Management options for metastatic melanoma in the era of novel therapies: a primer for the practicing dermatologist: part II: Management of stage IV disease

Presentation, Management, and Prognosis of Primary Gastrointestinal Melanoma: A Population-Based Study

BACKGROUND

Primary gastrointestinal (GI) melanomas, compared with cutaneous melanomas, have a much lower incidence. As a result, there is a paucity of data regarding their presentation, treatment, and prognosis. The aim of this study was to analyze the incidence, patient characteristics, treatment patterns, and survival of primary GI melanomas in comparison with cutaneous melanomas using a population-based cohort.

METHODS

Patients diagnosed with primary GI and cutaneous melanomas were identified from Surveillance, Epidemiology, and End Results 1973-2016 data.

RESULTS

A total of 872 primary GI melanomas and 319,327 cutaneous melanomas were identified. GI melanoma incidence increased by an annual percent change of 1.82 (P < 0.05) during the study period. The most common sites for GI melanoma were the anus (50%) and rectum (34%). Compared to cutaneous melanoma, patients diagnosed with GI melanomas were older, women (58% versus 45%), non-White (16% versus 6%), and presented with a higher stage (36% versus 4% distant stage, all P < 0.001). GI melanomas had significantly worse cancer-specific survival (CSS) than cutaneous melanoma. Despite the poor prognosis, the CSS has increased in recent years. Among patients with anorectal melanomas, local excision with chemotherapy and/or radiation had a similar CSS compared with those with major surgery only.

CONCLUSIONS

Despite a steady increasing incidence since 1975, GI melanomas are rare, present with advanced stages, and have worse outcomes than cutaneous melanomas. The improved prognosis of these tumors in recent years might reflect the impact of novel targeted treatments and the more common use of local tumor excision over major resections.

Unusual melanoma of the scalp with blue nevus-like features and local metastasis: A case report

We present an unusual case of melanoma in a 76-year-old female covering approximately 80% of her scalp. Partial sampling of the lesion revealed focal blue nevus-like features at the microscopic level. We discuss issues related to blue nevus-like melanomas and highlight the unique clinical presentation of the current case.

A tenebrous tale: malignant melanoma of the oesophagus

A 57-year-old man presented with a 4-month history of worsening symptoms of oesophageal obstruction. The physical examination was unremarkable. An oesophagogastroduodenoscopy revealed an exophytic tumour in the distal oesophagus. A biopsy demonstrated malignant melanoma. Staging of the melanoma showed disseminated lymph node and bony-spine metastases. He had no prior history of cutaneous or ocular melanoma. Following full multidisciplinary team input, he was palliated with a metal mesh stent and immunotherapy. He died 3 months later following community management.

Nivolumab: A Review in Advanced Melanoma

An improved understanding of cancer genetics and immune regulatory pathways, including those associated with evasion of immune surveillance by tumours, has culminated in the development of several targeted therapies. One such strategy that acts to negate evasion of immune surveillance by tumours is inhibition of the programmed cell death receptor-1 (PD-1) checkpoint pathway. Intravenous nivolumab (Opdivo(®)), a PD-1 checkpoint inhibitor, is approved or in pre-registration in various countries for use in adult patients with advanced melanoma, with the recommended monotherapy dosage being a 60-min infusion of 3 mg/kg once every 2 weeks. In well-designed multinational trials, as monotherapy or in combination with ipilimumab (a cytotoxic T-lymphocyte antigen 4 checkpoint inhibitor), nivolumab significantly improved clinical outcomes and had a manageable tolerability profile in adult patients with advanced melanoma with or without BRAF mutations. Nivolumab monotherapy was associated with a higher objective response rate (ORR) than chemotherapy in treatment-experienced patients and a higher ORR and prolonged progression-free survival (PFS) and overall survival than dacarbazine in treatment-naive patients. In combination with ipilimumab, nivolumab was associated with an improved ORR and prolonged PFS compared with ipilimumab monotherapy in treatment-naive patients. In addition, nivolumab monotherapy significantly prolonged PFS and improved ORRs compared with ipilimumab monotherapy. The optimal combination regimen for immune checkpoint inhibitors remains to be fully elucidated, with various combination regimens and different sequences of individual immunotherapies currently being investigated in ongoing clinical trials. Given the significant improvements in outcomes associated with nivolumab in clinical trials, nivolumab monotherapy or combination therapy is a valuable first-line or subsequent treatment option for adult patients with unresectable or metastatic melanoma, irrespective of BRAF mutation status.

The efficacy and safety of nivolumab in the treatment of advanced melanoma: a meta-analysis of clinical trials

Background

Nivolumab has become a therapeutic regimen for the treatment of patients with advanced melanoma. The goal of this study was to assess the efficacy and safety of nivolumab in patients with advanced melanoma.

Methods

A systematic search from January 2008 to August 2015 with “nivolumab” and “advanced melanoma” as search terms was performed for possible clinical trials. According to the hazard ratio and the 95% confidence interval (CI) for progression-free survival (PFS), rates of objective response, complete response, partial response, rates of toxic effects, and the efficacy and safety of nivolumab were assessed. Using the software Review Manager (version 5.3) a meta-analysis was performed.

Results

There were four trials with 1,910 patients included. Based on the four trials, the pooled hazard ratio of PFS was 0.53 (95% CI, 0.43–0.66; P<0.001). The pooled risk ratio for the objective response rate, complete response, and partial response was 2.98% (95% CI, 2.38%–3.73%; P<0.001), 3.71% (95% CI, 2.67%–5.14%; P<0.001), and 2.51% (95% CI, 2.12%–2.99%; P<0.001), respectively. Nivolumab plus ipilimumab therapy significantly increased the risk of grade 3/4 rash and fatigue.

Conclusion

Nivolumab-based therapy prolonged PFS in treatment of advanced melanoma, with less adverse effects. Nivolumab appears to be a favorable treatment option as a novel, targeted anticancer agent, for patients with advanced melanoma.

Emergency surgery for metastatic melanoma

Visceral metastases from malignant melanoma (stage M1c) confer a very poor prognosis, as documented on the most recent revised version of the TNM/AJCC staging system. Emergency surgery for intra-abdominal complications from the disease is rare. We report on our 5-year single institution experience with surgical management of metastatic melanoma to the viscera in the emergent setting. From 2009 to 2013, 14 patients with metastatic melanoma were admitted emergently due to an acute abdomen. Clinical manifestations encompassed intestinal obstruction and bleeding. Surgical procedures involved multiple enterectomies with primary anastomoses in 8 patients, and one patient underwent splenectomy, one adrenalectomy, one right colectomy, one gastric wedge resection, one gastrojejunal anastomosis, and one transanal debulking, respectively. The 30-day mortality was 7 percent. Median follow-up was 14 months. Median overall survival was 14 months. Median disease free survival was 7.5 months. One-year overall survival was 64.2 percent and 2-year overall survival was 14.2 percent. Emergency surgery for metastatic melanoma to the viscera is rare. Elective curative surgery combined with novel cytotoxic systemic therapies is under investigation in an attempt to grant survival benefit in melanoma patients with visceral disease.

Acute rhabdomyolysis as a complication of interferon treatment for stage IIIc melanoma

BACKGROUND

Interferon alfa-2b is a treatment option for select patients with stage 3 melanoma.

OBJECTIVE

To highlight the potential complication of acute rhabdomyolysis from interferon alfa-2b in this patient population.

METHODS

We present a case of a 63-year-old female with stage IIIc melanoma who developed acute rhabdomyolysis after completing 2 of 4 weeks of induction with high-dose interferon alfa-2b. She recovered after hydration with intravenous fluids and discontinuation of interferon alfa-2b.

RESULTS

Review of the literature revealed eight cases of reported rhabdomyolysis triggered by interferon use, including four cases of melanoma.

CONCLUSION

In patients treated with interferon, especially at high doses, screening for creatine kinase and myoglobinuria should be performed if the patient develops symptoms suggestive of acute rhabdomyolysis.

Defining the role of CD2 in disease progression and overall survival among patients with completely resected stage-II to -III cutaneous melanoma

BACKGROUND

Accurate assessment of prognosis remains clinically challenging in stage II to III cutaneous melanoma. Studies have implicated CD2 in immune surveillance, T-cell activation, and antitumor immunity, but its role in melanoma progression warrants further investigation.

OBJECTIVE

We sought to investigate the prognostic role of CD2 in primary cutaneous melanoma.

METHODS

Patients with American Joint Committee on Cancer stage II and III cutaneous melanoma were identified by retrospective review of dermatopathology databases from 2001 to 2010 at Mount Sinai Medical Center and Geisinger Medical Center. Additional patients were provided by New York University Medical Center based on retrospective review and tissue availability. Immunohistochemistry was performed on tumors from 90 patients with known recurrence status and documented follow-up.

RESULTS

Primary tumors from patients who developed recurrent disease had fewer CD2(+) cells (P = .0003). In multivariable analyses including standard clinicopathologic predictors, CD2 was an independent predictor of disease recurrence (P = .008) and overall survival (P = .007). CD2 count correlated with characterization of tumor-infiltrating lymphocytes (P = .0004). Among the intermediate prognosis group of patients with nonbrisk tumor-infiltrating lymphocytes, CD2 count was predictive of disease recurrence (P = .0006) and overall survival (P = .0318).

LIMITATIONS

Our retrospective design may have resulted in incomplete representation of patients lacking documented follow-up.

CONCLUSIONS

CD2 may be an independent predictor of disease recurrence and overall survival among patients with primary cutaneous melanoma.

Advances in personalized targeted treatment of metastatic melanoma and non-invasive tumor monitoring

Despite extensive scientific progress in the melanoma field, treatment of advanced stage melanoma with chemotherapeutics and biotherapeutics has rarely provided response rates higher than 20%. In the past decade, targeted inhibitors have been developed for metastatic melanoma, leading to the advent of more personalized therapies of genetically characterized tumors. Here we review current melanoma treatments and emerging targeted molecular therapies. In particular we discuss the mutant BRAF inhibitors Vemurafenib and Dabrafenib, which markedly inhibit tumor growth and advance patients' overall survival. However this response is almost inevitably followed by complete tumor relapse due to drug resistance hampering the encouraging initial responses. Several mechanisms of resistance within and outside the MAPK pathway have now been uncovered and have paved the way for clinical trials of combination therapies to try and overcome tumor relapse. It is apparent that personalized treatment management will be required in this new era of targeted treatment. Circulating tumor cells (CTCs) provide an easily accessible means of monitoring patient relapse and several new approaches are available for the molecular characterization of CTCs. Thus CTCs provide a monitoring tool to evaluate treatment efficacy and early detection of drug resistance in real time. We detail here how advances in the molecular analysis of CTCs may provide insight into new avenues of approaching therapeutic options that would benefit personalized melanoma management.