Combined Nivolumab and Ipilimumab or Monotherapy in Untreated Melanoma

Development of a Microvessel Density Gene Signature and Its Application in Precision Medicine

SIGNIFICANCE

A novel gene signature for MVD was developed. This MVD gene score enables the estimation of MVD, reflecting the sensitivity to antiangiogenic inhibitors, in transcriptomic datasets. We demonstrated the utility of the MVD gene score together with a T cell-inflamed gene signature for potential future use as a clinical biomarker.

Radiation therapy in combination with immune checkpoint inhibitors in metastatic lung cancer: Effect of fractionation

Immunotherapy with checkpoint inhibitors has improved the outcomes of patients with metastatic lung cancer in recent years. Despite improved prognosis, not all patients respond to treatment. Therapeutic interventions to build on the success of immune checkpoint inhibitors are needed. A retrospective review of patient records for patients who had received immune checkpoint inhibitors in a single cancer center over 4 years was undertaken. Demographic and disease characteristics of patients with metastatic non-small cell lung cancer were recorded. Data on other treatments including chemotherapy and radiation therapy were extracted, and survival outcomes were calculated. Most (81.8%) of the 77 metastatic lung cancer patients examined had received palliative radiation therapy within 3 months of starting immune checkpoint inhibitors. While the survival outcomes of these patients did not differ from patients who had not received radiotherapy, patients who had undergone hypofractionated radiotherapy (defined as one or more fractions of 700 cGy or higher) displayed a better overall survival (OS) than the rest of the cohort. Palliative radiation therapy administered in proximity with immune checkpoint inhibitors immunotherapy had no effect on the OS of metastatic lung cancer patients. However, patients receiving palliative radiotherapy with fractions above 700 cGy showed better OS. Further studies are needed to optimize a combination strategy.

Melanoma in pregnancy

Cutaneous melanoma is a malignant neoplasm of melanocytes that most frequently affects the skin. It is the most common malignancy in women of childbearing age, and accounts for almost one-third of all malignancies diagnosed during gestation. The pathophysiology of melanoma, particularly during pregnancy, is not well understood, but there are several ways in which the physiologic state pregnancy may impact melanoma. Based on the available literature, pregnancy does not seem to worsen maternal outcomes with melanoma, and outside of placental and fetal metastases, melanoma does not seem to cause serious obstetric or fetal complications. Treatment of localized melanoma during pregnancy follows guidelines for the general population, but advanced melanoma in pregnancy poses unique challenges given the lack of unifying research and management recommendations. Herein, we review the current literature, highlighting diagnostic clinical pearls and key multidisciplinary management considerations with regard to melanoma in the child-bearing population.

Efficacy of durvalumab plus tremelimumab treatment for unresectable hepatocellular carcinoma in immunotherapy era clinical practice

AIM

Since the development of tremelimumab plus durvalumab (Dur/Tre) for unresectable hepatocellular carcinoma (uHCC), it has been used as not only an initial but also later line treatment in clinical practice. This study aimed to elucidate clinical prognostic factors for progression-free survival (PFS) in Dur/Tre treatment cases.

METHODS

Enrolled were 183 uHCC patients treated with Dur/Tre from 2023 to May 2024 (median age, 74 years; male patients, 152; Child-Pugh class A:B, 150:33; Barcelona Clinic Liver Cancer stage B:C, 59:124; initial line use, 64). Clinical factors with prognostic influence on PFS in these patients were retrospectively evaluated.

RESULTS

The median observation period was 7.2 months (interquartile range, 3.2-10.4). History of atezolizumab plus bevacizumab (Atz/Bev) treatment was the only significant prognostic factor for PFS at introduction of Dur/Tre in multivariate analysis (hazard ratio 2.040, p = 0.028) (median PFS: without vs. with = 5.6 vs. 2.7 months, p < 0.001). Although immune-mediated adverse events (imAE) occurrence was only significant in univariate analysis, when objective response and disease control rates were examined according to imAE positivity (any grade) at the time of analysis, those were noted in 14.4% and 39.2%, respectively, of patients without imAE, while in patients with imAE (any grade), they were noted in 18.2% and 56.1%, respectively (p = 0.523 and p = 0.038, respectively).

CONCLUSION

History of Atz/Bev treatment may be an independent clinical factor for poor PFS at Dur/Tre introduction.

Prospects and Challenges of Immunotherapy for Thyroid Cancer

BACKGROUND

Thyroid cancer generally boasts a favorable prognosis; however, advanced and refractory cases exhibit aggressive characteristics and resistance to conventional therapies, necessitating the investigation of innovative treatment modalities. Immunotherapy, which harnesses the body's immune system to target cancer cells, has shown considerable promise for specific thyroid cancer subtypes.

OBJECTIVE

This review article aims to encapsulate the latest advancements in immunotherapy for thyroid cancer, examining its mechanisms, therapeutic efficacy, ongoing challenges, and the potential benefits of combination therapy approaches.

METHODS

An extensive literature review and critical analysis of clinical trial data were conducted to inform this synthesis.

RESULTS

The review reveals that immunotherapy strategies, encompassing immune checkpoint inhibitors, CAR-T cell therapy, tumor vaccines, and immunomodulators, are demonstrating efficacy in the treatment of thyroid cancer. Notably, checkpoint inhibitors have been particularly effective in anaplastic and poorly differentiated thyroid cancers, albeit with challenges such as treatment resistance and adverse effects. The application of CAR-T cell therapy, successful in hematologic cancers, provides a novel perspective for thyroid cancer treatment, although its efficacy in solid tumors requires further study. Additionally, research into tumor vaccines and immunomodulators is advancing, with preliminary evidence suggesting their therapeutic potential for thyroid cancer patients.

CONCLUSION

The recognition of the immune microenvironment's role in treatment responsiveness is pivotal for enhancing the care of thyroid cancer patients. This review underscores the significance of combination therapy as a means to optimize treatment outcomes and charts a course for future research endeavors to broaden the spectrum of effective treatment options available to thyroid cancer patients.

Loss of MNX1 Sensitizes Tumors to Cytotoxic T Cells by Degradation of PD-L1 mRNA

Immune checkpoint blockade (ICB) therapy, targeting programmed cell death ligand-1 (PD-L1)/programmed cell death protein 1 (PD-1) axis and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), has exhibited amazing clinical outcomes in various types of cancers. However, only a small portion of patients benefit from ICB therapy, indicating that the mechanism underlying immune checkpoint is still unclear. Here, it is reported that motor neuron and pancreas homeobox 1 (MNX1), a homeobox domain-containing transcription factor, contributes to the tumor immune escape. MNX1 increases PD-L1 expression in cancer cells by stabilizing PD-L1 mRNA rather than activating transcription. Mechanistically, MNX1 exists in the cytoplasm of cancer cells and interacts with Y-box binding protein 1 (YBX1), a multifunctional DNA/RNA-binding protein, to enhance the binding of YBX1 to PD-L1 mRNA. MNX1 ablation activates cytotoxic T cell-mediated anti-tumor immunity and sensitizes CTLA-4 blockade therapy. Moreover, MNX1 also facilitates tumor progression in an immune-independent manner in cancer cells. In addition, MNX1 is upregulated by its adjacent long non-coding RNA MNX1-AS1 via HECT and RLD domain containing E3 ubiquitin protein ligase 2 (HERC2). Together, these results reveal MNX1 as a novel immune checkpoint regulator with promising therapeutic potential.

Outcomes of Immunotherapy Treatment in Sinonasal Mucosal Melanoma

BACKGROUND

Sinonasal mucosal melanoma has poor survival despite multimodality treatment. While the impact of immunotherapy (IT) on metastatic cutaneous melanoma is well-defined, there are relatively little data on sinonasal mucosal melanoma.

OBJECTIVE

We sought to define immunotherapy outcomes in patients with sinonasal mucosal melanoma.

METHODS

A retrospective cohort study evaluated patients treated with IT during their overall treatment strategy for SNMM. Patient demographics, treatment, and survival outcomes were recorded.

RESULTS

52 patients had IT treatment for SNMM from 2000 to 2022, with an average age of 69.1 ± 11.9 years. The most common treatment was surgery with radiation and IT (n = 26, 50%). Most regimens consisted of a combination of Nivolumab and Ipilimumab (n = 17, 32.7%) or pembrolizumab (n = 14, 26.9%). 44.2% of patients experienced reported complications. Overall survival at 1-, 2-, and 5 years was 86.9%, 74.1%, and 39.1%, respectively.

CONCLUSION

Approximately half of patients will have a local response following immunotherapy, but it is rare to have improvement at metastatic locations. Further research within our group will assess optimal timing and markers that are predictive of response.

Cytochrome P450 2E1 inhibitor Q11 is effective on hepatocellular carcinoma by promoting peritumor neutrophil chemotaxis

Current studies found that the peritumoral tissue of hepatocellular carcinoma (HCC) may be different from normal liver tissue based on proteomics, and related to progression, recurrence and metastasis of HCC. Our previous study proposed "peritumor microenvironment (PME)" to summarize the influence of peritumor tissue on occurrence and progression of HCC. Peritumor CYP2E1 activity was significantly elevated in HCC, and related to occurrence and progression of HCC. However, the effectiveness and mechanism of inhibiting CYP2E1 against HCC remain unclear. In this study, by integrating the advantages of proteomics and transcriptomics, we reanalyzed the various influencing factors in PME. Although there were large differences in the occurrence and progression, the immunity and inflammation still played crucial roles. Peritumor neutrophil were "pro-tumor" phenotype in the stage of progression, while it showed cytotoxicity for tumor cell in the occurrence stage. CYP2E1 activity is associated with peritumor neutrophil infiltration and occurrence of HCC. CYP2E1 inhibitor Q11 showed anti-tumor effects in an orthotopic HCC mouse model by promoting secretion of chemokines and infiltration of neutrophils in peritumor tissue. Overall, these findings provided a reasonable mechanism of anti-tumor effects of CYP2E1 inhibitors, which may be a new strategy for the prevention and treatment of HCC.

Unravelling the Regulatory Roles of lncRNAs in Melanoma: From Mechanistic Insights to Target Selection

Melanoma is the deadliest form of skin cancer, and its treatment poses significant challenges due to its aggressive nature and resistance to conventional therapies. Long non-coding RNAs (lncRNAs) represent a new frontier in the search for suitable targets to control melanoma progression and invasiveness. Indeed, lncRNAs exploit a wide range of regulatory functions along chromatin remodeling, gene transcription, post-transcription, transduction, and post-transduction to ultimately tune multiple cellular processes. The understanding of this intricate and flexible regulatory network orchestrated by lncRNAs in pathological conditions can strategically support the rational identification of promising targets, ultimately speeding up the setup of new therapeutics to integrate the currently available approaches. Here, the most recent findings on lncRNAs involved in melanoma will be analyzed. In particular, the functional links between their mechanisms of action and some frequently underestimated features, like their different subcellular localizations, will be highlighted.

Targeting novel regulated cell death: disulfidptosis in cancer immunotherapy with immune checkpoint inhibitors

The battle against cancer has evolved over centuries, from the early stages of surgical resection to contemporary treatments including chemotherapy, radiation, targeted therapies, and immunotherapies. Despite significant advances in cancer treatment over recent decades, these therapies remain limited by various challenges. Immune checkpoint inhibitors (ICIs), a cornerstone of tumor immunotherapy, have emerged as one of the most promising advancements in cancer treatment. Although ICIs, such as CTLA-4 and PD-1/PD-L1 inhibitors, have demonstrated clinical efficacy, their therapeutic impact remains suboptimal due to patient-specific variability and tumor immune resistance. Cell death is a fundamental process for maintaining tissue homeostasis and function. Recent research highlights that the combination of induced regulatory cell death (RCD) and ICIs can substantially enhance anti-tumor responses across multiple cancer types. In cells exhibiting high levels of recombinant solute carrier family 7 member 11 (SLC7A11) protein, glucose deprivation triggers a programmed cell death (PCD) pathway characterized by disulfide bond formation and REDOX (reduction-oxidation) reactions, termed "disulfidptosis." Studies suggest that disulfidptosis plays a critical role in the therapeutic efficacy of SLC7A11high cancers. Therefore, to investigate the potential synergy between disulfidptosis and ICIs, this study will explore the mechanisms of both processes in tumor progression, with the goal of enhancing the anti-tumor immune response of ICIs by targeting the intracellular disulfidptosis pathway.

Effect of prior and first-line immunotherapy on baseline immune biomarkers and modulation of the tumor microenvironment in response to nivolumab and relatlimab combination therapy in patients with melanoma from RELATIVITY-020

BACKGROUND

Some patients with melanoma experience disease progression during immunotherapy (IO) and may benefit from novel combinations of immune checkpoint inhibitors (ICIs). We report results from exploratory biomarker analyses to characterize the responses of patients with advanced melanoma to treatment with nivolumab (anti-programmed cell death-1 (PD-1)) and relatlimab (anti-lymphocyte-activation gene 3 (LAG-3)) combination therapy in RELATIVITY-020 (NCT01968109).

METHODS

Tumor biopsies collected at baseline and ≤4 weeks after treatment initiation were evaluated for % LAG-3-positive and % CD8-positive immune cells and % programmed death-ligand 1 (PD-L1) expression on tumor cells. Baseline biomarker expression was compared among patients with IO-refractory melanoma based on last prior therapy and IO-resistance type, and between patients with IO-refractory and IO-naïve melanoma. Change in biomarker expression after treatment was evaluated in patients with IO-refractory and IO-naïve melanoma. Immune-related gene expression was compared among resistance groups and by the last prior treatment.

RESULTS

Among patients with IO-refractory melanoma (N=505), elevated baseline LAG-3, PD-L1, and CD8 expression (p≤0.01, p≤0.05, p≤0.001, respectively) was observed in patients whose last prior therapy was IO versus non-IO, and in those who responded (complete/partial per Response Evaluation Criteria in Solid Tumors V.1.1) to nivolumab and relatlimab combination therapy versus those who did not (stable/progressive disease). Inflammation-related gene expression was significantly higher (p<0.05) in patients with secondary versus primary resistance to prior IO treatment, and in those whose last prior therapy was IO versus non-IO. IO-refractory patients whose tumors responded to nivolumab and relatlimab combination therapy had higher inflammation-related gene expression than non-responders (p<0.05); proliferation and hypoxia-related gene expression were enriched in non-responders. During treatment with nivolumab and relatlimab combination therapy, LAG-3 expression increased significantly in patients with IO-refractory (p≤0.01) and IO-naïve melanoma (p≤0.001), and PD-L1 and CD8 increased significantly (p≤0.01 and p≤0.05, respectively) in patients with IO-naïve melanoma.

CONCLUSIONS

Nivolumab and relatlimab combination therapy can modulate the tumor microenvironment in patients with both IO-refractory and IO-naïve melanoma. Further research is needed to identify patients who will most benefit from anti-LAG-3/PD-(L)1 agents, and to elucidate the mechanisms of action of, and resistance to, this combination therapy in patients with advanced melanoma.

TRIAL REGISTRATION NUMBER

NCT01968109.

The Emerging Role of CD8+ T Cells in Shaping Treatment Outcomes of Patients with MDS and AML

CD8+ T cells are critical players in anti-tumor immunity against solid tumors, targeted by immunotherapies. Emerging evidence suggests that CD8+ T cells also play a crucial role in anti-tumor responses and determining treatment outcomes in hematologic malignancies like myelodysplastic neoplasms (MDS) and acute myeloid leukemia (AML). In this review, we focus on the implication of CD8+ T cells in the treatment response of patients with MDS and AML. First, we review reported studies of aberrant functionality and clonality of CD8+ T cells in MDS and AML, often driven by the immunosuppressive bone marrow microenvironment, which can hinder effective antitumor immunity. Additionally, we discuss the potential use of CD8+ T cell subpopulations, including memory and senescent-like subsets, as predictive biomarkers for treatment response to a variety of treatment regimens, such as hypomethylating agents, which is the standard of care for patients with higher-risk MDS, and chemotherapy which is the main treatment of patients with AML. Understanding the multifaceted role of CD8+ T cells and their interaction with malignant cells in MDS and AML will provide useful insights into their potential as prognostic/predictive biomarkers, but also uncover alternative approaches to novel treatment strategies that could reshape the therapeutic landscape, thus improving treatment efficacy, aiding in overcoming treatment resistance and improving patient survival in these challenging myeloid neoplasms.

Clinical Approaches for the Management of Skin Cancer: A Review of Current Progress in Diagnosis, Treatment, and Prognosis for Patients with Melanoma

Melanoma represents a significant public health challenge due to its increasing incidence and potential for metastasis. This review will explore the current clinical approaches to the management of melanoma, focusing on advancements in diagnosis, treatment, and prognosis. Methods for early detection and accurate staging have been enhanced by new diagnostic strategies. Treatment modalities have expanded beyond traditional surgical excision to include targeted therapy and immunotherapy. Prognostic assessment has benefited from the development of novel biomarkers and genetic profiling. This review will highlight the progress made in the multidisciplinary management of melanoma, underscoring the importance of continuous research to improve patient outcomes.

A Dual Stimuli-Responsive Nanoimmunomodulator for Antitumor Synergy of Macrophages and T Cells

Only a minority of patients benefit from current T-cell-focused adaptive immunotherapies, underscoring the need to engage innate immune cells, particularly macrophages, for multilayered tumor control. However, high-efficacy therapeutics capable of orchestrating multiple immune cells remain scarce. Herein, a dual stimuli-responsive nanoimmunomodulator (6EPP@si) that caters specifically to the tumor microenvironment (TME) is presented for the antitumor synergy of macrophages and T cells. Using the functional polymer-based carrier, we co-deliver the endoplasmic reticulum (ER)-localized photosensitizer 6E and small interfering RNA targeting CD47 (siCD47) into breast tumors. Within the acidic and high-glutathione TME, 6EPP@si undergoes self-lysosome escape and nanocleavage for precise, on-demand drug release. Consequently, siCD47 released into the cytoplasm enables potent CD47 silencing, while the ER-targeted photosensitizer 6E induces immunogenic cell death through reactive oxygen species-based ER stress, triggering the release of damage-associated molecular patterns, including calreticulin surface translocation. 6EPP@si enhances macrophage phagocytosis by modulating both antiphagocytic and prophagocytic signals and also promotes antigen presentation to activate T cells. In orthotopic breast tumor and spontaneous lung metastatic tumor models, this combined approach demonstrates robust antitumor effects and effective antimetastatic immunity, offering a meaningful strategy to simultaneously activate multiple immune cells for enhancing cancer immunotherapy.

Advancements in Melanoma Treatment: A Review of PD-1 Inhibitors, T-VEC, mRNA Vaccines, and Tumor-Infiltrating Lymphocyte Therapy in an Evolving Landscape of Immunotherapy

Melanoma, an aggressive skin cancer, presents significant therapeutic challenges. Consequently, innovative treatment strategies beyond conventional chemotherapy, radiation, and surgery are actively explored. This review discusses the evolution of immunotherapy in advanced melanoma, highlighting PD-1/PD-L1 inhibitors, mRNA vaccines, Talimogene Laherparepvec (T-VEC), and tumor-infiltrating lymphocyte (TIL) therapies. PD-1/PD-L1 inhibitors such as pembrolizumab and nivolumab block immune checkpoints, promoting T-cell cytotoxic activity and improving overall survival in patients with advanced melanoma. T-VEC, a modified oncolytic herpes virus, promotes a systemic anti-tumor response while simultaneously lysing malignant cells. mRNA vaccines, such as Moderna's mRNA-4157/V940, take advantage of malignant-cell-specific neoantigens to amplify the adaptive immune response while protecting healthy tissue. TIL therapy is a form of therapy involving ex vivo expansion and reinfusion of the patient's tumor-specific lymphocytes and has been shown to provide durable tumor control. While these therapies have demonstrated promising clinical outcomes, challenges such as tumor resistance, high financial burden, and limited accessibility pose challenges to their widespread use. This review explores combination therapies such as PD-L1 inhibitors with mRNA vaccines, or TIL therapy, which aim to enhance treatment through synergistic approaches. Further research is required to optimize these combinations, address barriers preventing their use, and control adverse events.

Inpatient Immunotherapy Outcomes Study: A Multicenter Retrospective Analysis

PURPOSE

Immune checkpoint inhibitors (ICIs) have revolutionized the care of patients with cancer, but use among hospitalized patients is controversial as a result of questionable benefit and high costs. To evaluate the role of ICIs in the inpatient (IP) setting, we conducted the Inpatient Immunotherapy Outcomes Study (IIOS) to describe characteristics and outcomes of patients who received IP ICIs.

METHODS

IIOS is a retrospective study of patients treated with ICIs during hospitalization between 2012 and 2021 at five academic institutions. Data collection was performed using each institution's electronic medical record. We estimated overall survival (OS) from the first administration of ICI using the Kaplan-Meier method and used adjusted Cox proportional hazards models to explore associations between clinicodemographic variables and OS.

RESULTS

Two hundred fifteen patients received IP ICIs (median age 60 years; 55% White; 14% Black; 13% Hispanic). Thoracic and head and neck (24%), GI (21%), and hematologic (19%) malignancies were most common. Most of the patients were ICI-naïve (75%), had stage IV solid malignancies (75%) at the time of IP ICI initiation, and had no radiographic response to ICI therapy (88%). Median OS from the first IP ICI dose was 1.55 months (95% CI, 1.08 to 1.81) for all patients and 1.28 months (95% CI, 0.95 to 1.80) for patients with advanced solid malignancies. Multivariable Cox proportional hazards model analysis found no clinicodemographic variables associated with improved OS after IP ICI administration.

CONCLUSION

IIOS is the largest multi-institutional effort to describe outcomes after IP ICI administration. Clinical outcomes are poor after IP ICI use and IP ICIs should be used with caution.

Prognostic value of body adipose tissue parameters in cancer patients treated with immune checkpoint inhibitors

Objective

This study aims to explore the relationship between body adipose tissue characteristics and clinical outcomes in cancer patients receiving immune checkpoint inhibitor (ICI) therapy.

Methods

We conducted an extensive literature search across three major online databases-Embase, PubMed, and the Cochrane Library-to identify studies examining the link between body adipose tissue and treatment outcomes in cancer patients undergoing ICI therapy, from the inception of each database until February 20, 2024. The quality of the included studies was evaluated using the Newcastle-Ottawa Scale. The primary outcomes analyzed were hazard ratios (HRs) for overall survival (OS) and progression-free survival (PFS), as well as odds ratios (ORs) for disease control rate (DCR). Pooled estimates and 95% confidence intervals (CIs) were calculated.

Results

A total of 23 studies were included, encompassing 2741 cancer patients. The analysis revealed that patients with higher levels of visceral adipose tissue (VAT) exhibited significantly improved OS (HR: 0.72, 95% CI: 0.59-0.89, p < 0.001) and PFS (HR: 0.80, 95% CI: 0.67-0.96, p = 0.015), along with a higher DCR (OR: 1.81, 95% CI: 1.26-2.60, p = 0.001), compared to those with lower VAT levels. Additionally, increased subcutaneous adipose tissue (SAT) levels were associated with significantly better OS (HR: 0.69, 95% CI: 0.58-0.82, p < 0.001) and PFS (HR: 0.82, 95% CI: 0.68-1.00, p = 0.049), and a higher DCR (OR: 1.99, 95% CI: 1.15-3.44, p = 0.014). Elevated total adipose tissue (TAT) levels were also linked to longer OS (HR: 0.73, 95% CI: 0.55-0.97, p = 0.028). However, a higher visceral-to-subcutaneous adipose tissue ratio (VSR) was associated with a shorter OS (HR: 1.43, 95% CI: 1.09-1.87, p = 0.010). No significant relationship was found between TAT (HR: 0.81, 95% CI: 0.54-1.23, p = 0.332) and VSR (HR: 1.20, 95% CI: 0.95-1.51, p = 0.131) with PFS in ICI-treated patients.

Conclusion

This study highlights the prognostic relevance of VAT and SAT in predicting treatment response and survival outcomes in cancer patients receiving ICIs. These findings suggest that assessments of VAT and SAT should be incorporated into prognostic evaluations for this patient population.

Mechanisms of Resistance to Anti-PD-1 Immunotherapy in Melanoma and Strategies to Overcome It

Resistance to anti-PD-1 therapy in melanoma remains a major obstacle in achieving effective and durable treatment outcomes, highlighting the need to understand and address the underlying mechanisms. The first key factor is innate anti-PD-1 resistance signature (IPRES), an expression of a group of genes associated with tumor plasticity and immune evasion. IPRES promotes epithelial-to-mesenchymal transition (EMT), increasing melanoma cells' invasiveness and survival. Overexpressed AXL, TWIST2, and WNT5a induce phenotypic changes. The upregulation of pro-inflammatory cytokines frequently coincides with EMT-related changes, further promoting a resistant and aggressive tumor phenotype. Inflamed tumor microenvironment may also drive the expression of resistance. The complexity of immune resistance development suggests that combination therapies are necessary to overcome it. Furthermore, targeting epigenetic regulation and exploring novel approaches such as miR-146a modulation may provide new strategies to counter resistance in melanoma.

Immune Checkpoint Inhibitors in the Treatment of Ocular Surface Cancers: A Review

BACKGROUND

Immune checkpoint inhibitors (ICIs) have transformed cancer therapy by targeting key immune pathways such as PD-1, PD-L1, CTLA-4, and LAG-3 to enhance the immune system's ability to combat malignancies. Their use in treating ocular surface tumors is an emerging area of interest, particularly in conjunctival melanoma (CM) and ocular surface squamous neoplasia (OSSN). Some studies have indicated the potential of ICI's in sebaceous gland carcinoma (SeC), conjunctival lymphoma, and Kaposi sarcoma.

PURPOSE

This review aims to evaluate the role of ICIs in treating ocular surface tumors, focusing on their mechanisms of action, clinical outcomes, and therapeutic potential.

METHODS

A literature review was conducted by searching Pubmed for studies published between January 2014 and October 2024. Studies included were original research, clinical trials, case reports and series, and reviews.

RESULTS

ICIs, including pembrolizumab and nivolumab, have shown promising results in CM, achieving tumor regression and disease stabilization in advanced and metastatic cases. ICIs have also demonstrated efficacy in OSSN, particularly in lesions with high tumor mutational burden, with responses ranging from partial to complete resolution. Although clinical data for SeC and conjunctival lymphoma remain limited to isolated reports, these studies suggest a role for ICIs in managing refractory or advanced disease.

CONCLUSION

ICIs hold transformative potential in improving outcomes for ocular surface malignancies, particularly in cases where conventional treatments fail or pose significant morbidity. Despite their promise, challenges persist, including variable response rates, immune-related adverse events, and the need for reliable predictive biomarkers. Comprehensive prospective studies are necessary to refine the application of ICIs, optimize treatment strategies, and expand therapeutic options for these challenging cancers.

The UBA1-STUB1 Axis Mediates Cancer Immune Escape and Resistance to Checkpoint Blockade

SIGNIFICANCE

Our study reveals UBA1 as a predictive biomarker for clinical outcomes in ICB cohorts, mediating cancer immune evasion and ICB resistance. We further highlight JAK1 stabilization as a key mechanism of UBA1 inhibition and nominate the UBA1-STUB1 axis as an immuno-oncology therapeutic target to improve the efficacy of ICB.

Recombinant CD80 fusion protein combined with discoidin domain receptor 1 inhibitor for cancer treatment

Immune checkpoint inhibitors (ICIs) have significantly advanced the field of cancer immunotherapy. However, clinical data has shown that many patients have a low response rate or even resistance to immune checkpoint inhibitor alone. The underlying reasons for its poor efficacy include the deficiency of immune infiltration and effective CD28/CD80 costimulatory signal in tumor. Discoidin domain receptor 1 (DDR1) has been reported to be negatively related to immune cell infiltration in tumors. Herein, we constructed a soluble fusion protein using CD80, the natural ligand of CD28, in combination with DDR1 inhibitor. Our results demonstrated that CD80-Fc effectively activated T cells and inhibited tumor growth in vivo, even in tumors with poor efficacy of ICIs. Importantly, CD80-Fc fusion protein had a milder affinity against the targets which suggested a potential higher safety than CD28 agonists. Further, in order to promote tumor immune infiltration, we attempted to combine CD80-Fc fusion protein with DDR1 inhibitor for treatment. Our results indicated that using CD80-Fc fusion protein along with DDR1 inhibitor significantly promoted T cell infiltration in tumor microenvironment and more strongly inhibited tumor growth. Therefore, the combination use of CD80 fusion protein and DDR1 inhibitor could become an effective tumor immunotherapy strategy, potentially benefiting a larger number of patients. KEY POINTS: • We successfully constructed, expressed, and purified the recombinant CD80-Fc fusion protein • We demonstrated that CD80-Fc fusion protein has good safety and anti-tumor activity • We demonstrated that using CD80-Fc fusion protein along with DDR1 inhibitor can significantly promote immune infiltration of T cells in tumor microenvironment and more strongly inhibit tumor growth.

Early detection of myocarditis caused by immune checkpoint inhibitor therapy with nivolumab and ipilimumab for advanced recurrent renal cell carcinoma

Combination therapy with nivolumab and ipilimumab for advanced renal cell carcinoma (RCC) may cause immune-related myocarditis; however, its incidence in this cancer type and regimen remains unknown. At our institution, we measure biomarkers, such as high-sensitivity Troponin (hsTn), and perform electrocardiograms (ECGs) and echocardiography before and every month after the initiation of this therapy, and the findings obtained and patients' symptoms are continuously monitored by physicians and pharmacists. A retrospective survey was conducted on physiological and biochemical test findings and immune-related adverse events in patients with advanced RCC who received combination therapy with nivolumab and ipilimumab between October 1, 2018 and December 31, 2023. Patients suspected of having myocarditis consulted with cardiologists. Myocarditis due to this therapy was detected in 5 of the 86 patients (5.8%) assessed using the European Society of Cardiology 2022 guidelines. There were no fatal symptoms or death due to myocarditis. The median time to the onset of myocarditis was 25 days (21-86 days). The early detection of myocarditis caused by this therapy requires the monitoring of changes by periodically measuring hsTn and other cardiac markers and performing ECGs and echocardiography from the early stages of administration through to the end of treatment. In addition to checking symptoms, if these abnormalities are detected and myocarditis is suspected, prompt collaboration with cardiologists is recommended. Our management strategy of care by a onco-cardiology team may contribute to the early diagnosis and treatment of myocarditis.

Phase I study of pembrolizumab in combination with ibrutinib for the treatment of unresectable or metastatic melanoma

Background

Immune checkpoint inhibitors (ICIs) have been transformative in the treatment of patients with metastatic melanoma, but primary and secondary resistance to ICI treatment is common. One key mechanism for ICI resistance is the skewing of the immune response from a cytotoxic (Th1) to a chronic inflammatory (Th2) profile. The small molecule ibrutinib is a dual-target agent that inhibits Bruton's Tyrosine Kinase (BTK) and Interleukin-2-inducible T-cell Kinase (ITK), a key regulator of Th2 immunity. Therefore, combining ibrutinib and pembrolizumab could potentially induce an increase in Th1 immune polarity in melanoma patients. We hypothesize that the combination would be well-tolerated and might result in clinical benefit for patients with metastatic melanoma. The primary aim of this phase I study was to evaluate the safety, tolerability, and determine the maximum tolerated dose (MTD) of ibrutinib in combination with pembrolizumab in patients with metastatic melanoma.

Methods

A 3 + 3 phase I clinical trial was conducted in patients with unresectable Stage III or metastatic melanoma (stage IV) not amenable to local therapy. Pembrolizumab (200 mg/kg every 3 weeks) was combined with ibrutinib, administered orally at the dose assigned at the time of registration (140 mg daily, 280 mg daily, and 420 mg daily). Patients were treated until disease progression, intolerability, or patient decision to discontinue. Blood samples were collected after each cycle of treatment for immunophenotyping and Th1/Th2 polarity assessment based on immune response markers.

Results

Between January 31, 2017 and January 9, 2023, 17 patients were enrolled. The MTD of ibrutinib in combination with pembrolizumab was determined to be 420 mg daily. The adverse events leading to discontinuation included: grade 4 ALT and AST increase (1 pt, DL0); grade 4 ALT increase with grade 3 AST increase (1 pt, DL1); and grade 3 hyponatremia, hypoxia, and maculo-papular rash (1 pt, DL1). Three of the 16 patients treated had objective responses (2 partial responses, 1 complete response) lasting over 8 months. The median progression-free survival was 3 months, and median and overall survival was 1.8 years. The combination treatment did not result in consistent increase in Th1 immune polarity.

Conclusion

In conclusion, the maximum tolerated dose of ibrutinib in combination with pembrolizumab in patients with advanced or metastatic melanoma was established at 420 mg by mouth once daily. The combination was well-tolerated but did not result in a consistent increase in Th1 immune polarity; further investigation is needed to assess the relative clinical efficacy of this approach. (Funded by Pharmacyclics; ClinicalTrials.gov number: NCT03021460).

Clinical trial registration

www.clinicaltrials.gov, identifier NCT03021460.

Inflammatory Stress Determines the Need for Chemotherapy in Patients with HER2-Positive Esophagogastric Adenocarcinoma Receiving Targeted Therapy and Immunotherapy

Anti-PD-1, trastuzumab, and chemotherapy are used in the treatment of patients with advanced HER2-positive esophagogastric adenocarcinoma, but long-term survival remains limited. In this study, we report extended follow-up data from the INTEGA trial (NCT03409848), which investigated the efficacy of the anti-PD-1 nivolumab, trastuzumab, and FOLFOX chemotherapy (FOLFOX arm) in comparison with a chemotherapy-free regimen involving nivolumab, trastuzumab, and the anti-CTLA-4 ipilimumab (Ipi arm) in the first-line setting for advanced disease. The 12-month overall survival (OS) showed no statistical difference between the arms, with 57% OS (95% confidence interval, 41%-71%) in the Ipi arm and 70% OS (95% confidence interval, 54%-82%) in the FOLFOX arm. Crossing of the survival curves indicated a potential long-term benefit for some patients within the Ipi arm, but early progressors in the Ipi arm underlined the need for biomarker-guided strategies to optimize treatment selection. To this end, metabolomic and cytokine analyses demonstrated elevated levels of normetanephrine, cortisol, and IL6 in immunotherapy-unresponsive patients in the Ipi arm, suggesting a role for systemic inflammatory stress in modulating antitumor immune responses. Patients with this signature also showed an increased neutrophil to lymphocyte ratio that persisted in the Ipi arm, but not in the FOLFOX arm, and strongly correlated with survival. Furthermore, a low neutrophil to lymphocyte ratio characterized patients benefiting from immunotherapy and targeted therapy without the need for additional chemotherapy. These data suggest that patient selection based on inflammatory stress-driven immune changes could help customize first-line treatment in patients with advanced HER2-positive esophagogastric adenocarcinoma to potentially improve long-term survival.

Adjuvant immunotherapy in patients with resected gastric and oesophagogastric junction cancer following preoperative chemotherapy with high risk for recurrence (ypN+ and/or R1): European Organisation of Research and Treatment of Cancer (EORTC) 1707 VESTIGE study

BACKGROUND

Patients with gastro-oesophageal adenocarcinoma with tumour-positive lymph nodes (ypN+) or positive surgical margins (R1) following neoadjuvant chemotherapy and resection are at high risk of recurrence. Adjuvant nivolumab is effective in oesophageal/oesophagogastric junction cancer and residual pathological disease following chemoradiation and surgery. Immune checkpoint inhibition has shown efficacy in advanced gastro-oesophageal cancer. We hypothesised that nivolumab/ipilimumab would be more effective than adjuvant chemotherapy in high-risk (ypN+ and/or R1) patients with gastro-oesophageal adenocarcinoma following neoadjuvant chemotherapy and resection.

PATIENTS AND METHODS

VESTIGE was an academic international, multicentre, open-label, randomised phase II trial evaluating the efficacy of adjuvant nivolumab/ipilimumab versus chemotherapy in gastro-oesophageal adenocarcinoma at high risk of recurrence. Patients were randomised 1 : 1 to receive standard adjuvant chemotherapy (same regimen as neoadjuvant) or nivolumab 3 mg/kg intravenously (i.v.) every 2 weeks plus ipilimumab 1 mg/kg i.v. every 6 weeks for 1 year. Key inclusion criteria included ypN+ and/or R1 status after neoadjuvant chemotherapy plus surgery. The primary endpoint was disease-free survival in the intent-to-treat population. Secondary endpoints included overall survival, locoregional and distant failure rates, and safety according to National Cancer Institute Common Terminology Criteria for Adverse Events v5.0.

RESULTS

The independent Data Monitoring Committee reviewed data from 189 of the planned 240 patients in June 2022 and recommended stopping recruitment due to futility. At the time of final analysis, median follow-up was 25.3 months for 195 patients (98 nivolumab/ipilimumab and 97 chemotherapy). Median disease-free survival for the nivolumab/ipilimumab group was 11.4 months [95% confidence interval (CI) 8.4-16.8 months] versus 20.8 months (95% CI 15.0-29.9 months) for the chemotherapy group, hazard ratio 1.55 (95% CI 1.07-2.25, one-sided P = 0.99). The 12-month disease-free survival rates were 47.1% and 64.0%, respectively. There were no toxicity concerns or excess early discontinuations.

CONCLUSION

Nivolumab/ipilimumab did not improve disease-free survival compared with chemotherapy in patients with ypN+ and/or R1 gastro-oesophageal adenocarcinoma following neoadjuvant chemotherapy and surgery.

Weight and Blood-Based Markers of Cachexia Predict Disability, Hospitalization and Worse Survival in Cancer Immunotherapy Patients

BACKGROUND

Cancer-associated cachexia can inhibit immune checkpoint inhibitor (ICI) therapy efficacy. Cachexia's effect on ICI therapy has not been studied in large cohorts of cancer patients aside from lung cancer. We studied associations between real-world routinely collected clinical cachexia markers and disability-free, hospitalization-free and overall survival of cancer patients.

METHODS

A retrospective study was conducted of electronic health records (EHR) of patients with lung, renal cell, melanoma and other cancers treated with ICI therapy at Northwestern Medicine of Chicago, IL, United States, between March 2011 and January 2022. Weight, body mass index, absolute neutrophil and lymphocyte counts, albumin and C-reactive protein (CRP) measures were analysed to calculate the Fearon consensus criteria for cachexia, weight loss grading system (WLGS) score, neutrophil-lymphocyte ratio (NLR), Prognostic Nutritional Index (PNI) and modified Glasgow Prognostic Score (mGPS) at ICI therapy initiation. Kaplan-Meier and Cox proportional hazards analyses were used to determine associations between these metrics and disability-free, hospitalization-free and overall survival.

RESULTS

EHR analysis uncovered 3285 cancer patients on ICI therapy (54% > 65 years of age, 50.7% male, 77.7% White). At ICI therapy initiation, 1282 (39.0%) patients had cachexia (consensus criteria), 1641 (50.0%) had a WLGS score ≥ 2, 1806 (55.0%) had an NLR > 3, 1087 (33.1%) had albumin < 3.5 g/dL and 1318 (40.1%) had a PNI < 44. Missing measurements included CRP missing for 98.2% and mGPS missing for 98.6% of patients. Disability-free (n = 1373), hospitalization-free (n = 2374) and overall survival (n = 1599) events were analysed with 1-year rates of 65% (64%-67%), 35% (34%-37%) and 65% (63%-66%), respectively. Multivariate Cox model analyses showed hazard ratios (HR) for cachexia at 1.58 (95% CI 1.38-1.80), 1.47 (95% CI 1.33-1.63) and 1.97 (95% CI 1.75-2.23) for disability, hospitalization and death, respectively. HRs for WLGS ≥ 2 were 1.45 (95% CI 1.28-1.66), 1.37 (95% CI 1.24-1.51) and 1.91 (95% CI 1.69-2.17). HRs for NLR > 3 were 1.57 (95% CI 1.35-1.83), 1.40 (95% CI 1.25-1.58) and 1.95 (95% CI 1.67-2.27). HRs for albumin < 3.5 g/dL were 1.33 (95% CI 1.15-1.54), 1.67 (95% CI 1.50-1.86) and 2.09 (95% CI 1.84-2.36). HRs for PNI < 44 were 1.60 (95% CI 1.39-1.84), 1.46 (95% CI 1.31-1.63) and 2.07 (95% CI 1.80-2.37).

CONCLUSIONS

Fearon consensus criteria, WLGS, NLR, albumin and PNI were routinely collected at ICI initiation in regular clinical practice and predictive of worse disability-free, hospitalization-free and overall survival in cancer patients receiving ICI therapy. These routine clinical measures may aid prognostication and decision-making in cancer patients with cachexia.

Thromboembolic events associated with immune checkpoint inhibitors in cancer patients: A Bayesian network meta-analysis

BACKGROUND

Immune checkpoint inhibitors (ICIs), which offer previously unknown therapeutic advantages, have revolutionized cancer treatment. However, the risk of thromboembolic events (TEEs) associated with ICIs remains unclear. The aim of this network meta-analysis (NMA) was to evaluate the incidence of TEEs in cancer patients receiving different treatment regimens.

METHODS

We searched for randomized clinical trials (RCTs) between January 2021 and December 2023 without restricting the cancer type. The percentages of TEEs were systematically extracted. An NMA was performed comparing atezolizumab, cemiplimab, durvalumab, ipilimumab, nivolumab, pembrolizumab, conventional therapy (which consists mainly of chemotherapy, targeted therapy, placebo, and their combinations), two ICI drugs, one ICI drug combined with conventional therapy, and two ICI drugs combined with conventional therapy. Additionally, subgroup analysis was conducted based on cancer type.

RESULTS

Eighty-three RCTs involving 54,736 patients were included. Patients receiving ICIs demonstrated comparable risks of arterial thromboembolism (ATE), deep vein thrombosis (DVT), myocardial infarction (MI), and cerebrovascular accidents (CVAs). Nivolumab (OR 0.39, 95 % CI 0.19 to 0.80) and two ICI drugs (OR 0.52, 95 % CI 0.29 to 0.89) had the lowest risk of venous thromboembolism (VTE) compared to two ICI drugs with conventional therapy. The risk of pulmonary embolism (PE) was greater for ipilimumab (OR 4.09, 95 % CI 1.13 to 15.51) than for nivolumab. For melanoma in the subgroup analysis, nivolumab significantly reduced the risk of VTE (OR 0.07, 95 % CI 0.00 to 0.76) compared to two ICI drugs. Among the single-ICI regimens, durvalumab was associated with the highest incidence of ATE, MI, and CVAs; ipilimumab had the highest incidence of VTE and PE; and pembrolizumab had the highest incidence of DVT. The combination of one ICI drug with conventional therapy was associated with a significantly greater risk of TEEs (except for MI) than the combination of two ICI drugs.

CONCLUSIONS

Various ICI regimens in cancer patients exhibit clinically significant differences in the risks of TEEs. Nivolumab exhibited a favorable safety profile regarding VTE, while ipilimumab had the highest risk of both VTE and PE. Different ICI regimens require tailored risk management strategies to reduce TEEs.

Management of immune checkpoint inhibitor-associated toxicities in older adults with cancer: recommendations from the International Society of Geriatric Oncology (SIOG)

Immune checkpoint inhibitors (ICIs) have substantially advanced the treatment landscape for a wide variety of malignancies. Older adults represent a large and rapidly growing demographic, among whom ICIs are widely prescribed. Management of ICI-associated toxicity among older adults, particularly in the presence of frailty and comorbidity, poses unique challenges. In this Policy Review, developed by the International Society of Geriatric Oncology (SIOG), we offer an evidence-based framework for health-care providers, caregivers, and policy makers for treating older adults with ICIs, focusing on unique considerations for this population that are not adequately addressed by existing guidelines, and expanding them to encompass geriatric oncology principles.

Elevated Neutrophil-to-Lymphocyte Ratio Correlates With Liver Metastases and Poor Immunotherapy Response in Stage IV Melanoma

BACKGROUND AND OBJECTIVES

Immune checkpoint inhibition (ICI) has revolutionized treatment for metastasized melanoma, but many patients remain unresponsive. Concerning potential adverse events, reliable biomarkers to predict ICI response are needed. In this context, neutrophil-to-lymphocyte ratio (NLR) and derived NLR (dNLR) have emerged. Liver metastases also limit ICI efficacy, correlating with diminished overall survival (OS) and progression-free survival (PFS) and may siphon activated T cells from the systemic circulation, creating an 'immune desert state'. We evaluated the predictive role of NLR and dNLR for ICI response and the impact of liver metastases on systemic immunity and treatment efficacy.

PATIENTS AND METHODS

In this single-center retrospective study, we included 141 stage IV melanoma patients undergoing ICI. NLR and dNLR were calculated from absolute neutrophil count, absolute lymphocyte count, and white blood cell count.

RESULTS

Elevated NLR and dNLR were associated with poor response to ICI and inferior PFS. Patients with liver metastases exhibited higher NLR and dNLR levels and showed diminished response to ICI.

CONCLUSIONS

Elevated baseline NLR and dNLR predict poor response to ICI and PFS in stage IV melanoma. Liver metastases are negative predictors for ICI response, with associated higher NLR and dNLR levels potentially contributing to therapy resistance.

An Overview of Liver Directed Locoregional Therapies

An overview of all liver-directed locoregional therapies, including surgical resection for melanoma liver metastases (MLMs), is provided. MLM patients are divided by their primary melanoma location; cutaneous, uvea (eye), and mucosal melanoma. If patients with isolated cutaneous MLMs are considered for surgical resection, treatment with systemic therapy should be part of the treatment course. For uveal MLMs, complete surgical or ablative treatment of all MLMs suggests superior results compared with other liver-directed or systemic therapies, based on current evidence, no recommendations for any liver-directed regional therapy in the treatment of mucosal MLMs can be made.

Immune-mediated liver injury from checkpoint inhibitors: mechanisms, clinical characteristics and management

Immunotherapy has changed the treatment landscape for patients with cancer in the past decade. Immune checkpoint inhibitor (ICI)-based therapies have proven effective in a range of malignancies, including liver and gastrointestinal cancers, but they can cause diverse off-target organ toxicities. With the increasingly wider application of these drugs, immune-mediated liver injury from ICIs has become a commonly encountered challenge in clinical hepatology and gastroenterology. In this Review, we discuss the evidence from human and animal studies on the immunological mechanisms of immune-mediated liver injury from ICIs and summarize its clinical features and practical considerations for its management.

Optimizing combination targeted immunotoxin therapy: Insights from HER2 and EpCAM expression profiles

Molecular targeted cancer therapy is a rapidly developing field, driving progress toward greater treatment efficacy. However, targeted monotherapy often fails due to the development of multidrug resistance in tumors. The combination of multiple targeted agents emerges as a possible solution to enhance treatment outcomes by activating different signaling pathways. This study systematically investigates the combined effect of targeted agents for the oncomarkers HER2 and EpCAM on cancer cells. Specifically, the study examined the impact of anti-HER2 (DARP_9.29-LoPE) and anti-EpCAM (DARP_EC1-LoPE) immunotoxins on a panel of cancer cells expressing various levels of HER2 and EpCAM. Using the Chou-Talalay combination indices, the study revealed that cells with low HER2 expression and high EpCAM expression are not optimal targets for combined HER2/EpCAM therapy. In contrast, the most effective approach involves the usage of an equimolar ratio of immunotoxins for cells exhibiting high HER2 and moderate EpCAM expression, resulting in a synergistic therapeutic effect. These findings provide significant insights into optimizing combination anti-HER2/EpCAM therapies and hold promise for the development of more effective cancer treatment strategies.

Hepatic Events During Immune Checkpoint Inhibitor Treatment Between Liver and Non-Liver Malignancies in Hepatitis B Endemic Areas

BACKGROUND

Notable advances have been made in immune checkpoint inhibitors (ICIs) for cancer treatment. However, the adverse effects of ICIs, especially hepatotoxicity, remain a challenging problem. Whether patients in hepatitis B virus (HBV)-endemic areas are prone to developing hepatic adverse events during ICI treatment warrants further exploration.

METHODS

From 2014 to 2020, the data of all patients with cancer who received ICI treatment at Taipei Veterans General Hospital were retrospectively reviewed. The incidence of and risk factors for hepatic adverse events, including hepatitis flare, immune-related hepatitis (irHepatitis) and HBV reactivation (HBVr), were analysed through a Cox proportional hazard regression model.

RESULTS

A total of 1283 patients with cancer (190 hepatocellular carcinoma [HCC] patients and 1093 patients with non-HCC malignancies) were eligible for analysis, of whom 283 (22.1%) were HBsAg-positive. The incidence of hepatitis flare events of any grade was significantly higher in HCC patients than in non-HCC patients (45.8% vs. 25.6%, p < 0.001). HCC and baseline alanine aminotransferase (ALT) > 40 U/L were independent risk factors for ≥ grade 3 hepatitis flare events. No difference was observed in irHepatitis risk between HCC patients and non-HCC patients. ALT > 40 U/L was an independent risk factor for irHepatitis. Among 283 HBsAg-positive patients, six patients (2.1%) experienced HBVr. HCC patients had a higher risk of HBVr than non-HCC patients (4.4% vs. 0.6%). No specific risk factor for HBVr could be identified. However, none of the patients under nucleos/tide analogue (NUC) prophylaxis experienced HBVr in this study.

CONCLUSIONS

Under ICI treatment, HCC patients had a higher risk of hepatitis flare events than non-HCC patients. Abnormal baseline ALT levels are a risk factor for hepatic adverse events. NUC prophylaxis can minimise the risk of HBVr.

Precision Oncology in Clinical Practice: Two Years of Comprehensive Genomic Profiling in Croatia

Background: The widespread adoption of precision medicine in routine cancer care remains a critical challenge, even as advanced technologies expand and personalized therapies demonstrate remarkable success in certain cancer types. While breakthrough innovations in targeted treatments have revolutionized outcomes for specific cancers, translating these scientific advances into standard clinical practice continues to be an evolving and complex endeavor. Croatia has a nationwide project of precision oncology through the comprehensive genomic profiling (CGP) analysis. Since collecting and analyzing real-world data is crucial for clinical research and defining the value of CGP in precision oncology, we aimed to present the data from everyday clinical practice given the opportunities and challenges we faced. Methods: This was a retrospective observational study conducted at the national level in all patients whose tumor samples were subjected to CGP between 1 January 2020 and 31 December 2021. Results: In total, 481 patients with CGP results were included in this study. Gastrointestinal and reproductive malignancies were the most common, accounting for 29.1% and 28.9% of all tested tumors, respectively. Specifically, colorectal tumors made up 19.1% of cases, while uterine tumors represented 11.2%. At least one clinically relevant genomic alteration was found in 76.7% of patients, with the KRAS mutation (27.2%) being the most common. During the two-year study period, 26,709 individuals lost their lives to cancer in Croatia. Combining this with the CGP selection criteria valid at the time, there was an estimated population of approximately 13,350 potentially eligible patients for the CGP analysis, meaning that only 3.6% of potentially eligible patients were tested. Conclusions: The analysis identified clinically actionable genomic alterations in approximately 80% of the evaluated patients, suggesting they could be candidates for targeted therapeutic interventions. The adoption of CGP remains limited, with estimates indicating that under 5% of metastatic cancer patients received testing in the initial two-year implementation period, despite established national insurance coverage guidelines. This low utilization rate suggests a significant gap in access to genomic testing, leaving many eligible cancer patients without the potential benefits of this diagnostic approach.

Targeting the PD-1/PD-L1 Signaling Pathway for Cancer Therapy: Focus on Biomarkers

The PD1/PD-L1 axis plays an important immunosuppressive role during the T-cell-mediated immune response, which is essential for the physiological homeostasis of the immune system. The biology of the immunological microenvironment is extremely complex and crucial for the development of treatment strategies for immunotherapy. Characterization of the immunological, genomic or transcriptomic landscape of cancer patients could allow discrimination between responders and non-responders to anti-PD-1/PD-L1 therapy. Immune checkpoint inhibitor (ICI) therapy has shown remarkable efficacy in a variety of malignancies in landmark trials and has fundamentally changed cancer therapy. Current research focuses on strategies to maximize patient selection for therapy, clarify mechanisms of resistance, improve existing biomarkers, including PD-L1 expression and tumor mutational burden (TMB), and discover new biomarkers. In this review, we focus on the function of the PD-1/PD-L1 signaling pathway and discuss the immunological, genomic, epigenetic and transcriptomic landscape in cancer patients receiving anti-PD-1/PD-L1 therapy. Finally, we provide an overview of the clinical trials testing the efficacy of antibodies against PD-1/PD-L1.

Acral Melanoma in Skin of Color: Current Insights and Future Directions: A Narrative Review

Acral melanoma (AM), also known as acral lentiginous melanoma (ALM), is a rare subtype of melanoma that predominantly occurs on the palms, soles, and nail beds (Figure 1) [...].

Prognostic value of immune biomarkers in melanoma loco-regional metastases

The prognosis for patients with melanoma loco-regional metastases is very heterogenous. Adjuvant PD-L1-inhibitors have improved clinical outcome for this patient group, but the prognostic impact of tumour PD-L1 expression and number of tumour infiltrating lymphocytes (TILs) is still largely unknown. Here, we investigated the impact on survival for CD3, CD8, FOXP3 and PD-L1 TIL counts and tumour PD-L1 expression in melanoma loco-regional metastases. In a patient series of loco-regional metastases from nodular melanomas (n = 78; n = 26 skin metastases, n = 52 lymph node metastases), expression of PD-L1 in tumour cells and the number of CD3, CD8, FOXP3 and PD-L1 positive TILs were determined by immunohistochemistry on tissue microarray (TMA) slides. Due to limited tumour tissue in the paraffin blocks, 67 of the 78 cases were included for tissue microarrays. Low FOXP3 TIL count and negative tumour PD-L1 expression (cut off 1%) were both significantly associated with reduced survival in lymph node metastases. Low FOXP3 TIL count was significantly associated with low CD8, CD3 and PD-L1 TIL counts. Negative tumour PD-L1 expression was significantly associated with low CD8 and PD-L1 TIL count, large lymph node metastasis tumour size and presence of necrosis in lymph node metastases. Our findings demonstrate for the first time the negative prognostic value of low FOXP3 TIL count and confirm a negative prognostic value of negative tumour PD-L1 expression in melanoma lymph node metastases.

Temporal and spatial composition of the tumor microenvironment predicts response to immune checkpoint inhibition

Immune checkpoint inhibition (ICI) has fundamentally changed cancer treatment. However, only a minority of patients with metastatic triple negative breast cancer (TNBC) benefit from ICI, and the determinants of response remain largely unknown. To better understand the factors influencing patient outcome, we assembled a longitudinal cohort with tissue from multiple timepoints, including primary tumor, pre-treatment metastatic tumor, and on-treatment metastatic tumor from 117 patients treated with ICI (nivolumab) in the phase II TONIC trial. We used highly multiplexed imaging to quantify the subcellular localization of 37 proteins in each tumor. To extract meaningful information from the imaging data, we developed SpaceCat, a computational pipeline that quantifies features from imaging data such as cell density, cell diversity, spatial structure, and functional marker expression. We applied SpaceCat to 678 images from 294 tumors, generating more than 800 distinct features per tumor. Spatial features were more predictive of patient outcome, including features like the degree of mixing between cancer and immune cells, the diversity of the neighboring immune cells surrounding cancer cells, and the degree of T cell infiltration at the tumor border. Non-spatial features, including the ratio between T cell subsets and cancer cells and PD-L1 levels on myeloid cells, were also associated with patient outcome. Surprisingly, we did not identify robust predictors of response in the primary tumors. In contrast, the metastatic tumors had numerous features which predicted response. Some of these features, such as the cellular diversity at the tumor border, were shared across timepoints, but many of the features, such as T cell infiltration at the tumor border, were predictive of response at only a single timepoint. We trained multivariate models on all of the features in the dataset, finding that we could accurately predict patient outcome from the pre-treatment metastatic tumors, with improved performance using the on-treatment tumors. We validated our findings in matched bulk RNA-seq data, finding the most informative features from the on-treatment samples. Our study highlights the importance of profiling sequential tumor biopsies to understand the evolution of the tumor microenvironment, elucidating the temporal and spatial dynamics underlying patient responses and underscoring the need for further research on the prognostic role of metastatic tissue and its utility in stratifying patients for ICI.

Dual-energy CT iodine concentration as a biomarker for immunotherapy treatment response in metastatic melanoma and renal cell carcinoma patients

OBJECTIVE

To investigate the predictive value of tumor iodine concentration obtained with dual-energy CT (DECT) for treatment response in patients treated with immune checkpoint inhibitors (ICI).

MATERIALS AND METHODS

Retrospective single-center study of consecutive metastatic melanoma and renal cell carcinoma (RCC) patients undergoing first-line ICI treatment. The iodine concentration measurement time points include prior to initiation of therapy (baseline [BL]), after initiation (follow-up [FU1]), and either time point nearest to 12 months or at time of progression (final follow-up [FFU]). Target lesion DECT-based whole-volume tumor normalized iodine concentration average (NICave) and size measurements were obtained. Reference standard was individual lesion FFU status categorized as responders or nonresponders per RECIST 1.1. Logistic regression model assessed NICave change and FU1 lesion response as predictors of FFU lesion outcome. Model's performance was summarized with AUC. Intraclass correlation coefficient (ICC) summarized inter-rater agreement of NICave.

RESULTS

Forty-six patients were included (mean age 61 ± 11 years, 12 women; 16 melanoma). Sixty-four of 175 target lesions were confirmed nonresponders at FFU. In a multivariable model, lesion status at FU1 (odds ratio [OR]: 27.4, p < 0.001) and changes in NICave from BL to FU1 (OR: 2.42 per 1-SD increase, p = 0.019) were significant predictors of lesion status at FFU. The model's AUC was 0.86 (95% CI: 0.76-0.93). Inter-rater reliability of NICave was 0.98 (95% CI: 0.97-0.99).

CONCLUSIONS

Changes in iodine concentration from baseline to first follow-up improve identification of delayed responding metastatic melanoma and RCC lesions treated with immune checkpoint inhibitor, initially classified as nonresponders by size change.

KEY POINTS

Question How can pseudoprogression/delayed treatment response in metastatic renal cell carcinoma (RCC) and melanoma patients on first-line immune checkpoint inhibitors be accurately identified? Findings Combining iodine concentration change from Dual-energy CT (baseline to first follow-up) with RECIST-based lesion size change improved prediction of final lesion outcome. Clinical relevance DECT-based whole-volume tumor iodine concentration for target lesions is useful as a predictive imaging biomarker for distinguishing delayed response from true progression in patients with metastatic RCC and melanoma treated with first-line immune checkpoint inhibitors.

Safety profiles in the use of immune checkpoint inhibitors by patients with cancer and pre-existing autoimmune diseases

INTRODUCTION

The treatment of cancer when associated with autoimmune diseases (AID) has been the subject of immunotherapy investigation, especially with the use of immune checkpoint inhibitors (ICI). Clinical studies have restricted the evaluation of its use in special populations such as patients with AID, leaving a gap regarding the safety of using immunotherapy.

OBJECTIVE

Discuss the safety of using ICI in patients with cancer and AID, in specialized oncology units, in the cities of Bahia, Brazil.

METHODS

Retrospective and quantitative cross-sectional study on immune-related adverse events (IRAE) to the use of ICI in patients with cancer and AID.

RESULTS

Patients (39 with cancer, and 14 with AID and cancer) were studied. Men (between 30 and 95 years old), melanoma and lung cancer and Hashimoto's thyroiditis were predominance. Pembrolizumab and Nivolumab (anti-PDL-1) were drugs most used. In general, patients using anti-PDL-1 with AID had IRAE with greater frequency and severity: Grade 1 (57%) and 3/4 grades (43%) reactions. The gastrointestinal system presented a greater IRAE in both groups, however in patients with AID more severe reactions were found (0% versus 60%). Patients with cancer and AID had higher rates of IRAE compared to patients without AID, respectively, of discontinuation (50% versus 18%) and interruption (85% versus 20%) of treatment.

CONCLUSION

IRAE increased in patients using ICI with cancer and AID. This suggests that the presence of IAD, in cancer patients, can increase the severity of IRAE. Therefore, the adoption of more appropriate therapeutic strategies is essential for better therapeutic results.

Application of adoptive cell therapy in malignant melanoma

Cutaneous melanoma is one of the most aggressive skin cancers originating from skin pigment cells. Patients with advanced melanoma suffer a poor prognosis and generally cannot benefit well from surgical resection and chemo/target therapy due to metastasis and drug resistance. Thus, adoptive cell therapy (ACT), employing immune cells with specific tumor-recognizing receptors, has emerged as a promising therapeutic approach to display on-tumor toxicity. This review discusses the application, efficacy, limitations, as well as future prospects of four commonly utilized approaches -including tumor-infiltrating lymphocytes, chimeric antigen receptor (CAR) T cell, engineered T-cell receptor T cells, and chimeric antigen receptor NK cells- in the context of malignant melanoma.

Exploring the relation between TGF-β pathway activity and response to checkpoint inhibition in patients with metastatic melanoma

INTRODUCTION

Immune checkpoint inhibition (ICI) is highly effective for the treatment of melanoma, but intrinsic resistance is present in a subgroup of patients. TGF-β pathway activity may play a role in this resistance by preventing T-cells from entering the tumor microenvironment, causing immune escape. We investigated the association of TGF-β signal transduction pathway activity with resistance to ICI treatment in advanced melanoma. Furthermore, other pathway activities were analyzed to better understand their potential role in ICI resistance.

METHOD

The activity of 8 signaling pathways (TGF-β, Hedgehog, MAPK, AR, NOTCH, PI3K, JAK/STAT1-2, and NFkB) was analyzed from tumor tissue from patients with advanced melanoma. Pathway activity scores (PAS) were explored for associations with survival and response to ICI in 34 patients (19 non-responders and 15 responders). A second, independent method to investigate the predictive value of TGF-β pathway activation was conducted by determining levels of phosphorylated SMAD2.

RESULTS

The mean TGF-β PAS of responders vs non-responders was 53.9 vs 56.8 (P = 0.265). No significant relation with progression-free survival was detected for TGF-β activity (P = 0.078). No association between pSMAD2 staining and treatment response or survival was identified. In contrast, Hedgehog scores of responders versus non-responders were 35.7 vs 41.6 (P = 0.038). High Hedgehog PAS was the sole significant predictor of resistance to ICI (OR 0.88, P = 0.033) and worse progression-free survival (HR 1-1.1, P = 0.012).

CONCLUSION

TGF-β pathway activation showed no significant relation with treatment response to ICI or survival in patients with advanced melanoma. Hedgehog PAS was identified as a possible biomarker associated with both treatment response and survival.

Role of the androgen receptor in melanoma aggressiveness

Malignant melanoma represents the fifth most common cancer in the world and its incidence is rising. Novel therapies targeting receptor tyrosine kinases, kinases and immune checkpoints have been employed with a significant improvement of the overall survival and long-term disease containment. Nevertheless, the disease often progresses and becomes resistant to the therapies. As such, the discovery of new targets and drugs for advanced melanoma still remains a difficult task. Gender disparities, with a female advantage in melanoma incidence and outcome, have been reported. Although emerging studies support the pro-tumorigenic role of androgen/androgen receptor axis in melanoma, the molecular bases of such evidence are still under intense investigation. We now report that ligand activation of the androgen receptor drives melanoma invasiveness and its escape from natural killer-mediated cytotoxic effect. By combining different experimental approaches, we observe that melanoma escape is mediated by the androgen-triggered shedding of the surface molecule MICA. Specific blockade of ADAM10 or androgen receptor impairs the androgen-induced MICA shedding and melanoma immune-escape. Further, the increase in MICA serum levels correlates with a poor outcome in melanoma patients treated with the anti-PD-1 monoclonal antibody, pembrolizumab. At last, melanoma cells depleted of the androgen receptor become more responsive to the most commonly used immunocheckpoint inhibitors, suggesting that the receptor dampens the immunotherapy efficacy. Taken together, our findings identify the androgen receptor as a diagnostic guidance in melanoma and support the repositioning of AR blockers in clinical management of patients.

Immune-related encephalitis after immune checkpoint inhibitor therapy

BACKGROUND

Immune checkpoint inhibitors (ICI) have revolutionized cancer treatment but can trigger immune-related encephalitis. We report one of the largest case series of patients with immune-related encephalitis and review of the literature.

METHODS

Retrospective series of patients with immune-related encephalitis and literature review.

RESULTS

Fourteen patients with cancer treated with ICI (50% combination therapy) developed immune-related encephalitis. Diagnostic testing revealed cerebral spinal fluid (CSF) lymphocytic pleocytosis (85%) and elevated protein (69%), abnormal brain magnetic resonance imaging(MRI) (33%) or brain FDG-PET (25%), electroencephalogram (EEG) abnormalities (30%), and autoantibodies (31%). Encephalitis treatment included: corticosteroids (86%), intravenous immunoglobulin (IVIg) (36%), plasmapheresis (7%), and rituximab (29%). There were no deaths and 12 patients had significant recovery, although long-term complications were observed. All patients discontinued ICI. Longitudinal follow-up demonstrated anti-cancer response to ICI at 3 months (85%) and 6 months post-ICI initiation (77%). A literature review identified 132 patients with immune-related encephalitis. Most were treated with PD-1 inhibitors (18% combination). Common abnormalities included elevated CSF protein (84%) or pleocytosis (77%), abnormal brain MRI (65%), or autoantibodies (47%). Nearly all were treated with corticosteroids, many required additional therapy with IVIg (26%) or rituximab (12%). Most patients had clinical improvement (81%) but a minority (10%) had a clinical relapse after completing corticosteroid taper. ICIs were resumed in 7 patients (5%), with relapse in 3.

CONCLUSIONS AND RELEVANCE

Immune-related encephalitis is treatable and improves with corticosteroids in most cases but may require additional immunosuppression. Re-emergence of encephalitis is rare and does not typically result in adverse outcomes, and this should be considered in neurological immune-related adverse event management guidelines.

Advances in Immunotherapy and Targeted Therapy of Malignant Melanoma

Malignant melanoma (MM) is a malignant tumor, resulting from mutations in melanocytes of the skin and mucous membranes. Its mortality rate accounts for 90% of all dermatologic tumor mortality. Traditional treatments such as surgery, chemotherapy, and radiotherapy are unable to achieve the expected results due to MM's low sensitivity, high drug resistance, and toxic side effects. As treatment advances, immunotherapy and targeted therapy have made significant breakthroughs in the treatment of MM and have demonstrated promising application prospects. However, the heterogeneity of tumor immune response causes more than half of patients to not benefit from clinical immunotherapy and targeted therapy, which delays the patient's condition and causes them to suffer adverse immune events' side effects. The combination of immunotherapy and targeted therapy can help improve therapeutic effects, delay drug resistance, and mitigate adverse effects. This review provides a comprehensive overview of the current development status and research progress of immune checkpoints, targeted genes, and their inhibitors, with a view to providing a reference for the clinical treatment of MM.

The prognostic value of circulating tumor DNA in malignant melanoma patients treated with immune checkpoint inhibitors: a systematic review and meta-analysis

Background

Circulating tumor DNA (ctDNA) is an emerging biomarker in malignant melanoma(MM), and high levels of ctDNA may reflect a higher tumor load. However, its prognostic value for MM receiving immune checkpoint inhibitors(ICI) remains controversial. This meta-analysis aimed to elucidate the prognostic significance of ctDNA in this patient population.

Methods

We conducted a comprehensive search of the PubMed, Cochrane Library, CNKI, and EMBASE databases, including studies published up to August 15, 2024, to investigate the prognostic impact of ctDNA in MM patients treated with ICI. Using a fixed-effects model, we systematically evaluated the association between ctDNA levels and key survival outcomes, including overall survival (OS) and progression-free survival (PFS). Additionally, funnel plots, Begg's test, and Egger's test were employed to assess potential publication bias.

Results

Twelve studies from eleven articles, involving a total of 1063 eligible MM patients receiving ICI therapy, were included. The results indicated that patients with detectable ctDNA before initiating ICI therapy had significantly poorer OS (HR = 3.19, 95% CI = 2.22-4.58, P < 0.001) and PFS (HR = 2.08, 95% CI = 1.61-2.69, P < 0.001). Furthermore, the detectability of ctDNA during treatment was also significantly associated with worse OS (HR = 4.57, 95% CI = 3.03-6.91, P < 0.001) and PFS (HR = 3.79, 95% CI = 2.13-6.75, P < 0.001).

Conclusions

This meta-analysis indicates that in MM patients receiving ICI therapy, detectable and high levels of ctDNA are significantly associated with poorer OS and PFS. Therefore, ctDNA can serve as a diagnostic and stratification tool prior to treatment, as well as an effective indicator for monitoring treatment response and disease progression.

Systematic Review Registration

www.inplasy.com, identifier INPLASY2024110018.

Anti-CTLA-4 generates greater memory response than anti-PD-1 via TCF-1

The effects of T cell differentiation arising from immune checkpoint inhibition targeting cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) and programmed cell death protein 1 (PD-1) on the immunological memory response remain unclear. Our investigation into the effects of anti-CTLA-4 and anti-PD-1 on memory T cell formation in mice reveals that memory T cells generated by anti-CTLA-4 exhibit greater expansion, cytokine production, and antitumor activity than those from anti-PD-1. Notably, anti-CTLA-4 preserves more T cell factor-1 (TCF-1)+ T cells during priming, while anti-PD-1 leads to more thymocyte selection-associated high mobility group box (TOX)+ T cells. Experiments using conditional Tcf7- or Tox-knockout mice highlight that TCF-1 is essential for the memory response generated by anti-CTLA-4, whereas TOX deletion alone in T cells has no effect on the response to anti-PD-1. Deepening our understanding of how checkpoint inhibition affects memory response is crucial for advancing our understanding of the enduring impacts of these immunotherapies on the immune system.

Setting "cold" tumors on fire: Cancer therapy with live tumor-targeting bacteria

Immunotherapy with checkpoint blockade has shown remarkable efficacy in many patients with a variety of different types of cancer. However, the majority of patients with cancer have yet to benefit from this revolutionary therapy. Studies have shown that checkpoint blockade works best against immune-inflamed tumors characterized by the presence of tumor-infiltrating lymphocytes (TILs). In this review, we summarize studies using live tumor-targeting bacteria to treat cancer and describe various strategies to engineer the tumor-targeting bacteria for maximized immunoregulatory effects. We propose that tumor-localized infections by such engineered bacteria can create an immune microenvironment in favor of a more effective antitumor immunity with or without other therapies, such as immune checkpoint blockade (ICB). Finally, we will briefly outline some exemplary oncology clinical trials involving ICB plus live therapeutic bacteria, with a focus on their ability to modulate antitumor immune responses.

Novel PD-L1/VISTA Dual Inhibitor as Potential Immunotherapy Agents

Inhibiting the activity of immune checkpoint proteins to reignite the antitumor activity of immune cells has emerged as a pivotal strategy. PD-L1 and VISTA, as critical proteins governing immune regulation, are concurrently upregulated under conditions such as hypoxia. Through a rational drug design process, P17, a dual-target inhibitor for PD-L1 and VISTA is identified. This inhibitor blocks the signaling pathways of both PD-L1 and VISTA at the protein and cellular levels, thereby reactivating the antitumor function of T cells. P17 displays encouraging attributes in terms of druggability and safety assessments. Notably, P17 demonstrates superior antitumor efficacy compared to single-target inhibitors at equivalent doses in in vivo experiments. More crucially, P17 significantly enhances the infiltration of immune cells. This study not only validates the effectiveness of a dual-target inhibitor strategy against PD-L1 and VISTA, but also identifies P17 as a promising candidate molecule with significant therapeutic potential.