Five-Year Survival with Combined Nivolumab and Ipilimumab in Advanced Melanoma

From ICI to ICU: A systematic review of patients with solid tumors who are treated with immune checkpoint inhibitors (ICI) and admitted to the intensive care unit (ICU)

PURPOSE

Immune checkpoint inhibitors (ICIs) have improved the survival of patients with different solid tumors and even resulted in cure of metastatic disease. Since the introduction of ICIs, an increasing number of patients is admitted to the ICU for severe and potentially life-threatening immune related adverse events (irAEs). The outcome of patients who are admitted to the ICU because of severe irAEs is still unknown. The aim of this systematic review is to collect evidence on the outcomes of patients with solid tumors who are admitted to the ICU because of irAEs.

METHODS

Medline, Embase, Cochrane central register of controlled trials and Google Scholar were searched systematically from 1975 to 24 September 2024. Articles were only included when describing patients with solid tumors who were admitted to the ICU because of irAEs after treatment with ICIs. Two independent reviewers extracted the data and assessed the risk of bias.

RESULTS

A total of 183 articles were included: two prospective ICU population-based studies, four retrospective ICU population-based studies, 25 retrospective studies describing irAEs with incidental ICU admissions, one review of case reports, and 153 articles with a total of 177 case reports. The six ICU population-based studies contained a total of 169 patients who were admitted to the ICU due to irAEs. In these six studies, the most frequently reported irAEs were pneumonitis and neurological irAEs. Of these 169 patients, 26% of the patients died on the ICU and an additional 8% of patients in the three to six months thereafter due to irAEs or disease progression. In all 183 included articles, various irAEs were described and the reported mortality rate varied from 0 to 53%.

CONCLUSION

The potential favorable outcomes of both the solid tumors and irAEs will probably result in more need for ICU admissions. Prospective clinical trials are needed to optimize the treatment strategy of severe irAEs at the ICU. Based on the favourable outcomes after life-threatening irAEs, ICU admission should definitely be considered for patients with solid tumors who have life-threatening irAEs.

Pre-treatment metastatic biopsy: a step towards precision oncology for urothelial cancer

Early metastatic spread and clonal expansion of individual mutations result in a heterogeneous tumour landscape in metastatic urothelial cancer (mUC). Substantial molecular heterogeneity of common drug targets, such as membranous NECTIN4, FGFR3 mutations, PDL1 or immune phenotypes, has been documented between primary and metastatic tumours. However, translational and clinical studies frequently do not account for such heterogeneity and often investigate primary tumour samples that might not be representative in patients with mUC. We propose this as a potential factor for why many biomarkers for mUC have failed to be integrated into clinical practice. Fresh pre-treatment metastatic biopsies enable the capturing of prevailing tumour biology in real time. The characterization of metastatic tumour samples can improve response prediction to immunotherapy, the anti-NECTIN4 antibody-drug conjugate enfortumab vedotin and the FGFR inhibitor erdafitinib. Routine metastatic biopsy can thus improve the precision of identifying driver druggable alterations, thus improving treatment selection for patients with mUC.

Multispecific Antibodies Targeting PD-1/PD-L1 in Cancer

The development of immune checkpoint inhibitors has revolutionized the treatment of patients with cancer. Targeting the programmed cell death protein 1 (PD-1)/programmed cell death 1 ligand 1(PD-L1) interaction using monoclonal antibodies has emerged as a prominent focus in tumor therapy with rapid advancements. However, the efficacy of anti-PD-1/PD-L1 treatment is hindered by primary or acquired resistance, limiting the effectiveness of single-drug approaches. Moreover, combining PD-1/PD-L1 with other immune drugs, targeted therapies, or chemotherapy significantly enhances response rates while exacerbating adverse reactions. Multispecific antibodies, capable of binding to different epitopes, offer improved antitumor efficacy while reducing drug-related side effects, serving as a promising therapeutic approach in cancer treatment. Several bispecific antibodies (bsAbs) targeting PD-1/PD-L1 have received regulatory approval, and many more are currently in clinical development. Additionally, tri-specific antibodies (TsAbs) and tetra-specific antibodies (TetraMabs) are under development. This review comprehensively explores the fundamental structure, preclinical principles, clinical trial progress, and challenges associated with bsAbs targeting PD-1/PD-L1.

Regimen Selection for Chemoimmunotherapy in Nonsquamous Non-Small Cell Lung Cancer with Low PD-L1 Expression: A Multicenter Retrospective Cohort Study

BACKGROUND

Although chemoimmunotherapy is recommended for advanced nonsquamous non-small cell lung cancer (NSCLC) with low programmed cell death ligand 1 (PD-L1) expression, no head-to-head comparisons of immune checkpoint inhibitors (ICIs) have been performed. Therefore, we compared the effect and safety of regimens in these patients to guide evidence-based treatment.

METHODS

This retrospective study included patients with advanced nonsquamous NSCLC with a PD-L1 tumor proportion score of 1% to 49% administered ICI combination platinum-based chemotherapy between May 2018 and May 2023 at 19 institutions in Japan. The main analysis compared survival outcomes and the incidence of grade ≥3 adverse events among regimens.

RESULTS

Among 316 included patients (median [range] age, 69 [36-89] years; 242 males; 41 never smokers), 200 (63%), 68 (22%), and 48 (15%) received chemotherapy combined with anti-programmed cell death protein 1 (PD-1), anti-PD-L1, and anti-PD-1/cytotoxic T-lymphocyte associated protein 4 (CTLA-4) antibodies, respectively. The median overall survival times were 28.6, 23.1, and 24.4 months (P = .41), and the median progression-free survival times were 9.4, 7.2, and 8.7 months (P = .28) in the anti-PD-1/Chemo, anti-PD-L1/Chemo and anti-PD-1/CTLA-4/Chemo groups, respectively. The anti-PD-1/CTLA-4/Chemo group had the lowest incidence of hematologic toxicity (P = .13) and the highest incidence of nonhematologic toxicity (P = .07). The incidence of grade ≥3 pneumonitis was significantly lower in the anti-PD-L1/Chemo group (P = .049).

CONCLUSIONS

Despite comparable survival benefits, adverse events differed among three regimens in patients with low PD-L1 expression. Notably, anti-PD-L1 antibody combination chemotherapy may reduce the risk of severe pneumonitis.

Predicting c-KIT Inhibitor Efficacy in Patient-Derived Models of Sinonasal Mucosal Melanomas through Integrated Histogram Analysis of Whole-Tumor DKI, IVIM, and DCE-MRI

PURPOSE

To evaluate whole-tumor histogram analysis of diffusion kurtosis imaging (DKI), intravoxel incoherent motion (IVIM), and dynamic contrast-enhanced MRI (DCE-MRI) in predicting the efficacy of imatinib, a c-KIT inhibitor, for treating patient-derived models derived from sinonasal mucosal melanomas (MM).

EXPERIMENTAL DESIGN

This study included 38 patients with histologically confirmed sinonasal MM, who underwent DKI, IVIM, and DCE-MRI. Patient-derived tumor xenograft models and precision-cut tumor slices were established to evaluate tumor response to imatinib. Whole-tumor histogram analysis was conducted on imaging parameters, and logistic regression models were applied to determine the predictive value of these metrics in differentiating responders from nonresponders.

RESULTS

Among the 38 patients with sinonasal MM, 12 were classified as responders and 26 as nonresponders based on patient-derived tumor xenograft and precision-cut tumor slice model responses to imatinib. The DKI model revealed significant differences in mean, median, 10th percentile, and 90th percentile values of Dk and K between responders and nonresponders (P < 0.05). The IVIM model indicated significant differences in 10th percentile and mean values of D, with kurtosis f being a strong predictor. The DCE-MRI model, using the 90th percentile Ktrans metric, demonstrated robust predictive performance, achieving an AUC of 0.89, with 80.77% specificity and 91.67% sensitivity. The combined logistic model integrating DKI, IVIM, and DCE-MRI metrics produced the highest predictive accuracy, with an AUC of 0.90.

CONCLUSIONS

Whole-tumor histogram analysis of DKI, IVIM, and DCE-MRI offers a noninvasive method for predicting the efficacy of c-KIT inhibitors in sinonasal MMs, presenting valuable implications for guiding targeted treatment in this rare cancer type.

[New systemic treatment approaches for conjunctival melanoma]

Conjunctival melanoma is a rare disease that nevertheless has a high tumor-associated mortality rate. A resection in sano with adjuvant local treatment currently represents the therapeutic gold standard and systemic treatment is used for metastasized conjunctival melanoma and/or very advanced nonresectable local findings. New knowledge on molecular changes in conjunctival melanoma shows a clear similarity to those of cutaneous melanoma. Therefore, many findings on new systemic forms of treatment for cutaneous melanoma can be transferred to conjunctival melanoma. In the clinical application BRAF/MEK inhibitors and immune checkpoint inhibitors are already in use and good response rates have been shown in small retrospective studies and case reports. Due to the rarity of conjunctival melanoma, there are no larger prospective studies comparing different systemic therapeutic agents. In a nonrandomized retrospective comparison, a better overall survival was shown for a combination of BRAF/MEK inhibitors (progression-free 1‑year survival probability of 54.7%; overall survival of 29.1 months) compared to a combination of PD1/CTLA4 antibodies (progression-free 1‑year survival probability of 42%; overall survival of 18 months). The current recommendation is to perform genomic profiling for every conjunctival melanoma, particularly to investigate a BRAF mutation. If a BRAF mutation is present, BRAF/MEK inhibitor treatment should preferably be initiated. Treatment with immune checkpoint inhibitors can be used in the case of BRAF-negative mutation status or treatment failure with BRAF/MEK inhibitors. Monotherapy with the CTLA4 antibody ipilimumab is not recommended due to its inferiority to PD1 antibodies. New knowledge in the genomic profiling of conjunctival melanoma could enable further targeted treatment options in the future.

Discovery of mutations predictive of survival benefit from immunotherapy in first-line NSCLC: A retrospective machine learning study of IMpower150 liquid biopsy data

Predictive biomarker identification in cancer treatment has traditionally relied on pre-defined analyses, limiting discoveries to expected biomarkers and potentially overlooking novel ones predictive of therapy response. In this work, we develop a novel machine-learning approach capable of exploring full landscape of mutations and combinations and identify potentially new predictive biomarkers for chemoimmunotherapy. Utilizing the liquid biopsy dataset from 313 non-small cell lung cancer (NSCLC) patients in the Phase 3 Impower150 trial (NCT02366143), we developed the HRdiffRF algorithm with a novel hazard ratio-splitting criterion. Predictive mutations and combinations were identified for overall survival (OS) improvement with atezolizumab plus bevacizumab plus carboplatin and paclitaxel (ABCP) compared to bevacizumab plus carboplatin and paclitaxel (BCP). Our analysis confirms the predictive role of KRAS mutations and reveals the predictive value of PTPRD and SMARCA4 mutations in chemoimmunotherapy efficacy. Unlike other KRAS wild-type NSCLC patients, NSCLC patients with KRAS wild-type status and mutations in FAT1, ERBB2, or PTPRD may benefit from chemoimmunotherapy, while NTRK3 and GNAS mutations could negatively impact survival. Patients harboring concurrent KRAS and KEAP1 mutations may not benefit from chemoimmunotherapy. These findings highlight the complex genetic factors influencing treatment response for chemoimmunotherapy in NSCLC. In summary, the proposed machine-learning tool identified potential predictive biomarkers for first-line chemoimmunotherapy in NSCLC and can be readily applied to other tumor types and studies. It can also be extended to explore predictive biomarkers beyond mutations.

Management of metastatic melanoma with combinations including PD-1 inhibitors

INTRODUCTION

Melanoma is among the most immunogenic malignancies. The advent of immune checkpoint inhibitors (ICIs) has revolutionized the landscape of melanoma treatment. Long-term durable cancer control is possible in nearly 50% of non-resectable, metastatic melanoma patients with anti-CTLA4 and anti-PD-1 antibodies.

AREAS COVERED

This review provides a critical overview of the current data and future research directions on the management of metastatic melanoma with ICIs. We reviewed the efficacy and safety of combinations with PD-1 inhibitors through PubMed database research (Nov 2024-Mar 2025).

EXPERT OPINION

A decade after ipilimumab's approval, challenges remain. To cure more patients, the development of combinations is warranted. Combinations with a limited number of ipilimumab applications improve the overall survival outcome by approximately 10%, with a dramatic increase in adverse events including fatal events. Anti-LAG3/nivolumab is a promising alternative, offering similar efficacy to ipilimumab/nivolumab with better tolerability. In our opinion, ipilimumab/nivolumab combination should be the first-line therapy for high-risk patients (high LDH, brain or liver metastasis), while nivolumab/relatlimab or PD-1 monotherapy may be preferable for lower-risk cases. However, treatment decisions are increasingly complex, since most patients nowadays are pretreated in the (neo)-adjuvant setting. The key limitation today is the lack of biomarkers to guide individualized treatment strategies.

PARP1 in melanoma: Mechanistic insights and implications for basic and clinical research

Targeted therapies and immunotherapies have revolutionized the treatment of metastatic melanoma and have set a successful example for the treatment of other cancers. A similar breakthrough was achieved with the advent of PARP inhibitors (PARPi) in breast and ovarian cancer. Recent evidence highlights the critical role of PARP1 in melanoma initiation and progression. High PARP1 expression correlates with aggressive melanoma characteristics and poor patient outcomes. Preclinical and clinical data suggest that PARPi, alone or in combination, can effectively reduce melanoma cell viability and inhibit tumor growth. However, integrating PARPi with current treatment approaches and identifying patients who could benefit the most from such combinations remain underexplored areas of investigation. This review highlights the need for further basic and clinical research on PARP1 in melanoma, to better understand its role and to tackle major challenges in the field, such as resistance to targeted therapies and immune checkpoint inhibitors.

18F-FDG PET/CT for the Detection of Immune-Related Adverse Events in Patients With Metastatic Melanoma Receiving Immunotherapy

Purpose: To evaluate frequency and distribution of immune-related adverse events detected by 18F-FDG PET/CT in patients with metastatic melanoma undergoing immunotherapy. Materials and Methods: Retrospective observational cohort study evaluating 147 patients with metastatic melanoma treated with immunotherapy and referred for therapy response assessment with 18F-FDG PET/CT at our institution from January 2010 to August 2022. In total, 201 PET/CT scans performed at various time points were analyzed. IRAEs detected on PET/CT were compared against clinical reference standards, including physical examinations, laboratory tests, and biopsies. Diagnostic performance metrics (sensitivity, specificity, positive predictive value, negative predictive value), and diagnostic yields were calculated. Results: There were 36/147 patients (24.5%) with IRAEs recorded according to standard of reference, with 39 IRAEs in the entire cohort. At time point level, PET/CT identified 36/36 (100%) patients with IRAEs confirmed by the reference standard, while clinical suspicion identified 26/36 (72%) cases. At IRAE level, PET/CT identified 36/39 (92%) of IRAEs confirmed by the reference standard. Thirteen out of 39 (33.3%) cases identified on PET/CT were not suspected clinically but confirmed by the reference standard. The most frequent IRAEs, both suspected clinically and on PET/CT, corresponded to thyroiditis and colitis. Among the PET/CT positive cases, the majority corresponded to grade 2 severity. Conclusion: 18F-FDG PET/CT is highly effective in detecting IRAEs in patients with metastatic melanoma on immunotherapy, uncovering clinically unsuspected events in up to 33% of cases. These results highlight its important role in early detection, guiding timely interventions, and improving overall outcomes of immunotherapy-related toxicities.

Psychosocial distress and persistent adverse events in long-term survivors of stage IV melanoma - a cross-sectional questionnaire study

BACKGROUND

Immune checkpoint inhibitors and targeted therapies have improved survival in patients with stage IV melanoma. However, the challenges faced by long-term survivors remain unclear. The long-term toxicity and psychosocial impact of these treatments in real-world patients have yet to be reported.

MATERIAL AND METHODS

We conducted a cross-sectional questionnaire study using established screening tools, including the Hornheide Screening Instrument (HSI), the Distress Thermometer (DT) with the National Comprehensive Cancer Network (NCCN) problem list, and melanoma-specific questions addressing persistent adverse events, social impairments, emotional needs, and financial concerns.

RESULTS

A total of 159 patients with stage IV melanoma (≥5 years after the initial diagnosis) were enrolled, of whom 93 completed the questionnaire. Approximately one-third of DT/HSI values exceeded the threshold, indicating a need for psycho-oncological support. More than 40% of patients reported persistent treatment-related complaints. Financial and work-related impacts were rare, affecting approximately 8% and 1% of patients, respectively.

CONCLUSIONS

High rates of psychosocial distress and persistent adverse events were observed, highlighting the need for cancer survivorship programs in the follow-up care of melanoma patients.

Potential of CLSPN as a therapeutic target in melanoma: a key player in melanoma progression and tumor microenvironment

BACKGROUND

Melanoma is a highly aggressive form of skin cancer. Despite significant advances in targeted therapies and immunotherapeutic approaches, some patients still have poor response rates, making a deeper understanding of melanoma pathogenesis essential.

METHODS

The expression of Claspin (CLSPN), prognosis and immune infiltration in skin cutaneous melanoma patients were analyzed by public databases. Immunohistochemistry was used to validate. Moreover, quantitative real-time polymerase chain reaction analysis, western blot, cell counting kit-8 assay, colony formation assay, flow cytometry, animal experiments, and RNA-seq were applied to explore its biological functions and potential molecular mechanisms of CLSPN in melanoma.

RESULTS

Our results demonstrated that abnormal CLSPN expression was correlated with poor prognosis in melanoma. Meanwhile, CLSPN may promote melanoma growth and progression in vivo and in vitro through IFI44L/JAK/STAT1 signaling. Additionally, CLSPN was associated with negative immune microenvironment in melanoma and may be related to polarization of tumor associated macrophages towards M2-type.

CONCLUSIONS

These findings suggest that CLSPN may be a promising new target for melanoma and accelerate personalized therapeutic strategies.

Current Treatment of Uveal Melanoma

Uveal melanoma (UM) is the most common primary intraocular malignancy in adults worldwide [...].

Optimizing anti-PD-1/PD-L1 therapy efficacy and fecal microbiota transplantation donor selection through gut mycobiome-based enterotype

Immunotherapy has revolutionized cancer treatment, but response variability remains a challenge. The gut microbiome's role in therapeutic efficacy is well established, but the impact of the gut mycobiome is less understood. Using unsupervised clustering, we identify two gut mycobiome-based enterotypes, favorable type and unfavorable type, characterized by distinct microbial compositions linked to immunotherapy outcomes. Favorable-type enterotypes exhibit higher fungal and bacterial alpha diversity, enriched butyrate-producing bacteria, and metabolic pathways related to butyric acid and sugar/starch metabolism. External validation confirms their predictive value in assessing immunotherapy efficacy. Multi-omics analysis reveals increased CD8+ T cell infiltration in the tumor microenvironment of favorable-type patients. Fecal microbiota transplantation (FMT) from favorable-type donors enhances anti-PD-1 sensitivity, promotes CD8+ T cell infiltration, and boosts butyrate production in vivo. These findings highlight the gut mycobiome's role in immunotherapy response and support FMT from favorable-type donors as a potential strategy for improving treatment outcomes and patient stratification.

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.

Gut microbiota affects PD-L1 therapy and its mechanism in melanoma

Immune checkpoint inhibitors (ICIs), particularly PD-1/PD-L1 blockade, have shown great success in treating melanoma. PD-L1 (B7-H1, CD274), a ligand of PD-1, binds to PD-1 on T cells, inhibiting their activation and proliferation through multiple pathways, thus dampening tumor-reactive T cell activity. Studies have linked PD-L1 expression in melanoma with tumor growth, invasion, and metastasis, making the PD-1/PD-L1 pathway a critical target in melanoma therapy. However, immune-related adverse events are common, reducing the effectiveness of anti-PD-L1 treatments. Recent evidence suggests that the gut microbiome significantly influences anti-tumor immunity, with the microbiome potentially reprogramming the tumor microenvironment and overcoming resistance to anti-PD-1 therapies in melanoma patients. This review explores the mechanisms of PD-1/PD-L1 in melanoma and examines how gut microbiota and its metabolites may help address resistance to anti-PD-1 therapy, offering new insights for improving melanoma treatment strategies.

Five-year overall survival update from the HIMALAYA study of tremelimumab plus durvalumab in unresectable HCC

BACKGROUND & AIMS

In the phase III HIMALAYA study (NCT03298451), STRIDE (Single Tremelimumab Regular Interval Durvalumab) significantly improved overall survival (OS) versus sorafenib in unresectable HCC (uHCC) and demonstrated long-term survival benefits. We report an updated exploratory analysis of OS with 5 years of follow-up, including survival by multiple tumour response measures.

METHODS

Participants were randomised to STRIDE (tremelimumab plus durvalumab), durvalumab or sorafenib. OS, depth of response and serious adverse events (AEs) were assessed. Extended long-term survivors (eLTS; ≥48 months beyond randomisation) were described. Updated data cut-off: 01 March 2024.

RESULTS

Median (95% CI) follow-up durations were 62.49 (59.47-64.79) months (STRIDE) and 59.86 (58.32-61.54) months (sorafenib). The OS HR (95% CI) for STRIDE versus sorafenib was 0.76 (0.65-0.89). OS rates at 60 months for STRIDE versus sorafenib were 19.6% versus 9.4% overall, 28.7% versus 12.7% in participants achieving disease control per RECIST v1.1 and 50.7% versus 26.3% in participants achieving >25% tumour shrinkage. No late-onset treatment-related serious AEs were reported for STRIDE. There were more eLTS with STRIDE (83/393, 21.1%) than sorafenib (45/389, 11.6%), and extended long-term survival occurred across all clinically relevant subgroups.

CONCLUSIONS

At 5 years, STRIDE sustained an OS benefit versus sorafenib and maintained a manageable safety profile. OS benefit with STRIDE was improved in participants with disease control. Data suggest that any degree of tumour shrinkage with STRIDE can be associated with improved OS, indicating that conventional response measures may not fully capture STRIDE benefits. Nevertheless, participants experiencing deep responses appear to have the greatest benefit. STRIDE continues to set new benchmarks in uHCC with 1 in 5 patients alive at 5 years.

IMPACT AND IMPLICATIONS

The phase III HIMALAYA study showed that STRIDE (Single Tremelimumab Regular Interval Durvalumab) improved overall survival (OS) versus sorafenib in participants with unresectable HCC (uHCC), including after 4 years of follow-up. Understanding the efficacy and safety of STRIDE over the longer term is important for healthcare providers; here, we demonstrate that STRIDE sustained an OS benefit versus sorafenib and maintained a manageable safety profile after 5 years of follow-up. OS benefit with STRIDE was improved in participants with disease control and any degree of tumour shrinkage, indicating that conventional response measures may not fully capture the benefits of STRIDE. These findings are important as they set new benchmarks in uHCC and may help guide clinical decisions in the future.

CD8+ T Cell Subsets as Biomarkers for Predicting Checkpoint Therapy Outcomes in Cancer Immunotherapy

The advent of immune checkpoint blockade (ICB) has transformed cancer immunotherapy, enabling remarkable long-term outcomes and improved survival, particularly with ICB combination treatments. However, clinical benefits remain confined to a subset of patients, and life-threatening immune-related adverse effects pose a significant challenge. This limited efficacy is attributed to cancer heterogeneity, which is mediated by ligand-receptor interactions, exosomes, secreted factors, and key transcription factors. Oncogenic regulators like E2F1 and MYC drive metastatic tumor environments and intertwine with immunoregulatory pathways, impairing T cell function and reducing immunotherapy effectiveness. To address these challenges, FDA-approved biomarkers, such as tumor mutational burden (TMB) and programmed cell death-ligand 1 (PD-L1) expression, help to identify patients most likely to benefit from ICB. Yet, current biomarkers have limitations, making treatment decisions difficult. Recently, T cells-the primary target of ICB-have emerged as promising biomarkers. This review explores the relationship between cancer drivers and immune response, and emphasizes the role of CD8+ T cells in predicting and monitoring ICB efficacy. Tumor-infiltrating CD8+ T cells correlate with positive clinical outcomes in many cancers, yet obtaining tumor tissue remains complex, limiting its practical use. Conversely, circulating T cell subsets are more accessible and have shown promise as predictive biomarkers. Specifically, memory and progenitor exhausted T cells are associated with favorable immunotherapy responses, while terminally exhausted T cells negatively correlate with ICB efficacy. Ultimately, combining biomarkers enhances predictive accuracy, as demonstrated by integrating TMB/PD-L1 expression with CD8+ T cell frequency. Computational models incorporating cancer and immune signatures could further refine patient stratification, advancing personalized immunotherapy.

DNA-based immunotherapy for cancer: In vivo approaches for recalcitrant targets

Immunotherapy has revolutionized cancer treatment and complements traditional therapies, including surgery, chemotherapy, radiation therapy, and targeted therapies. Immunotherapy redirects the patient's immune system against tumors via several immune-mediated approaches. Over the past few years, therapeutic immunization, which enable the patient's T cells to better recognize and kill tumors, have been increasingly tested in the clinic, with several approaches demonstrating treatment improvements. There has been a renewed interest in cancer vaccines due to advances in tumor antigen identification, immune response optimization, novel adjuvants, next-generation vaccine delivery platforms, and antigen designs. The COVID-19 pandemic accelerated progress in nucleic acid-based vaccine manufacturing, which spurred broader interest in mRNA or plasmid platforms. Enhanced DNA vaccine designs, including optimized leader sequences and RNA and codon optimizations, improved formulations, and delivery via adaptive electroporation using stereotactic intramuscular/intradermal methods have improved T cell responses to plasmid-delivered tumor antigens. Additionally, advancements for direct in vivo delivery of DNA-encoded monospecific/bispecific antibodies offer novel tumor-targeting strategies. This review summarizes the recent clinical data for therapeutic cancer vaccines utilizing the DNA platform, including vaccines targeting common tumor-associated and viral antigens and neoantigen vaccines using nucleic acid technologies. We also summarize preclinical data using DNA-launched monoclonal/bispecific antibodies, underscoring their potential as a novel cancer therapy tool.

Integration of graph neural networks and transcriptomics analysis identify key pathways and gene signature for immunotherapy response and prognosis of skin melanoma

OBJECTIVE

The assessment of immunotherapy plays a pivotal role in the clinical management of skin melanoma. Graph neural networks (GNNs), alongside other deep learning algorithms and bioinformatics approaches, have demonstrated substantial promise in advancing cancer diagnosis and treatment strategies.

METHODS

GNNs models were developed to predict the response to immunotherapy and to pinpoint key pathways. Utilizing the genes from these key pathways, multi-omics bioinformatics methods were employed to refine the construction of a gene signature, termed responseScore, aimed at enhancing the precision of immunotherapy response predictions. Subsequently, responseScore was explored from the perspectives of prognosis, genetic variation, pathway enrichment, and the tumor microenvironment. Concurrently, the association among 13 genes contributing to responseScore and factors such as immunotherapy response, prognosis, and the tumor microenvironment was investigated. Among these genes, PSMB6 was subjected to an in-depth analysis of its biological effect through experimental approaches like transfection and co-culture.

RESULTS

In the finalized model utilizing GNNs, it has revealed an AUC of 0.854 within the training dataset and 0.824 within the testing set, pinpointing key pathways such as R-HSA-70,268. The indicator named as responseScore excelled in its predictive accuracy regarding immunotherapy response and patient prognosis. Investigations into genetic variation, pathway enrichment, tumor microenvironment disclosed a profound association between responseScore and the enhancement of immune cell infiltration and anti-tumor immunity. A negative correlation was observed between the expression of PSMB6 and immune genes, with elevated PSMB6 expression correlating with poor prognosis. ELISA detection after co-cultivation experiments revealed significant reductions in the levels of cytokines IL-6 and IL-1β in specimens from the PCDH-PSMB6 group.

CONCLUSION

The GNNs prediction model and the responseScore developed in this research effectively indicate the immunotherapy response and prognosis for patients with skin melanoma. Additionally, responseScore provides insights into the tumor microenvironment and the characteristics of tumor immunity of melanoma. Thirteen genes identified in this study show promise as potential tumor markers or therapeutic targets. Notably, PSMB6 emerges as a potential therapeutic target for skin melanoma, where its elevated expression exhibits an inhibitory effect on the tumor immunity.

Lessons learned from a decade of immune checkpoint inhibition: The good, the bad, and the ugly

Discovering the brakes/checkpoints that cancer places on the immune system to prevent being eradicated led to the 2018 Nobel Prize and the development of multiple Food and Drug Administration-approved immune checkpoint inhibitors (ICIs). ICIs have transformed the treatment of numerous cancer types and, remarkably, some patients with end-stage metastatic disease can achieve durable, complete remissions - cures. Still, ICIs cause significant immune-related toxicities, and most tumors are resistant. Unusual progression patterns such as pseudo-progression and hyper-progression (accelerated progression) can occur. Biomarkers for ICI response/resistance include microsatellite instability, high tumor mutational burden, and PD-L1 immunohistochemistry positivity; but they are imperfect, perhaps because of immune system complexity. Herein, we explore the good, the bad, and the ugly of ICIs in cancer treatment.

Neoantigen peptide-pulsed dendritic cell vaccine therapy after surgical treatment of pancreatic cancer: a retrospective study

Introduction

Pancreatic cancer shows very poor prognosis and high resistance to conventional standard chemotherapy and immunotherapy; therefore, the development of new breakthrough therapies is highly desirable.

Method

We retrospectively evaluated the safety and efficacy of neoantigen peptide-pulsed dendritic cell (Neo-P DC) vaccine therapy after surgical treatment of pancreatic cancer.

Result

The result showed induction of neoantigen-specific T cells in 13 (81.3%) of the 16 patients who received Neo-P DC vaccines. In survival analysis of the nine patients who received Neo-P DC vaccines after recurrence, longer overall survival was observed in patients with neoantigen-specific T cell induction than those without T cell induction. Notably, only one of the seven patients who received Neo-P DC vaccines as adjuvant setting developed recurrence, and no patient died during median follow-up 61 months after surgery (range, 25-70 months). Furthermore, TCR repertoire analyses were performed in a case treated with Neo-P DC vaccine combined with long and short peptides, and one significantly dominant clone induced by the long peptide was detected among CD4+ T cell populations.

Discussion

The present study suggests the feasibility and efficacy of Neo-P DC vaccine therapy after surgical treatment of pancreatic cancer in both postoperative recurrence cases and adjuvant setting. A case analysis suggests the importance of combination with long peptides targeting CD4+ T cell.

Off-The-Shelf Multivalent Nanoconjugate Cancer Vaccine Rescues Host Immune Response against Melanoma

Tumor-associated antigen-based cancer vaccines suffer from limited clinical success compared to alternative immunotherapies in melanoma, an aggressive skin cancer with an immunosuppressive tumor microenvironment. The anti-tumor potential of a multivalent nanoconjugate cancer vaccine platform - a cross-linked star-shaped polyglutamate carrier (StCl) with marked lymphotropic character conjugated with melanoma-associated peptide antigens is evaluated through redox-responsive linkers. The co-delivery of melanoma-associated peptide antigens by the nanoconjugate platform induced significant effector immune responses in a mouse melanoma model. The nanoconjugate platform synergized with a PD-1 inhibitor to revert the immunosuppressive melanoma tumor microenvironment by improving cytotoxic T-cell infiltration, which prompted a superior anti-tumor effect with prolonged overall survival without acute organ toxicity. The antigen-specific anti-tumor immune response induced by the nanoconjugate platform is also validated in a melanoma patient-derived xenograft mouse model. A promising, versatile StCl-based platform is reported for generating off-the-shelf multivalent nanoconjugate cancer vaccines for the safe and efficient immunotherapeutic treatment of melanoma.

Immune checkpoint expression and therapeutic implications in IDH1-mutant and wild-type glioblastomas

Programmed cell death protein 1 (PDCD1) and cluster of differentiation 274 (CD274) expression is implicated in escaping tumors from immune surveillance. Immune checkpoint inhibitors show promise in cancer therapy, yet their efficacy in glioblastomas, particularly with IDH1 mutations, remains unclear. This study analyzed two independent NGS datasets (n = 577 and n = 153) from TCGA to investigate the expression of PDCD1 and CD274 in glioblastomas and their relationship with IDH1 mutations. We used cBioPortal for mutation analysis, RNA seq for expression analysis, miRDB and miRabel for differential expression of miRNAs, and Kaplan-Meier for survival prediction. We found that 5.4% of glioblastomas harbored IDH1 mutations, correlating with improved overall survival (OS) (p = 2.196e-3). Different glioblastoma cohorts showed a diverse IDH1 mutational prevalence (4-31%). Despite this, IDH1Mu was consistently associated with better OS (p = 8.235e-5). Notably, PDCD1 and CD274 were statistically significantly highly expressed in both IDH1Wt (p < 0.0001) and IDH1Mu tumors (p < 0.0001), with higher expression linked to poorer survival outcomes (PDCD1: p = 0.009; CD274: p = 0.02). Differential co-expression analyses revealed distinct gene and miRNA profiles for IDH1Wt and IDH1Mu glioblastomas, with specific upregulation of PTEN and downregulation of MUC16 in IDH1Wt, and upregulation of PIK3R1 in IDH1Mu. Additionally, PIK3R1 and ITGB2 emerged as critical druggable targets. Our findings indicate that PDCD1 and CD274 are highly expressed irrespective of IDH1 mutation statuses, suggesting that glioblastomas could benefit from immunotherapy. Moreover, IDH1Mu glioblastomas may require a combination of PI3K/AKT/mTOR inhibitors and immunotherapy due to PIK3R1 overexpression.

Development of a Decision Model to Estimate the Outcomes of Treatment Sequences in Advanced Melanoma

BackgroundA decision model for patients with advanced melanoma to estimate outcomes of a wide range of treatment sequences is lacking.ObjectivesTo develop a decision model for advanced melanoma to estimate outcomes of treatment sequences in clinical practice with the aim of supporting decision making. The article focuses on methodology and long-term health benefits.MethodsA semi-Markov model with a lifetime horizon was developed. Transitions describing disease progression, time to next treatment, and mortality were estimated from real-world data (RWD) as a function of time since starting treatment or disease progression and patient characteristics. Transitions were estimated separately for melanoma with and without a BRAF mutation and for patients with favorable and intermediate prognostic factors. All transitions can be adjusted using relative effectiveness of treatments derived from a network meta-analysis of randomized controlled trials (RCTs). The duration of treatment effect can be adjusted to obtain outcomes under different assumptions.ResultsThe model distinguishes 3 lines of systemic treatment for melanoma with a BRAF mutation and 2 lines of systemic treatment for melanoma without a BRAF mutation. Life expectancy ranged from 7.8 to 12.0 years in patients with favorable prognostic factors and from 5.1 to 8.7 years in patients with intermediate prognostic factors when treated with sequences consisting of targeted therapies and immunotherapies. Scenario analyses illustrate how estimates of life expectancy depend on the duration of treatment effect.ConclusionThe model is flexible because it can accommodate different treatments and treatment sequences, and the duration of treatment effects and the transitions influenced by treatment can be adjusted. We show how using RWD and data from RCTs can harness advantages of both data sources, guiding the development of future decision models.HighlightsThe model is flexible because it can accommodate different treatments and treatment sequences, and the duration of treatment effects as well as the transitions that are influenced by treatment can be adjusted.The long-term health benefits of treatment sequences depend on the place of different therapies within a treatment sequence.Assumptions about the duration of relative treatment effects influence the estimates of long-term health benefits.We show how the use of real-world data and data from randomized controlled trials harness the advantages of both data sources, guiding the development of future decision models.

Rate of response to immune checkpoint inhibitor therapy in patients with conjunctival melanoma

Our primary objective was to estimate the overall response rate to immune checkpoint inhibitors (ICIs) in patients with locally advanced, multiply recurrent, or metastatic conjunctival melanoma treated with ICIs. A retrospective review of all consecutive conjunctival melanoma patients who were treated with ICI between October 2017 and January 2024 was carried out. The study included 16 patients with a median age of 66 years. The indications for ICI were locally extensive conjunctival melanoma in the eye/orbital area without nodal or distant metastasis in 10 patients, local recurrence of conjunctival melanoma and simultaneous nodal or distant metastasis in four patients, and metastatic conjunctival melanoma without local recurrence in two patients. Five patients received PD-1 inhibitor monotherapy with nivolumab or pembrolizumab; the other 11 received ipilimumab (CTLA-4 inhibitor) and nivolumab for several cycles and were then continued on nivolumab monotherapy ( n = 6) or not given additional ICI therapy ( n = 3). The number of cycles of ICI ranged from 2 to 25 (median, 13). Eight patients achieved a complete response. Six patients had progressive disease. The overall rate of objective response to ICI therapy was 63% (10 of 16), and for the subset of patients with local disease only, the objective response rate was 70% (7 of 10). In 14 patients (88%), orbital exenteration or additional extensive surgery was avoided; two patients had progression despite ICI and eventually needed an orbital exenteration. Future studies should aim to correlate biomarker data with response to ICI therapy in patients with conjunctival melanoma.

Novel Combination Immunotherapy and Clinical Activity in Patients With HPV-Associated Cancers: A Nonrandomized Clinical Trial

IMPORTANCE

Patients who experience progression of advanced human papillomavirus (HPV)-associated cancers and who have previously received first-line systemic treatment have a poor prognosis and limited therapeutic options.

OBJECTIVE

To assess the clinical activity of the combination of the HPV type 16 therapeutic vaccine PDS0101, the tumor-targeting interleukin 12 antibody-drug conjugate PDS01ADC, and the bifunctional anti-programmed cell death ligand 1 (PD-L1)/transforming growth factor β (TGF-β) bintrafusp alfa in advanced HPV-associated cancers.

DESIGN, Setting, and Participants

This nonrandomized clinical trial was phase 1/2 and investigator initiated, and was conducted at a single US cancer research center between June 2020 and July 2022. Patients with advanced or metastatic HPV-associated cancers were eligible, including patients who were both immune checkpoint blockade (ICB) naive and ICB resistant. The cutoff date for data analysis was May 13, 2024.

INTERVENTION

Patients received 1 mL of PDS0101 subcutaneously every 4 weeks for 6 doses then every 12 weeks for 2 additional doses, PDS01ADC, 16.8 µg/kg, subcutaneously every 4 weeks or PDS01ADC, 8 µg/kg, subcutaneously every 2 weeks, and bintrafusp alfa, 1200 mg, intravenously every 2 weeks.

MAIN OUTCOMES AND MEASURES

Objective response rate (ORR) by Response Evaluation Criteria in Solid Tumors version 1.1 in ICB-naive patients.

RESULTS

Of the 50 eligible patients, 26 (52%) were men and the median age was 56 years (range, 28-80 years). The median (IQR) follow-up was 37.7 (30.6-42.0) months. Fourteen patients (28%) were ICB naive, with an ORR of 35.7% (95% CI, 12.8%-64.9%), and median overall survival (OS) 42.4 months (95% CI, 8.3 months-not estimable); in ICB-resistant patients, the ORR was 16.7% (6 of 36 patients; 95% CI, 6.4%-32.8%) and median OS was 15.8 months (95% CI, 9.0-21.3 months). Among patients with HPV-16-positive tumors (37 patients [74%]), in the ICB-naive group (8 patients [21.6%]) the ORR was 62.5% (95% CI, 24.5%-91.5%) and a median OS measure was not reached. Grade 3 and 4 treatment-related adverse events occurred in 26 of 50 patients (52%). There were no treatment-related deaths.

CONCLUSIONS AND RELEVANCE

In this trial, the combination of PDS0101, PDS01ADC, and bintrafusp alfa showed an acceptable safety profile and promising antitumor activity and improved OS in patients with HPV-16-positive cancers, in both ICB-naive and ICB-resistant patients, warranting further evaluation of the combination of PDS0101 and PDS01ADC with simultaneous PD-L1/TGF-β inhibition in these populations.

Trial Registration

ClinicalTrials.gov Identifier: NCT04287868.

Comparison of efficacy and adverse events by treatment cycles of nivolumab and ipilimumab in Japanese melanoma patients: A single-center, retrospective study

Combination therapy with nivolumab and ipilimumab (NIVO+IPI) is highly effective in treating advanced malignant melanoma (MM) but it is associated with a high incidence of treatment-related adverse events (TRAEs). This retrospective, cohort study evaluated the efficacy and TRAEs of NIVO+IPI in Japanese patients with unresectable stage III and IV MM, comparing outcomes based on the number of treatment cycles and the IPI dose. We reviewed data from 57 patients with advanced or recurrent MM who received NIVO+IPI at the Shizuoka Cancer Center between August 2015 and July 2024. Patients who received two or fewer NIVO + IPI cycles (NIVO+IPI ≤2 cycles) generally had worse Eastern Cooperative Oncology Group performance status and more advanced stages compared to those who received three or more cycles (NIVO+IPI ≥3 cycles). The analysis revealed that the NIVO+IPI ≥3 cycles group had significantly better overall survival compared to the NIVO+IPI ≤2 cycles group, although receiving three or more cycles was not an independent prognostic factor in multivariate analysis. There was no significant difference in the frequency or severity of TRAEs between the two groups, but the incidence of grade ≥3 TRAEs increased significantly between the first and second cycles of NIVO+IPI. Additionally, reducing the IPI dose from 3 mg/kg to 2 mg/kg appeared to lower the risk of grade ≥3 TRAEs. In conclusion, further research is needed to determine the optimal number of NIVO+IPI cycles for Japanese patients with advanced MM. However, assessing efficacy after the second cycle may help avoid unnecessary NIVO+IPI administration. Reducing the IPI dose to 2 mg/kg may also offer a safer treatment approach for these patients.

Clinical benefit of immune checkpoint inhibitors in elderly cancer patients: Current evidence from immunosenescence pathophysiology to clinical trial results

The age-related decline in immunity appears to be associated not only with cancer development but also with differential responses to immune checkpoint inhibitors (ICIs). Despite their increasing utility across various malignancies and therapeutic settings, limited data -derived primarily from subgroup analyses of randomized controlled trials (RCTs), pooled meta-analyses, and retrospective studies- are available on the effects of aging on their efficacy and toxicity. Immunosenescence, characterized by the progressive decline of the function of the immune system, and inflammaging, a state of persistent low-grade sterile inflammation, may influence ICI outcomes. Additionally, the incidence, severity, and subtypes of immune-related adverse events (irAEs) may differ between older and younger individuals due to loss of immunotolerance. In the current review, starting from a a comprehensive discussion of the pathophysiology of immunosenescence, we proceed to critically review age-related retrospective and randomized evidence supporting FDA-approved ICIs. We highlight similarities or differences across age groups and the clinical benefit of ICIs in elderly versus younger cancer patients. The optimal integration of ICIs in geriatric oncology necessitates greater inclusion of this patient demographic in RCTs along with real-world data in order to acquire robust data which will guide evidence-based treatment decisions for this population.

Arthralgia in patients with cancer receiving immune checkpoint inhibitors: a systematic review and meta-analysis

BACKGROUND

Although immune checkpoint inhibitors (ICIs) are widely used for patients with cancer, evidence of the impact of ICIs on the incidence of arthralgia remains limited.

OBJECTIVE

To evaluate the impact of ICIs on arthralgia incidences in patients with cancer.

METHODS

We performed a systematic review to identify phase 3 randomized control trials (RCTs) evaluating ICIs in patients with cancer and reporting the incidence of arthralgia. We performed a meta-analysis to pool odds ratios (ORs) of any grade and grade 3-5 arthralgia.

RESULTS

Forty RCTs (n = 26,610) were included. The incidence of any-grade and grade 3-5 treatment-related arthralgia was 12.0% (n = 1,125/9,395) and 0.54% (n = 47/8,723). The addition of an ICI to systemic therapy, such as chemotherapy, significantly increased any-grade (OR 1.32, 95% CI: 1.13-1.54, p = 0.001) and grade 3-5 arthralgia (OR 1.78, 95% CI: 1.08-2.94, p = 0.02) with low heterogeneity among ICI subtype subgroups (I2 = 0%). ICI monotherapy was associated with higher incidences of arthralgia than non-taxane (OR 6.83, 95% CI: 3.05-15.30, p < 0.001) but not than taxane chemotherapy (OR 0.74, 95% CI: 0.44-1.24, p = 0.25).

CONCLUSIONS

These results could guide oncologists to assess arthralgia in patients receiving ICIs.

Immunotherapy for treatment of female genital tract melanoma: National Cancer Database analysis

Goal of this study was to examine the impact of immunotherapy on overall survival (OS) in patients with female genital tract melanoma (GTM). This retrospective cohort study utilized the National Cancer Database to identify individuals with invasive vulvar or vaginal melanoma diagnosed between 2004 and 2019. Kaplan-Meier plots and multivariate Cox regression were used to describe the impact of immunotherapy on OS and to examine predictors of OS among those who received immunotherapy for those with vulvar or vaginal melanoma. Of the 870 patients with vaginal melanoma, 23.6% received immunotherapy. Receiving immunotherapy for treatment of vaginal melanoma was associated with improved OS (median: 21.8 versus 18.9 months; P = 0.01); this association remained after adjustment for other prognostic factors [hazard ratio (HR), 0.77; 95% confidence interval (CI), 0.62-0.95; P = 0.01]. The survival advantage was more pronounced among those who did not receive primary surgical resection (median: 18.6 versus 12.2 months; P = 0.0009). Among 3123 patients with vulvar melanoma, 15.3% received immunotherapy. Receiving immunotherapy for treatment of vulvar melanoma was associated with an improvement in OS (median: 43.6 versus 57.7 months; P = 0.06; HR, 0.86; 95% CI, 0.74-1.00; P = 0.04). Survival benefit was more pronounced when restricted to patients with advanced or unknown stage disease (median OS, 31.6 versus 24.2 months; P = 0.002; adjusted HR, 0.74; 95% CI, 0.61-0.89; P = 0.002) and among the small subset who did not receive primary surgical resection (median: 19.8 versus 9.6 months; P = 0.0005). Immunotherapy was associated with improved OS in patients with female GTM, with some subsets particularly benefitting.

Immune Checkpoint Inhibitors and Palliative Care at the End of Life: An Irish Multicentre Retrospective Study

Background and Objectives: Immune checkpoint inhibitors (ICIs) have less toxicity than standard chemotherapy and are now standard of care for many patients with advanced cancer. A manageable side effect profile and potential for durable responses may lead to aggressive care of the palliative patient. We sought to evaluate palliative care input and ICI use at the end of life at two Irish cancer centres. Methods: We identified deceased patients who received at least one dose of an ICI between first of January 2013 to 31st of December 2018. A retrospective electronic chart review was performed. Results: The electronic records of 102 patients were analysed. Fifty eight percent were male and the median age of diagnosis of advanced disease was 60 years (range 17-78). Median time from last dose of ICI to death was 57 days (range 8-574) and 20% of patients died within 30 days of last dose of ICI. Most patients, 92%, were referred to palliative care. The median time from palliative care referral to death was 64 days (range 1- 1010). In the last 30 days of life, 39% of patients attended the emergency department (ED) and 46% had at least one hospital admission. Late palliative care referrals, ≤3 months before death, were associated with hospitalisations in the last month of life (64% vs. 36%, P = .02). Timing of palliative care referral did not affect ICI prescribing at the end of life (P = 0.38). ICI use in the last 30 days of life was not associated with increased ED presentations or hospitalisations at the end of life. Patients who received ICI in the last month had a higher likelihood of in-hospital death (43% vs. 16%, P = 0.02). Conclusions: ICI within 30 days of death was associated with dying in hospital but did not lead to more hospitalisations and emergency department presentations. Early palliative care did not affect ICI use but reduced hospitalisations at the end of life.

Using Real-World Data for Machine-Learning Algorithms to Predict the Treatment Response in Advanced Melanoma: A Pilot Study for Personalizing Cancer Care

PURPOSE

The use of real-world data (RWD) in oncology is becoming increasingly important for clinical decision making and tailoring treatment. Despite the significant success of targeted therapy and immunotherapy in advanced melanoma, substantial variability in clinical responses to these treatments emphasizes the need for personalized approaches to therapy.

MATERIALS AND METHODS

In this pilot study, 239 patients with melanoma were included to predict the response to both targeted therapies and immunotherapies. We used machine learning (ML) to incorporate RWD and applied explainable artificial intelligence (XAI) to explain the individual predictions.

RESULTS

We developed, validated, and compared four ML models to evaluate 2-year survival using RWD. Our research showed encouraging outcomes, achieving an AUC of more than 80% and an estimated accuracy of over 74% across the four ML models. The random forest model exhibited the highest performance in predicting 2-year survival with an AUC of 0.85. Local interpretable model-agnostic explanations was used to explain individual predictions and provide trust and insights into the clinical implications of the ML model.

CONCLUSION

With this proof-of-concept, we integrated RWD into predictive modeling using ML techniques to predict clinical outcomes and explore their potential implications for clinical decision making. The potential of XAI was demonstrated to enhance trust and improve the usability of the model in clinical settings. Further research, including foundation modeling and generative AI, will likely increase the predictive power of prognostic and predictive ML models in advanced melanoma.

A comparison of myeloid-derived suppressor cell populations in patients with ulcerated vs non-ulcerated melanoma receiving immune checkpoint blockade

Myeloid-derived suppressor cells (MDSCs) are expanded in cancer patients, have an intrinsic immunosuppressive function, and thus may play a role in resistance to immunotherapy. Ulceration of the melanoma primary is associated with more aggressive disease and is an independent prognostic factor for melanoma-specific survival. However, the underlying factors contributing to this more aggressive phenotype are not completely understood. The current study aims to correlate changes in circulating MDSC during immunotherapy in patients with ulcerated vs non-ulcerated melanoma primary tumors. Longitudinal changes in levels of circulating MDSCs were analyzed via flow cytometry in melanoma patients receiving immune checkpoint inhibitors (ICIs) and stratified by ulceration status. Following the initiation of therapy, the percentage of total MDSCs increased significantly in patients with both ulcerated ( P  = 0.003) and non-ulcerated ( P  < 0.001) tumors. When MDSCs were stratified by subset, the proportion of granulocytic MDSC (PMN-MDSC) decreased in patients with non-ulcerated tumors ( P  = 0.023), while the proportion remained stable in patients with ulcerated tumors ( P  = 0.121). The reduction in the proportion PMN-MDSC in non-ulcerated patients coincided with a statistically significant increase in the proportion of CD14 + /CD15 + MDSC ( P  = 0.008), resulting in a greater proportion of CD14 + /CD15 + MDSC in non-ulcerated patients as compared to ulcerated melanoma patients following two infusions of ICIs (27.3 ± 19.2% vs 16.1 ± 19.2%; P  = 0.008). The trajectories of the MDSC populations described here provide insight into the altered tumor microenvironment in ulcerated melanoma and highlight key changes in a cell population that could contribute to immunotherapy resistance.

Adjuvant Anti-PD-1 Monotherapy Versus Observation for Stage III Acral Melanoma of the Sole: A Multicenter Retrospective Study in Japanese Patients

PURPOSE

Adjuvant anti-PD-1 (adj PD-1) antibodies are extensively used to improve survival in patients with resected melanoma. Clinical trials on adj PD-1 antibodies have revealed significant improvements in recurrence-free survival (RFS); however, few of these trials have included patients with acral melanoma (AM).

METHODS

Clinical data were retrospectively collected from Japanese patients who underwent resection of stage III sole AM between 2014 and 2021. Survival outcomes, including RFS, distant metastasis-free survival (DMFS), and overall survival (OS), were compared between patients without adjuvant therapy (OBS group) and those receiving adj PD-1 group.

RESULTS

This study included 139 patients (OBS: 79; adj PD-1: 60), with a median follow-up of 2.6 years. The baseline characteristics were comparable, except for age and nodal metastasis. No significant differences in survival were observed between the OBS and adj PD-1 groups (3-year RFS: 36.7% v 27.5%, P = .13; 3-year DMFS: 51.0% v 45.3%, P = .51; 3-year OS: 65.3% v 67.4%, P = .45). Multivariate analysis showed no survival benefit of adj PD-1 (RFS: hazard ratio [HR], 1.25, P = .29; DMFS: HR, 1.03, P = .89; and OS: HR, 0.69, P = .23). Each survival outcome after propensity score matching confirmed no significant difference between the matched OBS group (n = 52) and adj PD-1 group (n = 52; 3-year RFS: 34.3% v 25.9%, P = .22; 3-year DMFS: 45.6% v 46.5%, P = .85; 3-year OS: 60.7% v 68.9%, P = .29).

CONCLUSION

Adj PD-1 did not improve the prognosis in sole AM. However, further studies are essential to evaluate the efficacy of the adj anti-PD-1 antibody in AM.

T cell-based cancer immunotherapy: opportunities and challenges

T cells play a central role in the cancer immunity cycle. The therapeutic outcomes of T cell-based intervention strategies are determined by multiple factors at various stages of the cycle. Here, we summarize and discuss recent advances in T cell immunotherapy and potential barriers to it within the framework of the cancer immunity cycle, including T-cell recognition of tumor antigens for activation, T cell trafficking and infiltration into tumors, and killing of target cells. Moreover, we discuss the key factors influencing T cell differentiation and functionality, including TCR stimulation, costimulatory signals, cytokines, metabolic reprogramming, and mechanistic forces. We also highlight the key transcription factors dictating T cell differentiation and discuss how metabolic circuits and specific metabolites shape the epigenetic program of tumor-infiltrating T cells. We conclude that a better understanding of T cell fate decision will help design novel strategies to overcome the barriers to effective cancer immunity.

Circulating MicroRNAs: functional biomarkers for melanoma prognosis and treatment

MicroRNAs (miRNAs) hold significant promise as circulating cancer biomarkers and unlike many other molecular markers, they can provide valuable insights that extend beyond tumour biology. The expression of circulating miRNAs may parallel the cellular composition and dynamic activity within the tumour microenvironment and reveal systemic immune responses. The functional complexity of miRNAs-where a single miRNA can regulate multiple messenger RNAs (mRNAs) to fine tune fundamental processes, and a single mRNA can be targeted by multiple miRNAs-underscores their broad significance and impact. However, this complexity poses significant challenges for translating miRNA research into clinical practice. In melanoma, specific miRNA signatures have shown notable diagnostic, prognostic and predictive value, with lineage-specific and immune-related miRNAs frequently identified as valuable markers. In this review, we explore the role of circulating miRNAs as potential biomarkers in melanoma, and highlight the current status and advances required to translate miRNA research into therapeutic opportunities.

Germline prediction of immune checkpoint inhibitor discontinuation for immune-related adverse events

INTRODUCTION

Immune checkpoint inhibitors (ICIs) can yield remarkable clinical responses in subsets of patients with solid tumors, but they also commonly cause immune-related adverse events (irAEs). The predictive features of clinically severe irAEs leading to cessation of ICIs have yet to be established. Given the similarities between irAEs and autoimmune diseases, we sought to investigate the association of a germline polygenic risk score for autoimmune disease and discontinuation of ICIs due to irAEs.

METHODS

The Genetics of immune-related adverse events and Response to Immunotherapy (GeRI) cohort comprises 1302 patients with non-small cell lung cancer (NSCLC) who received ICI therapy between 2009 and 2022 at four academic medical centers. We used a published polygenic risk score for autoimmune diseases (PRSAD) in the general population and validated it in the All of Us. We then assessed the association between PRSAD and cessation of ICI therapy due to irAEs in the GeRI cohort, using cause-specific and Fine-Gray subdistribution hazard models. To further understand the differential effects of type of therapy on the association between PRSAD and cessation of ICI due to irAEs, we conducted a stratified analysis by type of ICI therapy.

RESULTS

Using a competing risk model, we found an association between PRSAD and ICI cessation due to irAEs (HR per SD=1.24, p=0.004). This association was particularly strong in patients who had ICI cessation due to irAEs within 3 months of therapy initiation (HR per SD=1.40, p=0.005). Individuals in the top quintile of PRSAD had 4.8% ICI discontinuation for irAEs by 3 months, compared with 2% discontinuation by 3 months among patients in the bottom quintile (log-rank p=0.03). In addition, among patients who received combination programmed cell death protein-1 (PD-1)/programmed death-ligand 1 (PD-L1) inhibitors and cytotoxic T-lymphocyte associated protein 4 (CTLA4) inhibitors, ICI discontinuation for irAEs by 3 months occurred in 4 of the 13 patients (30.8%) with high PRSAD genetic risk (top quintile) versus 3 of 21 patients (14.3%) with low PRSAD genetic risk (bottom quintile).

CONCLUSIONS

We demonstrate an association between a polygenic risk score for autoimmune disease and early ICI discontinuation for irAEs. Our results suggest that germline genetics may be used as an adjunctive tool for risk stratification around ICI clinical decision-making in solid tumor oncology.

The NF1 tumor suppressor regulates PD-L1 and immune evasion in melanoma

Hotspot BRAF, hotspot NRAS, and NF1 loss-of-function mutations are found in approximately 50%, 25%, and 15% of cutaneous melanomas, respectively. Compared to mutant BRAF and NRAS, the role of NF1 loss in melanoma remains understudied. NF1 has a RAS GTPase-activating protein (GAP) function; however, studies also support NF1 RAS-independent tumor-suppressor functions. Recent reports indicate that patients with NF1 mutant melanoma have high response rates to anti-PD-1 immune checkpoint inhibitors (ICIs) for reasons that are not entirely clear. Here, we present data demonstrating that NF1 interacts with PD-L1. Furthermore, NF1 loss in melanoma lines increases PD-L1 cell surface expression through a RAS-GAP-independent mechanism. Co-culture experiments demonstrate that NF1 depletion in melanoma increases resistance to T cell killing, which can be abrogated with anti-PD-1/PD-L1 ICIs. These results support a model whereby NF1 loss leads to immune evasion through the PD-L1/PD-1 axis, providing support for the examination of anti-PD-1 therapies in other NF1 mutant cancers.

Spectrum of presentation of intraocular metastases from cutaneous melanoma in the era of immunotherapy and targeted therapies

BACKGROUND

Intraocular metastases from cutaneous melanoma are rare. Diagnosis can be challenging and there is currently no consensus on treatment. However, with the increasing incidence of this cancer and improved survival of patients treated with targeted BRAF-MEK inhibitors and checkpoint inhibitors, it is likely that more cases will be referred to ocular oncology clinics.

SUBJECTS

Single-centre retrospective study. We included all the patients diagnosed with intraocular metastases from cutaneous melanoma seen between 2017 and 2022.

RESULTS

The first patient had bilateral choroidal metastases and unilateral vitreous cells (treated with external beam radiotherapy and immunotherapy), the second had unilateral amelanotic vitreous metastasis (treated with vitrectomy and BRAF-MEK inhibitors) and the third had bilateral multifocal choroidal metastases (treated with BRAK-MEK inhibitors followed by immunotherapy). The fourth patient (previously reported) had unilateral anterior segment and vitreous metastases (treated with immunotherapy and enucleation). Interestingly, two patients had a history of uveitis in the affected eye, unrelated to the ocular metastases. All four patients had synchronous systemic metastases.

CONCLUSIONS

The diagnosis of intraocular metastases from cutaneous melanoma is generally clinical but it is sometimes challenging because of possible masquerade syndromes. The presence of other extraocular metastatic sites is an indicator of the diagnosis. Cytopathologic proof combined with genetic analysis is sometimes necessary for diagnosis, especially with amelanotic vitreous debris or in rare cases where systemic screening is negative. New treatments with targeted BRAF-MEK inhibitors and checkpoint inhibition may avoid external beam radiotherapy and enucleation in some patients.

Macrophage-derived Fgl2 dampens antitumor immunity through regulation of FcγRIIB+CD8+ T cells in melanoma

Cancer immunotherapy has emerged as a promising therapeutic modality but heterogeneity in patient responsiveness remains. Thus, greater understanding of the immunologic factors that dictate response to immunotherapy is critical to improve patient outcomes. Here, we show that fibrinogen-like protein 2 (Fgl2) is elevated in the setting of melanoma in humans and mice and plays a functional role in inhibiting the CD8+ T cell response. Surprisingly, the tumor itself is not the major cellular source of Fgl2. Instead, we found that macrophage-secreted Fgl2 dampens the CD8+ T cell response through binding and apoptosis of FcγRIIB+CD8+ T cells. This regulation was CD8+ T cell autonomous and not via an antigen-presenting cell intermediary, as absence of Fcgr2b from the CD8+ T cells rendered T cells insensitive to Fgl2 regulation. Fgl2 is robustly expressed by macrophages in 10 cancer types in humans and in 6 syngeneic tumor models in mice, underscoring the clinical relevance of Fgl2 as a therapeutic target to promote T cell activity and improve patient immunotherapeutic response.

Endogenous viral elements constitute a complementary source of antigens for personalized cancer vaccines

Personalized cancer vaccines (PCVs) largely leverage neoantigens arising from somatic mutations, limiting their application to patients with relatively high tumor mutational burden (TMB). This underscores the need for alternative antigens to design PCVs for low TMB cancers. To this end, we substantiate endogenous retroviral elements (EVEs) as tumor antigens through large-scale genomic analyses of healthy tissues and solid cancers. These analyses revealed that the breadth of EVE expression in tumors stratify checkpoint inhibitor-treated melanoma patients into groups with differential overall and progression-free survival. To enable the design of PCVs containing EVE-derived epitopes with therapeutic potential, we developed a computational pipeline, ObsERV. We show that EVE-derived peptides are presented as epitopes on tumors and can be predicted by ObsERV. Preclinical testing of ObsERV demonstrates induction of sustained poly-functional CD4+ and CD8+ T-cell responses as well as long-term tumor protection. As such, EVEs may facilitate and improve PCVs, especially for low-TMB patients.

Myeloid-Derived Suppressor Cells: Implications in Cancer Immunology and Immunotherapy

Myeloid-derived suppressor cells (MDSCs) are believed to be key promoters of tumor development and are recognized as a hallmark of cancer cells' ability to evade the immune system evasion. MDSC levels often increase in peripheral blood and the tumor microenvironment (TME). These cells exert immunosuppressive functions, weakening the anticancer immune surveillance system, in part by repressing T-cell immunity. Moreover, MDSCs may promote tumor progression and interact with cancer cells, increasing MDSC expansion and favoring an immunotolerant TME. This review analyzes the primary roles of MDSCs in cancer and T-cell immunity, discusses the urgent need to develop effective MDSC-targeted therapies, and highlights the potential synergistic combination of MDSC targeting with chimeric antigen receptors and immune checkpoint inhibitors.

BET inhibitor in combination with BCG vaccine enhances antitumor efficacy and orchestrates T cell reprogramming for melanoma

Immunotherapy shows remarkable benefits in treating melanoma, yet existing approaches achieve limited overall responses. Here, we show that a combination of bromodomain and extra-terminal protein family inhibitor, NHWD-870, and Bacillus Calmette-Guérin vaccine is a promising therapeutic strategy for melanomas. Single-cell transcriptome analyses and functional experiments show that the combination therapy significantly inhibited tumor growth by reprogramming T cells toward an immune-activated state, enhancing their cytotoxicity, preventing their exhaustion, and increasing the recruitment of them into the tumor microenvironment. We identify the molecule, MT1, as a direct downstream target of BRD4, which is effectively suppressed by NHWD-870. Furthermore, our findings are reinforced by a humanized patient-derived xenograft (PDX) model, which exhibits notable antitumor effects in humanized tumor-bearing mice treated with the combination therapy. Our study underscores the immense potential of this therapeutic approach for clinical practice, offering promising prospects in overcoming the limitations of current treatments.

Programmed Cell Death Ligand as a Biomarker for Response to Immunotherapy: Contribution of Mass Spectrometry-Based Analysis

Immune checkpoint inhibition is a major component in today's cancer immunotherapy. In recent years, the FDA has approved a number of immune checkpoint inhibitors (ICIs) for the treatment of melanoma, non-small-cell lung, breast and gastrointestinal cancers. These inhibitors, which target cytotoxic T-lymphocyte antigen-4, programmed cell death (PD-1), and programmed cell death ligand (PD-L1) checkpoints have assumed a leading role in immunotherapy. The same inhibitors exert significant antitumor effects by overcoming tumor cell immune evasion and reversing T-cell exhaustion. The initial impact of this therapy in cancer treatment was justly described as revolutionary, however, clinical as well as research data which followed demonstrated that these innovative drugs are costly, are associated with potentially severe adverse effects, and only benefit a small subset of patients. These limitations encouraged enhanced research and clinical efforts to identify predictive biomarkers to stratify patients who are most likely to benefit from this form of therapy. The discovery and characterization of this class of biomarkers is pivotal in guiding individualized treatment against various forms of cancer. Currently, there are three FDA-approved predictive biomarkers, however, none of which on its own can deliver a reliable and precise response to immune therapy. Present literature identifies the absence of precise predictive biomarkers and poor understanding of the mechanisms behind tumor resistance as the main obstacles facing ICIs immunotherapy. In the present text, we discuss the dual role of PD-L1 as a biomarker for response to immunotherapy and as an immune checkpoint. The contribution of mass spectrometry-based analysis, particularly the impact of protein post-translational modifications on the performance of this protein is underlined.

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.

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.