Pembrolizumab versus placebo as adjuvant therapy in completely resected stage IIB or IIC melanoma (KEYNOTE-716): a randomised, double-blind, phase 3 trial

Number needed to treat (NNT) with pembrolizumab as an adjuvant therapy in resected patients with high-risk stage II (IIB and IIC) melanoma and its application to cost of preventing an event (COPE) in Mexico

INTRODUCTION

Melanoma, responsible for most skin cancer deaths globally, has mortality rates expected to double by 2040. Pembrolizumab is a highly selective antibody approved for melanoma treatment and other cancers. Despite new treatments for melanoma, high treatment costs and long approval times limit patient access to new therapies. To support decision-making regarding metastatic melanoma therapies, a model was developed to calculate the number needed to treat (NNT) and the cost of preventing an event (COPE) using KEYNOTE-716 (NCT03553836) data.

METHOD

A cost-per-responder model comparing the clinical and economic impacts of pembrolizumab versus best supportive care (BSC) was developed considering a 52.8-month follow-up for recurrence-free survival (RFS) and distant metastasis-free survival (DMFS) in patients with resected high-risk melanoma. KEYNOTE-716 RFS and DMFS survival curves were used to calculate restricted mean survival time (RMST). The RMST was used to calculate NNT (NNTRMST). The NNTRMST calculates the NNT to result in a difference in mean survival time for a death or an event. NNTRMST is subsequently used to quantify COPE outcomes.

RESULTS

NNT for RFS was 5.3, reflecting the number of patients needed to treat to gain the additional difference observed in the mean RFS for resected high-risk type II (IIB and IIC) melanoma patients treated with pembrolizumab. For DMFS, the NNTRMST was 7.8. The estimated COPE to prevent an RFS or DMFS event was Mexican Peso (Mex $) 9,554,593 (2024) and Mex $13,961,427, respectively.

CONCLUSIONS

NNT values for RFS and DMFS data were both lower than the published average NNT value for current melanoma therapies. This demonstrated that fewer additional patients need to be treated in order to avoid a recurrence or a distant metastases event, compared to currently available melanoma therapies. The NNT and COPE highlight the clinical and economic impact of introducing pembrolizumab therapy for the treatment of patients in resected high-risk stage II melanoma.

Nodal Management in Melanoma: Is Nodal Staging Needed, What Is the Value, and What Is the Extent of Surgery?

Historical management of melanoma metastatic to draining nodal basins involved prophylactic lymphadenectomy, a morbid procedure without proven survival benefit. Over the last decade sentinel lymph node biopsy (SLNB) became a key prognostic tool, identifying patients with clinically occult nodal metastases with minimal morbidity. More recently, with the approval of adjuvant therapies for high-risk melanomas, the role of SLNB in the treatment of melanoma has been questioned. However, no robust alternative prognostic tool exists. SLNB therefore remains a critical staging procedure, informing clinical decision making when weighing the risks and benefits of adjuvant treatment and surveillance.

Neoadjuvant Therapy: Changes in the Management of Macroscopic Stage III/Resectable Stage IV Melanoma

Existing adjuvant therapies improve outcomes for resected stage III and IV melanoma patients but fail in almost half to prevent recurrence and death. Large, multi-institution, randomized studies firmly establish the superiority of neoadjuvant to adjuvant therapy alone. Checkpoint inhibition, either anti-programmed cell death protein 1 monotherapy or combination with CTLA-4/LAG-3 blockage, demonstrates more durable event-free survival compared to targeted or targeted/immunotherapy combination therapies. Novel combinations of intralesional immunotherapies and other agents aim to increase clinical efficacy and limit toxicity of therapies. Pathologic response to treatment remains as the best prognostic surrogate for clinical outcomes for patients.

Radiation Therapy for Melanoma and Merkel Cell Carcinoma in the Contemporary Era

Over the last decade, the standard of care for patients with melanoma and Merkel cell carcinoma has undergone dramatic changes. These advancements have been largely driven by improvements in systemic therapy, altering treatment options for patients at every stage from localized to regional to distant disease. The optimal role of radiation therapy in this contemporary context is not always clear. Herein, the authors review the evidence regarding the role of radiation therapy for locoregional disease in these aggressive cutaneous malignancies in the modern era.

Adjuvant Therapy for Melanoma

In recent years, effective systemic therapies have emerged for patients with metastatic melanoma. These therapies have also made their way to the perioperative setting, demonstrating improved recurrence-free survival for subsets of individuals with stage III and IV disease that received therapy after having undergone surgical resection. While adjuvant therapy is recommended for certain patients with stage II, III, and IV disease, patient selection can be nuanced. Adjuvant therapies are not without their own risks, and an individual's ability to tolerate treatment must be weighed. We review key adjuvant therapy trials, recommendations for its use in contemporary practice, and future directions.

[Adjuvant treatment for melanoma]

BACKGROUND

Despite adequate treatment the probability of recurrence of malignant melanoma is high in patients with corresponding risk factors. Adjuvant treatment significantly reduces this risk; however, the choice of the appropriate adjuvant treatment can be difficult.

OBJECTIVES

This article presents the currently available adjuvant therapies (immune checkpoint inhibition with PD‑1 inhibitors and targeted therapy with BRAF and MEK inhibitors) and a comparison of the effectiveness of treatment in stage III.

MATERIAL AND METHODS

A literature search, a discussion of relevant approval studies and discussion of register data were carried out.

RESULTS

Although the available adjuvant therapies significantly reduce the risk of recurrence of malignant melanoma, approximately one quarter of the patients still experience recurrence within the first 2 years. Comparisons of clinical register data show that adjuvant targeted therapy for BRAF-mutated stage III melanoma is superior to PD‑1 inhibition. The final analysis of the COMBI-AD study, the approval trial of dabrafenib and trametinib, shows a survival benefit for melanomas with BRAFV600E mutations but not for BRAFV600K mutations compared to placebo .

CONCLUSION

New therapeutic approaches are urgently needed to further reduce the risk of recurrence of melanoma in the adjuvant setting. Therefore, suitable patients should be included in appropriate adjuvant clinical studies, if these are available at the respective sites.

Patterns of expression and prognostic implication of glycoprotein nonmetastatic protein B (GPNMB) expression in sentinel lymph nodes of melanoma patients

Sentinel lymph node biopsy (SLNB) is a critical procedure in the management of melanoma, offering prognostic information and guiding adjuvant therapy. Glycoprotein nonmetastatic melanoma protein B (GPNMB), a melanogenesis marker, has been implicated in melanoma progression. This study investigates the expression patterns of GPNMB in SLN metastases and their association with oncological outcomes. We conducted a retrospective analysis of 27 melanoma patients with positive SLNB at Tel Aviv Sourasky Medical Center between 2010 and 2020. Immunohistochemistry was used to assess GPNMB expression in SLN metastases, categorizing patients into two groups based on GPNMB expression patterns: homogeneous (GPNMBho) and margin high (GPNMBmh). Peri-tumoral CD8+ T cell infiltration was also evaluated. Clinical outcomes, including melanoma-specific survival (MSS) and disease-free survival (DFS), were analyzed. GPNMB expression in SLN metastases displayed two distinct patterns: uniform (GPNMBho) and high at the tumor margins (GPNMBmh). Patients in the GPNMBmh group had significantly more peri-tumoral CD8+ T cells and exhibited improved MSS (127.6, 95% CI: 111.7-143.5 vs 79.5, 95% CI: 48.2-110.9 months, P  = 0.018) and DFS (107.5, 95% CI: 79-135.8 vs 38, 95% CI: 15.2-60.8 months, P  = 0.04) compared to the GPNMBho group. Multivariate analysis confirmed that GPNMB expression pattern and lymph node metastasis size were independent predictors of both MSS and DFS. GPNMB expression patterns in SLN metastases are strongly associated with long-term oncological outcomes in melanoma patients. The GPNMBmh pattern, characterized by higher margin expression and increased CD8+ infiltration, may serve as a prognostic biomarker for recurrence if validated in larger cohorts.

[Biomarkers in adjuvant and neoadjuvant treatment of melanoma]

BACKGROUND

Personalized treatment of melanoma is becoming increasingly more important. Biomarkers offer the possibility of controlling treatment more precisely and reducing side effects.

OBJECTIVE

The aim of this text is to provide an overview of current tissue-based, blood-based and radiological biomarkers and their clinical application in melanomas.

MATERIAL AND METHODS

A literature research and analysis of current studies on biomarkers in adjuvant and neoadjuvant treatment of melanomas were carried out and relevant congress contributions were additionally included.

RESULTS

Tissue-based programmed cell death 1 ligand 1 (PD-L1) expression, interferon gamma (IFNγ) signature, gene expression profiles (GEP) and tumor mutational burden (TMB) are of prognostic and predictive relevance. Blood-based circulating tumor DNA (ctDNA) in the sense of a liquid biopsy should be emphasized as a personalized biomarker for longitudinal tracking during treatment or aftercare. Positron emission tomography computed tomography (PET-CT) and body composition enable an improved assessment of treatment efficiency. There are currently no data from prospective validation studies on these biomarkers; initial data from the NivoMela study are awaited.

CONCLUSION

The combination of tissue-based, blood-based and radiological biomarkers in terms of multiparametric approaches is promising but further prospective validation is needed for broad clinical use. These are currently not comprehensively implemented in the clinical routine in centers or in remuneration procedures.

Machine learning prediction for early-stage melanoma outcomes: recurrence-free survival, disease-specific survival, and overall survival

This study compared machine-learning models for predicting recurrence-free survival (RFS), disease-specific survival (DSS), and overall survival (OS) using clinicopathologic data from 1,621 stage I/II primary cutaneous melanoma patients. Our time-to-event models achieved concordance indices of 0.829 for RFS, 0.812 for DSS, and 0.778 for OS. Tumor thickness and mitotic rate were the most important predictors for RFS. Charlson comorbidity score and insurance type were critical for DSS and OS.

Machine-learning based classification of 2D-IR liquid biopsies enables stratification of melanoma relapse risk

Non-linear laser spectroscopy methods such as two-dimensional infrared (2D-IR) produce large, information-rich datasets, while developments in laser technology have brought substantial increases in data collection rates. This combination of data depth and quantity creates the opportunity to unite advanced data science approaches, such as Machine Learning (ML), with 2D-IR to reveal insights that surpass those from established data interpretation methods. To demonstrate this, we show that ML and 2D-IR spectroscopy can classify blood serum samples collected from patients with melanoma according to diagnostically-relevant groupings. Using just 20 μL samples, 2D-IR measures 'protein amide I fingerprints', which reflect the protein profile of blood serum. A hyphenated Partial Least Squares-Support Vector Machine (PLS-SVM) model was able to classify 2D-protein fingerprints taken from 40 patients with melanoma according to the presence, absence or later development of metastatic disease. Area under the receiver operating characteristic curve (AUROC) values of 0.75 and 0.86 were obtained when identifying samples from patients who were radiologically cancer free and with metastatic disease respectively. The model was also able to classify (AUROC = 0.80) samples from a third group of patients who were radiologically cancer-free at the point of testing but would go on to develop metastatic disease within five years. This ability to identify post-treatment patients at higher risk of relapse from a spectroscopic measurement of biofluid protein content shows the potential for hybrid 2D-IR-ML analyses and raises the prospect of a new route to an optical blood-based test capable of risk stratification for melanoma patients.

Adjuvant PD-1 Blockade With Camrelizumab for Nasopharyngeal Carcinoma: The DIPPER Randomized Clinical Trial

Importance

Approximately 20% to 30% of patients with locoregionally advanced nasopharyngeal carcinoma (NPC) experience disease relapse despite definitive chemoradiotherapy. The programmed cell death 1 (PD-1) blockade camrelizumab has demonstrated considerable value in recurrent or metastatic NPC, while its role in locoregionally advanced NPC is unclear.

Objective

To evaluate the efficacy and safety of adjuvant camrelizumab for patients with locoregionally advanced NPC.

Design, Setting, and Participants

Randomized, open-label, multicenter, phase 3 clinical trial conducted from August 2018 to November 2021 at 11 centers in China and enrolling 450 patients with T4N1M0 or T1-4N2-3M0 NPC who had completed induction-concurrent chemoradiotherapy. The final date of follow-up was March 20, 2024.

Interventions

Patients were randomized (1:1) to receive adjuvant camrelizumab (200 mg intravenously once every 3 weeks for 12 cycles; n = 226) or observation (standard therapy group; n = 224).

Main Outcomes and Measures

The primary end point was event-free survival (freedom from distant metastasis, locoregional relapse, or death due to any cause). Secondary end points included distant metastasis-free survival, locoregional relapse-free survival, overall survival, safety, and health-related quality of life.

Results

Among the 450 participants (mean age, 45 [SD, 10] years; 24% women), after a median follow-up of 39 (IQR, 33-50) months, the camrelizumab group had a 3-year event-free survival rate of 86.9%, whereas the standard therapy group had a rate of 77.3% (stratified hazard ratio, 0.56; 95% CI, 0.36-0.89; P = .01). Grade 3 or 4 adverse events were reported in 23 patients (11.2%) in the camrelizumab and 7 (3.2%) in the standard therapy group. Reactive capillary endothelial proliferation was the most common adverse event related to camrelizumab, occurring in 85.8% of patients at grade 1 or 2, while 2% of patients had grade 3 or 4 events. There was no significant deterioration in quality of life associated with camrelizumab treatment.

Conclusions and Relevance

Adjuvant PD-1 blockade with camrelizumab significantly improved event-free survival with manageable toxicities, highlighting its potential role in the management of locoregionally advanced NPC.

Trial Registration

ClinicalTrials.gov Identifier: NCT03427827.

Reduction in surgical interventions in melanoma

Melanoma surgery has evolved from elective lymph node dissection (ELND) to sentinel lymph node biopsy (SLNB) and wide local excision (WLE) margins have come down from 5 cm to nowadays 1 - 2 cm. Recent studies have illustrated the low frequency of residual tumour cells in WLE specimen, particularly for pT2 or lower tumours, where 97 % of patients cannot benefit from WLE. Moreover, a cohort of completely excised primary melanomas did not seem to have inferior clinical outcomes to those who did undergo WLE. Biomarkers, such as clinicopathological gene expression profilers (CP-GEP), can stratify high- and low-risk disease and make therapy decisions, in particular in clinical stage I/II melanoma and make sentinel lymph node biopsy (SLNB) largely redundant. Also SLNB needs to be reconsidered due to the lack of a clear overall survival benefit for adjuvant therapy in stage III. Moreover SLNB is redundant in stage IIB/C for decision making on adjuvant anti-PD1 therapy. Moreover the superiority of neo-adjuvant to salvage patients with macroscopic stage III over adjuvant therapy leads to sharp reduction of therapeutic lymph node dissections (TLND). Overall, the major impact of current developments is that SLNB might soon become obsolete and may be replaced by standard CP-GEP testing of the primary for clinical management, reduction of surgical interventions and simplification of follow up schedules in low risk patients. Thus, we are on the eve of a significant reduction in surgical interventions for melanoma that will come in the upcoming years.

Pembrolizumab versus placebo as adjuvant therapy in resected stage IIB or IIC melanoma: Long-term follow-up, crossover, and rechallenge with pembrolizumab in the phase III KEYNOTE-716 study

BACKGROUND

Adjuvant pembrolizumab prolonged recurrence-free survival (RFS) and distant metastasis-free survival (DMFS) in patients with resected stage IIB/IIC melanoma in KEYNOTE-716. Results of a post hoc 4-year analysis are reported, including progression/recurrence-free survival 2 (PRFS2).

METHODS

Patients were randomly assigned 1:1 to pembrolizumab 200 mg or placebo intravenously every 3 weeks (part 1). RFS was the primary end point; DMFS was secondary. Patients with recurrence following placebo or 17 cycles of pembrolizumab could cross over to or be rechallenged with pembrolizumab (part 2).

RESULTS

Median follow-up (n = 976) was 52.8 months (range, 39.4-64.8). RFS (HR, 0.62 [95 % CI, 0.50-0.78]) and DMFS (HR, 0.59 [0.45-0.77]) favored pembrolizumab. At 48 months, RFS rates were 71.3 % for pembrolizumab and 58.3 % for placebo, and DMFS rates were 81.0 % and 70.1 %, respectively. The HR for PRFS2 was 0.75 (95 % CI, 0.56-1.01); 48-month PRFS2 rates were 82.5 % for pembrolizumab and 76.7 % for placebo. In the crossover population, median follow-up was 36.9 months; median RFS was not reached (NR; 95 % CI, 16.8-NR; 48-month RFS, 50.6 %) in patients with resectable disease (n = 41) and median progression-free survival was 22.0 months (4.5-NR) in patients with unresectable disease (n = 30). Among patients rechallenged, median follow-up was 21.9 months; none with resectable disease had recurrence (n = 6) and 1 with unresectable disease had best response of stable disease (n = 3). No new safety signals were observed.

CONCLUSIONS

With > 4 years follow-up, pembrolizumab continued to prolong RFS and DMFS and had antitumor activity in patients who crossed over to pembrolizumab.

TRIAL REGISTRATION

NCT03553836.

Patient-reported outcomes with adjuvant nivolumab versus placebo after complete resection of stage IIB/C melanoma in the randomized phase 3 CheckMate 76 K trial

BACKGROUND

In the phase 3 CheckMate 76 K trial, adjuvant nivolumab significantly improved recurrence-free survival and distant metastasis-free survival versus placebo in patients with resected stage IIB/C melanoma. We report patient-reported outcomes from CheckMate 76 K.

METHODS

Change from baseline to week 53 in health-related quality of life (HRQoL), as measured using the EORTC QLQ-C30 and EQ-5D-5L utility index and visual analog scale (VAS), was compared between treatment groups using linear mixed-effect models. Time to confirmed deterioration (TTCD) in HRQoL was assessed using Cox regression. Bother from side effects, as measured by the FACIT-GP5, was descriptively compared between treatment groups.

RESULTS

There were no clinically meaningful differences in change from baseline between treatment groups in EORTC QLQ-C30 subscales, including global health status (GHS)/quality of life (QoL; least squares mean [LSM] difference: -1.3; 95 % confidence interval [CI]: -2.9, 0.4), and EQ-5D-5L utility index (LSM difference: -0.011; 95 % CI: -0.025, 0.004) and VAS (LSM difference: -1.3; 95 % CI: -2.6, 0.0). There was no difference in TTCD for nivolumab versus placebo in EORTC QLQ-C30 GHS/QoL (hazard ratio [HR]: 1.10; 95 % CI: 0.88, 1.36) or EQ-5D-5L utility index (HR: 1.10; 95 % CI: 0.86, 1.42); however, TTCD in EQ-5D-5L VAS was longer with placebo (HR: 1.92; 95 % CI: 1.39, 2.64). Proportions of patients reporting severe side effect bother ("quite a bit"/"very much") were minimal (nivolumab: 1 %-4 %; placebo: 0 %-2 %).

CONCLUSIONS

Patients with resected stage IIB/C melanoma treated with adjuvant nivolumab demonstrated stable HRQoL and minimal bother from side effects.

CLINICAL TRIAL INFORMATION

NCT04099251.

Management of metastatic melanoma with combinations including PD-1 inhibitors

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Monoclonal antibodies as adjuvant therapies for resected melanoma

INTRODUCTION

Systemic adjuvant therapy is indicated in patients with high-risk, resected melanoma to reduce recurrence risk and potentially improve survival rates. Monoclonal antibodies (mAbs) target immune checkpoints and have made significant advances as systemic adjuvant therapies.

AREAS COVERED

This review discusses the main clinical trials that tested adjuvant mAbs in resected high-risk melanoma, including anti-cytotoxic T-lymphocyte antigen-4 (CTLA-4) and anti-programmed cell death-1 (PD-1); in addition to newer immunotherapies being tested in the adjuvant setting, including anti-lymphocyte activation gene 3 (LAG-3). We also briefly discuss targeted therapies as an alternative choice. Moreover, we highlight the pros and cons of using mAbs in the adjuvant setting, the reported adverse events (AEs), and the quality of life impact. Finally, we report data related to biomarker studies tested in the context of these clinical trials.

EXPERT OPINION

Immune checkpoint inhibitors (ICIs) have been shown to significantly improve relapse-free survival (RFS) as adjuvant therapy for high-risk melanoma. The long-term impact on overall survival (OS) was demonstrated in two trials that tested ipilimumab as compared to placebo (EORTC18071) and interferon-α (ECOG-ACRIN E1609). Furthermore, emerging data with neoadjuvant therapy followed by surgery and adjuvant therapy utilizing ICIs have demonstrated improved outcomes in the management of locoregionally advanced disease when compared to upfront surgery followed by adjuvant therapy alone.

Efficacy of adjuvant therapy in patients with stage IIIA cutaneous melanoma

BACKGROUND

Patients with resected American Joint Committee on Cancer eighth edition (AJCC v8) stage IIIA melanoma have been underrepresented in clinical trials of adjuvant drug therapy. The benefit of adjuvant targeted therapy and immunotherapy in this population is unclear.

PATIENTS AND METHODS

In this multicentre, retrospective study, patients with stage IIIA melanoma (AJCC v8) who received adjuvant pembrolizumab or nivolumab [anti-programmed cell death protein 1 (PD-1)], BRAF/MEK-targeted therapy dabrafenib + trametinib (TT) or no adjuvant treatment [observation (OBS)] were included. Recurrence-free survival (RFS), distant metastasis-free survival (DMFS) and toxicity rates were examined.

RESULTS

A total of 628 patients from 34 centres across Australia, Europe and the United States were identified-256 in anti-PD-1, 80 in TT and 292 in OBS. The median follow-up was 2.6 years (interquartile range 1.6-3.4 years). The presence of some key poor prognostic variables was significantly higher in anti-PD-1 compared with OBS. The 2-year RFS was 79.3% [95% confidence interval (CI) 74.1% to 84.8%] for anti-PD-1, 98.6% (95% CI 96.0% to 100%) for TT and 84.3% (95% CI 79.9% to 89.0%) for OBS. The 2-year DMFS was 88.4% (95% CI 84.3% to 92.8%) in anti-PD-1, 100% in TT and 91.1% (95% CI 87.7% to 94.7%) in OBS. Higher Breslow thickness and higher mitotic rate were associated with higher risk of recurrence in anti-PD-1 and OBS (P < 0.05). Rates of ≥grade 3 toxicities were 10.9% with anti-PD-1 and 17.5% with TT; discontinuation due to toxicity occurred in 13.3% and 21.2%, respectively. Rates of unresolved toxicity at last follow-up were 26.9% in the anti-PD-1 group and 12.5% in the TT group.

CONCLUSIONS

Stage IIIA melanoma has a modest risk of recurrence. Adjuvant anti-PD-1 did not significantly improve RFS or DMFS compared with OBS alone. Adjuvant TT appears promising over anti-PD-1 or OBS. Outcomes after adjuvant therapy in this population needs further study in larger datasets with longer follow-up or prospective randomised trials.

Novel bioengineered drugs with immunotherapies for malignant pleural effusion: Remodulate tumor immune microenvironment and activate immune system

Malignant pleural effusion (MPE) remains a clinical issue since it is associated with advanced-stage cancers and dismal survival, with immunosuppressive tumor microenvironment (TME) and ineffective drug delivery. Conventional therapies such as thoracentesis and pleurodesis are for symptom relief but palliative, without inducing immunity and prolonging survival. Emerging new bioengineered drugs, synergizing with immunotherapies, offer a new paradigm by dual-targeting TME remodeling and immune activation. These technologies leverage nanotechnology, gene editing, and biomaterials to offer precise spatiotemporal control. This review illustrates the molecular mechanism of the immunosuppressive TME in MPE. It examines the newest bioengineering platforms-such as cytokine-encapsulated nanoparticles and oncolytic viruses-that can reactivate immune mechanisms. We highlight preclinical and clinical evidence of the effectiveness of combinatorial strategies in overcoming local immune tolerance and potential risks in adverse events. While the clinical transformation challenge remains, future directions necessitate cross-disciplinary convergence to engineer intelligent delivery vehicles and predictive biomarkers for patient stratification. By integrating immunotherapy with bioengineering, this strategy not only restores antitumor immunity but also portends a new epoch of precision medicine for MPE.

Cutaneous melanoma

Cutaneous melanoma is a common cancer in Australia and New Zealand, Europe, and North America, and its incidence is still increasing in many regions. Ultraviolet (UV) radiation exposure (for example, through excessive sunlight exposure) remains the primary risk factor for melanoma; however, public awareness campaigns have led to a marked reduction in mortality. In addition to genetic damage from UV radiation, specific genetic alterations have been linked to melanoma. The stage of the tumour at the time of diagnosis is of greater importance for melanoma prognosis than in almost any other cancer. Context-dependent genetic mutations that attenuate tumour-suppressive mechanisms or activate growth-promoting signalling pathways are crucial factors in the development of cutaneous melanoma. In addition to external factors such as UV radiation, the tumour microenvironment can contribute to melanoma progression, invasion and metastasis. Cutaneous melanoma treatment has improved considerably over the past decade with the discovery and development of immune checkpoint inhibitors and therapy targeting BRAF and MEK. Over the next decade, several priorities are likely to influence melanoma research and management, including the continued advance of precision medicine methods to identify the most suitable patients for the most effective treatment, with the aim of improving clinical outcomes.

Patterns of Failure in Cutaneous Head and Neck Melanoma Following Negative Sentinel Lymph Node Biopsy: A Retrospective Cohort Study

BackgroundCutaneous head and neck melanoma (cHNM) has a high rate of false-negative sentinel lymph node biopsy (SLNB) and up to a 25% risk of recurrence despite negative SLNB. The aim of this study was to investigate the pattern of melanoma recurrence in patients with cHNM with negative SLNB.MethodsA retrospective cohort study of consecutive cHNM patients at a tertiary care centre from 2014-2022. We included all cHNM patients with negative SLNB. All patients were categorized into Breslow thickness >2 mm and ≤2 mm and extracted information pertaining to histopathological characteristics and the presence and type of disease recurrences. We performed multivariable analysis using logistic and cox regression. We used an alpha of 0.05 and all statistical analyses were performed using R software.ResultsOverall, 167 patients met eligibility criteria and of these, 53.5% patients had cHNM ≤2 mm thick and 46.7% had lesions >2 mm thick. The overall recurrence rate was 29.3%. Multivariable analysis demonstrated that Breslow thickness [aOR: 5.89 (95% CI: 1.37, 32.3), P = 0.02] was associated with distant recurrence. Multivariable cox regression also identified that pathological ulceration [aHR: 3.17 (95% CI: 1.61, 7.66), P = 0.01] predicted time to distant recurrence. The SLNB false omission rate was 3.6% (95% CI: 1.3%, 7.7%).ConclusionSLNB-negative cHNM patients with high-risk pathological features may benefit from adjuvant immunotherapy.

BAUSSS biomarker improves melanoma survival risk assessment

BACKGROUND

The American Joint Committee on Cancer (AJCC) method of staging melanoma is dated and inaccurate. It ignores important prognostic melanoma features, especially the patient's age. BAUSSS is more accurate in determining survival risk for primary cutaneous melanoma patients who have no clinical or imaging evidence of nodal or distant metastases. BAUSSS is an algorithm incorporating analysis of Breslow thickness, Age, Ulceration, Subtype of melanoma, Sex and Site. These are the six features from the patient history along with the details from the melanoma pathology report that are most predictive of mortality outcome.

OBJECTIVE

To develop a single-page document that allows the clinician to determine BAUSSS biomarker-predicted prognosis in consultation with the patient.

METHOD

From various data sources, we developed an algorithm to predict melanoma mortality using the BAUSSS biomarker system. The single-page algorithm was made available to download at https://globalmelanoma.net/bausss-survival-chart, thus being readily available without charge to all clinicians and their patients.

RESULTS

BAUSSS method of determining melanoma prognosis is more accurate and less costly than the AJCC staging system. The only surgery the patient requires is wide local excision of the primary tumour. This method of ascertaining melanoma risk does not require added surgery, costs, hospitalization, tests and anaesthesia, such as would be required if sentinel lymph node biopsy was undertaken. BAUSSS can be a useful tool in determining which primary melanoma patients are at sufficiently high risk to be considered for adjuvant drug therapy.

CONCLUSIONS

We encourage clinicians to download and print in colour this single-page BAUSSS mortality prediction tool, laminate it, and use it face to face with the patient in consultations. Not only will the patient be able to recognize his/her long-term prognosis but will also be able to see how their tumour severity compares with others.

Adjuvant Pembrolizumab in Stage II Melanoma: Outcomes by Primary Tumor Location in the Randomized, Double-Blind, Phase III KEYNOTE-716 Trial

BACKGROUND

Previous results from the KEYNOTE-716 trial demonstrated significantly improved recurrence-free survival (RFS) and distant metastasis-free survival (DMFS) with adjuvant pembrolizumab versus placebo in patients with resected stage IIB or IIC melanoma. We present a post hoc analysis of efficacy according to primary tumor location.

METHODS

KEYNOTE-716 (NCT03553836) is a randomized, multicenter, double-blind, phase III study. Patients aged ≥ 12 years with newly diagnosed, resected stage IIB or IIC melanoma (sentinel node-negative) were randomly assigned (1:1) to pembrolizumab 200 mg every 3 weeks (2 mg/kg up to 200 mg for pediatric patients) or placebo. This post hoc analysis evaluated RFS and DMFS by primary tumor location of the head/neck, trunk, or extremities.

RESULTS

Overall, 976 patients were assigned to pembrolizumab (n = 487) or placebo (n = 489). Median follow-up was 39.4 months (range 26.0-51.4). The hazard ratios {HRs (95% confidence interval [CI])} for RFS were 0.60 (0.38-0.93) for the head/neck subgroup, 0.57 (0.38-0.84) for the trunk subgroup, and 0.69 (0.47-1.02) for the extremities subgroup. The HRs (95% CI) for DMFS were 0.65 (0.37-1.14) for the head/neck subgroup, 0.59 (0.38-0.92) for the trunk subgroup, and 0.53 (0.31-0.90) for the extremities subgroup.

CONCLUSION

RFS and DMFS consistently favored adjuvant pembrolizumab over placebo in most subgroups analyzed in this post hoc analysis from the KEYNOTE-716 trial. These results support the benefit of adjuvant pembrolizumab on RFS and DMFS in patients with resected high-risk stage II melanoma, irrespective of primary tumor location.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Circulating MicroRNAs: functional biomarkers for melanoma prognosis and treatment

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

Real-World Impact of Low-Grade Toxicities to Adjuvant Pembrolizumab in Stage III Melanoma

PURPOSE

Primary malignant melanoma is a curable disease, with surgical resection being the gold standard of treatment. For stage III melanoma, which poses a high risk of recurrence, adjuvant checkpoint inhibitors are used to reduce the risk of relapse. However, adjuvant treatment carries a risk of immune-related adverse events that can significantly impact on quality of life. Although the impact of grade 3 to 4 toxicities has been well characterized, the impact of lower-grade toxicity in this setting has not been as robustly discussed in the literature.

METHODS

We gathered retrospective data on patients with stage III melanoma who underwent adjuvant pembrolizumab treatment between December 2019 and December 2022 from two sites (Belfast City Hospital and Royal Preston Hospital). This included information on toxicity on the basis of Common Terminology Criteria for Adverse Events grading (version 5), treatment discontinuation, hospital admission, toxicity treatments, and disease progression.

RESULTS

Data were collected on 142 patients. 67 (47%) completed a 1-year course of adjuvant pembrolizumab. Median recurrence-free survival was 36.2 months. One hundred (70%) experienced treatment-related toxicity, of whom 72 (51%) had only low-grade toxicity (grade 1 to 2). In patients with only low-grade toxicity, 15% were hospitalized, 31% had treatment stopped because of toxicity, and 33% required immunosuppression treatment. The rate of early treatment discontinuation was higher among patients age 65 years or older compared with patients younger than 65 years (66% v 38%, P < .001).

CONCLUSION

In addition to the impact of grade 3 to 4 toxicities, there is a substantial burden of low-grade toxicity in patients undergoing adjuvant pembrolizumab treatment for stage III melanoma. Clinicians should discuss its potentially significant impact with patients and prepare to support them through these effects.

Association of HLA-A*02:01 type with efficacy and toxicity of immune checkpoint inhibitor therapy in melanoma patients: a retrospective cohort study

BACKGROUND

Immune checkpoint inhibitors (ICI) are highly effective but may induce severe or even fatal and unpredictable immune-related adverse events (irAEs). It is unclear whether human leukocyte antigen (HLA) genes contribute to the susceptibility of developing irAEs during ICI therapy.

METHODS

This multicentre retrospective study investigated the association of irAE and outcome with HLA-A*02:01 status in a cohort of 97 patients with metastatic melanoma undergoing ICI therapy. Organ-specific irAEs and therapy outcome as assessed by response rate, progression-free survival (PFS) and overall survival (OS) were analysed depending on HLA type HLA-A*02:01. For the outcome only patients with cutaneous melanoma were analysed. Chi square test, exact fisher test, Kruskal Wallis test and log rank test were employed for statistical analysis (p ≤ 0.05).

RESULTS

The cohort included 38 HLA-A*02:01 positive (39.2%) and 59 HLA-A*02:01 negative (60.8%) patients. Data showed no evidence of an association of HLA-A*02:01 with organ-specific irAEs except for a numerical difference in immune-related colitis. Furthermore, response rates of the subgroup of patients with metastatic cutaneous melanoma did not differ between the two cohorts. The median PFS was 5 months and 8 months in HLA-A*02:01 positive and negative patients with cutaneous melanoma, respectively.

CONCLUSION

HLA-A*02:01 was not associated with specific checkpoint inhibitor-induced organ toxicity in this cohort of HLA-A-typed melanoma patients. Interestingly, in the relatively small subgroup of patients with cutaneous melanoma an earlier progression in HLA-A*02:01 positive patients was observed, however not in the long term. These findings are exploratory due to the limited sample size and require validation in larger, prospective cohorts.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Circulating Tumor DNA in High-Risk Stage II/III Cutaneous Melanoma: A Feasibility Study

BACKGROUND

Adjuvant therapies reduce recurrence in patients with clinical stage IIB/IIC/III melanoma; however, better risk stratification and patient selection are needed. Circulating tumor DNA (ctDNA) as a marker of micrometastatic residual disease is being explored for such purposes in other malignancies. We aimed to explore the feasibility of serial ctDNA monitoring in patients with stage II/III melanoma, as well as the association of ctDNA elevation with disease burden and outcomes.

METHODS

A single-institution prospective study was conducted on patients with clinical stage IIB/IIC/III melanoma. Primary tumor was sent to Natera for generation of a tumor-informed mPCR-NGS assay (Signatera™). Peripheral blood was collected for analysis at pre-specified timepoints. Patients were stratified by ctDNA elevations both pre- and postoperatively to compare tumor characteristics and recurrence-free survival (RFS).

RESULTS

Overall, 30 patients were enrolled. The median Breslow depth was 4.4 mm and 70% were ulcerated. Signatera™ assays were successfully created for all 30 patients. Median follow-up from the time of surgery was 16 months and 13 patients recurred with median RFS of 19 months. Eight of these 13 patients (62%) had detectable ctDNA levels predating their clinical or radiographic recurrence. Elevated ctDNA at the first post-operative timepoint was associated with worse RFS.

CONCLUSIONS

ctDNA monitoring is feasible for patients with high-risk cutaneous melanoma. Our findings suggest that detectable ctDNA post-operatively may be associated with worse outcomes. Elevations during surveillance may predict subsequent clinical recurrence; however, the role of ctDNA in adjuvant therapy decision-making and surveillance is not yet ready for broad application.

A US Survey Across Seven Early-Stage Cancers Assessing the Humanistic Burden of Recurrence on Patients and Caregivers

INTRODUCTION

Patients diagnosed with an early-stage cancer are at risk of recurrence. Although the economic burden of a cancer recurrence is described in the literature, little is known about the humanistic burden of an early-stage cancer recurrence. Therefore, we surveyed patients and caregivers to understand the impact of a first cancer recurrence on patient and caregiver quality of life (QoL).

METHODS

Patients with early-stage bladder, gastric, head and neck (HN), melanoma, non-small cell lung, renal cell, and triple-negative breast cancers (TNBC) that recurred and caregivers of such patients completed a self-administered, online survey exploring QoL impacts. QoL was evaluated using de novo questions and the following instruments: EQ-5D-5L (patients and caregivers), European Organisation for Research and Treatment of Cancer Core Quality of Life questionnaire (patients only), and CareGiver Oncology Quality of Life questionnaire (caregivers only). Patient and caregiver responses and scores were stratified by type of cancer and type of recurrence (locoregional or distant/metastatic).

RESULTS

Among patients (N = 202), QoL was found to differ significantly across tumor types at time of survey, with lower scores seen in patients with renal cell carcinoma, gastric cancer, and HN cancer and higher scores seen in patients with melanoma and TNBC. Among caregivers (N = 100), QoL did not differ across tumor types. In both patients and caregivers, decreases in QoL were observed from pre-recurrence to post-recurrence, with greater worsening in QoL seen with distant/metastatic versus locoregional recurrences. Most patients reported worrying and feeling anxious and stressed about their condition. Most caregivers reported worrying about the cared-for person's cancer getting worse or coming back and that caring for the person was challenging post-recurrence.

CONCLUSION

Our findings demonstrate the importance of preventing recurrences and their negative impact on patients' and caregivers' QoL. Early-stage cancer treatments that prevent recurrences can provide better QoL.

Tumor-infiltrating lymphocyte scoring improves progression risk prediction in stage II melanoma: A retrospective cohort study

BACKGROUND

The American Joint Committee on Cancer eighth edition substaging might be suboptimal for predicting melanoma progression. Using it to select stage II patients for adjuvant immunotherapy risks overtreating low-risk stage IIB/IIC patients and undertreating high-risk stage IIA patients. Prognostic capability of tumor-infiltrating lymphocytes (TILs) is unclear in stage II melanoma.

OBJECTIVE

To evaluate the American Joint Committee on Cancer eighth edition substaging and TIL scoring as predictors of progression in stage II melanoma.

METHODS

Retrospective cohort study of 366 sentinel lymph node negative stage II melanoma patients from 4 UK hospitals (2004-2017), with long-term follow-up.

RESULTS

Twenty-three percent of melanomas progressed (median 9.5-year follow-up). Among those, 41.5% were stage IIA, 41.5% IIB, and 17.1% IIC. TIL scoring independently predicted progression risk (brisk vs non-brisk: odds ratio: 0.298, P = .009; absent vs non-brisk: odds ratio: 0.436, P = .049) and progression-free survival. Nonbrisk TILs, present in 80% of progressing tumors, denoted high risk. TIL scoring split patients into high and low risk across substages: stage IIA patients with non-brisk TILs had similar 5-year progression-free survival to stage IIB/IIC patients with absent/brisk TILs.

LIMITATIONS

Retrospective study design and unknown generalizability.

CONCLUSION

Stage II melanoma progression is poorly predicted by the American Joint Committee on Cancer eighth edition substage. TIL scoring offers improved risk stratification across substages and could serve as a cost-effective method to better identify patients who may benefit from adjuvant immunotherapies.

Assessing the clinical, humanistic, and economic impact of early cancer diagnosis: a systematic literature review

Introduction

There is a clear consensus among healthcare providers on the advantages of early cancer detection and treatment. However, no in-depth review has yet fully presented the clinical, humanistic, and economic benefits of early cancer diagnosis compared to late detection across a broad range of tumor types.

Methods

A systematic literature review was conducted to determine the clinical, humanistic, and economic benefits of early cancer diagnosis, as opposed to late diagnosis, as reported in non-interventional studies conducted worldwide. Searches were conducted using electronic databases (MEDLINE and Embase), conference repositories and grey literature. Observational studies in adults diagnosed with bladder cancer, gastric cancer, head and neck cancer (HNC), melanoma, non-small cell lung cancer (NSCLC), renal-cell carcinoma (RCC), and triple negative breast cancer (TNBC) were eligible for inclusion if they reported survival, health-related quality of life (HRQoL), healthcare resource utilization and/or costs, according to stage at diagnosis. Identified records were screened and extracted by two independent reviewers, and discrepancies were resolved by a third reviewer. The quality of studies was assessed using the Newcastle-Ottawa scale and the Larg and Moss adapted checklist.

Results

Of the 3,159 records identified, 103 studies were included in this review. The general trend showed worse clinical, humanistic, and economic outcomes when patients were diagnosed at a later stage compared to an earlier stage. Patients diagnosed at an earlier stage, had on average, substantially higher survival rates and lower mortality rates across all cancer types and incurred lower resource utilization and costs (with available evidence for patients with NSCLC, TNBC, and HNC), compared to those diagnosed at a more advanced/later stage. Limited evidence on the humanistic burden suggested that with a more advanced stage at diagnosis, patients with bladder cancer experienced reduced HRQoL.

Conclusion

Early cancer diagnosis (i.e., cancer diagnosed at earlier stages or with lower grades) was associated with longer survival, improved quality of life and lower healthcare costs and resource utilization compared to diagnosis of cancer at later stages or higher grades, as reported by overall survival (OS) and HRQoL outcomes. These findings emphasize the importance of screening and early detection of cancer to improve outcomes among patients diagnosed with cancer.

Society of Surgical Oncology Consensus Statement: Assessing the Evidence for and Utility of Gene Expression Profiling of Primary Cutaneous Melanoma

INTRODUCTION

Gene expression profiling (GEP) of primary cutaneous melanoma aims to offer prognostic and predictive information to guide clinical care. Despite limited evidence of clinical utility, these tests are increasingly incorporated into clinical care.

METHODS

A panel of melanoma experts from the Society of Surgical Oncology convened to develop recommendations regarding the use of GEP to guide management of patients with melanoma. The use of currently available GEP tests were evaluated in three clinical scenarios: (1) the utility in patient selection for sentinel lymph node biopsy; (2) the utility to guide surveillance; and (3) the utility to inform adjuvant therapy. As a basis for these recommendations, the panel performed a systematic review of the literature, including articles published from January 2012 until August 2023.

RESULTS

After review of 137 articles, 50 met the inclusion criteria. These articles included evidence related to three available GEP tests: 31-GEP, CP-GEP, and 11-GEP. The consensus recommendations were finalized using a modified Delphi process. The panel found that current evidence often fails to account for known clinicopathologic risk factors and lacks high-level data. The panel recognizes that the study of GEP tests is still evolving. The integration of GEP into routine clinical practice for predicting sentinel lymph node status and patient prognosis in melanoma is therefore not currently recommended.

CONCLUSION

At present, GEP should be considered primarily an investigational tool, ideally used in the context of clinical trials or specialized research settings.

Declining Clinical Utility of Tools for Predicting Sentinel Lymph Node Biopsy Status: A Single Institution Experience from 2000 to 2021

INTRODUCTION

Clinicopathologic data-based sentinel lymph node (SLN) prediction models are used to select patients with melanoma for sentinel lymph node biopsy (SLNB). However, the temporal performance of these models is unknown. Therefore, we investigated whether the performance and clinical utility of the Melanoma Institute of Australia, Memorial Sloan Kettering Cancer Center, and Friedman et al. models changed over time.

PATIENTS AND METHODS

Primary cutaneous melanoma cases that underwent SLNB at a single tertiary-care cancer center from 2000 to 2021 were identified from a prospectively maintained database. Calibration plots were generated. Values for estimated risks of SLN positivity and area under the receiver operator curve (AUC) were calculated. Clinical utility was assessed at thresholds between 5 and 10% using decision curve analysis.

RESULTS

In total, 2977 SLNB cases were included. The estimated risk of SLN positivity and AUCs were similar across periods for all models. However, calibration decreased over time for all models, with progressive underprediction of SLN positivity. Clinical utility also declined over time; in the most recent period investigated (2018-2021), no model offered clinical utility at risk thresholds ≤ 8%, and only the Friedman model provided clinical utility at risk thresholds of 9-10%.

CONCLUSIONS

The calibration and clinical utility of three predominant models for SLN prediction declined over time. There is a need to periodically reassess the performance of SLN prognostic tools as they are applied to contemporary cohorts. Future studies are needed to determine whether findings are generalizable outside of this study cohort.

Distress and Its Determinants in 820 Consecutive Melanoma Patients

BACKGROUND

Psycho-oncological burden not only affects patients' mental health but can also decrease treatment compliance and impair outcomes. The Distress Thermometer (DT) is a widely used screening tool in real-world medical care for identifying and monitoring psychological distress. Patients with melanoma presenting in oncologic outpatient departments comprise a wide range of characteristics. Although young adults may face challenges related to pivotal life stages, such as career responsibilities or parenting, older adults often contend with mobility issues, preexisting comorbidities, or age-related physical limitations.

METHODS

We conducted a retrospective evaluation of DT data from 820 patients with melanoma treated at our outpatient department between July and September 2016. These patients underwent routine DT screening and completed the associated National Comprehensive Cancer Network (NCCN) Problem List. The study aimed to identify factors influencing DT values above the threshold (≥ 5), further characterizing the patients' complaints according to the NCCN Problem List.

RESULTS

A total of 820 patients with melanoma underwent psycho-oncological screening. More than 40% had DT values above the threshold. Significant factors associated with DT values over the threshold included female gender, younger age, and advanced melanoma stages III-IV. Analysis of the NCCN Problem List revealed complaints such as fear, sleep issues, tingling in hands and feet, feeling swollen, problems at work or school, concerns regarding God, and loss of faith.

CONCLUSION

The results indicate a high need for psycho-oncological support for patients with melanoma. Particular attention should be given to patients with the identified factors that are associated with exceeding the DT threshold.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Downregulation of MHC-I on Melanoma Cells and Decreased CD8+ T-Cell Infiltration Are Associated With Metastatic Spread and Resistance to Immunotherapy

The success of immune checkpoint inhibitors (ICI) in melanoma therapy has catalyzed the introduction of ICI in increasingly early stages of the disease. This exposes many patients with a lower risk of relapse to the risk of protracted adverse events, highlighting the need for biomarkers guiding the use of ICI. Already many years ago, brisk infiltration of primary melanomas by lymphocytes has been linked to improved patient outcome, but controversial findings due to a high variability in classification systems have been described CD8+ T cells have been identified as a primary mediator of antitumor immunity in patients treated with ICI. As CD8+ T cells require the presentation of antigens via MHC-I on target cells, downregulation and loss of MHC-I have been observed as resistance mechanisms to ICI. In this study, we revisit the role of MHC-I expression and CD8+ T-cell infiltration in melanoma evolution using a cohort of advanced primary and matched metastatic melanomas by using an automated immunohistochemistry and digital pathology workflow. Our results show that downregulation of MHC-I expression is a frequent event in advanced primary melanomas that is associated with decreased CD8+ T-cell infiltration and an early metastatic spread to sentinel lymph nodes. Furthermore, MHC-I downregulation and decreased infiltration with CD8+ T cells are also associated with resistance to ICI. Our results suggest that analyses of MHC-I expression and CD8+ T-cell infiltration patterns could serve as future biomarkers to guide the decision to treat patients in early stages of melanoma with ICI.

Challenges and opportunities of predicting overall survival benefit from improvements to recurrence-free survival in stage II/III melanoma: a correlation meta-analysis

Background

We evaluated the association between treatment effects on recurrence-free survival (RFS) and overall survival (OS) in randomized controlled trials (RCTs) studying resected stage II/III melanoma.

Methods

Hazard ratios (HRs) of RFS and OS were obtained from a literature review. Bivariate random-effects meta-analysis (BRMA) and weighted linear regression (WLR) models estimated correlations [95% confidence interval (CI)] between HRRFS and HROS. Slopes and intercepts of surrogacy equations were estimated. Surrogate threshold effect was derived from WLR for various sample sizes. Validity and predictive performance of WLR were assessed using leave-one-out cross-validation. Sensitivity analyses evaluated impact of RCTs violating proportional hazards assumption, publication year, treatments' mechanism of action, and cancer stage.

Results

Across 30 RCTs, treatments included interferon-α (n = 17), other immunotherapy-containing regimens (n = 10), immune checkpoint inhibitors (n = 3), and targeted therapies (n = 2). BRMA (0.68, 95% CI 0.45-0.82) and WLR (0.71, 95% CI 0.42-0.87) estimated moderate correlation between HRRFS and HROS. Surrogate threshold effect was 0.66/0.68 for studies with 800/1000 patients. Slope coefficients were statistically significant in both models (95% CI 0.09-0.61 BRMA; 95% CI 0.41-0.92 WLR). The 95% prediction intervals around the HROS predicted by WLR accurately contained 29/31 (93.5%) of observed HROS. Across sensitivity analyses correlations ranged between 0.69 and 0.84 (BRMA) and 0.55 and 0.77 (WLR).

Conclusions

Statistically meaningful correlation between HRRFS and HROS can assist earlier predictions of OS benefit from improvements in RFS for RCTs in resected stage II/III melanoma and provide insights for the earlier evaluation of emerging therapies. Primary model predictions should be approached with caution as nearly half of the evidence base comprised interferon-α trials.

[Adjuvant and neoadjuvant treatments of melanoma]

The management of melanoma has evolved significantly over the past decade with the advent of immunotherapies and BRAF/MEK inhibitors, which have changed the prognosis for patients with advanced disease. Having demonstrated their efficacy in advanced disease, these treatments have been evaluated and shown to be effective in adjuvant treatment at earlier stages, first in stage III and then in stage IIB-IIC. Alongside the development of these adjuvant treatments, which have become the standard of care, new therapeutic strategies have emerged. Neoadjuvant treatments have been shown to be superior to adjuvant treatments in phase II and III trials. These neoadjuvant strategies will undoubtedly become the new standard for patients with macroscopic lymph node disease. However, there are still many unanswered questions regarding the optimal treatment regimen. Should mono- or bi-immunotherapy be used? Can surgery be de-escalated? Is additional adjuvant treatment essential or can it be withheld in the event of a major pathological response? Should patients with BRAFV600 mutations switch to targeted therapies in the event of pathological non-response? Should we switch to targeted therapies in the event of pathological non-response in BRAFV600 mutant patients? Therapeutic strategies, which are becoming increasingly personalised, are evolving very rapidly, with a trend towards de-escalation. We still lack robust biomarkers for patient selection.

Cancer Stem Cells and the Renin-Angiotensin System in the Tumor Microenvironment of Melanoma: Implications on Current Therapies

Multiple signaling pathways are dysregulated in melanoma, notably the Ras/RAF/MAPK/ERK and PI3K/AKT/mTOR pathways, which can be targeted therapeutically. The high immunogenicity of melanoma has been exploited using checkpoint inhibitors. Whilst targeted therapies and immune checkpoint inhibitors have improved the survival of patients with advanced melanoma, treatment resistance, their side effect profiles, and the prohibitive cost remain a challenge, and the survival outcomes remain suboptimal. Treatment resistance has been attributed to the presence of cancer stem cells (CSCs), a small subpopulation of pluripotent, highly tumorigenic cells proposed to drive cancer progression, recurrence, metastasis, and treatment resistance. CSCs reside within the tumor microenvironment (TME) regulated by the immune system, and the paracrine renin-angiotensin system, which is expressed in many cancer types, including melanoma. This narrative review discusses the role of CSCs and the paracrine renin-angiotensin system in the melanoma TME, and its implications on the current treatment of advanced melanoma with targeted therapy and immune checkpoint blockers. It also highlights the regulation of the Ras/RAF/MAPK/ERK and PI3K/AKT/mTOR pathways by the renin-angiotensin system via pro-renin receptors, and how this may relate to CSCs and treatment resistance, underscoring the potential for improving the efficacy of targeted therapy and immunotherapy by concurrently modulating the renin-angiotensin system.

Optimized monitoring for immune checkpoint inhibitor induced myocarditis using high-sensitivity troponin-T

BACKGROUND

Immune checkpoint inhibitor (ICI)-induced Myocarditis (irMyocarditis) is a rare adverse event with a high mortality rate of 40-50 % and which is mostly not diagnosed until clinical symptoms emerge.

OBJECTIVES

This study aims to screen patients for irMyocarditis using high-sensitivity cardiac troponin-T (hs-TnT) before and regularly during therapy with ICI.

METHODS

A cohort of 280 cancer patients were prospectively screened for levels of hs-TnT at baseline and prior to every ICI infusion. In case of elevation of hs-TnT, patients were referred for further work-up.

RESULTS

In total, 196 patients exhibited a baseline hs-TnT ≤ 14 ng/l (99th percentile concentration for general population; group A) and 84 patients a hs-TnT > 14 ng/l at baseline (group B). An increase of hs-TnT during ICI-treatment was observed in 56 out of 196 (27.6 %) and 56 out of 84 patients (66.7 %) in group A and B. Cardiovascular assessment was performed in 11.2 % and 27.4 % of patients, respectively, and 4.1 % and 9.5 % of patients were diagnosed with irMyocarditis and treated with corticosteroids. No fatalities occurred in any of the 16 irMyocarditis patients. Defining a threshold with the highest sensitivity and maximum specificity in receiver-operating characteristics curves, identified a limit of 22 ng/l (group A) and 60 ng/l (group B) hs-TnT, associated with a sensitivity of 100 % in both and a specificity of 91.0 % and 89.6 %, respectively, to detect irMyocarditis.

CONCLUSION

Screening of hs-TnT can identify irMyocarditis early and lead to reduction of MACE and mortality risk through interruption of ICI-treatment and prompt therapy with corticosteroids.

Is pathological response an adequate surrogate marker for survival in neoadjuvant therapy with immune checkpoint inhibitors?

Pathological response (PR) is an oncological outcome measure that indicates the therapeutic response to neoadjuvant therapy. In clinical trials involving neoadjuvant or perioperative interventions, overall survival and disease/event-free survival are typically the primary outcome measures. Although some evidence suggests that pathological complete response (pCR) can serve as a surrogate marker for the primary endpoint in prospective trials, it remains uncertain whether pCR is a true surrogate marker for patients with cancer undergoing curative resection across all solid tumours. Here, we review the role of PR as a surrogate marker and its associated methodological issues in the era of perioperative immune checkpoint inhibitors.

Impact of recurrence on employment, finances, and productivity for early-stage cancer patients and caregivers: US survey

BACKGROUND

Following an early-stage cancer diagnosis, recurrences can occur. To quantify financial impacts of a first recurrence, we surveyed patients and caregivers.

METHODS

The survey was self-administered online to patients (N = 202) with early-stage bladder, gastric, head and neck, melanoma, non-small cell lung, renal cell, and triple-negative breast cancers that recurred and caregivers (N = 100) of such patients. Work productivity and financial impacts were explored.

RESULTS

Negative impacts on work productivity, employment, finances, and healthcare resource use were identified, with significant differences seen across cancer types, between locoregional and distant/metastatic recurrences, and from pre-recurrence to post-recurrence.

CONCLUSIONS

The financial burden to patients, caregivers, healthcare systems, and society following early-stage cancer recurrence is substantial. Treatments that decrease recurrences can reduce this burden.

Natural product Eriocalyxin B exerts anti-tumor effects by downregulating TCEA3 expression and sensitizes immune checkpoint blockade therapy in osteosarcoma

Osteosarcoma (OS) remains the most common bone tumor and the prognosis for many patients remains stagnant due to the unsatisfactory therapeutic effect of conventional treatment regimens. This research explored the effect and mechanism of a novel natural product, Eriocalyxin B (EB), in pathogenesis and immunotherapy in OS. Cell Count Kit 8 assay, colony formation assay, and wound healing assay were employed to detect the proliferative, colony-forming, and migratory abilities of human OS cells following EB treatment. Moreover, xenograft growth assay was performed to assess the effect of EB on OS in vivo. Subcutaneous OS models constructed in immunocompetent mice were employed to evaluate the effect of EB treatment in combination with immune checkpoint blockades (ICBs) PD1ab and CTLA4ab. Immunohistochemistry (IHC) staining was utilized to detect the level of CD8+ T cells infiltration and Ki67 expression. TARGET database, RNA interference technology, and qPCR assay were employed to explore the mechanism of EB on OS. EB inhibited the proliferative, colony-forming, and migratory abilities of the human OS cells MG63 and U2OS both in vitro and in vivo. TARGET data analysis demonstrated that up-regulation of TCEA3 was significantly negatively correlated with overall survival in OS patients. EB exerted anti-tumor activity via downregulation of TCEA3. EB, in conjunction with ICBs, synergistically optimized anti-tumorigenic activity against OS in immunocompetent mice. EB may promote infiltration of CD8+ T cells and down-regulate Ki67 expression. These results signaled that EB may have a role as a candidate therapeutic or preventive agent for the treatment of OS.

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.

European consensus-based interdisciplinary guideline for melanoma. Part 2: Treatment - Update 2024

A unique collaboration of multi-disciplinary experts from the European Association of Dermato-Oncology (EADO), the European Dermatology Forum (EDF), and the European Organization of Research and Treatment of Cancer (EORTC) was formed to make recommendations on cutaneous melanoma diagnosis and treatment, based on systematic literature reviews and the experts' experience. Cutaneous melanomas are excised with one to two-centimeter safety margins. For a correct stage classification and treatment decision, a sentinel lymph node biopsy shall be offered in patients with tumor thickness ≥ 1.0 mm or ≥ 0.8 mm with additional histological risk factors, although there is as yet no clear survival benefit for this approach. Therapeutic decisions should be primarily made by an interdisciplinary oncology team ("Tumor Board"). Adjuvant therapies can be proposed in completely resected stage IIB-IV. In stage II only PD-1 inhibitors are approved. In stage III anti-PD-1 therapy or dabrafenib plus trametinib for patients with BRAFV600 mutated melanoma can be discussed. In resected stage IV, nivolumab can be offered, as well as ipilimumab and nivolumab, in selected, high-risk patients. In patients with clinically detected macroscopic, resectable disease, neoadjuvant therapy with ipilimumab plus nivolumab followed complete surgical resection and adjuvant therapy according to pathological response and BRAF status can be offered. Neoadjuvant therapy with pembrolizumab followed by complete surgical resection and adjuvant pembrolizumab is also recommended. For patients with disease recurrence after (neo) adjuvant therapy, further treatment should consider the type of (neo) adjuvant therapy received as well as the time of recurrence, i.e., on or off therapy. In patients with irresectable stage III/IV disease systemic treatment is always indicated. For first line treatment PD-1 antibodies alone or in combination with CTLA-4 or LAG-3 antibodies shall be considered. In stage IV melanoma with a BRAFV600 mutation, first-line therapy with BRAF/MEK inhibitors can be offered as an alternative to immunotherapy, in selected cases. In patients with primary resistance to immunotherapy and harboring a BRAFV600 mutation, this therapy shall be offered as second line. Other second line therapies include therapy with tumor infiltrating lymphocytes and combinations of immune checkpoint inhibitors not used in first line. This guideline is valid until the end of 2026.

Female Oncofertility and Immune Checkpoint Blockade in Melanoma: Where Are We Today?

The incidence of melanoma among young adults has risen, yet mortality has declined annually since the introduction of immune checkpoint inhibitors (ICI). The utilization of peri-operative ICI has significantly altered the treatment landscape in melanoma, with PD-1 inhibitors showing promising efficacy in improving relapse-free survival rates in high-risk stage II-III disease. With the increasing use of ICI, secondary concerns have emerged regarding the impact of cancer drugs on fertility and reproductive health among women of childbearing potential, especially in early-stage cancer settings. The exclusion of pregnant women from trials contributes to limited human data and clinical uncertainties, such as maternal and fetal toxicities related to ICI exposure during pregnancy, as well as the value of fertility preservation before ICI therapy. Uncertainty persists regarding pregnancy post-adjuvant immunotherapy, given the potential detrimental effects of hormonal and immunological changes during pregnancy on melanoma relapse. There is additional uncertainty about whether pregnancy-associated melanoma (PAM) represents a distinct disease entity that warrants tailored management compared to non-pregnant cases. Our review aims to give an overview of oncofertility practices among female melanoma patients after immunotherapy. We also focus on the literature gap in the published evidence and synthesize summaries regarding ICI toxicities on reproductive health and fetal development, pregnancy planning, and recurrence risks after melanoma treatment.