Adjuvant Nivolumab versus Ipilimumab in Resected Stage III or IV Melanoma

Management of In-transit Disease: Regional Therapies, Intralesional Therapies, and Systemic Therapy

In-transit (IT) melanoma represents a distinct, heterogeneous pattern of disease that arises as superficial tumors along the track between the primary site and the draining regional lymph node basin. Many therapies have been explored for treatment of this disease with the goal of maximizing delivery of the therapeutic agent to the tumor while minimizing systemic toxicities. These include regional chemotherapies, intralesional injections, checkpoint inhibitors, immunomodulators, and vaccines in various combinations or as monotherapy. Here, we review the general managemnt of patients with ITmelanoma, the range of currently available treatment options, and recommendations for specific therapies for individual patients.

Adoptive T-Cell Therapy in Melanoma: How This Will Impact Surgical Practice and the Role of Surgeons

Melanoma is one of a small number of cancers where there is a clear role for surgery in selected patients with metastatic disease. However, the role of surgery for metastatic melanoma in the age of immune checkpoint blockade is not clearly delineated. Adoptive cell therapies, which include tumor-infiltrating lymphocytes and chimeric antigen receptor T cells, often require metastasectomy to obtain the tumor-specific immune cells and/or antigens necessary to create personalized cell-based products. It is, therefore, essential that the surgeon be well-versed in techniques for procuring appropriate tissue and familiar with their delivery to ensure appropriate preoperative planning and postoperative recovery.

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.

Systemic Therapy for Melanoma: What Surgeons Need to Know

Immune checkpoint inhibitors and targeted therapies (BRAF/MEK inhibitors) have transformed the care of patients with stage IV melanoma, now with 5-year overall survival rates around 50%. Surgeons should be acquainted with these drugs, the multidisciplinary considerations of their use, and the unique immune-related adverse events (irAEs) they can cause. In this review, we discuss systemic therapies for cutaneous melanoma, including the biology of immune checkpoint inhibition, treatment indications, and toxicities. We also explain how these irAEs and other toxicities can impact surgical planning and perioperative management.

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.

[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.

Muscle atrophy and organ enlargement associated with quality of life during systemic therapy for melanoma: findings from an AI-based body composition analysis

INTRODUCTION

Health-related quality of life (HRQoL) is emerging as an endpoint, adjunct to survival, in cancer treatment. For this reason, the European Organization for Research and Treatment of Cancer (EORTC) has developed standardized quality-of-life questionnaires to collect patient-reported outcome measurement (PROM), which so far have been widely used in clinical trials to evaluate the impact of new drugs on cancer patients. However, while these questionnaires comprehensively describe patient functions, little is known about their association with patient characteristics. This study aims to bridge this gap and investigate the association between patient body composition and HRQoL.

MATERIALS AND METHODS

A retrospective cohort of melanoma patients treated with systemic therapy who completed HRQoL questionnaires and had regular imaging follow-ups was included. The primary endpoint was the association between n = 116 AI-measured longitudinal volumes of thoracic and abdominal organs, subcutaneous and visceral fat, skeleton and muscles (estimated by TotalSegmentator), and physical functioning (PF), role functioning (RF) and fatigue (FA) (estimated by the EORTC-QLQ-C30).

RESULTS

The n = 358 patients were included. Our findings show larger liver, spleen, and gallbladder volumes associated with decreased PF and RF and an increase in FA (p < 0.05). Furthermore, larger muscle volumes were associated with an increase in PF and RF and a decrease in FA (p < 0.01).

DISCUSSION

Our findings show significant associations between AI-measured body and organ analysis and HRQoL in patients with melanoma on systemic treatment. Future research is needed to understand the underlying cause and determine the possible predictive ability of these imaging features.

KEY POINTS

Question Are changes in body composition associated with changes in HRQoL in melanoma patients undergoing systemic therapy? Findings AI-based body composition analysis shows that larger muscle volumes are linked to improved HRQoL, while organ enlargement is associated with a decline in it. Clinical relevance Our findings indicate new imaging biomarkers that can help monitor patients and evaluate treatment responses. These biomarkers link patient function to physical changes during treatment, offering insights for creating response evaluation criteria that also consider improvements in quality of life.

Economic Evaluation of Inguinal Versus Ilio-inguinal Lymphadenectomy for Patients with Stage III Metastatic Melanoma to Groin Lymph Nodes: Evidence from the EAGLE FM Randomized Trial

PURPOSE

We compared health outcomes and costs of inguinal lymphadenectomy (IL) versus ilio-inguinal lymphadenectomy (I-IL) for removal of metastatic melanoma to lymph nodes of the groin in adults with stage III melanoma.

METHODS

A within-trial cost-utility analysis was performed alongside an international randomized trial (EAGLE-FM) with 36 months follow-up from a health system perspective. Healthcare costs were measured by using trial records, and effectiveness measured in quality-adjusted life years (QALYs). Deterministic sensitivity analyses assessed the impact of changes in costs or quality of life on overall results. Statistical bootstrapping was employed to estimate confidence intervals around the cost-utility ratio.

RESULTS

Among 98 trial participants (IL n = 50, I-IL n = 48), with no pelvic or distant disease clinically or on PET/CT imaging, the mean life years saved for those randomized to IL showed a small but nonsignificant increase of 0.05 years compared with those in the I-IL group (2.56 vs. 2.51 years, 95% confidence interval [CI] -0.78 to 0.87). The mean difference in QALYs gained showed a small but nonsignificant increase of 0.04 QALYs (1.95 vs. 1.91, 95% CI -0.49 to 0.57). The mean hospital stay among IL patients was 6.16 days, 1.24 days shorter than I-IL patients (7.40 days) at 36 months follow-up. Mean per-patient healthcare costs of IL surgery were AU$6938 lower than for I-IL surgery ($26,555 vs. $33,493, 95% CI -$24,360 to $10,484). Inguinal lymphadenectomy was slightly more effective and slightly less expensive) over I-IL; a finding supported by 81% of bootstrapped estimates and upheld across sensitivity analyses.

CONCLUSIONS

Our study indicates that less extensive IL surgery might be the preferred surgical strategy for metastatic melanoma to the groin when PET/CT imaging shows no pelvic disease. This surgery is likely to improve quality-adjusted survival and may reduce healthcare costs; however, the differences noted in EAGLE-FM were limited by a small sample size and were not statistically significant.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02166788; anzctr.org.au ACTRN12614000721606.

Gut Microbiota in Immuno-Oncology: A Practical Guide for Medical Oncologists With a Focus on Antibiotics Stewardship

The gut microbiota has emerged as a critical determinant of immune checkpoint inhibitor (ICI) efficacy, resistance, and toxicity. Retrospective and prospective studies profiling the taxonomic composition of intestinal microbes of patients treated with ICI have revealed specific gut microbial signatures associated with response. By contrast, dysbiosis, which can be caused by chronic inflammatory processes (such as cancer) or comedications, is a risk factor of resistance to ICI. Recent large-scale meta-analyses have confirmed that antibiotic (ATB) use before or during ICI therapy alters the microbiota repertoire and significantly shortens overall survival, even after adjusting for prognostic factors. These results underscore the importance of implementing ATB stewardship recommendations in routine oncology practice. Microbiota-centered interventions are now being explored to treat gut dysbiosis and optimize ICI responses. Early-phase clinical trials evaluating fecal microbiota transplantation (FMT) from ICI responders or healthy donors have shown that this approach is safe and provided preliminary data on potential efficacy to overcome both primary and secondary resistance to ICI in melanoma, non-small cell lung cancer, and renal cell carcinoma. More targeted interventions including live bacterial products including Clostridium butyricum and Akkermansia massiliensis represent novel microbiome-based adjunct therapies. Likewise, dietary interventions, such as high-fiber diets, have shown promise in enhancing ICI activity. In this ASCO Educational Book, we summarize the current state-of-the-evidence of the clinical relevance of the intestinal microbiota in cancer immunotherapy and provide a practical guide for ATB stewardship.

Immune checkpoint inhibitors: From friend to foe

Immune checkpoints are crucial in regulating the activation of cell-mediated and humoral immune responses. However, cancer cells hijack this mechanism to evade the immune surveillance and anti-cancer response. Typically, receptors like PD-1 and CTLA4, expressed on immune cells, prevent the activation and differentiation of T cells. They also inhibit the development of autoimmune reactions. However, ligands such as PD-L1 for the receptor PD-1 are also expressed on the surface of cancer cells that help prevent the activation of anti-cancer immune responses by blocking the signalling pathways mediated by PD-1 and CTLA4. Immune checkpoint inhibitors (ICIs) have promising therapeutic efficacy for treating several cancers by activating T cells and their differentiation into effector cells against tumours. Nonetheless, hyperactivated immune cells usually contribute to detrimental issues, also known as immune-related adverse effects (IrAE). IrAEs have been observed in multiple organs, leading to neurological issues, colitis, endocrine dysfunction, renal issues, hepatitis, pneumonitis, and dermatitis. The interplay between hyperactivated T cells and Treg cells helps in orchestrating the development of autoimmunity. Moreover, the crosstalk between proinflammatory interleukins and the development of autoantibodies also mediates the multiorgan effects of ICIs in cancer patients. IrAEs are generally managed by terminating the ICI therapy, reducing the ICI dose, and by using corticosteroids to subvert inflammation. Therefore, the present review aims to delineate the impacts of ICIs on the development of autoimmune diseases and inflammatory outcomes in cancer patients. In addition, mechanistic insight involving immune cells, cytokines, and autoantibodies for ICI-mediated IrAEs will also be discussed with updated findings in this field.

Role of Surgery for Metastatic Melanoma in the Era of Checkpoint Blockade

Treatment paradigms have shifted with the introduction of checkpoint inhibitors, facilitating less extensive surgical procedures in some scenarios. Resection and adjuvant therapy are key components in patients with locally advanced or limited metastatic disease. Alternately, these patient populations may benefit from peri-operative systemic therapy based on recent clinical trial data. Resection is also integral to administering tumor infiltrating lymphocyte therapy in patients with treatment-refractory, unresectable melanoma. The role of surgery continues to evolve, and ranges the spectrum from resection with curative intent, to palliative interventions intended to effectively manage symptoms or disease-related complications.

Return to work after neoadjuvant versus adjuvant immunotherapy in stage III melanoma patients

PURPOSE

Neoadjuvant immunotherapy in stage III melanoma has recently been shown to improve event-free and distant metastasis-free survival compared to adjuvant therapy. Pathologic response allows for subsequent personalization of surgery and omission/application of adjuvant therapy. We addressed the question whether neoadjuvant therapy allows an earlier and more to a more extent return to work in this curatively treated patient population.

METHODS

In this single-center retrospective analysis of patients participating at the Netherlands, we interviewed via the telephone 88 stage III melanoma patients treated with neoadjuvant versus adjuvant immunotherapy in regards of their stopping work during therapy, and when returning partially or fully to work.

RESULTS

Six, 12, and 24 months post start of therapy at least partially worked 80% versus 61%, 84% versus 73%, and 91% versus 82% in the neoadjuvant versus adjuvant groups. Full return to work was observed at 6 months in 52% versus 48%, at 1 year in 71% versus 52%, and at 2 years 82% versus 62%, respectively. Return to work (RTW) started in general in both groups after finishing the systemic therapies.

CONCLUSIONS

Our data suggest that the manner of therapy (neoadjuvant versus adjuvant) and potentially its treatment duration might be major factors influencing the timing and extent of RTW.

IMPLICATIONS FOR CANCER SURVIVORS

A faster and full RTW is not only of importance for the patient's well-being and QoL, but has also a significant financial impact on patients and their families.

Recommendations of perioperative systemic therapies considering age or comorbidities in the National Comprehensive Cancer Network (NCCN) guidelines and quality of cited evidence

IMPORTANCE

Perioperative therapy for cancer is offered to reduce the recurrence and improve overall long-term outcomes. Age and comorbidities of patients can influence the effectiveness and/or safety of perioperative therapy. It is important that key national guidelines, such as the National Comprehensive Cancer Network (NCCN) guidelines, reflect the benefit of perioperative therapy for key subpopulations of patients. However, this has not been evaluated.

OBJECTIVE

To evaluate the perioperative treatment guidance, with regards to age and comorbidities, reported in the NCCN guidelines DESIGN SETTING, AND PARTICIPANTS: NCCN age and comorbidity in perioperative treatment guidelines.

INTERVENTION

Age and Comorbidities MAIN OUTCOME AND MEASURE: The existence of age or comorbidity-specific guidelines for perioperative therapy, the presence of literature support for these specific guidelines, and where they exist.

RESULTS

Only 2 of the 10 cancer types studied had specific guidelines on perioperative therapy based on age, and 4/10 had guidelines on perioperative therapy considering patients' comorbidities. 5 of the 10 cancer guidelines and 4/10 had vague advice on consideration of age and comorbidities respectively. A total of 30 recommendations made across the guidelines studied. Studies that are cited to support these recommendations were often pooled analyses of RCTs or subgroup analysis of randomized controlled trials (RCTs) (33%).

CONCLUSION AND RELEVANCE

This study shows the lack of age and comorbidity-specific guidelines for many cancer types in the NCCN guidelines. In addition, several of these recommendations, where they exist, are also not supported by strong evidence such as RCTs. There is a need for more comprehensive guidelines that make recommendations accounting for patient-intrinsic factors.

Optimising Cancer Medicine in Clinical Practices: Are Neoadjuvant and Adjuvant Immunotherapies Affordable for Cancer Patients in Low- and Middle-Income Countries?

Cancer immunotherapy, encompassing neoadjuvant and adjuvant interventions, has transformed treatment paradigms in multiple malignancies by leveraging the host immune system to combat tumour cells. While immunotherapies have demonstrated remarkable efficacy, particularly immune checkpoint inhibitors, high treatment costs undermine their accessibility and affordability in low- and middle-income countries (LMICs). This paper provides a prospective overview of the clinical benefits of neoadjuvant and adjuvant immunotherapies, examines the barriers to implementing these treatments in LMICs, and suggests potential strategies to improve equitable access. Such interventions necessitate a combined effort from healthcare providers, policymakers, and stakeholders to ensure their sustainable integration into global cancer care.

Survival Correlates With Adjuvant Choice in Sentinel Node Positive Head and Neck Cutaneous Melanoma

OBJECTIVE(S)

The objective of this study is to evaluate the utilization and outcomes of completion lymph node dissection (CLND) and immunotherapy for sentinel lymph node biopsy (SLNB) positive head and neck cutaneous melanoma (HNCM).

METHODS

Patients with primary HNCM and positive SLNB in the 2020 National Cancer Database (NCDB) Melanoma file were reviewed. The frequency of CLND and immunotherapy was tracked from 2012 to 2019. Clinicodemographic features of patients were evaluated with respect to their post-SLNB treatment choice. Overall survival (OS) was calculated from the time of diagnosis, and the association of therapy choice with survival was determined using a multivariate Cox regression analysis.

RESULTS

The rates of CLND declined from 66% to 18% while adjuvant immunotherapy increased to a peak of approximately 40%, with an inflection point occurring in 2016. Multivariate survival analysis indicated that immunotherapy use alone, though not CLND, was associated with improved prognosis (hazard ratio 0.65, 95% confidence interval 0.45-0.93). Patient characteristics associated with immunotherapy administration included age (p < 0.01), insurance type (p = 0.002), income (p < 0.001), and healthcare facility type (p = 0.005).

CONCLUSION

In this retrospective NCDB-based study, we find that the modern management of SLNB-positive patients has shifted towards greater use of adjuvant immunotherapy and a decline in CLND; the use of immunotherapy is associated with improved OS. Patients treated with immunotherapy were more likely to be younger, of higher income, and with private health insurance.

LEVEL OF EVIDENCE: 4

The emerging role of lymphocyte-activation gene 3 targeting in the treatment of solid malignancies

PD-(L)1-based immune checkpoint inhibitor therapies have profoundly impacted the treatment of many solid malignancies. Although the addition of CTLA-4 checkpoint inhibitors can enhance anticancer activity, it also significantly increases the rate of immune-related adverse events. Therefore, there has been much interest in identifying additional immune checkpoints to improve the outcomes seen with PD-1-based therapy while minimizing additional side effects. One such target, lymphocyte-activation gene 3 (LAG-3), has long been recognized as an important inhibitor of T-cell function via modulation of the T-cell receptor pathway. Several drugs targeting LAG-3 have been developed, including most prominently the monoclonal antibody relatlimab. To date, the most significant demonstration of efficacy in targeting LAG-3 has been the use of relatlimab with the PD-1 inhibitor nivolumab in the treatment of advanced melanoma. The combination of nivolumab plus relatlimab is more efficacious compared to PD-1 inhibition alone, as has been previously seen with the combination of CTLA-4 inhibitor ipilimumab with nivolumab. However, nivolumab plus relatlimab offers a potentially more favorable toxicity profile. Here, the authors review the mechanism of the LAG-3 pathway and its rationale as a target for anticancer therapy as well as currently available data regarding the use of LAG-3 agents in treating melanoma and other solid tumors. Other investigational agents that target LAG-3 via novel mechanisms are also reviewed.

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.

An Implantable Double-Layered Spherical Scaffold Depositing Gene and Cell Agents to Facilitate Collaborative Cancer Immunotherapy

Gene therapies and adoptive cell therapy (ACT) are promising strategies for cancer immunotherapy. Referring to their different mechanisms, the combination of these two might result in a strategy with potential collaborative and compensatory effects. However, it is challenging to combine gene therapies and ACT that work in a proper logical order. Here, we developed a double-layered spherical scaffold (DLS) to codeliver mRNA and T cells and constructed an implantable hydrogel formulation, named the GD-920 scaffold. With a diameter of 7 mm, this scaffold loaded primary T cells in the inner layer and the Bim mRNA nanocomplex in the outer layer. While maintaining their bioactivities, GD-920 released gene and cell payloads in a controllable and sequential manner. The mRNA complex from the outer layer was first released and induced immunogenic tumor cell death. The produced antigens then migrated into the scaffold with dendritic cells, triggering a tumor-specific immune response. Finally, activated T cells released by the inner layer attacked the tumor tissue via massive infiltration. We showed that in situ implantation of the GD-920 scaffold is capable of effectively inhibiting tumor growth and is far more potent than that of control scaffolds containing a single payload. Our results demonstrated the outstanding potential of this DLS in combining gene and cell therapeutic approaches to cancer immunotherapy.

Promising Treatment Strategy for Primary Malignant Melanoma of the Esophagus by Radical Esophagectomy and Nivolumab as Adjuvant Therapy: A Case Report

INTRODUCTION

Primary malignant melanoma of the esophagus (PMME) is a rare malignant tumor of the esophagus with very poor prognosis due to high rates of recurrence and metastasis even after radical resection. Recently, however, immune checkpoint inhibitors such as anti-programmed cell death-1 antibodies have been suggested to improve the prognosis of malignant melanoma. This report describes the use of postoperative nivolumab as adjuvant therapy after surgical resection of PMME, with recurrence-free follow-up for more than 1 year.

CASE PRESENTATION

A 69-year-old man had chest discomfort and tightness in his throat. Upper gastrointestinal endoscopy revealed multiple melanosis and an elevated lesion in the middle esophagus. After histological examination, he was diagnosed as having PMME, so he underwent thoracoscopic subtotal esophagectomy, three-field lymphadenectomy, pedunculated jejunum reconstruction with super-charge and super-drainage, and feeding jejunostomy due to the past history of gastrectomy. The adjuvant therapy using nivolumab (every 2 weeks, 240 mg) for 1 year was completed with no serious side effects, and there was no recurrence for more than 1 year postoperatively.

CONCLUSIONS

Although cases of PMME treated with adjuvant nivolumab have rarely been reported, the present case suggests that this approach may represent a promising treatment option, similar to cutaneous melanoma.

Critical evaluation of sentinel lymph node biopsy in pT1b and pT2a melanoma patients: A nationwide population-based study

INTRODUCTION

Sentinel lymph node biopsy (SLNB) aims to stage patients. According to the 8th edition of the American Joint Committee on Cancer(AJCC) staging manual, patients with pT1b or pT2a melanoma can be eligible for adjuvant immunotherapy, however, only if they have a sentinel node (SN) tumour burden > 1 mm. This study aims to determine the percentage of patients with pT1b or pT2a that will become eligible for adjuvant immunotherapy following SLNB.

METHODS

A nationwide, population-based study was conducted using data from the Dutch Pathology Databank. Patients diagnosed with pT1b and pT2a melanoma between 2002 and 2023 were included. The primary endpoint was the number of SNs with a tumour burden > 1 mm.

RESULTS

We identified 36,606 patients of who 16,042 underwent SLNB. SN positivity was 5 % for patients with pT1b melanoma, and 11 % for pT2a melanoma. A tumour burden > 1 mm was found in 1.5 % and 4.1 %, translating to a number needed to treat (NNT) of 69 for pT1b and 25 for pT2a.

CONCLUSION

This nationwide study demonstrated a low incidence of positive SNs and minimal likelihood of significant clinical outcomes following SLNB. Given the high NNT to be eligible for adjuvant immunotherapy, SLNB may no longer be justified for pT1b melanoma. For patients with pT2a melanoma, SLNB should be considered carefully, balancing limited clinical benefits against potential risks.

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.

Immune checkpoint inhibition in metastatic or non-resectable melanoma after failure of adjuvant anti-PD-1 treatment. A EUMelaReg real-world evidence study

BACKGROUND

Adjuvant immune checkpoint inhibition (ICI) with anti-PD-1 antibodies in high-risk resected melanoma has been shown to improve recurrence-free survival. It is unclear whether prior adjuvant anti-PD-1 therapy is associated with altered response to subsequent ICI treatment in the metastatic setting.

METHODS

Using data from the European Melanoma Registry (EUMelaReg), we analyzed the efficiency of first-line (1L) ICI in non-resectable or metastatic melanoma after failure from prior adjuvant anti-PD-1 treatment. Both single-agent anti-PD-1 and combined anti-PD-1/CTLA-4 (Ipi/Nivo) 1L regimes were included in the analysis. We identified 389 patients receiving 1L ICI with prior adjuvant anti-PD-1 treatment. The control population was selected from a pool of 3390 PD-1-naive cases by 1:1 matching for the type of 1L ICI and various prognostic factors. As outcome measure, overall remission rates (ORR) were calculated and progression-free survival (PFS) was evaluated by Kaplan-Meier and Cox regression analysis.

RESULTS

Out of 389 patients, 303 (77.9 %) received Ipi/Nivo and 86 (22.1 %) anti-PD-1 in 1L. ORR was significantly lower in pre-treated patients (31.4 %) as compared to anti-PD-1 naive patients (48.8 %; p < 0.0001). Kaplan-Meier analysis showed significantly shorter median PFS for pre-treated patients. This applied to both anti-PD-1 and Ipi/Nivo treatment. Patients with early recurrence from adjuvant treatment (during or up to 12 weeks after end of treatment) showed lower ORR (28.5 %) and shorter PFS (3.1 months) than those who recurred later (37.7 % and 6.1 months, respectively).

CONCLUSIONS

Patients with metastatic melanoma, previously exposed to anti-PD-1 ICI in the adjuvant setting showed significantly lower ORR and shorter PFS to 1L ICI with either Ipi/Nivo or single-agent anti-PD-1 retreatment.

National Trends in Management of the Nodal Basin for Pediatric Patients With Occult Stage III Melanoma in the United States

BACKGROUND

Following the publication of recent trials (MSLT-I, MSLT-II, DeCOG), routine completion lymph node dissection (CLND) after positive sentinel lymph node biopsy (SLNB) is no longer recommended for adults with melanoma, while adjuvant immunotherapy (IO) was approved for selected patients with positive SLNB. Given the exclusion of pediatric patients from these studies, we aimed to characterize trends in nodal management for pediatric patients with Stage III melanoma.

PROCEDURE

The National Cancer Database (NCDB) was queried for pediatric patients (age ≤20 years) with melanoma (clinical Stage I/II; pathologic Stage III) who underwent resection from 2012 to 2019. The primary objective was to examine trends in the extent of nodal surgery, the number of lymph nodes examined, and adjuvant IO utilization. Secondary objectives included comparing overall survival (OS) by nodal management and receipt of adjuvant IO using Kaplan-Meier methods.

RESULTS

Overall, 98 patients met inclusion criteria. From 2012 to 2019, the percentage of patients receiving SLNB alone increased (from 13% to 89%); conversely, therapeutic lymph node dissection (TLND) decreased (from 60% to 0%), as did CLND (from 27% to 11%). Median lymph nodes examined decreased from 2012 to 2019 (from 22 to 2), while receipt of adjuvant IO increased (from 33% to 44%). OS did not differ by nodal management nor receipt of adjuvant IO.

CONCLUSIONS

The findings of this study support clinical observation after SLNB in pediatric patients with melanoma, as we noted de-escalation in the extent of nodal surgery without compromising OS. We also noted increasing utilization of adjuvant IO among patients with positive SLNB. Multidisciplinary discussion remains vital for managing melanoma in pediatric patients.

Cardiovascular Risk Profile of Nivolumab Anti-cancer Therapy: A Review of Current Literature

OBJECTIVES

Immune checkpoint inhibitors (ICI) upregulate host antitumor immunity, proving efficacy across diverse tumor types. Currently approved ICI treatment primarily targets the programmed cell death receptor 1 (PD-1) and its ligand PD-L1, and cytotoxic T lymphocyte-antigen 4 (CTLA-4). Nivolumab is a monoclonal antibody that targets the human PD-1 receptor and is an entirely human immunoglobulin G4 (IgG4), approved by the FDA for various cancers like advanced melanoma, metastatic renal cell carcinoma, Hodgkin lymphoma, and advanced lung carcinoma. This review will summarise and discuss the recent literature on cardiotoxicity associated with nivolumab therapy.

METHODS

We searched online databases like PubMed, Scopus, Google Scholar, and Embase for articles related to Nivolumab.

RESULTS

Cardiotoxicity with ICI use is most commonly represented as myocarditis. Patients present with complaints of shortness of breath, palpitations, edema, and fatigue. Takotsubo cardiomyopathy, or broken heart syndrome, is characterized by systolic dysfunction of the left ventricle, mimicking a myocardial infarction but without associated coronary ischemia and with minimal elevation of cardiac enzymes. In the CHECKMATE-037 trial, ventricular arrhythmias occurred in <10% of those who received nivolumab. In a retrospective analysis of patients treated with ICI (predominantly nivolumab monotherapy) for lung cancer, 11% of the patients developed major adverse cardiac events, including myocarditis, non-ST-segment elevated myocardial infarction, supraventricular tachycardia, and pericardial disorders.

CONCLUSION

Close collaboration between cardiology and oncology specialists is crucial for early detection and effective management of cardiac complications, enhancing the safety of nivolumab anticancer therapy.

[New systemic treatment approaches for conjunctival melanoma]

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

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.

GLUT-1-negative Choroidal Malignant Melanoma with Liver Metastasis Recurrence 12 Years after Surgery without FDG Accumulation in a Recurrent Lesion on FDG-PET/CT

Choroidal malignant melanoma is a rare malignant tumor that develops in adult eyeballs. It causes early lymph node and distant metastasis. Fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography (CT) is widely used for screening malignant melanoma metastases. We encountered a 58-year-old man with choroidal malignant melanoma in whom liver metastasis recurred 12 years after surgery, without any observable FDG accumulation. Immunostaining revealed the absence of glucose transporter type 1 (GLUT-1) expression, crucial for intracellular FDG uptake. The lack of FDG accumulation in the lesion could be attributed to the diminished cellular FDG uptake due to the absence of GLUT-1 expression.

Combinational therapeutic strategies to overcome resistance to immune checkpoint inhibitors

Over the past few years, immune checkpoint inhibitors resulted in magnificent and durable successes in treating cancer; however, only a minority of patients respond favorably to the treatment due to a broad-spectrum of tumor-intrinsic and tumor-extrinsic factors. With the recent insights gained into the mechanisms of resistance, combination treatment strategies to overcome the resistance and enhance the therapeutic potential of immune checkpoint inhibitors are emerging and showing promising results in both pre-clinical and clinical settings. This has been derived through multiple interconnected mechanisms such as enhancing tumor immunogenicity, improving neoantigen processing and presentation in addition to augmenting T cell infiltration and cytotoxic potentials. In the clinical settings, several avenues of combination treatments involving immune checkpoint inhibitors were associated with considerable improvement in the therapeutic outcome in terms of patient's survival and tumor growth control. This, in turn, increased the spectrum of cancer patients benefiting from the unprecedented and durable effects of immune checkpoint inhibitors leading to their adoption as a first-line treatment for certain cancers. Moreover, the significance of precision medicine in cancer immunotherapy and the unmet demand to develop more personalized predictive biomarkers and treatment strategies are also highlighted in this review.

Adjuvant BRAF/MEK versus anti-PD-1 in BRAF-mutant melanoma: a propensity score matched survival analysis

BACKGROUND

Adjuvant BRAF/MEK inhibitors (BRAF/MEK) and anti-PD-1 therapy have become the standard care in resected stage III/IV melanoma. A head-to-head clinical trial comparison is lacking.

METHODS

All stage III BRAF-mutant melanoma patients who received adjuvant BRAF/MEK or anti-PD-1 (2018-2022) were included from the Dutch Melanoma Treatment Registry. Propensity score matching (PSM) was used to compare 1- and 2-year recurrence-free survival (RFS), distant metastasis-free survival (DMFS), and overall survival (OS), and toxicity rates.

FINDINGS

Among 952 patients (226 BRAF/MEK and 726 anti-PD-1), BRAF/MEK-treated patients had lower disease stages (16·4% versus 9·9% stage IIIA; p < 0·01) and more often comorbidities (75·2% versus 63·4%; p < 0·01). Median follow-up was 29 months. PSM created two similar groups of 223 patients. RFS, DMFS, and OS were not significantly different before and after PSM. Two-year RFS was 62% (95% CI 55-71) for BRAF/MEK and 65% (95% CI 58-72) for anti-PD-1; 2-year DMFS was 81% (95% CI 74-87) versus 81% (95% CI 75-86); 2-year OS was 86% (95% CI 81-92) versus 89% (95% CI 85-94), respectively. Grade ≥ 3 toxicity was reported in 11·7% (BRAF/MEK) and 13·4% (anti-PD-1).

CONCLUSION

After PSM, no significant differences in outcomes were observed between adjuvant anti-PD-1 and BRAF/MEK-treated patients with stage III BRAF-mutant melanoma.

Longitudinal Analysis Reveals Dynamic Changes in Histopathologic Features in Responders to Neoadjuvant Treatment in a Stage III BRAF-Mutant Melanoma Cohort

Despite advances in systemic therapies, cutaneous melanoma remains a highly deadly disease. Patients with high-risk stage III melanoma have a significant likelihood of recurrence following surgery. Although adjuvant immunotherapy has been the standard of care, recent evidence demonstrates that neoadjuvant immunotherapy is more effective for higher-risk stage III patients, showing superior survival outcomes compared with adjuvant immunotherapy. This has led to an immediate paradigm shift in clinical practice toward neoadjuvant therapy for this cohort. The NeoTrio clinical trial assessed the efficacy of sequential or combination BRAF-targeted therapy with anti-programmed cell death-1 in the neoadjuvant setting. However, research on longitudinal histopathologic changes during this treatment period remains limited. Analysis of hematoxylin and eosin slides from 60 patients across 4 matched neoadjuvant timepoints revealed dynamic changes in a number of treatment response features. Females achieved significantly higher rates of major pathologic response (P = .002) and displayed higher levels of inflammatory fibrosis (P = .04) and hyalinized fibrosis (P = .01). The presence of tertiary lymphoid structures (P = .013) and plasma cells (P = .02) at resection was significantly associated with response. Combination scoring of histopathologic features (composite score and the immune-related pathologic response [irPR] score) was significantly associated with response early during the neoadjuvant period (composite score at week 2 on-treatment, P = .03; high irPR score at week 2 on-treatment, P = .01). A high irPR score at week 2 on-treatment was also found to be significantly associated with a lower chance of recurrence at this early neoadjuvant timepoint (P = .02). Other features associated with a lower likelihood of recurrence included increased hyalinized fibrosis (P = .015) and the presence of extensive lymphocyte density score (P = .01), tertiary lymphoid structures (P = .03), and plasma cells (P = .01). This study deepens our understanding of treatment response markers and their dynamic changes during neoadjuvant therapy. It underscores the significance of these features, particularly given their early emergence and strong associations with response and recurrence.

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.

Immune-Based Strategies for Pancreatic Cancer in the Adjuvant Setting

Pancreatic ductal adenocarcinoma (PDAC) is the third leading cause of cancer-related mortality in the United States, with poor overall survival across all stages. Less than 20% of patients are eligible for curative surgical resection at diagnosis, and despite adjuvant chemotherapy, most will experience disease recurrence within two years. The incorporation of immune-based strategies in the adjuvant setting remains an area of intense investigation with unrealized promise. It offers the potential of providing durable disease control for micro-metastatic disease following curative intent surgery and enabling personalized treatments based on mutational neoantigen profiles derived from resected specimens. However, most of these attempts have failed to demonstrate significant clinical success, likely due to the immunosuppressive tumor microenvironment (TME) and individual genetic heterogeneity. Despite these challenges, immune-based strategies, such as therapeutic vaccines targeted towards neoantigens, have demonstrated promise via immune activation and induction of T-cell tumor infiltration. In this review, we will highlight the foundational lessons learned from previous clinical trials of adjuvant immunotherapy, discussing the knowledge gained from analyses of trials with disappointing results. In addition, we will discuss how these data have been incorporated to design new agents and study concepts that are proving to be exciting in more recent trials, such as shared antigen vaccines and combination therapy with immune-checkpoint inhibitors and chemotherapy. This review will evaluate novel approaches in ongoing and future clinical studies and provide insight into how these immune-based strategies might evolve to address the unique challenges for treatment of PDAC in the adjuvant setting.

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.

SIAD onset in a patient affected by metastatic melanoma treated with immune checkpoint inhibitors: the role of nivolumab treatment

Malignant melanoma is a broad and heterogeneous class of malignant tumors derived from melanocytes and classified as cutaneous (skin), uveal, and mucosal melanoma. The incidence of melanoma has increased worldwide in recent decades. Surgery remains the mainstay of treatment, but a dramatic change in systemic treatment occurred when immune checkpoint inhibitors (ICIs) entered the therapeutic armamentarium for metastatic melanoma. Pembrolizumab and nivolumab, both anti-programmed death antibodies, demonstrated superiority over standard therapies with a 5-year survival rate. Toxicities resulting from ICIs have an autoimmune etiology and can affect any organ system. We then present a case of a patient with metastatic melanoma treated with an ICI strategy who developed endocrine toxicity such as the syndrome of inappropriate antidiuresis (SIAD). A previous case report concerning an anti-programmed death ligand 1 antibody suggests that this pathway may be involved in the development of SIAD.

Rosmarinic acid modulates purinergic signaling and induces apoptosis in melanoma cells

Cancer cases have increased worldwide. Cutaneous melanoma (CM), a highly metastatic skin cancer, largely contributes to global statistical cancer death data. Research has shown that rosmarinic acid (RA) is a promising phenolic compound with antineoplastic properties. Thus, we investigated the effects of RA on apoptosis-inducing in melanoma cells, purinergic signaling modulation, and cytokine levels. We treated SK-MEL-28 cells for 24 h with different concentrations of RA and assessed the apoptosis, CD39, CD73, and A2A expression, and cytokine levels. We found RA-induced apoptosis in melanoma cells. Regarding the purinergic system, we verified that RA downregulated the expression of CD73 and A2A, specially at high concentrations of treatment. Additionally, RA increased IL-6, IL-4, IL-10, IFN-γ, and TNF-α levels. Our in vitro results confirm RA's potential to be used to induce melanoma cell apoptosis, having CD73 and A2A as targets when reversion of immune suppression is desired. Further studies in animal models and clinical trials focusing on RA's modulation of purinergic signaling in melanoma are required.

Melanoma neoadjuvant treatment: review and update of recent trials

INTRODUCTION

Neoadjuvant immunotherapy is emerging as an effective approach for resectable stage III/IV melanoma, showing improvements in disease response and survival outcomes.

AREAS COVERED

This review summarizes findings from neoadjuvant treatment trials in melanoma patients. Using the PubMed search engine and including the keywords 'neoadjuvant,' 'immunotherapy,' and 'melanoma,' we selected 18 trials that showed efficacy in patients with melanoma, mainly testing checkpoint inhibitors alone or in combination. Across all trials examined, treatments showed objective disease responses, which frequently translated into improved disease-free survival.

EXPERT OPINION

Additional phase III studies comparing neoadjuvant and adjuvant therapies are needed to establish the optimal standard of care. The variety of regimens and dosing schedules investigated highlights the need for further research to determine the most appropriate treatments in this clinical setting. Advances in the study of biomarkers that can identify specific subgroups of patients will guide future research in this field.

Malignant Melanoma of the Foot in Five Elderly Patients: Clinicopathologic Features and Treatment Outcomes

Malignant melanoma, an aggressive neoplasm of melanocytes, remains a leading cause of skin cancer-related deaths globally, with rising incidence among elderly populations. Foot melanomas are often diagnosed at advanced stages due to delayed detection and misdiagnosis. They exhibit poorer outcomes compared to melanomas at other sites. This case series presents five elderly patients (ages 58-80) with malignant melanoma of the foot, detailing their clinicopathological features, treatment strategies, and outcomes. All cases presented with advanced disease, emphasizing the challenges of late diagnosis in this demographic. Histopathological evaluation confirmed nodular, superficial spreading, and acral lentiginous subtypes, with Breslow thicknesses ranging from 1.5 mm to 3.5 cm. Management involved wide local excision, lymph node dissection, and adjuvant chemotherapy in high-risk cases. Recurrence occurred in one patient, underscoring the aggressive nature of the disease. The series highlights the necessity of early detection, multidisciplinary care, and tailored adjuvant therapies to improve outcomes in elderly patients with foot melanoma.

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.

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.

Highly Efficient Bifunctional Peptides for Tumor Immunotherapy by Simultaneously Activating T Cells and Blocking PD-L1 Immune Checkpoint

Immune checkpoint inhibitors represented by PD-1/PD-L1 monoclonal antibodies have shown great success in tumor immunotherapy. However, the response rate of immune checkpoint blockade (ICB) therapy alone is far from satisfactory due to insufficient and exhausted tumor-infiltrating T cells. Meanwhile, antibody-based drugs have some drawbacks such as high cost and complicated preparation, which require further development of nonantibody immune checkpoint inhibitors and more rational strategies for improving the effectiveness of tumor treatment. Here, a highly efficient bifunctional peptide (Bi-pep) was constructed for tumor treatment by simultaneously activating T cells and blocking the PD-L1 immune checkpoint. This peptide not only can block the PD-1/PD-L1 immunosuppressive pathway but also directly and efficiently promote the activation and proliferation of T cells, thereby showing a significant effect on promoting T cell killing of tumor cells. The Bi-pep-induced antitumor effect was verified on both subcutaneous and orthotopic tumor models, which can significantly inhibit tumor growth and thus prolong the survival of tumor-bearing mice, holding great potential for biomedical applications.

Design considerations for randomized comparisons of neoadjuvant-adjuvant versus adjuvant-only cancer immunotherapy when tumor measurement schedules do not align (SWOG S1801)

BackgroundIn 2022, SWOG S1801 was the first trial to demonstrate that single-agent anti-PD-1 checkpoint inhibition used as neoadjuvant-adjuvant therapy leads to significantly improved outcomes compared to adjuvant-only therapy. Endpoints in trials comparing neoadjuvant-adjuvant to adjuvant strategies need special consideration to ensure that event measurement timing is appropriately accounted for in analyses to avoid biased comparisons artificially favoring one arm over another.MethodsThe S1801 trial is used a case study to evaluate the issues involved in selecting endpoints for trials comparing neoadjuvant-adjuvant versus adjuvant-only strategies.ResultsDefinitions and timing of measurement of events is provided. Trial scenarios when recurrence-free versus event-free survival should be used are provided.ConclusionsIn randomized trials comparing neoadjuvant-adjuvant to adjuvant-only strategies, event-free survival endpoints measured from randomization are required for unbiased comparison of the arms. The time at which events can be measured on each arm needs to be carefully considered. If measurement of events occurs at different times on the randomized arms, modified definitions of event-free survival must be used to avoid bias.

Molecular analysis of immune checkpoint inhibitor associated erythema nodosum-like toxicity

Purpose

Immune checkpoint inhibitors (ICIs) are increasingly used to treat advanced malignancy but can induce immune-related adverse events (irAE). The mechanisms behind these sporadic and sometimes life-threatening irAEs remain largely unexplored. Here, we present a case report and in-depth molecular analysis of an erythema nodosum (EN) like irAE occurring in a melanoma patient with isolated brain metastasis, aiming to explore the potential mechanism of this irAE.

Methods

We performed RNA and T cell receptor (TCR) sequencing on the patient's resected brain metastasis and biopsy of EN-like irAE. Single cell RNA/TCR sequencing was conducted on the patient's peripheral blood mononuclear cells (PBMC) at baseline, 3 weeks after ipilimumab and nivolumab combination therapy, during EN toxicity and after resolution.

Results

The site of EN-like irAE showed a distinct accumulation of pro-inflammatory immune cells, accompanied by the upregulation of inflammatory and interferon response signatures. In addition, clonal expansion and activation of irAE-associated CD8 T cells and upregulation of monocyte-specific interferon signatures occurred concurrently with irAE onset.

Conclusion

The unique immune landscape at the EN-like irAE could indicate that this irAE is distinct from anti-tumor immune and analogous non-ICI autoimmune milieus. Our data also suggests that systemic immune activation induced by ICI treatment, as reflected in PBMC, may help monitor the patient's treatment response and access irAE risk.

Estimating Long-Term Survivorship Rates Among Patients With Resected Stage III/IV Melanoma: Analyses From CheckMate 238 and European Organization for Research and Treatment of Cancer 18071 Trials

PURPOSE

Standard-of-care treatments for patients with resected stage III/IV melanoma include the immuno-oncology (IO) agents nivolumab (NIVO) and ipilimumab (IPI). This study used mixture cure models (MCMs) to estimate cure rates among patients treated with NIVO or IPI in the phase III CheckMate 238 (ClinicalTrials.gov identifier: NCT02388906) and European Organization for Research and Treatment of Cancer (EORTC) 18071 (ClinicalTrials.gov identifier: NCT00636168) trials, and to assess the impact of use of adjuvant immunotherapy on cure rates versus watchful waiting.

METHODS

MCMs were applied to patient-level recurrence-free survival data from CheckMate 238 and EORTC 18071. Cured patients were assumed to experience no disease recurrence and mortality risks similar to the general population. Uncured patients were at risk of disease recurrence and all-cause death. The survival trend of the cured patients was estimated using life expectancy data for a general population with the same baseline demographic characteristics. A regression model assessed the odds ratios (ORs) of cure across key subgroups on the basis of baseline characteristics of the study populations.

RESULTS

In CheckMate 238, estimated cure rates were 48.3% (95% CI, 41.8 to 54.9) with NIVO and 38.2% (95% CI, 32.7 to 44.1) with IPI. In EORTC 18071, estimated cure rates were 38.0% (95% CI, 32.1 to 44.2) with IPI and 29.2% (95% CI, 24.4 to 34.6) with placebo. In the indirect comparison of the two trials, the odds of cure were significantly higher with NIVO than with placebo (OR, 2.33 [95% CI, 1.49 to 3.65]).

CONCLUSION

Analyses involving two large phase III trials investigating adjuvant IO treatment for resected melanoma demonstrate higher cure rates for both NIVO and IPI than placebo, with NIVO providing the highest cure rate. Similar cure rates were estimated for patients treated with IPI in both trials, despite staging and dosing differences.

Relapse-free survival with adjuvant dabrafenib/trametinib therapy after relapse on a prior adjuvant CPI in BRAF V600-mutated stage III/IV melanoma

BACKGROUND

In BRAF-mutated high-risk melanoma, targeted therapy (BRAF/MEK inhibitors) and checkpoint inhibitor (CPI) immunotherapy have durable benefits as first-line (1L) adjuvant therapy. Based on differing action mechanisms of BRAF/MEK inhibitors and CPI immunotherapies, there is interest in evaluating the activity of 2L adjuvant targeted therapy in decreasing the risk of subsequent recurrence after repeat resection following relapse on/after 1L adjuvant CPI.

PATIENTS AND METHODS

This was a retrospective review of BRAF V600-mutated resected stage III/IV melanoma patients in the United States, Australia, and The Netherlands who received 1L adjuvant CPI immunotherapy, relapsed locoregionally/distantly, were again resected to no evidence of disease, and received dabrafenib/trametinib (dab/tram) as 2L adjuvant therapy. The primary endpoint was relapse-free survival (RFS) from initiation of 2L adjuvant dab/tram (RFS-2), analyzed via Kaplan-Meier methods.

RESULTS

Thirty-eight patients were included (median age 50 years, 63% male, 87% stage III, median follow-up 19 months from 2L dab/tram initiation). Median dab/tram duration was 10.1 months (range: 1 day-22.7 months), with half discontinuing due to progression or adverse events. Median (95% CI) RFS-2 was 18.9 (14.9-28.1) months, with 91%, 81%, and 58% remaining relapse-free at 6, 12, and 18 months, respectively. Most patients remained distant metastasis-free at 6, 12, and 18 months (97%, 85%, and 71%, respectively). Two patients were deceased at the last follow-up, with 97% alive at 18 months.

CONCLUSIONS

Over 80% of patients remained relapse- and metastasis-free at 12 months after 2L dab/tram initiation, with only 2 deaths observed. Dab/tram appears to have activity in the 2L adjuvant setting, although more follow-up is required.

Multicenter analysis of the surgical management and adjuvant therapy of patients with melanoma and a positive sentinel lymph node biopsy

INTRODUCTION

Complete lymph node dissection (CLND) was the standard practice for patients with melanoma and a positive sentinel lymph node biopsy (SLNB) until the results of 2 clinical trials published in 2016 and 2017 demonstrated that it did not improve melanoma-specific survival (MSS). However, it continues to be performed in some scenarios. No studies have ever been published on lymph node management after a positive SLNB in the routine clinical practice in our setting.

OBJECTIVES

To determine the evolution of the indication for CLND in patients with a positive SLNB, as well as the characteristics associated with its performance.

MATERIAL AND METHODS

We conducted a multicenter retrospective observational study with patients with skin melanoma and positive sentinel lymph nodes diagnosed from 2017 through 2022 at 8 Spanish centers and 1 Italian center.

RESULTS

A total of 430 patients were included, 54% men, with 358 (75.1%) aged between 45 and 80 years. A total of 133 cases (31%) exhibited Breslow thickness > 4mm, 206 cases (49.1%) were ulcerated, and in 213 cases (55.7%), lymph node metastasis was > 1mm. Isolated lymphadenectomy or followed by adjuvant therapy was performed in 146 patients (34.1%). After multivariate logistic regression, the factors associated with the performance of CLND were the acral lentiginous melanoma histological subtype, lymph node metastasis size > 1mm, extracapsular spread, and the participant hospital. Age > 80 years was inversely associated.

CONCLUSION

While the frequency of CLND in patients with melanoma and positive SLNB has decreased, the indication for systemic adjuvant therapy in these patients has increased. However, CLND is still indicated in patients with high-risk characteristics.

Real-World Evidence of Adjuvant Immunotherapy in Resected Stage III and IV Melanoma Patients: CADIM Trial Final Results. Experience from 2 Tertiary Referral Centers

INTRODUCTION

Clinical trials have validated the use of nivolumab and pembrolizumab as adjuvant therapies regarding relapse-free survival in patients with resected stage III and IV melanoma. Evidence in real-world patients is currently limited.

MATERIAL AND METHOD

The CADIM trial (Characterization of adjuvant immunotherapy in melanoma patients) recruited a total of 81 patients with resected stage III and IV melanoma on nivolumab or pembrolizumab as adjuvant therapy from February 2018 through December 2022.

RESULTS

The stage distribution rate was 81.5% (n=71) for stage III, while 15 patients (18.5%) had resected stage IV. Among stage III patients, 38 were stage IIIC (46.9%). With a median follow-up of 22.8 months, the relapse-free survival in the intention-to-treat population was 84% at one year and 81.5% at 2 years. The overall survival rate was 99% at one year and 91.4% at 2 years. Grade 3-4 treatment-related adverse events were reported in 12.3% of the patients.

CONCLUSIONS

This study shows the results of resected stage III and IV melanoma patients on adjuvant therapy with anti-PD-1, and eventually confirmed the safety and efficacy profile described by clinical trials. Comparing clinical trial data with real-world evidence is necessary for a more practical, reliable, and accessible use of these drugs.

Survival Outcomes in Patients Undergoing Pelvic Exenteration for Pelvic Mucosal Melanomas: Retrospective Single Institution Australian Study

BACKGROUND

Pelvic mucosal melanomas, including anorectal and urogenital melanomas, are rare and aggressive, with a median overall survival of up to 20 months. Pelvic mucosal melanomas behave differently from their cutaneous counterparts and present late with locoregional disease, making pelvic exenteration its only curative surgical option.

OBJECTIVE

This study aimed to evaluate the survival outcomes after pelvic exenteration in pelvic mucosal melanomas at Royal Prince Alfred Hospital.

DESIGN

Retrospective case series from a prospectively collected pelvic exenteration database from October 1994 to November 2023.

SETTING

Royal Prince Alfred Hospital (quaternary institution), Camperdown, New South Wales, Australia.

PATIENTS

Seven patients undergoing pelvic exenteration for pelvic mucosal melanoma.

MAIN OUTCOME MEASURES

Overall survival, disease-free survival, and complication rates.

RESULTS

Of the 7 patients, most were women (n = 5; 71.4%) and had a median age of 65 years (range, 36-79). Five patients (71.4%) underwent pelvic exenteration for primary pelvic mucosal melanoma, 3 of which were anorectal and 2 vaginal melanomas. Two patients (28.6%) had recurrent anorectal melanoma and received neoadjuvant radiotherapy after an initial wide local excision. Three patients (42.9%) required total pelvic exenteration, whereas 2 required a central pelvic exenteration (28.6%). The remaining procedures included central and lateral pelvic exenteration and anterior, central, and lateral pelvic exenteration. The median length of hospital stay was 19.7 days. Five patients had postoperative complications with 1 major complication (Clavien-Dindo grade IIIa). At the completion of the study, there were 4 mortalities. Mean survival was 23.6 months (range, 2-100) with a recurrence rate of 83%. The median time to recurrence was 3 months, despite 6 patients (85.7%) having R0 resections. Distant recurrence, specifically to bone, the lungs, and the liver, was most common.

LIMITATIONS

Small study cohort due to rarity of disease, limiting generalizability.

CONCLUSIONS

Pelvic exenteration for pelvic mucosal melanoma appears to help control local disease as recurrence is most commonly distant or regional. See Video Abstract .

RESULTADOS DE SUPERVIVENCIA EN PACIENTES SOMETIDOS A EXENTERACIN PLVICA POR MELANOMAS DE LA MUCOSA PLVICA ESTUDIO RETROSPECTIVO AUSTRALIANO DE UNA SOLA INSTITUCIN

ANTECEDENTES:Los melanomas de la mucosa pélvica (MM), incluidos los melanomas anorrectales y urogenitales, son raros y agresivos, con una supervivencia global media de hasta 20 meses. Los melanomas de la mucosa pélvica se comportan de manera diferente a sus contrapartes cutáneas y se presentan tardíamente con enfermedad locoregional, lo que hace que la exenteración pélvica (EP) sea su única opción quirúrgica curativa.OBJETIVO:Este estudio tuvo como objetivo evaluar los resultados de supervivencia tras la exenteración pélvica en melanomas de la mucosa pélvica en el Royal Prince Alfred Hospital.DISEÑO:Serie de casos retrospectivos de una base de datos de exenteración pélvica recopilada prospectivamente desde octubre de 1994 hasta noviembre de 2023.ESCENARIO:Royal Prince Alfred Hospital (institución cuaternaria), Camperdown, Nueva Gales del Sur, Australia.PACIENTES:Siete pacientes sometidos a exenteración pélvica por melanoma de la mucosa pélvica.PRINCIPALES MEDIDAS DE RESULTADOS:Supervivencia general, supervivencia libre de enfermedad y tasas de complicaciones.RESULTADOS:De los siete pacientes, la mayoría fueron mujeres (n = 5, 71,4%) y tenían una edad media de 65 años (rango 36-79). Cinco pacientes (71,4%) fueron sometidos a una exenteración pélvica por melanoma primario de la mucosa pélvica; tres de los cuales eran melanomas anorrectales y dos vaginales. Dos pacientes (28,6%) tuvieron melanoma anorrectal recurrente y recibieron radioterapia neoadyuvante después de una escisión local amplia inicial.Tres pacientes (42,9%) requirieron una exenteración pélvica total, mientras que dos requirieron una exenteración pélvica central (28,6%). Los procedimientos restantes fueron una exenteración pélvica central y lateral; junto con una exenteración pélvica anterior, central y lateral. La duración media de la estancia hospitalaria fue de 19,7 días. Cinco pacientes tuvieron complicaciones postoperatorias con una complicación mayor (Clavien-Dindo IIIa). Al finalizar el estudio, hubo cuatro muertes. La supervivencia media fue de 23,6 meses (rango 2-100) con una tasa de recurrencia del 83%. El tiempo medio hasta la recurrencia fue de tres meses, a pesar de que seis pacientes (85,7%) tuvieron resecciones R0. La recurrencia distante, es decir, en hueso, pulmón e hígado fueron la más comúnes.LIMITACIONES:Cohorte de estudio pequeña debido a la rareza de la enfermedad, lo que limita la generalización.CONCLUSIÓN:La exenteración pélvica para el melanoma de la mucosa pélvica parece ayudar a controlar la enfermedad local, ya que la recurrencia es más comúnmente distante o regional. (Traducción-Dr Osvaldo Gauto ).