Novel Therapies for Metastatic Melanoma: An Update on Their Use in Older Patients

Occurrence of Fatal Tubulopathy in an Old, Fit Patient Receiving Nivolumab and Ipilimumab for Metastatic Melanoma: A Case Report

Introduction

The use of immune checkpoint inhibitors has revolutionized cancer treatment, and their application to older people is considered safe by the scientific community. However, immune-related adverse events (irAEs) remain common, and their management poses significant challenges, especially in this population.

Case Presentation

We report the case of a fit 82-year-old woman who developed immune-mediated colitis and Fanconi syndrome during treatment with ipilimumab and nivolumab for metastatic melanoma. Treatment consisted of discontinuation of immunotherapy, use of systemic corticosteroids, and second-line immunosuppressants. Despite well-managed treatment, the patient did not recover and died from a gastrointestinal infection.

Conclusion

Although studies have shown identical efficacy and safety in younger patients compared to older patients, the consequences of irAEs can potentially be more serious in the older population. The fatal outcome despite well-managed treatment highlights the need to identify predictive factors of immunotherapy-related adverse events in the older population.

Melanin-targeted [18F]-PFPN PET imaging for prognosticating patients with melanoma

PURPOSE

Positron emission tomography (PET) using [18F]-PFPN, a melanin-targeted imaging tracer, has excellent diagnostic performance in patients with melanoma. This study aimed to investigate its value in prognostication and determine predictors of progression-free survival (PFS) and overall survival (OS).

METHODS

We reviewed melanoma patients who underwent [18F]-PFPN and [18F]-FDG PET from February 2021 to July 2022. Clinical characteristics, follow-up data, and the following [18F]-PFPN PET parameters were recorded: maximum standardized uptake value (SUVmax), whole-body melanotic tumoral volume (WBMTV), and whole-body total lesion melanin (WBTLM). Receiver operating characteristic (ROC), Kaplan-Meier and Cox regression analyses were performed.

RESULTS

Seventy-six patients (47 men and 29 women; mean age, 57.99 ± 10.72 years) were included for analysis. Median follow-up was 12.0 months (range: 1-22 months). Eighteen patients died and 38 experienced progression. Median OS was 17.60 months (95% confidence interval, 15.89-19.31). In the ROC analysis, [18F]-PFPN PET parameters were superior to those of [18F]-FDG PET in prognosticating death and disease progression. PFS and OS were significantly better in patients with lower SUVmax, WBMTV, and WBTLM on [18F]-PFPN PET (log-rank, P < 0.05). In the univariate analyses, distant metastasis, SUVmax, WBMTV, and WBTLM were significantly associated with cumulative incidence of PFS and OS (P < 0.05). In the multivariate analysis, SUVmax was an independent predictor of PFS and OS.

CONCLUSIONS

[18F]-PFPN PET has a role in prognostication of melanoma patients. Patients with higher [18F]-PFPN SUVmax have worse prognosis.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT05645484. Registered 9 December, 2022, https://clinicaltrials.gov/ct2/show/NCT05645484?cond=The+Prognostic+Value+of+18F-PFPN+PET+Imaging+in+Patients+With+Malignant+Melanoma&draw=2&rank=1.

Treatment of Metastatic Melanoma in the Elderly

PURPOSE OF REVIEW

This study aims to review the clinical experience of melanoma treatments in patients with advanced age.

RECENT FINDINGS

During the last decade, the treatment paradigm for melanoma has changed dramatically with the use of checkpoint inhibitors, oncolytic viruses, and targeted therapies. We reviewed both the clinical trial and real-world experience of these therapies in patients of advanced age, and discuss how a personalized approach should be taken for these patients with consideration of incidence and management of side effects. Although special consideration should be taken, immunotherapy, oncolytic viruses, and targeted therapy have shown efficacy and tolerability in older patients with melanoma.

Nivolumab in metastatic melanoma: good efficacy and tolerability in elderly patients

Background

Nivolumab is an anti-PD-1 antibody that restores the antitumour immune function of T cells, blocking the binding of PD-1 with its ligand PD-L1. PD-1 is expressed on T cells and interacts with PD-L1 on tumour cells. The PD-1-PD-L1 link inhibits T cell activation. In metastatic melanoma, PD-1-PD-L1 binding plays a critical role, and the advent of the immune checkpoint inhibitor nivolumab has delivered new and effective treatment options with proven clinical benefit. In the present study, we evaluated the efficacy of nivolumab in elderly patients with metastatic melanoma.

Methods

The study enrolled 55 elderly patients (75 years of age and older) with a diagnosis of metastatic melanoma. Primary endpoints of the study were progression-free survival (pfs) and the objective response rate; secondary endpoints were overall survival, reduction in serum lactate dehydrogenase (ldh) from before to after treatment, and tolerability.

Results

Nivolumab was well tolerated and resulted in good disease control, with a manageable toxicity profile and significant clinical benefit. The duration of pfs was 5.1 months (95% confidence interval: 3.5 months to 6.8 months). A significant correlation was observed between reduction in serum ldh and pfs: 0.60 (95% confidence interval: 0.28 to 0.86; p = 0.002).

Conclusions

Nivolumab is an immunotherapy treatment that has proved to be an effective and well-tolerated therapeutic option in elderly patients with metastatic melanoma.

A Comprehensive Review of the Diagnosis and Pharmacological Management of Crohn's Disease in the Elderly Population

Crohn's disease (CD) in the elderly is rising in prevalence, which is related to an increase in its incidence and improving life expectancies. There are differences in the presentation, natural history, and treatment of CD between adult-onset patients who progress to older age and patients who are initially diagnosed at an older age. Presentation at an older age may also delay or make diagnosis challenging due to accumulating co-morbidities that mimic inflammatory bowel disease. Differences exist between adult- and older-onset disease, yet many guidelines do not specifically distinguish the management of these two distinct populations. Identifying patients at high risk for progression or aggressive disease is particularly important as elderly patients may respond differently to medical and surgical treatment, and may be at higher risk for adverse effects. Despite newer agents being approved for CD, the data regarding efficacy and safety in the elderly are currently limited. Balancing symptom management with risks of medical and surgical therapy is an ongoing challenge and requires special consideration in these two distinct populations.

Immunotherapy and targeted therapies in older patients with advanced melanoma; Young International Society of Geriatric Oncology review paper

Malignant melanoma is an aggressive cancer associated with a poor prognosis in patients with metastatic disease. As in many other cancers, the incidence of melanoma rises with age; and combined with the longer life expectancy, this led to an increasing prevalence of melanoma in the older population. Recently, immune checkpoint inhibitors significantly improved the treatment of melanoma given their efficacy and tolerability profile. Two major classes of agents include the anti-cytotoxic T lymphocyte-associated protein 4 (CTLA-4) inhibitors, such as ipilimumab, and the anti-programmed death-ligand 1 (PD-1) inhibitors, such as nivolumab and pembrolizumab. Treatment of metastatic disease with immune checkpoint inhibitors demonstrated improved efficacy and better safety profiles compared to cytotoxic drugs and appears to be an attractive treatment option. Nevertheless, there is a need for tools designed to better predict which older patients will benefit from its use and who will experience toxicities related to the treatment. Current data do not show a major increase in toxicity rates in older patients. However, patients above 75 are often under-represented and those who are included are not representative of the general population of older patients, thereby also stressing the need for real-life data. Ongoing research is aiming at maximizing the potential treatment efficacy and developing novel immune-targeting modalities. Future studies should include older patients and assess geriatric domains in these older patients to better guide decision-making. This review discusses published clinical trials and where known, the efficacy and toxicity in older patients. Moreover, the clinical implications and future perspectives are discussed, with current recommendations for older patients, management of toxicities, and a proposal for an initial approach to the treatment of older patients with metastatic melanoma.

Prognostic significance of cyclooxygenase 2 and phosphorylated Akt1 overexpression in primary nonmetastatic and metastatic cutaneous melanomas

Cyclooxygenase 2 (COX-2) and phosphorylated Akt1 (p-Akt1) are associated with tumor spreading, cell proliferation, high metabolism, and angiogenesis in solid tumors. This study aimed to investigate COX-2 and p-Akt1 expression in primary and metastatic melanomas by correlating with the cellular proliferation index (as revealed by minichromosome maintenance 2 expression) and the outcome of patients with malignant melanomas. Seventy-seven biopsies of malignant melanomas, including 42 primary nonmetastatic melanomas (PNMMs), 12 primary metastatic melanomas (PMMs), and 23 metastatic melanomas (MMs), were retrospectively selected. Tissue microarrays were developed and submitted for immunohistochemical staining for COX-2, p-Akt1, and minichromosome maintenance 2. Increased COX-2 cytoplasmic staining patterns were observed in PMM and MM when compared with PNMM (P=0.0011). Higher nuclear and cytoplasmic expression of p-Akt1 was more closely associated with PMM than with MM and PNMM (P<0.00001). Coexpression of these biomarkers was closely correlated with lower overall survival rates in melanomas. Furthermore, we observed a statistically significant positive correlation between the mitosis index and increased COX-2 expression (P=0.0135) and between p-Akt1 (P=0.0038) and the cellular proliferation index (P=0.0060). Taken together, our findings demonstrate that COX-2 and p-Akt1 play an important combined role during melanoma progression and are associated with highly metastatic tumors and survival rates in patients with MM. In addition, these biomarkers can be used to predict melanoma prognosis independently of metastatic status. However, further studies are required to elucidate the biological role of these biomarkers during the progression of MM events.

High fat diet increases melanoma cell growth in the bone marrow by inducing osteopontin and interleukin 6

The impact of metabolic stress induced by obesity on the bone marrow melanoma niche is largely unknown. Here we employed diet induced obese mice model, where mice received high-fat (HFD) or normal diet (ND) for 6 weeks before challenge with B16F10 melanoma cells. Tumor size, bone loss and osteoclasts numbers were assessed histologically in the tibial bones. For defining the molecular pathway, osteopontin knock-out mice, interleukin 6 neutralizing antibody or Janus kinase 2 inhibition were carried out in the same model. Mechanistic studies such as adipocyte-melanoma co-cultures for defining adipocyte induced changes of tumor cell proliferation and expression profiles were also performed. As results, HFD enhanced melanoma burden in bone by increasing tumor area and osteoclast numbers. This process was associated with higher numbers of bone marrow adipocytes expressing IL-6 in direct vicinity to tumor cells. Inhibition of IL-6 or of downstream JAK2 blocked HFD-induced tumor progression. Furthermore, the phenotypic changes of melanoma cells triggered macrophage and osteoclast accumulation accompanied by increased osteopontin expression. Osteopontin triggered osteoclastogenesis and also exerted a positive feedback loop to tumor cells, which was abrogated in its absence. Metabolic stress by HFD promotes melanoma growth in the bone marrow by an increase in bone marrow adipocytes and IL-6-JAK2-osteopontin mediated activation of tumor cells and osteoclast differentiation.

Impact of Age on Outcomes with Immunotherapy for Patients with Melanoma

BACKGROUND

Monoclonal antibodies (mAb) targeting PD-1/PD-L1 have revolutionized melanoma treatment, yet data regarding effectiveness and tolerability across age groups is limited. We sought to determine the impact of age on overall survival (OS), progression-free survival (PFS), and rates of immune-mediated toxicities in patients treated with anti-PD-1/anti-PD-L1 mAb at two academic medical centers.

METHODS

We retrospectively collected data on all patients with metastatic melanoma treated with anti-PD-1/PD-L1 mAb between May 2009 and April 2015. We used Kaplan-Meier and Cox regression analyses to assess OS and PFS and identify factors associated with these outcomes. We also compared rates of autoimmune toxicity across age groups.

RESULTS

Of 254 patients, 57 (22.4%) were <50 years old, 85 (33.5%) were age 50-64, 65 (25.6%) were age 65-74, and 47 (18.5%) were ≥75 years. Across age groups, no differences existed in median OS (age <50: 22.9 months, age 50-64: 25.3 months, age 65-74: 22.0 months, age ≥75: 24.3 months) or PFS (age <50: 4.1 months, age 50-64: 6.5 months, age 65-74: 5.4 months, age ≥75: 7.9 months). The presence of liver metastases and elevated pre-treatment lactate dehydrogenase (LDH) were associated with reduced OS. Presence of liver metastasis, pretreatment LDH, BRAF mutation, and type of melanoma correlated with PFS. Overall, 110 patients (43.3%) experienced immune-mediated toxicities; 25 (9.8%) had colitis and 26 (10.2%) had endocrine toxicity. Rates of colitis, hepatitis, and pneumonitis did not differ across age groups.

CONCLUSION

We demonstrated that patients could safely tolerate anti-PD1/PDL-1 mAb therapy and achieve similar outcomes regardless of their age.

IMPLICATIONS FOR PRACTICE

Immunotherapy has revolutionized treatment for patients with metastatic melanoma, yet data are lacking regarding the effectiveness and tolerability of these treatments for older patients. In this study, we demonstrated that patients with melanoma safely tolerate immunotherapy and achieve similar outcomes regardless of their age. Specifically, we utilized data from two academic cancer centers and found no significant difference in overall survival, progression free survival, or immune-related toxicities, other than arthritis, across age groups. As the population ages, studies such as this will become critical to help us understand how best to treat older adults with cancer.

Baicalein Inhibits the Migration and Invasion of B16F10 Mouse Melanoma Cells through Inactivation of the PI3K/Akt Signaling Pathway

Baicalein, a natural flavonoid obtained from the rhizome of Scutellaria baicalensis Georgi, has been reported to have anticancer activities in several human cancer cell lines. However, its antimetastatic effects and associated mechanisms in melanoma cells have not been extensively studied. The current study examined the effects of baicalein on cell motility and anti-invasive activity using mouse melanoma B16F10 cells. Within the noncytotoxic concentration range, baicalein significantly inhibited the cell motility and invasiveness of B16F10 cells in a concentration-dependent manner. Baicalein also reduced the activity and expression of matrix metalloproteinase (MMP)-2 and -9; however, the levels of tissue inhibitor of metalloproteinase-1 and -2 were concomitantly increased. The inhibitory effects of baicalein on cell motility and invasiveness were found to be associated with its tightening of tight junction (TJ), which was demonstrated by an increase in transepithelial electrical resistance and downregulation of the claudin family of proteins. Additionally, treatment with baicalein markedly reduced the expression levels of lipopolysaccharide-induced phosphorylated Akt and the invasive activity in B16F10 cells. Taken together, these results suggest that baicalein inhibits B16F10 melanoma cell migration and invasion by reducing the expression of MMPs and tightening TJ through the suppression of claudin expression, possibly in association with a suppression of the phosphoinositide 3-kinase/Akt signaling pathway.

Cancer and inflammatory bowel disease in the elderly

Cancer may be a complication of inflammatory bowel disease (IBD) or its treatments. In older Crohn's disease and ulcerative colitis patients, the risk of malignancy is of particular concern. IBD diagnosis at an advanced age is associated with earlier development of colitis-associated colorectal cancer. Thiopurine use in older IBD patients is tied to an increased risk of non-Hodgkin's lymphoma, nonmelanoma skin cancer, and urinary tract cancers. Additionally, older age is accompanied by multimorbidity, an increased risk of malnutrition, and decreased life expectancy, factors that complicate the management of cancer in the elderly. The optimal approach to the increased risk of malignancy in older age IBD is appropriate cancer screening and medical treatment. This may include age-specific colorectal cancer screening and limiting UV radiation exposure. With a growing number of older IBD patients, further studies are necessary to delineate the risk of cancer in this population.