminotransferase (ALT) levels (OR: 0.97, 95% CI: 0.94-0.99, p = 0.015) as significant predictors, along with ICI regimen types selected using the Akaike information criterion. The logistic regression model, expressed as p = 1/{1 + (-(5.02 + 1.20 × (sex [F:0, M:1])) - 0.87 × albumin [g/dL] - 0.03 × ALT [U/L] - 0.9 × (drug [non-anti-cytotoxic T lymphocyte antigen 4 (CTLA-4) related regimen:0, anti-CTLA-4 related regimen:1]))}, achieved an area under the ROC (AUROC) of 0.73 (95% CI: 0.63-0.82) in the training cohort. At a cut-off of 0.86, the sensitivity was 60.3%, specificity 74.4%, positive predictive value 92.3%, and negative predictive value 26.9%. In the validation cohort, the AUROC was 0.752 (95% CI: 0.476-1.00).

Conclusion

This predictive model demonstrates its utility in classifying ICI-LI types.

Unravelling Cancer Immunity: Coagulation.Sig and BIRC2 as Predictive Immunotherapeutic Architects

Immune checkpoint inhibitors (ICIs) represent a groundbreaking advancement in cancer therapy, substantially improving patient survival rates. Our comprehensive research reveals a significant positive correlation between coagulation scores and immune-related gene expression across 30 diverse cancer types. Notably, tumours exhibiting high coagulation scores demonstrated enhanced infiltration of cytotoxic immune cells, including CD8+ T cells, natural killer (NK) cells, and macrophages. Leveraging the TCGA pan-cancer database, we developed the Coagulation.Sig model, a sophisticated predictive framework utilising a coagulation-related genes (CRGs) to forecast immunotherapy outcomes. Through rigorous analysis of ten ICI-treated cohorts, we identified and validated seven critical CRGs: BIRC2, HMGB1, STAT2, IFNAR1, BID, SPATA2, IL33 and IFNG, which form the foundation of our predictive model. Functional analyses revealed that low-risk tumours characterised by higher immune cell populations, particularly CD8+ T cells, demonstrated superior ICI responses. These tumours also exhibited increased mutation rates, elevated neoantigen loads, and greater TCR/BCR diversity. Conversely, high-risk tumours displayed pronounced intratumor heterogeneity (ITH) and elevated NRF2 pathway activity, mechanisms strongly associated with immune evasion. Experimental validation highlighted BIRC2 as a promising therapeutic target. Targeted BIRC2 knockdown, when combined with anti-PD-1 therapy, significantly suppressed tumour growth, enhanced CD8+ T cell infiltration, and amplified IFN-γ and TNF-α secretion in tumour models. Our findings position the Coagulation.Sig model as a novel, comprehensive approach to personalised cancer treatment, with BIRC2 emerging as both a predictive biomarker and a potential therapeutic intervention point.

iMLGAM: Integrated Machine Learning and Genetic Algorithm-driven Multiomics analysis for pan-cancer immunotherapy response prediction

To address the substantial variability in immune checkpoint blockade (ICB) therapy effectiveness, we developed an innovative R package called integrated Machine Learning and Genetic Algorithm-driven Multiomics analysis (iMLGAM), which establishes a comprehensive scoring system for predicting treatment outcomes through advanced multi-omics data integration. Our research demonstrates that iMLGAM scores exhibit superior predictive performance across independent cohorts, with lower scores correlating significantly with enhanced therapeutic responses and outperforming existing clinical biomarkers. Detailed analysis revealed that tumors with low iMLGAM scores display distinctive immune microenvironment characteristics, including increased immune cell infiltration and amplified antitumor immune responses. Critically, through clustered regularly interspaced short palindromic repeats screening, we identified Centrosomal Protein 55 (CEP55) as a key molecule modulating tumor immune evasion, mechanistically confirming its role in regulating T cell-mediated antitumor immune responses. These findings not only validate iMLGAM as a powerful prognostic tool but also propose CEP55 as a promising therapeutic target, offering novel strategies to enhance ICB treatment efficacy. The iMLGAM package is freely available on GitHub (https://github.com/Yelab1994/iMLGAM), providing researchers with an innovative approach to personalized cancer immunotherapy prediction.

Secondary Sclerosing Cholangitis due to Drugs With a Special Emphasis on Checkpoint Inhibitors

BACKGROUND

Secondary sclerosing cholangitis (SSC), is one of the phenotypes of DILI first described in the 1980s. Check point inhibitors (CPIs) are currently the most frequent cause of SCC.

AIMS

To describe the epidemiology, clinical and biochemical features at presentation, differential diagnoses, pathophysiology, imaging, histological characteristics and management associated with SSC.

MATERIALS AND METHODS

A language and date-unrestricted Medline literature search was conducted to identify case reports and clinical series on SSC with special emphasis on CPIs (2007-2023).

RESULTS

We identified 19 different drugs that have been shown to induce SSC. A total of 64 cases with SSC due to CPIs are presented. This was mostly seen in patients treated with anti-Programmed cell death (PD)-1/PD-L1 inhibitors. The most frequent presenting signs and symptoms were abdominal pain and jaundice. Large-duct cholangitis induced by CPIs is a very rare condition while small-duct cholangitis is more common. Nivolumab and pembrolizumab were the most commonly implicated agents. Biopsies have revealed predominant CD8+ T cell infiltration in biliary strictures. Corticosteroids is linked to a low frequency of success and is the only agent recommended to begin the treatment.

CONCLUSIONS

CPIs-induced SSC seems to affect the entire biliary system. Clinicians should consider and suspect SSC when a probable CPIs-induced hepatitis does not respond to corticosteroids. Additionally, further randomized, controlled trials should prospectively investigate alternative therapies for treatment.

Melanoma neoadjuvant treatment: review and update of recent trials

INTRODUCTION

Neoadjuvant immunotherapy is emerging as an effective approach for resectable stage III/IV melanoma, showing improvements in disease response and survival outcomes.

AREAS COVERED

This review summarizes findings from neoadjuvant treatment trials in melanoma patients. Using the PubMed search engine and including the keywords 'neoadjuvant,' 'immunotherapy,' and 'melanoma,' we selected 18 trials that showed efficacy in patients with melanoma, mainly testing checkpoint inhibitors alone or in combination. Across all trials examined, treatments showed objective disease responses, which frequently translated into improved disease-free survival.

EXPERT OPINION

Additional phase III studies comparing neoadjuvant and adjuvant therapies are needed to establish the optimal standard of care. The variety of regimens and dosing schedules investigated highlights the need for further research to determine the most appropriate treatments in this clinical setting. Advances in the study of biomarkers that can identify specific subgroups of patients will guide future research in this field.

Investigating the potential of oncolytic viruses in the treatment of melanoma: where do we go from here?

Oncolytic viruses (OVs) can destroy cancer cells without harming healthy cells. This review explores the mechanisms by which OVs operate and the methods of delivering them. Melanoma is a common type of skin cancer with increasing prevalence in the UK; therefore, finding effective strategies to combat the disease is paramount. To understand the potential of OVs in treating melanoma, different types of viruses will be reviewed. Talimogene laherparepvec (T-VEC) is the only OV to be approved for treating melanoma; this review aims to understand the efficacy of T-VEC as a monotherapy and combined with other treatments. There is substantial evidence to support the use of OVs in treating melanoma by synthesizing the current perspectives of their use where they proved to be effective in clinical trials, as monotherapies and in combination with other treatments, as well as exciting innovative ventures using novel virus species. Gaps are also highlighted in the research, such as determining the influence that cancer gene mutational status has on how the tumour cells react to treatment, a concept that should also be considered in future research.

Prognostic value of the CONUT score with immune checkpoint inhibitors as first-line therapy for metastatic malignant melanoma

The recent availability of immune checkpoint inhibitors (ICIs) has revolutionized the treatment of advanced malignant melanoma (MM). However, many patients with MM do not benefit from ICI treatment. As immunotherapy is associated with significant toxicity and high treatment costs despite its excellent efficacy, it is pertinent to select patients who are likely to respond to ICIs. In this single-center, retrospective study we investigated whether the controlling nutritional status (CONUT) score is a useful prognostic marker in Japanese patients with advanced-stage cancer. We analyzed 123 patients with stage IV MM treated with ICIs as first-line systemic treatment at our hospital between February 2012 and July 2024. Receiver operating characteristic curve analysis was used to calculate the CONUT cut-off value and CONUT into two groups of ≥3 and ≤2. Progression-free survival (PFS) and overall survival (OS) were determined using the Kaplan-Meier method, and differences in survival were assessed using the log-rank test. The Cox proportional hazard regression model was used to evaluate independent prognostic factors. Objective response rate (ORR), PFS, and OS were significantly low in the CONUT ≥3 group, characterized by low nutritional status and high inflammation. Multivariate analysis identified the CONUT score as an independent prognostic factor for both PFS and OS. The CONUT score was not significantly associated with the development of serious immune-related adverse events. The simplicity of the CONUT score may aid in identifying patients with MM who are suitable candidates for ICI treatment.

Pannexin 1 crosstalk with the Hippo pathway in malignant melanoma

In this study, we explored the intricate relationship between Pannexin 1 (PANX1) and the Hippo signaling pathway effector, Yes-associated protein (YAP). Analysis of The Cancer Genome Atlas (TCGA) data revealed a significant positive correlation between PANX1 mRNA and core Hippo components, Yes-associated protein 1 [YAP], Transcriptional coactivator with PDZ-binding motif [TAZ], and Hippo scaffold, Ras GTPase-activating-like protein IQGAP1 [IQGAP1], in invasive cutaneous melanoma and breast carcinoma. Furthermore, we demonstrated that PANX1 expression is upregulated in invasive melanoma cell lines and is associated with increased YAP protein levels. Notably, our investigations uncovered a previously unrecognized interaction between endogenous PANX1 and the Hippo scaffold protein IQGAP1 in melanoma cells. Moreover, our findings revealed that IQGAP1 exhibits differential expression in melanoma cells and plays a regulatory role in cellular morphology. Functional studies involving PANX1 knockdown provided compelling evidence that PANX1 modulates YAP protein levels and its cotranscriptional activity in melanoma and breast carcinoma cells. Importantly, our study highlights the potential therapeutic significance of targeting PANX1. Pharmacological inhibition of PANX1 using selective FDA-approved inhibitors or PANX1 knockdown reduced YAP levels in melanoma cells. Furthermore, our Clariom™ S analysis unveiled key genes implicated in cell proliferation, such as neuroglin1 (NRG1), β-galactoside binding protein and galectin-3 (LGALS3), that are affected in PANX1-deficient cells. In summary, our investigation delves into the intricate interplay between PANX1 and YAP in the context of invasive melanoma, offering valuable insights into potential therapeutic strategies for effective treatment.

Malignant Melanoma of the Foot in Five Elderly Patients: Clinicopathologic Features and Treatment Outcomes

Malignant melanoma, an aggressive neoplasm of melanocytes, remains a leading cause of skin cancer-related deaths globally, with rising incidence among elderly populations. Foot melanomas are often diagnosed at advanced stages due to delayed detection and misdiagnosis. They exhibit poorer outcomes compared to melanomas at other sites. This case series presents five elderly patients (ages 58-80) with malignant melanoma of the foot, detailing their clinicopathological features, treatment strategies, and outcomes. All cases presented with advanced disease, emphasizing the challenges of late diagnosis in this demographic. Histopathological evaluation confirmed nodular, superficial spreading, and acral lentiginous subtypes, with Breslow thicknesses ranging from 1.5 mm to 3.5 cm. Management involved wide local excision, lymph node dissection, and adjuvant chemotherapy in high-risk cases. Recurrence occurred in one patient, underscoring the aggressive nature of the disease. The series highlights the necessity of early detection, multidisciplinary care, and tailored adjuvant therapies to improve outcomes in elderly patients with foot melanoma.

Deciphering T-cell exhaustion in the tumor microenvironment: paving the way for innovative solid tumor therapies

In solid tumors, the tumor microenvironment (TME) is a complex mix of tumor, immune, stromal cells, fibroblasts, and the extracellular matrix. Cytotoxic T lymphocytes (CTLs) constitute a fraction of immune cells that may infiltrate into the TME. The primary function of these T-cells is to detect and eliminate tumor cells. However, due to the immunosuppressive factors present in the TME primarily mediated by Myeloid-Derived Suppressor Cells (MDSCs), Tumor associated macrophages (TAMs), Cancer Associated Fibroblasts (CAFs) as well as the tumor cells themselves, T-cells fail to differentiate into effector cells or become dysfunctional and are unable to eliminate the tumor. In addition, chronic antigen stimulation within the TME also leads to a phenomenon, first identified in chronic lymphocytic choriomeningitis virus (LCMV) infection in mice, where the T-cells become exhausted and lose their effector functions. Exhausted T-cells (Tex) are characterized by the presence of remarkably conserved inhibitory receptors, transcription and signaling factors and the downregulation of key effector molecules. Tex cells have been identified in various malignancies, including melanoma, colorectal and hepatocellular cancers. Recent studies have indicated novel strategies to reverse T-cell exhaustion. These include checkpoint inhibitor blockade targeting programmed cell death protein 1 (PD-1), T-cell immunoglobulin and mucin-domain containing-3 (Tim-3), cytotoxic T-lymphocyte associated protein 4 (CTLA-4), or combinations of different immune checkpoint therapies (ICTs) or combination of ICTs with cytokine co-stimulation. In this review, we discuss aspects of T-cell dysfunction within the TME with a focus on T-cell exhaustion. We believe that gaining insight into the mechanisms of T-cell exhaustion within the TME of human solid tumors will pave the way for developing therapeutic strategies to target and potentially re-invigorate exhausted T-cells in cancer.

First-line cadonilimab plus chemotherapy in HER2-negative advanced gastric or gastroesophageal junction adenocarcinoma: a randomized, double-blind, phase 3 trial

Programmed cell death protein-1 (PD-1) inhibitors plus chemotherapy have been the standard of care in the first-line treatment of advanced gastric or gastroesophageal junction (G/GEJ) adenocarcinoma; however, the survival benefits are modest in patients with low programmed death ligand 1 (PD-L1) expression. Here we investigated the efficacy and safety of cadonilimab (PD-1/cytotoxic T lymphocyte antigen-4 (CTLA-4) bispecific antibody) plus chemotherapy as first-line treatment in G/GEJ adenocarcinoma. The prespecified interim analysis is reported here. This was a randomized, double-blind, placebo-controlled phase 3 study. Eligible patients were adults with untreated, unresectable, locally advanced or metastatic G/GEJ adenocarcinoma. Patients were randomized 1:1 to receive cadonilimab (10 mg kg-1 every 3 weeks) or placebo plus chemotherapy (every 3 weeks). The primary endpoint was overall survival (OS) in the intention-to-treat population (one-sided significance level, P = 0.025). Secondary endpoints included OS in patients with a PD-L1 combined positive score ≥5, progression-free survival, objective response rate, duration of response and safety. As of 18 August 2023, 610 patients from 75 study centers were randomized to cadonilimab (n = 305) or placebo (n = 305). With a median follow-up of 18.7 months, the cadonilimab group had a significantly longer median OS (14.1 versus 11.1 months; hazard ratio (HR) 0.66; 95% confidence interval (CI) 0.54-0.81; P < 0.001) than the placebo group. The primary endpoint was met. The median progression-free survival was 7.0 months versus 5.3 months (HR 0.53, 95% CI 0.44-0.65). The median OS in patients with a PD-L1 combined positive score ≥5 was 15.3 months versus 10.9 months (HR 0.58, 95% CI 0.41-0.82). The objective response rate was 65.2% versus 48.9% with a median duration of response of 8.8 months versus 4.4 months. Grade ≥3 treatment-related adverse events occurred in 65.9% of the cadonilimab group and 53.6% of the placebo group, and the most common were decreased platelet count, decreased neutrophil count and anemia. Most of the immune-related adverse events were grade 1 or 2. No new safety signals were observed. Cadonilimab plus chemotherapy significantly improved OS with a manageable safety profile in patients with advanced G/GEJ adenocarcinoma. ClinicalTrials.gov registration: NCT05008783 .

Immune checkpoint inhibitors and myocarditis in advanced non-small cell lung cancer: a nationwide cohort study

OBJECTIVE

Evidence suggests immune checkpoint inhibitor (ICI) can increase the risk of myocarditis. We investigated it in a large national cohort in China.

METHODS

Patients with stage IIIB-IV non-small cell lung cancer (NSCLC) using data from China's National Anti-Tumor Drug Surveillance System between January 2013 and December 2021. Exposure density sampling was applied to control for immortal time bias. Multivariate Cox regression with time-dependent exposures was used to examine the association between ICI therapy and the incidence of myocarditis while controlling for confounders.

RESULTS

55,219 patients were included. The median age was 61 years, and 62% were males. At one-year follow-up (median 335 days), there were 26 cases of myocarditis among ICI users and 28 cases among ICI non-users (a cumulative incidence of 4.8 and 0.6 per 1000 person-years respectively). The adjusted hazard ratio (HR) of myocarditis for ICI users was 7.41 (95% confidence interval [CI]: 3.29-16.67). For programmed cell death protein 1 inhibitor users the HR was 8.39 (95% CI: 3.56-19.77). No significant interactions were observed in subgroup analysis. The results remained unchanged in sensitivity analyses.

CONCLUSIONS

This study showed that ICI therapy considerably increased the risk of myocarditis, supporting the need for closer monitoring of patients receiving ICI therapies.

Thermoresistant flagellin-adjuvanted cancer vaccine combined with photothermal therapy synergizes with anti-PD-1 treatment

BACKGROUND

Cancer immunotherapy, leveraging the immune system to target and eradicate cancer cells, has transformed cancer treatment paradigms. Immune checkpoint inhibitors (ICIs) are used in a wide array of cancers, but only a limited fraction of patients are responding. Cancer vaccines could elicit antigen-specific immune responses and establish long-term immune memory, preventing recurrence and metastasis. Despite their promising profiles, ICIs and cancer vaccines by themselves are often insufficient to overcome the immunosuppressive tumor microenvironment (TME) and recurrence/metastasis. Addressing these challenges is crucial for improving cancer immunotherapy outcomes.

METHODS

The targeted liposomal formulation (TLIF), displaying Cyclic RGD (cRGD) peptide on the surface and encapsulating ICG and thermoresistant flagellin (FlaB) inside, was used for photothermal therapy (PTT), which was designed to induce robust immunogenic cell death (ICD) and release tumor antigens (TAs). We employed a mouse breast cancer model amenable to PTT. Utilizing a bilateral DD-Her2/neu tumor implantation model, we evaluated local and abscopal effects of combinatorial approaches employing PTT, FlaB-adjuvanted peptide vaccine (FlaB-Vax), and anti-PD-1 treatment. FlaB-Vax was designed to trigger tumor-associated antigen (TAA)-specific immune responses, which will trigger specific anti-tumor immunity. TLIF-PTT aimed to reduce tumor burden and induce ICD-mediated TA liberation for epitope spreading. Sustained anti-tumor immune memory was assessed by orthotopic rechallenging cured mice with the DD-Her2/neu tumor cells.

RESULTS

The combination of TLIF-PTT and FlaB-Vax provided significantly enhanced primary tumor suppression, with strong abscopal effects and long-lasting immune memory. The addition of anti-PD-1 therapy further improved long-term relapse-free survival, highlighting the potential of this combinatorial approach to induce durable antitumor immunity and sustainably prevent cancer recurrence and metastasis.

CONCLUSION

This study demonstrates that the combination of TLIF-PTT and FlaB-Vax synergistically induced synergistic anti-tumor immune responses, which were efficaciously potentiated by anti-PD-1 treatment for recurrence-free long-term survival.

Sex-Related Differences in Immunotherapy Toxicities: Insights into Dimorphic Responses

Significant sex-based differences exist in the immune system and antitumor immune responses, potentially leading to variations in both the efficacy and toxicity of anticancer immunotherapies. Women generally mount stronger innate and adaptive immune responses than men, which can result in more severe immune-related adverse events (irAEs) during treatments with immune checkpoint inhibitors (ICIs). However, the importance of sex dimorphism in the safety of cancer immunotherapy remains underexplored in clinical oncology, despite its profound implications for treatment outcomes. Our review highlights the critical influence of biological sex on pharmacokinetics, pharmacodynamics, and immune responses, shaping ICI efficacy and the prevalence, type, and severity of irAEs. Integrating sex as a critical variable in cancer treatment and clinical trial design is essential for personalizing therapeutic strategies, bridging existing knowledge gaps, and enhancing survival rates and quality of life for patients across genders.

Circadian rhythm related genes identified through tumorigenesis and immune infiltration-guided strategies as predictors of prognosis, immunotherapy response, and candidate drugs in skin cutaneous malignant melanoma

Background

Skin cutaneous malignant melanoma (SKCM) is among the most aggressive forms of skin cancer, notorious for its rapid progression and poor prognosis under late diagnosis. This study investigates the role of circadian rhythm-related genes (CRGs) in SKCM addressing a gap in understanding how CRGs affect tumor progression and patient outcomes.

Methods

An analysis of CRGs expression was conducted on SKCM samples derived from The Cancer Genome Atlas datasets(TCGA). Moreover, a correlation between various subtypes and their clinical features was identified. The study employed various bioinformatics methods, including differential expression analysis, consensus clustering, and survival analysis, to investigate the role of CRGs. The functional consequences of various CRG expression patterns were further investigated using immune infiltration analysis and gene set variation analysis (GSVA). A scoring system based on CRGs was developed to predict overall survival (OS) and treatment responses in SKCM patients. The predictive accuracy of this score system was then tested, and a nomogram was used to improve its clinical usefulness.

Results

Key findings from this study include significant genetic alterations in circadian rhythm-related genes (CRGs) in skin cutaneous melanoma (SKCM), such as mutations and CNVs. Two molecular subtypes with distinct clinical outcomes and immune profiles were identified. A prognostic model based on six CRGs (CMTM, TNPO1, CTBS, UTRN, HK2, and LIF) was developed and validated with TCGA and GEO datasets, showing high predictive accuracy for overall survival (OS). A high CRGs score correlated with poor OS, immune checkpoint expression, and reduced sensitivity to several chemotherapeutics, including AKT inhibitor VIII and Camptothecin.

Conclusions

This work provides valuable insights into the circadian regulation of SKCM and underscores the potential of CRGs as biomarkers for prognosis and targets for therapeutic interventions. The novel molecular subtypes and CRGs prognostic scoring model introduced in this study offer significant contributions to the understanding and management of SKCM.

Nivolumab With or Without Ipilimumab in Patients With Recurrent or Metastatic Merkel Cell Carcinoma: A Nonrandomized, Open-Label, International, Multicenter Phase I/II Study

PURPOSE

Approximately 50% of patients with advanced Merkel cell carcinoma (MCC) have primary or acquired resistance to PD-(L)1 blockade, which may be overcome using combination immune checkpoint inhibition (ICI) with anti-cytotoxic T lymphocyte antigen-4 antibody. We present results from the recurrent/metastatic MCC cohort in CheckMate 358, a nonrandomized, multicohort, phase I/II study of nivolumab (NIVO) with or without ipilimumab (IPI) in virus-associated cancers (ClinicalTrials.gov identifier: NCT02488759).

METHODS

ICI-naïve patients with recurrent/metastatic MCC and 0-2 previous systemic therapies were administered NIVO monotherapy at 240 mg once every 2 weeks or combination therapy with NIVO 3 mg/kg once every 2 weeks + IPI 1 mg/kg once every 6 weeks. The primary end point was objective response. Secondary end points included duration of response (DOR), progression-free survival (PFS), and overall survival (OS).

RESULTS

Sixty-eight patients received NIVO (n = 25) or NIVO + IPI (n = 43). The objective response rate (95% CI) and median DOR (95% CI), respectively, were 60% (38.7 to 78.9) and 60.6 months (16.7 to not applicable [NA]) with NIVO and 58% (42.1 to 73) and 25.9 months (10.4 to NA) with NIVO + IPI. The median PFS (95% CI) and OS (95% CI), respectively, were 21.3 (9.2 to 62.5) and 80.7 (23.3 to NA) months with NIVO and 8.4 (3.7 to 24.3) and 29.8 (8.5 to 48.3) months with NIVO + IPI. The incidence of grade 3/4 treatment-related adverse events was 28% with NIVO and 47% with the combination.

CONCLUSION

This nonrandomized study showed frequent and durable responses with both NIVO and NIVO + IPI in patients with ICI-naïve advanced MCC. However, it did not show improvement in efficacy with the combination, thus contradicting previous study reports that had suggested clinical benefit with combination ICI. A randomized trial of NIVO + IPI versus NIVO monotherapy is warranted.

New approaches to targeted drug therapy of intracranial tumors

Intracranial tumors encompass a heterogeneous group of neoplasms, including gliomas, meningiomas, pituitary adenomas, schwannomas, craniopharyngiomas, ependymomas, medulloblastomas, and primary central nervous system lymphomas. These tumors present significant challenges due to their diverse molecular characteristics, critical locations, and the unique obstacles posed by the blood-brain barrier (BBB) and blood-tumor barrier (BTB), which limit the efficacy of systemic therapies. Recent advances in molecular biology and genomics have enabled the identification of specific molecular pathways and targets, paving the way for innovative precision therapies. This review examines the current state of targeted therapies for intracranial tumors, including receptor tyrosine kinase (RTK) inhibitors, PI3K/AKT/mTOR inhibitors, RAF/MEK/ERK pathway inhibitors, IDH mutation inhibitors, immune checkpoint inhibitors, and CAR-T cell therapies. Emphasis is placed on the role of the BBB and BTB in modulating drug delivery and therapeutic outcomes. Strategies to overcome these barriers, such as focused ultrasound, nanoparticle-based delivery systems, and convection-enhanced delivery, are also explored. Furthermore, the manuscript reviews clinical trial data, highlighting successes and limitations across different tumor types. It delves into emerging therapeutic approaches, including combination of regimens and personalized treatments based on molecular profiling. By synthesizing the latest research, this article aims to provide a comprehensive understanding of the advancements and ongoing challenges in the targeted treatment of intracranial tumors. The findings underscore the necessity for innovative delivery systems and more extensive clinical trials to optimize therapeutic strategies. This review aspires to inform future research and clinical practices, aiming to improve patient outcomes and quality of life in the management of these complex and life-threatening conditions.

Enhanced Antitumor Immunity Through T Cell Activation with Optimized Tandem Double-OX40L mRNAs

Purpose

The tumor immune microenvironment (TIME) is often dysfunctional and complex, contributing to tumor metastasis and drug resistance. This study investigates the use of mRNA-based cancer agents as promising tools to combat and reverse refractory TIME conditions.

Methods

We optimized and engineered an mRNA cancer agent encoding double tandemly repeated sequences of the T cell costimulator Oxford 40 ligand (diOX40L). The diOX40L mRNAs were encapsulated into lipid nanoparticles (LNPs) for effective delivery. The research explored its safety and antitumor effects through a series of in vivo and in vivo experiments.

Results

Our results demonstrate that diOX40L mRNAs efficiently express increased levels of OX40L proteins. The optimized diOX40L mRNA cancer agent generated potent immune costimulatory signals within the TIME, leading to decreased tumor growth and improved survival compared to the original sequence agent. OX40L expression in subcutaneous tumors promoted CD4+ and CD8+ T cell activation, resulting in heightened IFN-γ and IL-2 secretion and robust immune responses. Combination therapy involving PD-1 antibodies and diOX40L substantially enhanced antitumor efficacy, with increased infiltration of activated CD4+ and CD8+ T cells.

Discussion

In conclusion, our findings highlight the therapeutic potential of the optimized diOX40L mRNA cancer agent in cancer treatment and its potential as an innovative alternative to protein-based therapies. The study underscores the significance of mRNA-based agents in modulating the immune microenvironment and enhancing antitumor responses.

Contrasting roles of PSGL-1 and PD-1 in regulating T-cell exhaustion and function during chronic viral infection

Immune checkpoints are critical regulators of T-cell exhaustion, impairing their ability to eliminate antigens present during chronic viral infections. Current immune checkpoint inhibitors (ICIs) used in the clinic aim to reinvigorate exhausted T cells; yet, most patients fail to respond or develop resistance to these therapies, underscoring the need to better understand these immunosuppressive pathways. PSGL-1 (Selplg), a recently discovered immune checkpoint, negatively regulates T-cell function. We investigated the cell-intrinsic effects of PSGL-1, PD-1, and combined deletion on CD8+ T cells during chronic viral infection. We found that combined PSGL-1 and PD-1 (Selplg-/-Pdcd1-/-) deficiency in CD8+ T cells increased their frequencies and numbers throughout chronic infection compared to the wild type. This phenotype was primarily driven by PD-1 deficiency. Furthermore, while PD-1 deletion increased virus-specific T-cell frequencies, it was detrimental to their function. Conversely, PSGL-1 deletion improved T-cell function but resulted in lower frequencies and numbers. The primary mechanism behind these differences in cell maintenance was driven by proliferation rather than survival. Combined PSGL-1 and PD-1 deletion resulted in defective T-cell differentiation, driving cells from a progenitor self-renewal state to a more terminal dysfunctional state. These findings suggest that PD-1 and PSGL-1 have distinct, yet complementary, roles in regulating T-cell exhaustion and differentiation during chronic viral infection. Overall, this study provides novel insights into the individual and combined roles of PSGL-1 and PD-1 in CD8+ T-cell exhaustion. It underscores the potential of targeting these checkpoints in a more dynamic and sequential manner to optimize virus-specific T-cell responses, offering critical perspectives for improving therapeutic strategies aimed at reinvigorating exhausted CD8+ T cells.IMPORTANCEOur findings provide a comprehensive analysis of how the dual deletion of PD-1 and PSGL-1 impacts the response and function of virus-specific CD8+ T cells, revealing novel insights into their roles in chronic infection. Notably, our findings show that while PD-1 deletion enhances T-cell frequencies, it paradoxically reduces T-cell functionality. Conversely, PSGL-1 deletion improves T-cell function but reduces their survival. Whereas the combined deletion of PSGL-1 and PD-1 in CD8+ T cells improved their survival but decreased their function and progenitor-exhausted phenotypes during infection. We believe our study advances the understanding of immune checkpoint regulation in chronic infections and has significant implications for developing more effective immune checkpoint inhibitor (ICI) therapies.

Clinical features of nivolumab-induced Stevens-Johnson syndrome/toxic epidermal necrolysis: retrospective analysis based on case reports

Background

Stevens - Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a life-threatening adverse reaction to nivolumab. This study investigated the clinical features of nivolumab induced SJS/TEN to provide evidence for diagnosis and treatment.

Methods

Relevant articles on nivolumab induced SJS/TEN published before December 31, 2024 were collected by searching the database, and then extracting the data for summary analysis.

Results

Thirty-one patients were enrolled with a median age of 65 years (range 43, 86). SJS/TEN appear at a median of 5.5 weeks (range, 0.9 108). Bullae/blisters (64.5%), erythema (54.8%), skin rash (54.8%), epidermal detachment (29.0%) and pain (29.0%) were the main skin symptoms. Skin biopsy showed epidermal necrosis (41.9%), keratinocytic necrosis (38.7%), interface dermatitis (29.0%) and inflammatory cell infiltration (45.2%). After stopping nivolumab and receiving treatment, 74.2% of the patients had improvement in skin symptoms, and 22.6% of the patients died of TEN.

Conclusion

As a rare immune-related adverse event of nivolumab, SJS/TEN should be closely monitored during the treatment. Nivolumab induced SJS/TEN has a long incubation period, serious clinical symptoms and poor prognosis.

Pyrotinib monotherapy for advanced HER2-positive esophageal adenocarcinoma with trastuzumab resistance and chemotherapy intolerance: a case report and literature review

HER2-positive advanced esophageal adenocarcinoma (EAC) cases demonstrate a poor prognosis because of drug resistance that develops after standard first-line trastuzumab therapy. The patient was initially diagnosed with stage cT2N1M0 III EAC. He underwent neoadjuvant chemotherapy, radical esophageal resection, and postoperative adjuvant radiotherapy. However, four months after treatment, the lesion relapsed and progressed to the right back, rendering the case inoperable. Pathological analysis revealed HER2 amplification. Given a poor tolerance to chemotherapy, the patient was administered cadonilimab and trastuzumab for three months. Subsequently, the second-line therapy was switched to pyrotinib monotherapy as a salvage treatment. Remarkably, after one month of treatment, the tumor showed significant reduction, with mild toxic side effects. Pyrotinib can be used for salvage later-line therapy in HER2-positive advanced EAC with trastuzumab resistance or poor chemotherapy tolerance, which deserves further promotion.

Cyclin E1 overexpression triggers interferon signaling and is associated with antitumor immunity in breast cancer

BACKGROUND

Cyclin E1 overexpression drives oncogenesis in several cancers through deregulation of DNA replication and induction of genomic instability, which may potentially trigger immune signaling via cytoplasmic DNA. However, the effects of cyclin E1 overexpression on tumor immunity and its effects on the response to immune checkpoint inhibitors remain largely unclear.

METHODS

Tissue microarrays and clinical outcomes of 398 patients with breast cancer were analyzed to explore the correlation between cyclin E1 expression, patient survival, and immune cell infiltration using immunohistochemistry. Genomic data from publicly available data sets and three clinical trials evaluating immunotherapy were assessed to measure the impact of cyclin E1 expression on the immune cells in the tumor microenvironment and response to immunotherapy in patients with breast cancer. In addition, breast cancer cell lines with inducible cyclin E1 overexpression were employed to analyze the effects of cyclin E1 on inflammatory signaling.

RESULTS

Increased cyclin E1 expression in breast cancer was positively correlated with immune cell infiltration, including T cells, B cells, and natural killer cells, and activation of interferon-related pathways. Importantly, higher cyclin E1 expression or CCNE1 amplification was associated with better response to immunotherapy in three clinical trials. Mechanistically, cyclin E1 overexpression resulted in micronuclei formation and activation of innate immune signaling, resulting in increased immune cell migration.

CONCLUSIONS

Our data show that cyclin E1 overexpression associate with antitumor immunity through activation of innate inflammatory signaling and warrants investigation into amplification or overexpression of cyclin E1 in identifying patients with breast cancer eligible for immunotherapy.

New progress in imaging diagnosis and immunotherapy of breast cancer

Breast cancer (BC) is a predominant malignancy among women globally, with its etiology remaining largely elusive. Diagnosis primarily relies on invasive histopathological methods, which are often limited by sample representation and processing time. Consequently, non-invasive imaging techniques such as mammography, ultrasound, and Magnetic Resonance Imaging (MRI) are indispensable for BC screening, diagnosis, staging, and treatment monitoring. Recent advancements in imaging technologies and artificial intelligence-driven radiomics have enhanced precision medicine by enabling early detection, accurate molecular subtyping, and personalized therapeutic strategies. Despite reductions in mortality through traditional treatments, challenges like tumor heterogeneity and therapeutic resistance persist. Immunotherapies, particularly PD-1/PD-L1 inhibitors, have emerged as promising alternatives. This review explores recent developments in BC imaging diagnostics and immunotherapeutic approaches, aiming to inform clinical practices and optimize therapeutic outcomes.

Neoadjuvant cadonilimab plus FLOT chemotherapy in locally advanced gastric/gastroesophageal junction adenocarcinoma: A multicenter, phase 2 study

BACKGROUND

Treatment with cadonilimab and chemotherapy has shown promise as a first-line treatment for gastric or gastroesophageal junction (G/GEJ) adenocarcinoma. However, its application in neoadjuvant settings has not yet been documented.

METHODS

This multicenter, phase 2 trial (ChiCTR2200066893) was conducted at four hospitals across China. Treatment-naive patients with locally advanced G/GEJ adenocarcinoma (cT3/4, N+, M0) and who were human epidermal growth factor receptor 2 negative received 3-cycle or 4-cycle neoadjuvant treatment of cadonilimab plus FLOT (5-fluorouracil, leucovorin, oxaliplatin, and docetaxel) chemotherapy, followed by gastrectomy and 4-cycle adjuvant FLOT chemotherapy. The primary endpoint was the pathological complete response (pCR) rate. Secondary endpoints included major pathological response (MPR), overall response rate (ORR), disease control rate (DCR), R0 resection rate, downstaging rate, and safety.

FINDINGS

Between December 23, 2022, and December 15, 2023, 32 of 38 patients completed the scheduled treatment, achieving an R0 resection rate of 100% (32/32). The pCR rate was 21.1% (8/38, 90% confidence interval [CI]: 9.7-32.4), and the MPR rate was 44.7% (17/38, 90% CI: 30.9-58.5). Radiological evaluations were available for 28 of 38 patients by blinded independent central review. The ORR was 60.7% (17/28, 90% CI: 44.7-76.7), and the DCR was 100.0% (28/28, 90% CI: 100.0-100.0). Tumor downstaging occurred in 71.9% of patients (23/32), with consistent efficacy across all populations observed in the subgroup analysis. Grade 3 adverse events occurred in 31.6% of patients without severe safety issues.

CONCLUSIONS

Neoadjuvant cadonilimab plus FLOT chemotherapy treatment exhibits promising efficacy with manageable toxicities in locally advanced G/GEJ adenocarcinoma, providing preliminary evidence for further investigation.

FUNDING

This study was funded by Akeso Biopharma.

Neurological complications of immune checkpoint inhibitors: a practical guide

Immune checkpoint inhibition unleashes the power of the immune system against tumour cells. Immune checkpoint inhibitors (ICIs) block the inhibitory effects of cytotoxic T-lymphocyte associated protein 4 (CTLA-4), programmed death protein 1 (PD-1), programmed death ligand 1 (PD-L1) and lymphocyte activation gene 3 (LAG-3) molecules on T-cells, and so enhance physiological cytotoxic effects. ICIs can significantly improve survival from cancers, including those previously associated with poor treatment response, such as metastatic melanoma. However, on-target off-tumour effects of ICIs result in immune-related adverse events. These toxicities are common and require new multidisciplinary expertise to manage. ICI neurotoxicity is relatively rare but ominous due to its severity, heterogenous manifestations and potential for long-term disability. Neurotoxic syndromes are novel and often present precipitously. Here, we describe ICI mechanisms of action, their impact on cancer outcomes and their frequency of immune-related adverse events. We focus particularly on neurotoxicity. We discuss the current appreciation of neurotoxic syndromes, management strategies and outcomes based on clinical expertise and consensus, multi-specialty guidance. The use of immunotherapy is expanding exponentially across multiple cancer types and so too will our approach to these cases.

Nephrotoxicity of Immune Checkpoint Inhibitors in Single and Combination Therapy-A Systematic and Critical Review

Background/Objectives: Immune checkpoint inhibitors (ICIs) have generated a revolutionary approach in the treatment of cancer, but their effectiveness has been compromised by immune-related adverse events, including renal damage. Although rare, these effects are relevant because they have been related to poor patient prognoses. The objective of this review was to estimate the current incidence of nephrotoxicity in patients treated with single and double ICI therapies. Methods: A total of 1283 potential articles were identified, which were reduced to 50 after applying the exclusion and inclusion criteria. Results: This study reveals the increase in acute kidney injury associated with these drugs in the last decade and shows that, interestingly, combined therapies with ICIs does not lead to an increase in kidney damage compared with anti-CTLA-4. It also suggests that kidney damage could be underdiagnosed when it comes to interstitial nephritis, because definitive evidence requires a renal biopsy. Conclusions: In perspective, these conclusions could guide clinicians in making decisions for therapy personalization and highlight the need to search for new diagnostic systems that are more sensitive and specific to the type of damage and could replace the biopsy.

Identification and validation of a CD4+ T cell-related prognostic model to predict immune responses in stage III-IV colorectal cancer

BACKGROUND

CD4+ T cells play an indispensable role in anti-tumor immunity and shaping tumor development. We sought to explore the characteristics of CD4+ T cell marker genes and construct a CD4+ T cell-related prognostic signature for stage III-IV colorectal cancer (CRC) patients.

METHOD

We combined scRNA and bulk-RNA sequencing to analyze stage III-IV CRC patients and identified the CD4+ T cell marker genes. Unsupervised cluster analysis was performed to divide patients into two clusters. The LASSO and multivariate Cox regression were performed to establish a prognostic-related signature. RT-qpcr and immunofluorescence staining were performed to examine the expression of ANXA2 in CRC tissue.

RESULT

We found a higher infiltration abundance of activated memory CD4+ T cells was associated with improved prognosis in stage III-IV CRC patients. Patients were divided into two subgroups with distinct clinical and immunological behaviors based on CD4+ T cell marker genes. And then a prognostic signature consisting of six CD4+ T cell marker genes was established, which stratified patients into high- and low-risk groups. Immune spectrum showed that the low-risk group had higher immune cell infiltration than the high-risk group. Furthermore, the risk score of this signature could predict the susceptibility of stage III-IV CRC patients to immune checkpoint inhibitors and chemotherapy drugs. Finally, we validated that ANXA2 was enriched in Tregs and was associated with infiltration of Tregs in CRC tumor microenvironment.

CONCLUSION

The CD4+ T cell-related prognostic signature established in the study can predict the prognosis and the response to immunotherapy in stage III-IV CRC patients. Our findings provide new insights for tumor immunotherapy of advanced CRC patients.

Gut microbiota as a new target for anticancer therapy: from mechanism to means of regulation

In order to decipher the relationship between gut microbiota imbalance and cancer, this paper reviewed the role of intestinal microbiota in anticancer therapy and related mechanisms, discussed the current research status of gut microbiota as a biomarker of cancer, and finally summarized the reasonable means of regulating gut microbiota to assist cancer therapy. Overall, our study reveals that the gut microbiota can serve as a potential target for improving cancer management.

Combination Immunotherapy With Nivolumab Plus Ipilimumab in Melanoma of Unknown Primary

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

Pooled Long-Term Outcomes With Nivolumab Plus Ipilimumab or Nivolumab Alone in Patients With Advanced Melanoma

PURPOSE

Nivolumab (NIVO) + ipilimumab (IPI) combination and NIVO monotherapy have demonstrated durable clinical benefit in patients with unresectable/metastatic melanoma. This analysis describes long-term overall survival (OS) with the combination or monotherapy pooled across all major company-sponsored trials, as well as clinical factors associated with survival, in patients with immune checkpoint inhibitor (ICI) treatment-naïve unresectable/metastatic melanoma.

METHODS

Data were pooled from six CheckMate studies in ICI treatment-naïve patients receiving NIVO + IPI (NIVO 1 mg/kg + IPI 3 mg/kg or NIVO 3 mg/kg + IPI 1 mg/kg) or NIVO monotherapy (3 mg/kg). OS was assessed for each treatment, as well as in select subgroups. Cox proportional multivariate analysis (MVA) and classification and regression tree (CART) analyses were performed within treatment arms.

RESULTS

Median follow-up for OS was 45.0 months for patients treated with NIVO + IPI (n = 839) and 35.8 months for patients treated with NIVO (n = 536). OS was longer with NIVO + IPI versus NIVO monotherapy (hazard ratio, 0.78 [95% CI, 0.67 to 0.91]), with 6-year OS rates of 52% versus 41%, respectively. Consistent benefit was observed in BRAF-mutant and BRAF-wild-type patients and those with normal and elevated lactate dehydrogenase (LDH). Numerical difference in OS was also observed across PD-L1 expression levels, although more pronounced with no/low PD-L1 expression. Clinical factors associated with decreased survival in both the MVA and CART analyses were LDH > upper limit of normal with either treatment, age ≥65 years with NIVO + IPI, and the presence of liver metastases with NIVO monotherapy.

CONCLUSION

In this large, pooled nonrandomized retrospective analysis, we observed that NIVO + IPI provides longer OS than NIVO in patients with ICI treatment-naïve advanced melanoma and identifies clinical factors that appear to be associated with survival for each treatment, which may assist with treatment decision making.

Opportunities for Discovery Using Neoadjuvant Immune Checkpoint Blockade in Melanoma

Treatment of resectable advanced-stage melanoma with neoadjuvant immunotherapy is rapidly becoming the new standard of care due to significant improvements in event-free survival (EFS) compared to surgery first followed by immunotherapy. The level of responsiveness seen in patients receiving immune checkpoint inhibitors (ICIs) must be mechanistically understood not only for the standardization of treatment but also to advance the novel concept of personalized cancer immunotherapy. This review aims to elucidate markers of the tumor microenvironment (TME) and blood that can predict treatment outcome. Interestingly, the canonical proteins involved in the molecular interactions that immunotherapies aim to disrupt have not been consistent indicators of treatment response, which amplifies the necessity for further research on the predictive model. Other major discussions surrounding neoadjuvant therapy involve the higher-level investigation of ICI efficacy due to the ability to examine a post-treatment tumor molecularly and pathologically, which this review will also cover. As neoadjuvant ICI becomes the standard of care in advanced melanoma treatment, further research aiming to identify more predictive biomarkers of treatment response to advance medical decision-making and patient care should continue to be sought after.

Synergistic effects of cold atmospheric plasma and doxorubicin on melanoma: A systematic review and meta-analysis

Melanoma is responsible for the majority of skin cancer deaths, but there are ways to combat this deadly disease. One method is using anti-neoplastic agents, such as Doxorubicin (DOX). Unfortunately, DOX can be toxic and may lead to drug resistance. However, researchers are excited about the potential of Cold Atmospheric Plasma (CAP) treatment cancer cells and overcome drug resistance selectively. To better understand the effectiveness of the combination of CAP and DOX on melanoma cell viability, cytotoxicity, and cell death, we conducted a comprehensive evaluation and meta-analysis in this study. 41 studies out of 121 met our inclusion criteria. The pooled analysis found that CAP and DOX combination had a significant effect on cell viability (ES = 6.75, 95% CI 1.65 to 11.85, and I2 = 71%) and cytotoxicity (ES = 11.71, 95% CI 3.69 to 19.73, and I2 = 56%). however, no statistically significant association was found between cell death with combination treatment. Our studies have confirmed that the combined treatment of CAP and DOX has a synergistic effect on reducing cell viability and increasing cytotoxicity in melanoma cells. These results can assist researchers in selecting more effective treatment methods to address melanoma.

irAE-GPT: Leveraging large language models to identify immune-related adverse events in electronic health records and clinical trial datasets

Background

Large language models (LLMs) have emerged as transformative technologies, revolutionizing natural language understanding and generation across various domains, including medicine. In this study, we investigated the capabilities, limitations, and generalizability of Generative Pre-trained Transformer (GPT) models in analyzing unstructured patient notes from large healthcare datasets to identify immune-related adverse events (irAEs) associated with the use of immune checkpoint inhibitor (ICI) therapy.

Methods

We evaluated the performance of GPT-3.5, GPT-4, and GPT-4o models on manually annotated datasets of patients receiving ICI therapy, sampled from two electronic health record (EHR) systems and seven clinical trials. A zero-shot prompt was designed to exhaustively identify irAEs at the patient level (main analysis) and the note level (secondary analysis). The LLM-based system followed a multi-label classification approach to identify any combination of irAEs associated with individual patients or clinical notes. System evaluation was conducted for each available irAE as well as for broader categories of irAEs classified at the organ level.

Results

Our analysis included 442 patients across three institutions. The most common irAEs manually identified in the patient datasets included pneumonitis (N=64), colitis (N=56), rash (N=32), and hepatitis (N=28). Overall, GPT models achieved high sensitivity and specificity but only moderate positive predictive values, reflecting a potential bias towards overpredicting irAE outcomes. GPT-4o achieved the highest F1 and micro-averaged F1 scores for both patient-level and note-level evaluations. Highest performance was observed in the hematological (F1 range=1.0-1.0), gastrointestinal (F1 range=0.81-0.85), and musculoskeletal and rheumatologic (F1 range=0.67-1.0) irAE categories. Error analysis uncovered substantial limitations of GPT models in handling textual causation, where adverse events should not only be accurately identified in clinical text but also causally linked to immune checkpoint inhibitors.

Conclusion

The GPT models demonstrated generalizable abilities in identifying irAEs across EHRs and clinical trial reports. Using GPT models to automate adverse event detection in large healthcare datasets will reduce the burden on physicians and healthcare professionals by eliminating the need for manual review. This will strengthen safety monitoring and lead to improved patient care.

Targeting the TRIM21-PD-1 axis potentiates immune checkpoint blockade and CAR-T cell therapy

Dysregulation of T cells is a major limitation for the clinical success of T cell-based cancer immunotherapies, such as immune checkpoint blockade and chimeric antigen receptor (CAR)-T cell therapy. Understanding the underlying mechanisms for regulating T cell functions can facilitate designing therapeutic strategies to improve immunotherapies. Here, we report that TRIM21 impairs CD8+ T cell activation and anti-tumor immunity. Mechanistically, TRIM21 catalyzes the K63-linked ubiquitination on programmed cell death-1 (PD-1) at K233, leading to stabilization of PD-1 through antagonizing its K48-linked ubiquitination and degradation. Thus, Trim21 knockout (KO) significantly decreases PD-1 expression and enhances the activation of cytotoxic CD8+ T cells, which sensitizes tumors to anti-CTLA-4 immunotherapy. Notably, Trim21 KO anti-CD19 CAR-T cells exhibit improved anti-tumor efficacy. These results reveal the molecular mechanism by which TRIM21-mediated K63-linked ubiquitination on PD-1 restrains the activation of CD8+ T cells, highlighting that targeting the TRIM21-PD-1 axis as a potential therapeutic strategy to potentiate cancer immunotherapy.

Revolutionary Cancer Therapy for Personalization and Improved Efficacy: Strategies to Overcome Resistance to Immune Checkpoint Inhibitor Therapy

Cancer remains a significant public health issue worldwide, standing as a primary contributor to global mortality, accounting for approximately 10 million fatalities in 2020 [...].

Mathematical Modeling Predicts Optimal Immune Checkpoint Inhibitor and Radiotherapy Combinations and Timing of Administration

Radiotherapy (RT) combined with immune checkpoint inhibitor (ICI) therapy has attracted substantial attention due to its potential to improve outcomes for patients with several types of cancer. However, the optimal administration timepoints and drug combinations remain unclear because the mechanisms underlying RT-induced changes in immune checkpoint molecule expression and interaction with their ligand(s) remain unclear. In this study, we demonstrated the dynamics of lymphocyte-mediated molecular interactions in tissue samples from patients with esophageal cancer throughout RT schedules. Single-cell RNA sequencing and spatial transcriptomic analyses were performed to investigate the dynamics of these interactions. The biological signal in lymphocytes transitioned from innate to adaptive immune reaction, with increases in ligand-receptor interactions, such as PD-1-PD-L1, CTLA4-CD80/86, and TIGIT-PVR interactions. A mathematical model was constructed to predict the efficacy of five types of ICIs when administered at four different timepoints. The model suggested that concurrent anti-PD-1/PD-L1 therapy or concurrent/adjuvant anti-CTLA4/TIGIT therapy would exert a maximal effect with RT. This study provides rationale for clinical trials of RT combined with defined ICI therapy, and these findings will support future studies to search for more effective targets and timing of therapy administration.

Late-Onset Immune-Related Adverse Events After Immune Checkpoint Inhibitor Therapy

Importance

The use of immune checkpoint inhibitors (ICIs) is increasing. Little is known about the frequency of late-onset immune-related adverse events (irAEs) and the patient-specific risk factors associated with their development.

Objectives

To assess the incidence of persistent or de novo late-onset irAEs requiring hospitalization and identify patient factors associated with risk of late-onset irAEs.

Design, Setting, and Participants

This retrospective observational cohort study conducted from January 2011 to October 2022 included patients who received ICIs and were hospitalized with irAEs at an academic medical center. Exclusion criteria included ICI therapy outside of the hospital system and no irAE diagnosis during admission. Data were analyzed from November 15, 2022, to January 8, 2025.

Exposure

Late-onset irAEs.

Main Outcomes and Measures

The main study outcomes were (1) incidence of irAE hospitalization at 0 to 6 months (early), more than 6 to 12 months (intermediate), and more than 12 months (late) after ICI initiation and (2) patient factors associated with risk of late-onset irAEs.

Results

Among the 795 patients hospitalized with irAEs, the median age was 67.3 years (IQR, 58.3-74.8 years); 476 (59.9%) were male. Most patients (n = 517 [65.0%]) received anti-programmed death ligand 1 (PD-L1) and anti-programmed cell death 1 monotherapy, with the most common indications being melanoma (n = 335 [42.1%]) and lung cancer (n = 167 [21.0%]). The median time from start of ICI therapy to hospital admission was 2.7 months (IQR, 1.2-6.1 months), with 14.7% of patients (n = 117 of 795) presenting 6 to 12 months after initial ICI exposure and 10.8% of patients (86 of 795) presenting more than 12 months after initial exposure. The irAEs most likely to present late included those involving the kidney (10 of 32 [31.3%]) and hematologic (5 of 23 [21.7%]) organ systems. In univariate analysis, ICI type was significantly associated with the timing of hospital admission for irAEs; of the 517 patients receiving anti-PD-L1-based therapy, 13.5% (n = 70) presented late compared with 5.4% (9 of 167) receiving dual therapy with anti-cytotoxic T-lymphocyte-associated protein 4 (P < .001). Patients receiving perioperative ICI therapy were significantly more likely to be admitted at the intermediate interval (16 of 68 [23.5%]) compared with those with metastatic disease (87 of 678 [12.8%]) (P = .03). Timing of irAE was also significantly associated with active ICI exposure; among the patients presenting late, 7.4% (48 of 651) had received ICI therapy within the last 60 days compared with 26.4% (38 of 144) who had not had recent ICI exposure (P < .001).

Conclusions and Relevance

The findings of this retrospective observational cohort study suggest that late irAEs are possible, with a subset of patients presenting years after the start of ICI therapy. Clinicians must remain vigilant for irAEs regardless of elapsed time from ICI therapy, especially as patients live longer and ICIs become more widely used. Future investigations are needed to better understand the risk factors for late-onset irAEs and the distinct immunologic pathways that underlie such events.

Individualized Neoantigen-Directed Melanoma Therapy

Individualized neoantigen-directed therapy represents a groundbreaking approach in melanoma treatment that leverages the patient's own immune system to target cancer cells. This innovative strategy involves the identification of unique immunogenic neoantigens (mutated proteins specific to an individual's tumor) and the development of therapeutic vaccines that either consist of peptide sequences or RNA encoding these neoantigens. The goal of these therapies is to induce neoantigen-specific immune responses, enabling the immune system to recognize and destroy cancer cells presenting the targeted neoantigens. This individualized approach is particularly advantageous given the genetic heterogeneity of melanoma, which exhibits distinct mutations among different patients. In contrast to traditional therapies, neoantigen-directed therapy offers a tailored treatment that potentially reduces off-target side effects and enhances therapeutic efficacy. Recent advances in neoantigen prediction and vaccine development have facilitated clinical trials exploring the combination of neoantigen vaccines with immune checkpoint inhibitors. These trials have shown promising clinical outcomes, underscoring the potential of this personalized approach. This review provides an overview of the rationale behind neoantigen-directed therapies and summarizes the current state of knowledge regarding personalized neoantigen vaccines in melanoma treatment.

Fibroblast Growth Factor 11 Promotes Immune Escape of Cervical Cancer Cells by Promoting Infiltration of CD4+ T Cells, Particularly Regulatory T Cells

Background: Cervical cancer (CC) is one of the leading gynecological malignancies. Immunotherapy has shown limited efficacy, particularly for advanced, recurrent CC. Consequently, dependable prognostic biomarkers and treatment targets are needed. Methods and Results: In this study, we aimed to determine the association of fibroblast growth factor 11 (FGF11) with prognosis. FGF11 expression was assessed in both tissues and cells through immunohistochemical and immunocytochemical staining. Immune cell infiltration was predicted using Tumor Immune Estimation Resource (TIMER) and TIMER2.0. FGF11 was significantly correlated with prognosis. FGF11 expression was significantly elevated in CC tissues. Moreover, FGF11 expression was significantly higher in SiHa and HeLa cancer cells than in normal H8 cells, particularly SiHa cells. Enrichment analyses suggested that FGF11 may be involved in arachidonic acid and linoleic acid metabolism, indicating roles in epithelial adhesion and cell differentiation. FGF11 correlated positively with CD4+ T, regulatory T, and dendritic cells but negatively with CD8+ T cells. FGF11 also correlated positively with Cluster of Differentiation 4 (CD4), CD25, Forkhead box P3 (FOXP3), and transforming growth factor β but negatively with human leukocyte antigens. Conclusions: FGF11 may enhance the immune escape abilities of CC cells by promoting CD4+ T cell infiltration (particularly regulatory T cells) into the tumor microenvironment, leading to poor prognosis. These findings provide a reference for the exploration of FGF11 as a prognostic biomarker and treatment target in CC.

Cancer stem-like cells stay in a plastic state ready for tumor evolution

Cell plasticity emerges as a novel cancer hallmark and is pivotal in driving tumor heterogeneity and adaptive resistance to different therapies. Cancer stem-like cells (CSCs) are considered the root of cancer. While first defined as tumor-initiating cells with the potential to develop a heterogeneous tumor, CSCs further demonstrate their roles in cancer metastasis and adaptive therapeutic resistance. Generally, CSCs come from the malignant transformation of somatic stem cells or the de-differentiation of other cancer cells. The resultant cells gain more plasticity and are ready to differentiate into different cell states, enabling them to adapt to therapies and metastatic ecosystems. Therefore, CSCs are likely the nature of tumor cells that gain cell plasticity. However, the phenotypic plasticity of CSCs has never been systematically discussed. Here, we review the distinct intrinsic signaling pathways and unique microenvironmental niches that endow CSC plasticity in solid tumors to adapt to stressful conditions, as well as emerging opportunities for CSC-targeted therapy.

Ipilimumab plus nivolumab versus nivolumab alone in patients with melanoma brain metastases (ABC): 7-year follow-up of a multicentre, open-label, randomised, phase 2 study

BACKGROUND

Patients with melanoma brain metastases respond well to immunotherapy, but long-term comparative survival data are scarce. We aimed to assess the efficacy of ipilimumab plus nivolumab versus nivolumab alone in patients with melanoma brain metastases at 7 years.

METHODS

This open-label, randomised, phase 2 study was conducted at four sites (two research institute cancer centres and two university teaching hospitals) in Australia. Patients aged 18 years or older with active, immunotherapy-naive melanoma brain metastases and Eastern Cooperative Oncology Group performance status of 0-2 were eligible. Asymptomatic patients with no previous brain-directed therapy were randomly assigned (5:4) using the biased-coin minimisation method (after a safety run-in of six patients) to cohort A (intravenous ipilimumab 3 mg/kg plus nivolumab 1 mg/kg every 3 weeks for four doses, then nivolumab 3 mg/kg every 2 weeks) or cohort B (intravenous nivolumab 3 mg/kg every 2 weeks). Patients with previous brain-directed therapy, neurological symptoms, or leptomeningeal disease were assigned to cohort C (non-randomised; intravenous nivolumab 3 mg/kg every 2 weeks). The primary endpoint was best intracranial response (complete or partial response) from week 12. Secondary survival endpoints included intracranial progression-free survival and overall survival. Safety was assessed from the first dose of treatment to at least 100 days after treatment discontinuation. Analyses were performed in patients who received at least one dose of study drug. The main analysis has been reported, and this is a long-term follow up of the ABC trial. This trial is registered with ClinicalTrials.gov, NCT02374242, and is ongoing.

FINDINGS

Between Nov 4, 2014, and April 21, 2017, 89 patients were assessed for eligibility, 79 of whom were enrolled and assigned to cohort A (n=36), cohort B (n=27), or cohort C (n=16). Three patients (one in cohort A and two in cohort B) were excluded due to ineligibility. 17 (22%) of 76 patients were female and 59 (78%) were male. At data cutoff (March 26, 2024), the median follow-up was 7·6 years (IQR 6·9-8·2). Overall intracranial responses occurred in 18 (51% [95% CI 34-69]) patients from cohort A, five (20% [7-41]) from cohort B, and one (6% [0-30]) from cohort C. 7-year intracranial progression-free survival was 42% (95% CI 29-63) in cohort A, 15% (6-39) in cohort B, and 6% (1-42) in cohort C. 7-year overall survival was 48% (34-68) in cohort A, 26% (13-51) in cohort B, and 13% (3-46) in cohort C. Safety results were consistent with the primary analysis. 50 patients died, including 18 (51%) from cohort A, 18 (72%) from cohort B, and 14 (88%) from cohort C.

INTERPRETATION

Our findings suggest that ipilimumab plus nivolumab maintains efficacy to at least 7 years in patients with active asymptomatic brain metastasis. Upfront ipilimumab plus nivolumab should be the standard of care for patients with melanoma brain metastasis; a trial investigating the role of stereotactic surgery in this new paradigm is ongoing.

FUNDING

Melanoma Institute Australia and Bristol Myers Squibb.

Navigating the landscape of immune checkpoint inhibitors and novel immunotherapies in melanoma: long-term outcomes, progress, and challenges

INTRODUCTION

Melanoma has become the poster child for transformative outcomes in advanced malignancy from the use of immunotherapy over the last 10-15 years with median survival improving from ~ 1 to > 5 years. With the increasing repertoire of immune checkpoint inhibitors (ICI) and other novel immunotherapeutic approaches, integrating and sequencing treatments to create new paradigms has gained prominence, with focus on optimizing toxicity management and complex scenarios such as immunotherapy resistance, brain metastases, fertility, and duration of follow-up.

AREAS COVERED

In this review, we summarize the progress and emerging evidence in melanoma treatments to date and consider management and possible future directions to improve outcomes for above-mentioned specific patient cohorts.

EXPERT OPINION

Personalized care with integration of novel prognostic and predictive biomarkers is the way forward in tailoring not only patient selection and choice of therapy, but also duration of treatment and surveillance to allow for early recurrence detection and access to newer therapies such as tumor infiltrating lymphocytes (TIL) to maximize the curative fraction of melanoma patients. Further research is needed in optimizing ICI and other immunotherapy toxicity management, including reducing steroid exposure for better patient outcomes and preserving quality of life.

Metastatic Melanoma to the Small Bowel and Colon: A Systematic Review of the Global Experience and Institutional Cohort Analysis Detailing a Rare Clinical Entity

INTRODUCTION

Cutaneous melanoma is among the most common solid tumors to metastasize to the gastrointestinal (GI) tract. Literature summarizing the clinical experience and features of this unique pathology is lacking.

METHODS

A systematic review of the available literature reporting clinically salient features of melanoma metastases to the small and large intestines was conducted. Additionally, we surveyed our institutional experience of surgically treated melanoma metastasis to the small bowel and colon. A descriptive analysis was performed. Kaplan-Meier curves with log-rank tests were used to analyze time-to-event intervals. Univariable and multivariable Cox logistic regression models were generated to identify predictors of survival.

RESULTS

Over 100 studies including 1153 patients were included. GI metastases predominantly affected males, were in the small bowel/jejunum, equally presented as solitary and multiple lesions, and were generally not the first site of distant metastatic disease. The median time from primary lesion diagnosis to GI metastasis was 48 months. Analysis of our institutional cohort suggested that survival in patients receiving complete GI-specific surgical resection and immune checkpoint inhibitors (ICIs) was prolonged compared to palliative resection and without ICI therapy. Positive prognostic factors for survival following GI metastasis included fewer GI metastatic lesions, complete resection, and longer duration between primary tumor diagnosis and GI metastasis.

CONCLUSIONS

GI metastases are a sign of advanced metastatic melanoma. Clinical suspicion of metastatic involvement in patients with a history of melanoma who develop any abdominal symptoms or anemia should remain high. Receipt of complete surgical resection and ICIs may prolong survival in disseminated melanoma.

Real world experience with omission of therapeutic lymph node dissection in clinical stage III malignant melanoma treated with checkpoint or kinase inhibition systemic therapy

Background

Management of clinical stage III melanoma, which historically was treated with surgical therapeutic lymph node dissection (TLND), has changed significantly due to the introduction of effective systemic therapies including immune checkpoint and BRAF/MEK inhibitors. We asked how surgical interventions changed progression free survival and overall survival in this population.

Methods

The Flatiron Health electronic health records database for Advanced Melanoma was queried for patients with clinical stage III melanoma treated between 2018 and 2022 with systemic therapy. Patients were stratified by receipt of TLND.

Results

There were 533 patients with clinical stage III melanoma treated with systemic therapy identified; 235 (44.1 %) underwent TLND prior to systemic therapy, 17 (3.2 %) underwent TLND after receipt of systemic therapy, and 281 (52.7 %) received systemic therapy alone and did not have surgery. There were 38.1 % (n = 203) who experienced disease progression at 2 years. Patients in the no surgery group had the best 2-year progression free survival (67.3 %) compared to the upfront surgery (58.3 %) and surgery after systemic therapy groups (23.5 %, p = 0.001), and there was no difference in 2-year overall survival (82.2 % vs 80.0 % vs 82.3 %, p = 0.81). These findings persisted on multivariable analysis.

Conclusions

In this modern era dataset, more than half of patients with clinical stage III melanoma were treated with systemic therapy alone, despite guideline recommendations for TLND. They had superior progression free survival and similar overall survival compared to those also treated with potentially morbid surgery. Randomized data are needed to evaluate appropriate omission of surgery in this patient population.