Overall Survival with Combined Nivolumab and Ipilimumab in Advanced Melanoma

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.

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.

Durable responses upon short-term addition of targeted therapy to anti-PD1 in advanced melanoma patients: 5-year progression-free and overall survival update of the IMPemBra trial

BACKGROUND

The addition of targeted therapy (TT) to immune checkpoint inhibitors has been shown to transiently increase immune infiltration in melanoma. This formed the rationale for the IMPemBra trial, which showed a numerical increase in progression-free survival (PFS) in patients treated with short-term/intermittent TT and anti-PD1 compared to anti-PD1 alone. In this report, the final toxicity-analysis, 5-year PFS and exploratory analysis of overall survival (OS) will be reported, together with an analysis of subsequent therapies.

PATIENTS AND METHODS

32 treatment-naïve patients with a BRAFV600E/K-mutated advanced melanoma were treated with 2 cycles of pembrolizumab 200 mg every 3 weeks, followed by randomization to continue pembrolizumab monotherapy for six weeks in cohort-1 versus pembrolizumab plus intermittent dabrafenib 150 mg BID + trametinib 2 mg QD 2×1-week (cohort 2), 2×2-weeks (cohort 3), or 1×6-weeks (cohort 4). After week 12, all patients continued pembrolizumab monotherapy for a maximum of 2 years.

RESULTS

With a median follow-up of 73 months, final grade 3-4 immune-related adverse events are 12 % (cohort 1), 12 % (cohort 2), 38 % (cohort 3) and 63 % (cohort 4). Estimated 5-year PFS and OS rates were 25 % and 50 % for pembrolizumab monotherapy (cohort-1) and 46 % and 71 % for pembrolizumab + intermittent TT (cohorts 2-4). Estimated 5-year PFS and OS were 63 % and 63 % (cohort 2), 38 % and 75 % (cohort 3), and 38 % and 75 % (cohort 4), respectively. The subsequent therapies were balanced between cohorts. Patients treated with short-term/intermittent schemes achieved durable responses upon subsequent TT again.

CONCLUSION

This survival update from the IMPemBra trial demonstrates that combination of short-term TT and checkpoint inhibition can induce long-lasting responses, warranting further analyses in larger cohorts, and in a randomized design.

Advances in nanoplatform-based multimodal combination therapy activating STING pathway for enhanced anti-tumor immunotherapy

Activation of the cyclic GMP-AMP synthase(cGAS)-stimulator of interferon genes (STING) has great potential to promote antitumor immunity. As a major effector of the cell to sense and respond to the aberrant presence of cytoplasmic double-stranded DNA (dsDNA), inducing the expression and secretion of type I interferons (IFN) and STING, cGAS-STING signaling pathway establishes an effective natural immune response, which is one of the fundamental mechanisms of host defense in organisms. In addition to the release of heterologous DNA due to pathogen invasion and replication, mitochondrial damage and massive cell death can also cause abnormal leakage of the body's own dsDNA, which is then recognized by the DNA receptor cGAS and activates the cGAS-STING signaling pathway. However, small molecule STING agonists suffer from rapid excretion, low bioavailability, non-specificity and adverse effects, which limits their therapeutic efficacy and in vivo application. Various types of nano-delivery systems, on the other hand, make use of the different unique structures and surface modifications of nanoparticles to circumvent the defects of small molecule STING agonists such as fast metabolism and low bioavailability. Also, the nanoparticles are precisely directed to the focal site, with their own appropriate particle size combined with the characteristics of passive or active targeting. Herein, combined with the cGAS-STING pathway to activate the immune system and kill tumor tissues directly or indirectly, which help maximize the use of the functions of chemotherapy, photothermal therapy(PTT), chemodynamic therapy(CDT), and radiotherapy(RT). In this review, we will discuss the mechanism of action of the cGAS-STING pathway and introduce nanoparticle-mediated tumor combination therapy based on the STING pathway. Collectively, the effective multimodal nanoplatform, which can activate cGAS-STING pathway for enhanced anti-tumor immunotherapy, has promising avenue clinical applications for cancer treatment.

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.

A Bayesian Hierarchical Mixture Cure Modelling Framework to Utilize Multiple Survival Datasets for Long-Term Survivorship Estimates: A Case Study From Previously Untreated Metastatic Melanoma

Time to an event of interest over a lifetime is a central measure of the clinical benefit of an intervention used in a health technology assessment (HTA). Within the same trial, multiple end-points may also be considered. For example, overall and progression-free survival time for different drugs in oncology studies. A common challenge is when an intervention is only effective for some proportion of the population who are not clinically identifiable. Therefore, latent group membership as well as separate survival models for identified groups need to be estimated. However, follow-up in trials may be relatively short leading to substantial censoring. We present a general Bayesian hierarchical framework that can handle this complexity by exploiting the similarity of cure fractions between end-points; accounting for the correlation between them and improving the extrapolation beyond the observed data. Assuming exchangeability between cure fractions facilitates the borrowing of information between end-points. We undertake a comprehensive simulation study to evaluate the model performance under different scenarios. We also show the benefits of using our approach with a motivating example, the CheckMate 067 phase 3 trial consisting of patients with metastatic melanoma treated with first line therapy.

Connecting the Dots: Practical Strategies for Academic and Community Oncology Synergy to Advance Multidisciplinary Management in Immunotherapy Toxicity Care

Immunotherapy has significantly affected cancer treatment and survival rates, accompanied by an increase in immune-related adverse events (irAEs) requiring new management strategies. irAEs can affect various organ systems and have varying severity levels, with higher rates observed when combining immune checkpoint inhibitors. National organizations such as ASCO, the National Comprehensive Cancer Network, the Society for Immunotherapy of Cancer, and the European Society for Medical Oncology have created guidelines for managing irAEs. This chapter expands on these guidelines by discussing practical strategies to improve the multidisciplinary management in irAE care, focusing on the who, what, and how to bridge gaps in care and enhance collaboration between academic and community oncology practices. Effective irAE management involves early recognition and guideline-adherent approaches using a multidisciplinary team, including oncologists, other subspecialists, primary care clinicians, and all care team members. Institutions are developing methods to integrate irAE care into clinical workflows, such as incorporating urgent care clinics and e-consults for efficient irAE management and developing hub-and-spoke models to extend specialized care from academic centers to community hospitals for equitable care delivery. Additionally, effective patient education is critical for improving irAE recognition and health literacy. The new ASCO Community of Practice called the Alliance for Support and Prevention of Immune-Related Adverse Events consortium and patient advocacy group Standing Together to Optimize Research, Interventions, and Education in irAEs initiatives aim to advance irAE clinical care, research, and education through global collaboration, standardized data collection, and improved outreach to patients and caregivers.

Clinical Management and Outcomes of Immune-Related Adverse Events During Treatment with Immune Checkpoint Inhibitor Therapies in Melanoma and Renal Cell Carcinoma: A UK Real-World Evidence Study

INTRODUCTION

Immune checkpoint inhibitor (ICI) therapy, although effective in treating patients with a variety of advanced malignancies, can result in potentially severe or even fatal immune-related adverse events (irAEs). This study aimed to generate real-world evidence on irAE characteristics, clinical management and clinical outcomes among patients with advanced (unresectable or metastatic) malignant melanoma (a/mMM) or advanced renal cell carcinoma (aRCC) treated with nivolumab (NIVO) and/or ipilimumab (IPI) in the UK.

METHODS

This was a multi-centre, retrospective cohort study of adult patients with a/mMM or aRCC, who received NIVO and/or IPI at one of five specialist treatment centres in the UK between 1 January 2016 and 31 March 2020. The incidence and grading of irAEs were described, as well as time to irAE onset, the management of irAEs and overall survival (OS).

RESULTS

In total, 199 patients were included in the study: 162 with a/mMM and 37 with aRCC. The majority of patients in both a/mMM (75.3%) and aRCC (62.2%) cohorts reported any irAE, while 45.9% and 30.4% in the a/mMM and aRCC cohorts reported grade 3 or 4 irAEs, respectively. Colitis/diarrhoea, skin reactions and hepatitis were most frequently reported, and the predominant treatment prescribed for any irAE was corticosteroids only. Analysis indicated a positive association between the development of an irAE and longer OS.

CONCLUSIONS

Findings from this study support current literature, provide further insights into the characteristics and clinical management of irAEs and support an association between the development of an irAE and improved OS in these patient groups.

Unmasking the Rare but Lethal Cardiac Complications of Immune Checkpoint Inhibitor Therapy: A Review of Mechanisms, Risk Factors, and Management Strategies

OPINION STATEMENT

Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment by enabling the immune system to effectively target and destroy cancer cells. While ICIs offer significant survival benefits across various malignancies, their use is associated with a unique profile of immune-related adverse events, including potentially fatal cardiovascular toxicities. Recent studies have highlighted various cardiac complications associated with ICIs, such as myocarditis, arrhythmias, heart failure, pericarditis, atherosclerosis, and hypertension. These complications arise from mechanisms involving T-cell activation and cytokine release. Patient-related factors such as pre-existing cardiovascular disease, diabetes mellitus, age, gender, and genetic predisposition, along with treatment-related factors like specific ICI regimens, contribute to these toxicities. To manage these complications effectively, comprehensive cardiovascular risk assessment and monitoring before, during, and after ICI therapy are crucial. Adhering to guidelines from the European Society of Cardiology (ESC) and other international organizations allows for early recognition of cardiovascular toxicities and tailored interventions. This review emphasizes the importance of cardioprotective measures, regular monitoring, and multidisciplinary collaboration between oncologists and cardiologists to mitigate cardiovascular risk and optimize patient outcomes. Ongoing research is essential to better understand the mechanisms of ICI-induced cardiovascular toxicities and to develop effective management strategies for affected patients. As we continue to expand the use of ICIs in oncology, balancing oncologic efficacy with cardiovascular safety remains critical.

Acceptability of an Electronic Patient-Reported Outcomes-Based Model of Care to Monitor Symptoms Related to Cancer Treatment with Immune Checkpoint Inhibitors: Results from the IePRO Randomized Controlled Trial

OBJECTIVES

This study analyzed the acceptability of an electronic patient-reported outcomes measures-based model of care (IePRO MoC) and the usability of its complementary ePROM mobile app to monitor and manage symptoms related to immune checkpoint inhibitors. In this MoC, symptoms reported by patients treated at an outpatient clinic were reviewed by oncology triage nurses who provided symptom management interventions by telephone.

METHODS

As part of a larger intervention trial (ClinicalTrials.gov.NCT05530187) we conducted an abductive, semantic thematic analysis through semistructured interviews of patients participating in the intervention arm. Acceptability was deduced from Sekhon et al's (2017) Theoretical Framework of Acceptability completed with inductively generated themes. Usability analysis was guided by the mHealth App Usability Questionnaire's domains by Zhoul et al (2019).

RESULTS

A total of 17 interviews were performed. The IePRO MoC was reported to be an acceptable intervention. Patients expressed feeling safe and empowered due to continuous monitoring and timely support from nurses. Personalized support motivated patients to use the MoC throughout treatment. Some questioned the predefined response options of the app, and the standardized approach regarding notifications and monitoring requirements. Despite high app usability, some expressed discomfort from being frequently reminded of their illness and being confronted with questions about their sexuality and other intimate themes.

CONCLUSIONS

The feedback loop between patients and nurses facilitated the acceptability of the IePRO MoC. The app's usability further facilitated adherence to the MoC. A more personalized approach regarding the frequency of assessments and the way symptoms are conveyed is recommended to decrease discomfort and support the implementation of similar MoCs in the future.

Multicenter phase Ib/II study of second-line durvalumab and tremelimumab in combination with paclitaxel in patients with biomarker-selected metastatic gastric cancer

BACKGROUND

This multicenter phase Ib/II trial aimed to evaluate the safety and efficacy of combining durvalumab, tremelimumab, and paclitaxel as second-line treatment for biomarker-selected patients with metastatic gastric cancer.

METHODS

In phase Ib, the standard 3 + 3 dose escalation method was used. Durvalumab and tremelimumab were administered every 4 weeks for 13 and 4 cycles, respectively, combining paclitaxel 80 mg/m2 (dose level 2) or 60 mg/m2 (dose level 1) on days 1, 8, and 15. The primary outcome for phase II was the objective response rate (ORR).

RESULTS

In phase Ib (n = 7), dose level-1 was selected as the recommended phase II dose. In phase II, 48 patients were enrolled: microsatellite instability-high or deficient mismatch repair protein tumors (n = 16); EBV-positive tumors (n = 15); high tumor mutation burden ( ≥ 5/Mb) (n = 11); CD274 amplification (n = 5); and POLD1 mutation (n = 1). The ORR was 52.1%, meeting the primary endpoint. The median progression-free survival and overall survival were 5.3 and 13.1 months, respectively. The most common any-grade and grade 3-4 adverse events were anemia (41.7%) and neutropenia (10.4%), respectively.

CONCLUSIONS

Durvalumab-tremelimumab with paclitaxel was tolerable and efficacious in biomarker-selected gastric cancer patients as a second-line treatment, highlighting the importance of biomarker-based approaches for immunotherapy in gastric cancer.

CLINICAL TRIAL REGISTRATION

NCT03751761.

Immune checkpoint inhibitor (ICI) therapy in central nervous system cancers: State-of-the-art and future outlook

Invasive central nervous system (CNS) cancers are an area where the development of breakthrough therapies is urgently needed. For instance, conditions such as glioblastoma multiforme (GBM) are associated with poor clinical prognosis, with the majority of trials offering no improvement to marginally enhanced survival. Unleashing the potential of targeting the immune system in CNS cancers has gained attention in recent years. Inhibition of immune checkpoints such as CTLA-4, PD-1/PD-L1, TIM-3, and LAG-3 has been attempted in recent trials. While potentially offering a notable edge over other immunotherapies, multi-organ adverse events have been found with the administration of immune checkpoint inhibitors (ICIs). The present review captures the state-of-the-art evidence on ICI treatments in different CNS cancers. Also, we discuss the value of combinational therapies involving ICIs as well as next-generation therapeutics such as bispecific antibodies targeting PD-1/LAG-3/TIM-3 and CRISPR-Cas9-edited PD-1-knock-out checkpoint-resistant CAR T-cells.

The efficacy and safety of first-line metastatic melanoma treatment with ipilimumab + nivolumab vs. nivolumab in a real-world setting

BACKGROUND

The Checkmate 067 randomized controlled trial, published in 2015, demonstrated improved progression-free survival (PFS) and numerically, although not statistically, superior overall survival (OS) for ipilimumab + nivolumab (I + N).

OBJECTIVES

The objective of this study was to compare the efficacy and safety of N with I + N as first-line treatment for metastatic melanoma in a real-world setting.

METHODS

Patients were prospectively included in the French MelBase cohort from 2013 to 2022. Eligible patients were those in first-line treatment for stage IIIc or IV melanoma, undergoing immunotherapy with N or I + N. The primary endpoint was OS at 36 months. The secondary endpoints included PFS at 36 months, best radiological response, and safety analyses. We conducted a propensity score using the inverse probability of treatment weighting (IPTW) method to overcome the various confounding factors and also a subgroup analysis (brain metastasis, lactate dehydrogenase levels and BRAF mutation status).

RESULTS

Patients were treated with N (n = 406) or I + N (n = 416). OS at 36 months was higher in the I + N group at 57.1% [95% confidence interval (CI) 50.7-64.2] than in the N group [46.6% (95% CI 41.6-52.1)]; hazard ratio (HR) 1.4 (95% CI 1.1-1.8). PFS at 36 months was significantly improved in the I + N group (42.3%) compared with the N group (21.9%), with a HR of 1.6 (95% CI 1.4-1.9). The objective response rate (ORR) was similar for the two groups (44%). The overall incidence of side-effects was comparable (82% vs. 84%), and severe toxicity (grade ≥ 3) was more frequent, although not significantly so, in the I + N arm vs. the N arm (41% vs. 29%).

CONCLUSIONS

Our results are consistent with those from the Checkmate 067 study, except for the ORR and the incidence of toxicities, which proved to be lower in our analysis.

Immune Checkpoint Inhibitors and Immunosuppressive Tumor Microenvironment: Current Challenges and Strategies to Overcome Resistance

Immune checkpoint inhibitors (ICIs) are shown to improve cancer treatment effectiveness by boosting the immune system of the patient. Nevertheless, the unique and highly suppressive TME poses a significant challenge, causing heterogeneity of response or resistance in a considerable number of patients. This review focuses on the evasive attributes of the TME. Immune evasion mechanism in TME include immunosuppressive cells, cytokine and chemokine signaling, metabolic alterations and overexpression of immune checkpoint molecules such as PD-1, CTLA-4, LAG-3, TIM-3, TIGIT, BTLA and their interactions within the TME. In addition, this review focuses on the overcoming resistance by targeting immunosuppressive cells, normalizing tumor blood vessels, blocking two or three checkpoints simultaneously, combining vaccines, oncolytic viruses and metabolic inhibitors with ICIs or other therapies. This review also focuses on the necessity of finding predictive markers for the stratification of patients and to check response of ICIs treatment. It remains to be made certain by new research and intelligent innovations how these discoveries of the TME and its interplay facilitate ICI treatment and change the face of cancer treatment.

Impact of assessment-to-treatment interval and metastatic biopsy site on the predictive value of PD-L1 expression at the 1 % cut-off level in melanoma

BACKGROUND

Intratumoral PD-L1 expression at the 1 % cut-off predicts clinical outcomes and may guide first-line immune checkpoint inhibitor (ICI) selection for metastatic melanoma (MM). However, the impact of the interval between PD-L1 assessment and ICI initiation and the metastatic site used for PD-L1 evaluation, remains unclear.

METHODS

In this nationwide cohort study we used the Danish Metastatic Melanoma Database (DAMMED) and the Danish Pathology Registry to analyze patients with MM treated with anti-PD-1 or anti-PD-1 plus anti-CTLA-4 from January 2017 to February 2024. Progression-free survival (PFS) and overall survival (OS) were analyzed using Log-rank tests and Cox regression.

RESULTS

Data from 1137 patients were analyzed. Among patients with PD-L1 assessed within 90 days of treatment (n = 964; 55.2 % PD-L1 <1 %, 44.8 % PD-L1 ≥1 %), combination therapy improved outcomes in PD-L1 < 1 % (PFS adjusted (a)HR 0.62; 95 % CI 0.48-0.80; p < 0.001, OS aHR 0.64; 95 % CI 0.48-0.85; p = 0.002), while outcomes were comparable for PD-L1 ≥ 1 % patients (PFS aHR 0.90; 95 % CI 0.62-1.30; p = 0.57, OS aHR 0.97; 95 % CI 0.60-1.57; p = 0.89). For PD-L1 assessed > 90 days prior (n = 173), this pattern was less pronounced. Among 48 paired PD-L1 assessments from the same organ, discordance occurred in 25 %. Combination therapy improved PFS for patients with PD-L1 < 1 % skin/subcutaneous (aHR 0.51; 95 % CI 0.34-0.76; p < 0.001) and visceral metastases (aHR 0.65; 95 % CI 0.42-1.02; p = 0.060) while this association was not evident for lymph node metastases (aHR 0.79; 95 % CI 0.48-1.29; p = 0.35).

CONCLUSIONS

PD-L1 seems a reliable predictive biomarker in MM, when assessed on tissue obtained within 90 days prior to ICI initiation. Non-nodal metastatic sites appear preferable.

Tyrosinase in melanoma inhibits anti-tumor activity of PD-1 deficient T cells

BACKGROUND

Melanoma is one of the most commonly diagnosed malignancies and serves as a model for studying immunotherapy. The B16 melanoma model, resembling human cold tumors that lack T cell infiltration and show minimal response to PD-1 blockade, is widely used for studying melanoma and its resistance to immunotherapy. Therefore, understanding the molecular basis that prevents T cell-mediated anti-tumor activity in B16 melanoma is of great significance.

RESULTS

In this study, we generated tyrosinase knockout B16 melanoma cells using CRISPR/Cas9 and discovered that tyrosinase in melanoma significantly inhibits the anti-tumor activity of T cells. Tyrosinase deficiency leads to a 3.80-fold increase in T-cell infiltration and enhances T-cell activation within the tumor. Single-cell RNA sequencing reveals an altered cold tumor immunophenotype in tyrosinase-deficient B16 melanoma. In wild-type mice, T cells in tyrosinase-deficient tumors express elevated levels of PD-1 and Foxp3. However, strikingly, in PD-1 deficient mice, the loss of tyrosinase in B16 melanoma unleashes the anti-tumor activity of PD-1 deficient T cells. This enhanced anti-tumor activity is explained by significantly increased tumor T cell infiltration accompanied by reduced frequencies of regulatory T cells in PD-1 knockout mice.

CONCLUSIONS

These findings suggest that targeting tyrosinase could convert cold tumors into an immune-responsive state in vivo using murine models. Inhibiting tyrosinase could enhance the effectiveness of PD-1 blockade, offering a new approach for melanoma patients who fail in current PD-1 inhibitor treatment.

Associations between immune checkpoint inhibitor response, immune-related adverse events, and steroid use in RADIOHEAD: a prospective pan-tumor cohort study

BACKGROUND

Immune checkpoint inhibitors (ICIs) have led to enduring responses in subsets of patients with cancer. However, these responses carry the risk of immune-related adverse events (irAEs), which can diminish the overall benefit of ICI treatment. While associations between irAE development and overall survival have been increasingly documented, there is a need for further understanding of these connections in large prospective real-world cohorts.

METHODS

The Resistance Drivers for Immuno-Oncology Patients Interrogated by Harmonized Molecular Datasets (RADIOHEAD) study, a pan-tumor, prospective cohort of 1,070 individuals undergoing standard of care first-line ICI treatment, aims to identify factors driving irAEs and clinical response. Clinical data and longitudinal blood samples were collected prospectively at multiple time points from 49 community-based oncology clinics across the USA. Structured, harmonized clinical data underwent unbiased statistical analysis to uncover predictors of real-world overall survival (rwOS) and risk factors for irAEs.

RESULTS

Across 1,070 participants' treatment courses, RADIOHEAD accumulated over 4,500 clinical data points. Patients experiencing any irAE (25.4%, n=272) exhibited significantly improved rwOS in the pan-tumor cohort (n=1,028, HR=0.41, 95% CI=(0.31, 0.55)). This association persisted when adjusting for age and metastatic disease in multivariate time-dependent Cox proportional hazard analysis, and was consistent across major tumor subtypes, including lung cancer and melanoma. Skin and endocrine irAEs of any grade were strongly associated with improved rwOS (Cox proportional hazard analysis, skin, p=2.03e-05; endocrine, p=0.0006). In this real-world cohort, the irAE rate appeared lower than those reported in clinical trials. Patients receiving corticosteroids prior to initiation of ICI treatment had significantly worse survival outcomes than non-users (HR 1.37, p=0.0054), with a stronger association with systemic steroid use (HR 1.75, p=0.0022). The risk of irAE was increased by exposure to combination immunotherapy relative to monotherapy (OR 4.17, p=2.8e-7), zoster vaccine (OR 2.4, p=5.2e-05), and decreased by prior chemotherapy (OR 1.69, p=0.0005).

CONCLUSION

The RADIOHEAD cohort is a well-powered, real-world cohort that clearly demonstrates the association between irAE development with improved response and baseline steroid use with worse response to ICI treatment after adjustment for survival bias.

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.

Management of immune-related myocarditis, myositis and myasthenia gravis (MMM) overlap syndrome: a single institution case series and literature review

Background

Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of various malignancies, particularly melanoma. However, immune-related adverse events (irAEs) pose significant challenges, particularly in cases of severe toxicity syndromes. One such life-threatening irAE is the myocarditis, myositis, and myasthenia gravis (MMM) overlap syndrome, which occurs in less than 1% of patients but has in-hospital mortality rates ranging from 40 to 60%. Due to its rarity and complexity, early recognition and a multidisciplinary approach are critical to improving outcomes.

Methods

We present a single-institution case series of four patients diagnosed with MMM overlap syndrome following ICI therapy. Clinical presentation, laboratory findings, imaging, and electrophysiological tests were analyzed to confirm the diagnosis. Therapeutic interventions-including corticosteroids, intravenous immunoglobulins (IVIG), plasma exchange (PLEX), tocilizumab, and rituximab- were evaluated in terms of efficacy and clinical outcomes.

Results

The onset of MMM syndrome varied from 2 to 4 weeks after initiating ICI therapy. Patients presented with rapidly progressive symptoms, including ptosis, bulbar dysfunction, respiratory distress, myopathy, and cardiac conduction abnormalities. Immunosuppressive therapy with high-dose corticosteroids was initiated in all cases. Additional immunomodulatory treatments (IVIG, tocilizumab, PLEX, and rituximab) were administered based on clinical deterioration and autoimmune profile. Two patients achieved complete recovery, one remains on maintenance immunosuppression, and one died due to respiratory failure despite aggressive treatment.

Conclusion

MMM overlap syndrome is a severe and often fatal irAE associated with ICI therapy. Early identification, aggressive immunosuppressive treatment, and individualized therapeutic strategies are essential to optimize patient outcomes. Further research is needed to refine diagnostic criteria, identify predictive biomarkers, and establish standardized treatment protocols.

Mechanism of selenium-doped black phosphorus nanosheets wrapped with biomimetic tumor cell membrane for prostate cancer immunotherapy

Prostate cancer (PCa) is commonly considered a "cold tumor" due to its immunosuppressive microenvironment. Cold tumors are typically identified by the absence of T-cell infiltration within the tumor, while other immune populations and myeloid cells can be observed in these tumors. To achieve light-heat combined immunotherapy checkpoint inhibitor treatment for castration-resistant prostate cancer, we aimed to transforming "cold tumors" into "hot tumors". We designed and synthesized a two-dimensional material, selenium-doped black phosphorus (BP), to enhance the photothermal conversion efficiency, and formed Se@BPNSs by liquid-phase exfoliation. To address the issue of enhanced permeability and retention effect, and to achieve efficient targeting, we coated the Se@BPNSs with RM-1 cell membrane derived from mouse prostate cancer cells. By injecting a certain dose of Se@BPNSs into the tumor and irradiating with a 808 nm laser, the Se@BPNSs converted light energy into heat to kill tumor cells at high temperatures while releasing antigens captured by dendritic cells. In addition, we combined the immunotherapy checkpoint inhibitor anti-PD1 to enhance the immune response and promote immune cell infiltration. The successful preparation of Se@BPNSs was verified through material characterization, cell-level and animal-level experiments, and the antitumor effect was meanwhile verified, which further provided guidance for prostate cancer treatment by photothermal synergistic immunotherapy.

CD200R blockade enhances anti-tumor immunity by unleashing NK and CD8+ T cells in tumor

Immune checkpoint inhibitors have revolutionized cancer therapy, but a large proportion of patients do not respond well to current checkpoint immunotherapies. CD200R (also known as OX2R) is a transmembrane glycoprotein of the immunoglobulin superfamily that is mainly expressed on myeloid and lymphoid-derived immunocompetent cells such as myeloid cells, natural killer (NK), and CD8+ T cells. In this study, we investigated the therapeutic potential and cellular mechanisms of targeting CD200R in tumor immunotherapy. We established 4 subcutaneous tumor mouse models using MC38 (colon cancer), MCA205 (fibrosarcoma), LLC (lung cancer), and EO771 (mammary cancer) cell lines. We found that CD200R was highly expressed on tumor-infiltrating NK and CD8+ T cells with exhausted phenotypes in the four subcutaneous tumor mouse models. Either genetic ablation or antibody blockade of CD200R retarded tumor growth and prolonged the survival of tumor-bearing mice by preventing or reversing exhaustion of both NK cells and CD8+ T cells. The combined therapy of CD200R antibody with anti-PD-1/anti-PD-L1 synergistically inhibited tumor growth. By depletion of NK or/and CD8+ T cells, we demonstrated that both cell types contributed to the anti-tumor efficacy of CD200R blockade in tumor-bearing mice. Further, the blockade of human CD200R significantly enhanced human NK cell function and inhibited human tumor growth in PBMC-reconstituted xenograft mice. Our results demonstrate that CD200R is a potential immune checkpoint molecule that can suppress the tumoricidal activities of NK and CD8+ T cells, and could thus be exploited as a therapeutic target in the future.

First-line checkpoint inhibitor therapy in metastatic acral lentiginous melanoma compared to other types of cutaneous melanoma: A multicenter study from the prospective skin cancer registry ADOREG

BACKGROUND

Melanoma is the main cause of skin cancer-related death. Treatment with immune checkpoint inhibitors (CPI) has improved the prognosis in recent years. However, subtypes of melanoma differ in their response. Acral lentiginous melanoma (ALM) has a worse prognosis compared to cutaneous melanoma other than ALM (CM) and is therefore of particular relevance.

AIMS

To evaluate the efficacy of CPI in first-line treatment of patients with advanced ALM compared CM.

METHODS

Retrospective analysis of patients with metastatic ALM (n = 45) or CM (n = 328) who received first-line CPI therapy from the multicenter prospective skin cancer registry ADOREG. Study endpoints were best overall response (BOR), progression-free survival (PFS) and overall survival (OS).

RESULTS

ALM patients had significantly higher rates of ulcerated tumors, loco regional metastases and fewer BRAF-mutated tumors compared to CM patients. Combined CPI was administered in 48.9 % ALM patients and 39.3 % of CM patients, while the remaining patients received PD-1 monotherapy. OS trended to be shorter in patients with ALM (18.1 vs. 43.8 months, p = 0.10) with no significant differences in PFS (7.0 vs. 11.5 months, p = 0.21). In patients with CM, median OS with combined CPI was not reached, whereas the median OS after PD-1 monotherapy was 37.8 months (p = 0.22). Conversely, in patients with ALM, OS with combined CPI was 17.8 months, compared to 26 months with PD-1 monotherapy (p = 0.15). There were no significant differences in BOR between patients with ALM or CM.

CONCLUSION

Analysis of this real-world cohort of patients with metastatic melanoma showed a trend towards poorer survival outcomes upon first-line treatment with CPI in ALM compared to cutaneous melanoma of other subtypes.

Pulmonary Metastasectomy for Melanoma

Early-stage melanoma has a favorable prognosis with a 94% 5-year survival rate, but survival declines significantly with metastasis. Traditional treatments like metastasectomy have evolved due to advancements in targeted therapies and immune checkpoint inhibitors, improving 5-year survival rates from 18% in 2009 to 52% in 2018. The lung is the most common site for metastasis, and the criteria for pulmonary metastasectomy have changed, allowing for surgical intervention even with extrapulmonary metastasis if complete resection is possible. This highlights the role of thoracic surgeons in selecting ideal candidates for surgery, emphasizing a multidisciplinary approach and minimally invasive techniques.

A Novel Polymersome Nanocarrier Promotes Anti-Tumour Immunity by Improved Priming of CD8 + T Cells

Cancer is one of the leading causes of death worldwide. In recent years, immune checkpoint inhibitor therapies, in addition to standard immuno- or chemotherapy and surgical approaches, have massively improved the outcome for cancer patients. However, these therapies have their limitations and improved strategies, including access to reliable cancer vaccines, are needed. Here, we describe the use of self-assembling artificial cell membrane (ACM) polymersomes to deliver tumour-specific peptides to trigger sustainable and efficient anti-tumour immune responses. We found that ACM polymersomes were highly efficient in targeting and activating mononuclear phagocytes (MNP) including dendritic cells (DC), while providing long-term reservoirs of antigens for continued immune cell priming. Subcutaneous injection of ACM-encapsulated tumour-antigen-peptides into tumour-bearing mice resulted in improved priming of CD8+ T cells and increased generation of tumour-antigen-peptide specific CD8+ effector T cells. Prophylactic and therapeutic immunisation with ACM-encapsulated peptides resulted in changes to the MNP composition in the tumour microenvironment, tumour regression and improved survival of immunised mice. Combining anti-PD-1 immune checkpoint inhibitor therapy with ACM polymersome peptide delivery further boosted anti-tumour immunity. Our results show that ACM polymersome nanocarriers efficiently instruct anti-tumour immune responses offering a promising new approach for vaccination and cancer immunotherapy. Trial Registration: NCT05385991.

Oral Melanoma in Older Adults: Epidemiology, Molecular Landscape, and Treatment Strategies

Oral melanoma is an aggressive neoplasm arising from melanocytes in the mucosal epithelium, accounting for 0.2%-0.8% of all melanomas. Unlike cutaneous melanoma, it is not associated with UV exposure, and its pathogenesis involves complex genetic and molecular alterations. This neoplasm predominantly affects older adults (≥ 60 years). Clinically, lesions often present as macular or nodular with an exophytic growth pattern, sometimes ulcerated, and exhibit varied pigmentation. Diagnosis is further complicated by non-pigmented (amelanotic) variants that can resemble other oral pigmentations. Wide surgical excision remains the mainstay treatment, often combined with chemotherapy; however, recurrence and distant metastasis remain high. While immunotherapy has shown promise in other melanoma subtypes, its efficacy in oral melanoma remains uncertain. Treatment in older adults is particularly challenging due to comorbidities and treatment-related morbidity. This review summarizes the epidemiology, clinical features, and current treatment strategies for oral melanoma in older adults. Key advances in the molecular mechanisms underlying this neoplasm are also outlined. As a strategic approach, integrating oral melanoma screening into routine geriatric dental care, supported by diagnostic algorithms, may improve early detection, prognosis, and survival outcomes in this vulnerable population.

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.

Microbiome Landscape and Association with Response to Immune Checkpoint Inhibitors in Advanced Solid Tumors: A SCRUM-Japan MONSTAR-SCREEN Study

Although the gut microbiome is associated with cancer development and progression, little is known about the effects of the gut microbiome landscape and the efficacy of immune checkpoint inhibitors (ICI) across cancer types. We investigated the association between the microbiome, clinical features, and ICI efficacy across cancer types in a large nationwide screening project for solid tumors. Among 2,180 patients with advanced solid tumors enrolled in the SCRUM-Japan MONSTAR-SCREEN between October 2019 and September 2021, in the chemotherapy-naïve cohort (n = 817), a high prevalence of oral bacteria was observed in patients using proton pump inhibitors (PPI) and those with upper gastrointestinal cancers, particularly postoperative patients with gastric or pancreatic cancer. Among patients treated with ICIs (n = 333), a high abundance of sequence variants in the gut microbiome was not significantly associated with ICI efficacy across cancer types (HR = 0.94; 95% confidence interval, 0.73-1.21). However, high oral bacteria in feces significantly correlated with a shorter progression-free survival compared with low oral bacteria (median, 4.34 vs. 6.97 months; HR = 1.38; 95% confidence interval, 1.07-1.78). Notably, in patients using PPIs, a higher proportion of oral bacteria influenced progression-free survival outcomes of ICI treatment (median, 3.15 vs. 2.04 months; P = 0.08), unlike in PPI nonusers (median, 7.13 vs. 5.55 months; P = 0.74). This study of the gut microbiome has unveiled significant insights into its landscape and potential impact on ICI efficacy. It highlights that the abundance of oral bacteria in feces may play a critical role in diminishing ICI efficacy among patients using PPIs.

SIGNIFICANCE

As part of the MONSTAR-SCREEN, a prospective nationwide project for patients with solid tumors, we found that although gut microbiome diversity does not consistently predict ICI efficacy across cancer types, a high level of oral bacteria in the gut is linked to reduced ICI effectiveness, especially in patients using PPIs. These findings highlight the potential clinical impact of microbiome variations on cancer treatment outcomes.

Selective tubulin-binding drugs induce pericyte phenotype switching and anti-cancer immunity

The intratumoral immune milieu is crucial for the success of anti-cancer immunotherapy. We show here that stromal modulation by the tubulin-binding anti-cancer drugs combretastatin A4 (CA-4) and eribulin improved tumor perfusion and anti-tumor immunity. This was achieved by reverting highly proliferative, angiogenic pericytes into a quiescent, contractile state which durably normalized the vascular bed and reduced hypoxia in mouse models of pancreatic neuroendocrine cancer, breast cancer and melanoma. The crucial event in pericyte phenotype switching was RhoA kinase activation, which distinguished CA-4 and eribulin effects from other anti-mitotic drugs such as paclitaxel and vinorelbine. Importantly, eribulin pre-treatment sensitized tumors for adoptive T cell therapy or checkpoint inhibition resulting in effector cell infiltration and better survival outcomes in mice. In breast cancer patients, eribulin neoadjuvant treatment induced pericyte maturity and RhoA kinase activity indicating similar vessel remodeling effects as seen in mice. Moreover, a contractile pericyte signature was associated with overall better survival outcome in two independent breast cancer cohorts. This underscores the potential of re-purposing specific anti-cancer drugs to enable synergistic complementation with emerging immunotherapies.

PARP1 in melanoma: Mechanistic insights and implications for basic and clinical research

Targeted therapies and immunotherapies have revolutionized the treatment of metastatic melanoma and have set a successful example for the treatment of other cancers. A similar breakthrough was achieved with the advent of PARP inhibitors (PARPi) in breast and ovarian cancer. Recent evidence highlights the critical role of PARP1 in melanoma initiation and progression. High PARP1 expression correlates with aggressive melanoma characteristics and poor patient outcomes. Preclinical and clinical data suggest that PARPi, alone or in combination, can effectively reduce melanoma cell viability and inhibit tumor growth. However, integrating PARPi with current treatment approaches and identifying patients who could benefit the most from such combinations remain underexplored areas of investigation. This review highlights the need for further basic and clinical research on PARP1 in melanoma, to better understand its role and to tackle major challenges in the field, such as resistance to targeted therapies and immune checkpoint inhibitors.

Immunotherapy in Advanced Cutaneous Melanoma: From the Optimal Treatment Duration to the Impact on Survival in Case of Early Discontinuation Due to Immune-Related Adverse Events

Immune checkpoint inhibitors (ICIs) have improved the prognosis of patients with cutaneous melanoma. Immunotherapy (IT) is generally well tolerated, but an increasing area of investigation concerns the optimal treatment duration of anti-programmed cell death-1 (anti-PD1) regimens to limit the immune-related adverse events in patients who obtained a clinical response. Another point of interest is the impact of the early discontinuation of ICIs on the maintenance of response in terms of survival in patients developing grade 3-4 adverse events that mostly occur in those receiving the combo-IT. Currently, we are still far from having final conclusions on these topics and, thus, the present review aims to describe the recent data about the optimal treatment duration and the maintenance of response in the case of early discontinuation. In this context, we include data on the real life of patients from our Medical Oncology Center who discontinued anti-PD1 after at least a stable disease or those interrupting the combo-IT due to adverse events.

Muscleblind-like proteins are novel modulators of the tumor-immune microenvironment

Exploiting the immune system to eradicate cancer cells is an area of intense clinical study. However, the mechanisms that shape the tumor-immune microenvironment are incompletely understood. Here, we identify Muscleblind-like (MBNL) proteins as novel modulators of the tumor-immune microenvironment across diverse cancers. We demonstrate that loss of tumor MBNL expression results in an attenuated response to interferon gamma and reduced tumor antigen presentation in melanoma, breast cancer, and colorectal cancer cells. Parallel experiments in a syngeneic mouse melanoma model revealed that MBNL loss reduces tumor cell killing by CD8 + T cells in vitro and facilitates tumor escape from cytotoxic CD8 + T cell infiltration in vivo. Finally, we extended these studies to 29 human cancer types to find that MBNL expression levels are strongly associated with gene expression signatures of T cell tumor infiltration. These insights suggest that MBNL proteins play important roles in shaping the immune landscape across diverse malignancies.

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.

Genetic and transcriptional insights into immune checkpoint blockade response and survival: lessons from melanoma and beyond

BACKGROUND

Integration of immune checkpoint inhibitors (ICIs) with non-immune therapies relies on identifying combinatorial biomarkers, which are essential for patient stratification and personalized treatment.

METHODS

We analyzed genomic and transcriptomic data from pretreatment tumor samples of 342 melanoma patients treated with ICIs to identify mutations and expression signatures associated with ICI response and survival. External validation and mechanistic exploratory analyses were conducted in two additional datasets to assess generalizability.

RESULTS

Responders were more likely to have received anti-PD-1 therapy rather than anti-CTLA-4 and exhibited a higher tumor mutation burden (both P < 0.001). Mutations in the dynein axonemal heavy chain (DNAH) family genes, specifically DNAH2 (P = 0.03), DNAH6 (P < 0.001), and DNAH9 (P < 0.01), were enriched in responders. The combined mutational status of DNAH 2/6/9 effectively stratified patients by progression-free survival (hazard ratio [HR]: 0.69; 95% confidence interval [CI] 0.51-0.92; P = 0.013) and overall survival (HR: 0.58; 95% CI 0.43-0.78; P < 0.001), with consistent association observed in the validation cohort (HR: 0.28; 95% CI 0.12-0.61; P < 0.001). DNAH-altered melanomas exhibited upregulation of chemokine signaling, cytokine-cytokine receptor interaction, and cell cycle-related pathways, along with elevated expression of immune-related signatures in interferon signaling, cytolytic activity, T cell function, and immune checkpoints. Using LASSO logistic regression, we identified a 26-gene composite signature predictive of clinical response, achieving an area under the curve (AUC) of 0.880 (95% CI 0.825-0.936) in the training dataset and 0.725 (95% CI 0.595-0.856) in the testing dataset. High-risk patients, stratified by the expression levels of a 13-gene signature, demonstrated significantly shorter overall survival in both datasets (HR: 3.35; P < 0.001; HR: 2.93; P = 0.002).

CONCLUSIONS

This analysis identified potential molecular determinants of response and survival to ICI treatment. Insights from melanoma biomarker research hold significant promise for translation into other malignancies, guiding individualized anti-tumor immunotherapy.

Current Treatment of Uveal Melanoma

Uveal melanoma (UM) is the most common primary intraocular malignancy in adults worldwide [...].

Open-label nonrandomized phase IB study to characterize the safety and recommended dose of tinostamustine in combination with nivolumab in patients with advanced melanoma (ENIgMA)

Tinostamustine is a first-in-class alkylating deacetylase inhibitor that facilitates access to cancer cell DNA, resulting in its damage and counteracting DNA repair systems. We hypothesize that the addition of tinostamustine to immune checkpoint inhibitors (ICIs) improves melanoma treatment. This open-label, nonrandomized phase IB study characterized dose-limiting toxicity (DLT) and the recommended dose (RD) of 2-weekly intravenous tinostamustine at escalating doses of 15 and 30 mg/m2 when administered with 2-weekly nivolumab 3 mg/kg added in cycle 2 in patients with melanoma. We included 17 patients (four at 15 mg/m2 and 13 at 30 mg/m2 tinostamustine). A total of 13/17 (77%) patients were ICI-resistant, 7/17 (41%) had unfavorable melanoma subtypes. No DLT was identified. Tinostamustine RD was 30 mg/m2 every 2 weeks. One patient experienced grade 2 nivolumab-associated immune-related pneumonitis. Tinostamustine-associated grade 3 leukocytopenia was documented in one patient, grade 2 leukocytopenia in five patients, and grade 1 thrombocytopenia in three patients. Treatment discontinuation occurred in one patient for nivolumab-associated immune-related pneumonitis and in another patient for tumor-related hemorrhage. A total of 7/13 (54%) evaluable patients had at least stable disease as best treatment response, including 3/13 (23%) patients with a confirmed partial response. Median progression-free survival was 8.3 weeks [95% confidence interval (CI): 2.4-15.4 weeks), median overall survival was 19.1 weeks (95% CI: 2.4-41 weeks). Two-weekly intravenous tinostamustine at an immune-modulatory dose of 30 mg/m2 is safe when coadministered with nivolumab 3 mg/kg and resulted in 54% disease stabilization and 23% confirmed partial responses in patients with predominantly ICI-resistant, advanced melanoma.

Demographic and clinicopathological factors associated with biomarker-inflammatory indices and the AMIRI scoring system for predicting acral melanoma mortality-A retrospective study

Background Acral melanoma (AM) is a highly aggressive skin cancer associated with high mortality. In this study, we measured inflammatory biomarkers, identified cutoff values, and developed a scoring system to predict mortality in patients with AM. Aims This study aimed to identify inflammatory biomarker cut-off points and factors in AM patients, introducing the Acral Melanoma Inflammatory Risk Index (AMIRI) to predict mortality. Methods In this retrospective cohort study, we analysed 394 patients diagnosed with AM. Demographic and clinicopathological data were obtained from medical records. Inflammatory markers (neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and absolute neutrophil count (ANC)) were measured at diagnosis. The AMIRI scoring system was used to categorise patients into three risk groups: low (AMIRI ≤ 1), intermediate (1 < AMIRI ≤ 2), and high (AMIRI > 2). We used logistic regression models to evaluate associations between inflammatory markers and mortality. Results The median age of the 394 AM patients was 67 years. The AMIRI scoring system effectively categorised patients into risk groups, with higher scores correlating with increased mortality risk. The Cox model showed a significant increase in 5-year mortality risk for moderate [OR 1.94] and high [OR 1.96] AMIRI risk groups compared to low-risk patients. Limitations This study has limitations, including its retrospective design, being conducted at a single center, incomplete data on adjuvant therapy, and the exclusion of immunotherapy from biomarker analysis, with potential biases from factors like steroid use and associated diseases. Conclusion Inflammatory biomarkers are valuable prognostic tools in AM. The AMIRI scoring system effectively stratifies patients, identifying those with higher mortality risk.

Recent Developments in Targeting the Cell Cycle in Melanoma

Melanoma is an aggressive cancer with rising incidence, particularly among older individuals. Despite advancements in targeted therapies for BRAF and MEK proteins and immunotherapies, many patients either fail to respond or develop resistance. For those progressing on immunotherapy, limited treatment options remain. The Cyclin D-CDK4/6-RB pathway is commonly dysregulated in melanoma, with up to 90% of cases showing alterations that activate it. Although targeting Cyclin-CDK complexes has shown promise in preclinical models, clinical responses have been suboptimal. This review explores the molecular mechanisms behind Cyclin-CDK dysregulation in melanoma and the challenges of targeting this pathway. It also discusses strategies to improve the efficacy of CDK4/6 inhibitors, including combination therapies to overcome resistance and enhance patient outcomes. Understanding these mechanisms can guide the development of more effective treatments for melanoma.

MLKL-Mediated Necroptosis Predominantly Contributes to Immune-Associated Myocardial Damage

Activated T cells and macrophages play a critical role in immune-associated myocarditis. However, the molecular and cellular mechanisms driving cardiomyocyte damage by immune cells remain poorly understood. In this study, we co-cultured human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) with activated human peripheral blood mononuclear cells (aPBMCs) to recapitulate myocardial infiltration of immune cells. Our results demonstrated that aPBMCs induced hiPSC-CMs death in a dose- and time-dependent manner. Transcriptome analysis revealed the activation of several death pathways, including pyroptosis, apoptosis and necroptosis. The time course of immunofluorescence staining of key proteins related to different death pathways demonstrated that necroptosis was the earliest activated pathway. Pharmacological blockade of necroptosis by targeting mixed lineage kinase domain-like protein (MLKL), receptor-interacting protein kinase 1 (RIPK1) and receptor-interacting protein RIPK1 kinase 3 (RIPK3) protected hiPSC-CMs against injury induced by aPBMCs, while inhibitors of pyroptosis and apoptosis showed no protective effect. Moreover, MLKL knockdown in hiPSC-CMs prevented cell death due to aPBMCs challenge. Additionally, we validated the cardioprotective effects of blocking necroptosis in a mouse model of immune checkpoint inhibitors (ICIs)-related myocarditis using a combination of long-term anti-programmed cell death 1 (PD- 1) and anti-cytotoxic T-lymphocyte antigen- 4 (CTLA- 4) antibodies. ICIs led to elevation of myocardial injury markers in serum and activated immune cells infiltration. Furthermore, in vivo administration of a MLKL inhibitor prevented ICIs-induced myocardial injury. In conclusion, our findings suggested that MLKL-mediated necroptosis predominantly contributed to cardiomyocyte death resulting from activated immune cells. Suppressing necroptosis may be an effective therapeutic approach against myocardial damage in myocarditis.

Exhaled breath analysis with the use of an electronic nose to predict response to immune checkpoint inhibitors in patients with metastatic melanoma: melaNose trial

Introduction

Immune checkpoint inhibitors (ICIs) have significantly improved the overall survival for patients with different solid tumors. However, there is an urgent need for predictive biomarkers to identify patients with metastatic melanoma who do not benefit from treatment with ICIs, to prevent unnecessary immune related adverse events (irAEs). Electronic noses (eNoses) showed promising results in the detection of cancer as well as the prediction of response outcome in patients with cancer. In this feasibility study, we aimed to investigate whether the breath pattern measured using eNose can be used as a simple biomarker to predict clinical benefit to first-line treatment with ICIs in patients with metastatic melanoma.

Methods

In this prospective, observational single-center feasibility study, patients with metastatic melanoma performed a breath test using Aeonose™ before start of first-line treatment with ICIs. The detected exhaled breath pattern of volatile organic compounds (VOC) was used for machine learning in a training set to develop a model to identify patients who do not benefit from treatment with ICIs. Lack of clinical benefit was defined as progressive disease according to best tumor response using RECIST v1.1. Primary outcome measures were sensitivity, specificity and accuracy.

Results

The eNose showed a distinct breath pattern between patients with and without clinical benefit from ICIs. To identify patients who do not benefit from first-line ICIs treatment, breath pattern analysis using the eNose resulted in a sensitivity of 88%, specificity of 79%, and accuracy of 85%.

Conclusion

Exhaled breath analysis using eNose can identify patients with metastatic melanoma who will not benefit from first-line treatment with ICIs and guide treatment strategies. When validated in an external cohort, eNose could be a useful tool to select these patients for alternative treatment strategies in clinical practice.

Enhancing immunotherapy with tumour-responsive nanomaterials

The targeted delivery of immunotherapies to tumours using tumour-responsive nanomaterials is a promising area of cancer research with the potential to address the limitations of systemic administration such as on-target off-tumour toxicities and a lack of activity owing to the immunosuppressive tumour microenvironment (TME). Attempts to address these challenges include the design and functionalization of nanomaterials capable of releasing their cargoes in response to specific TME characteristics, thus facilitating the targeted delivery of immune-checkpoint inhibitors, cytokines, mRNAs, vaccines and, potentially, chimaeric antigen receptors as well as of agents that modulate the extracellular matrix and induce immunogenic cell death. In this Review, we describe these various research efforts in the context of the dynamic properties of the TME, such as pH, reductive conditions, reactive oxygen species, hypoxia, specific enzymes, high levels of ATP and locoregional aspects, which can be leveraged to enhance the specificity and efficacy of nanomaterial-based immunotherapies. Highlighting preclinical successes and ongoing clinical trials, we evaluate the current landscape and potential of these innovative approaches. We also consider future research directions as well as the most important barriers to successful clinical translation, emphasizing the transformative potential of tumour-responsive nanomaterials in overcoming the barriers that limit the activity of traditional immunotherapies, thus improving patient outcomes.

Novel drugs approved by the EMA, the FDA and the MHRA in 2024: A year in review

In the past year, the European Medicines Agency (EMA), the Food and Drug Administration (FDA) and the Medicines and Healthcare Products Regulatory Agency (MHRA) authorised 53 novel drugs. While the 2024 harvest is not as rich as in 2023, when 70 new chemical entities were approved, the number of 'orphan' drug authorisations in 2024 (21) is similar to that of 2023 (24), illustrating the dynamic development of therapeutics in areas of unmet need. The 2024 approvals of novel protein therapeutics (15) and advanced therapy medicinal products (ATMPs, 6) indicate a sustained trend also noticeable in the 2023 new drugs reviewed in this journal last year (16 and 11, respectively). Clearly, the most striking characteristic of the 2024 drug yield is the creative pharmacological design, which allows these medicines to employ a novel approach to target a disease. Some notable examples are the first drug successfully using a 'dock-and-block' mechanism of inhibition (zenocutuzumab), the first approved drug for schizophrenia designed as an agonist of M1/M4 muscarinic receptors (xanomeline), the first biparatopic antibody (zanidatamab), binding two distinct epitopes of the same molecule, the first haemophilia therapy that instead of relying on external supplementation of clotting factors, restores Factor Xa activity by inhibiting TFPI (marstacimab), or the first ever authorised direct telomerase inhibitor (imetelstat) that reprogrammes the oncogenic drive of tumour cells. In addition, an impressive percentage of novel drugs were first in class (28 out of 53 or 53% of the total) and a substantial number can be considered disease agnostic, indicating the possibility of future approved extensions of their use for additional indications. The 2024 harvest demonstrates the therapeutic potential of innovative pharmacological design, which allows the effective targeting of intractable disorders and addresses crucial, unmet therapeutic needs.

3'-deoxy-3'-18F-fluorothymidine PET imaging of lymphoid tissues in patients with advanced non-small cell lung cancer undergoing anti-programmed cell death-1 therapy

BACKGROUND

Anti-programmed cell death-1 (anti-PD-1) therapy has become the standard immunotherapy for patients with advanced non-small cell lung cancer (NSCLC). However, little is known about the organs influenced by PD-1 inhibitors on a patient's tumor immunity. We examined the changes in lymphoid tissue proliferation before and after PD-1 inhibitor treatment using 3'-deoxy-3'-[18F]-fluorothymidine (18F-FLT) positron emission tomography (PET). This study included 25 patients with advanced NSCLC who underwent 18F-FLT PET before and 2 and 6 weeks after the initiation of PD-1 inhibitor treatment. We determined the average standardized uptake value (SUVmean) in the spleen, maximum SUV (SUVmax) in the lymph nodes, and the SUVmax, SUVmean, proliferative vertebral volume (PVV), and total vertebral proliferation (TVP) in the thoracolumbar vertebral bodies using 18F-FLT PET and blood test data. The relationship between the rate of change in these parameters before and after treatment and the tumor response was evaluated.

RESULTS

The baseline 18F-FLT accumulation in the lymphoid tissues or blood test data between the progressive disease (PD) and non-PD groups were not significantly different. In the spleen and lymph nodes, changes in 18F-FLT accumulation from baseline to 2 or 6 weeks did not differ between the non-PD and PD groups. However, mediastinal lymph node accumulation tended to increase transiently at week 2 compared to that before treatment initiation (median SUVmax 2.19 vs. 2.64, P = 0.073). Regarding changes in vertebral accumulation in the non-PD group, the SUVmax, and PVV were significantly lower at weeks 2 and 6. In the percent changes in 18F-FLT accumulation of the vertebrae after the treatment initiation, the PD group was significantly higher than the non-PD group at the 6-week evaluation (median ΔTVP0-6, 17.0% vs. -13.0%, P = 0.0080).

CONCLUSIONS

In patients with advanced NSCLC who achieved a tumor response, proliferation decreased in the bone marrow, but not in the spleen or lymph nodes, 6 weeks after treatment initiation. 18F-FLT PET can help monitor changes in tumor immunity in each lymphoid tissue and may serve as a biomarker for the response to immune checkpoint inhibitor therapy.

Investigating the synergistic effects of immunochemotherapy in esophageal squamous cell carcinoma

BACKGROUND

Although combinations of immune-checkpoint inhibitors (ICI) with chemotherapy have been approved for esophageal squamous cell carcinoma (ESCC), it remains unclear whether immunochemotherapy (ICT) offers advantages over the simple addition of individual monotherapies. This study aimed to investigate whether ICT exhibits a synergistic effect in patients with advanced ESCC.

METHODS

Reconstructed individual patient data of 3330 patients were electronically extracted from the Kaplan-Meier (KM) curves of eight randomized-controlled trials (ATTRACTION-3, CheckMate648, KEYNOTE-181, KEYNOTE-590, RATIONALE-302, RATIONALE-306, ESCORT, and ESCORT-1st). The observed progression-free survival (PFS) curve of each constituent monotherapies was used to estimate simulated PFS curves expected under a model of independent drug action. If the observed curve demonstrated significantly better PFS than the simulated curve, the combination of ICI and chemotherapy may have a synergistic effect, implying a superior outcome compared to simply adding the component monotherapy.

RESULTS

The 1-year, 2-year, and median PFS of the observed and simulated KM curves were 26.3% vs. 24.8%, 14.6% vs. 12.0%, and 6.9 vs. 6.4 months, respectively. The one-sample log-rank test showed no significant differences between the observed and simulated KM curves (p = 0.073).

CONCLUSIONS

The observed PFS with ICT was comparable to the simulated PFS estimated from the data for each monotherapy. Although it is unclear whether potential synergies exist for ICT, these findings suggest that the benefits of ICI and chemotherapy do not interfere with each other, thereby providing theoretical support for the efficacy of ICT.

Longitudinal Evaluation of Immune Checkpoint Inhibitor-Induced Fatigue Syndrome by Rest, Stress, and Speckle-Tracking Strain Echocardiography

BACKGROUND

Immune checkpoint inhibitor (ICI) anti-tumor therapy is commonly associated with reports of significant fatigue. Whether ICI-induced fatigue is linked to subclinical cardiac toxicity is not well understood.

METHODS

We performed a prospective observational study to monitor cardiac function following initiation of ICI in cancer patients. Rest and staged exercise stress transthoracic echocardiograms (TTE) were captured at baseline, 3 and 6 months after ICI initiation.

RESULTS

Thirteen patients completed baseline testing, of whom 10 completed 3 month testing and 8 completed 6 month testing. Patients had elevated fatigue as per Common Terminology Criteria for Adverse Events (CTCAE) criteria and FACIT-Fatigue subscale scores (47.5 [42.5-52] vs. 47 [38-48], p = 0.001). Among resting echocardiographic parameters, left ventricular (LV) outflow tract velocity time integral (VTI) was reduced at 6 months (22.6 cm [21.2-24.5] vs. 19.8 cm [17.2-21.2], p = 0.001), albeit still within normal range. Measures of biventricular size and systolic function, along with LV global longitudinal strain (GLS) and LA global strain, were not significantly changed. Among exercise parameters, peak heart rate was reduced at 6 months (143.4 bpm [128.5-153.5] vs. 123.5 [110.2-130.8], p = 0.048); of those who completed 6 month testing, two (29%) were unable to achieve the previous peak stage of exercise.

CONCLUSIONS

In patients starting ICI, statistically-significant reductions in cardiac systolic function (LVOT VTI) and peak HR were observed, with nearly one-third unable to achieve peak exercise at 6 months. This finding, combined with reported fatigue and lack of changes to biventricular systolic functional measures, suggests induced functional cardiac limitations are due to deconditioning, rather than cardiotoxicity.

Real-world response assessment of immune checkpoint inhibition: comparing iRECIST and RECIST 1.1 in melanoma and non-small cell lung cancer patients

OBJECTIVES

To compare immune response evaluation criteria in solid tumors (iRECIST) and response evaluation criteria in solid tumors (RECIST) 1.1 for response assessment of immune checkpoint inhibitor (ICI) therapy in a real-world setting in patients with melanoma and non-small cell lung cancer (NSCLC).

METHODS

Two-hundred fifty-two patients with melanoma and NSCLC who received CTLA-4 inhibitor ipilimumab or PD-1 inhibitors nivolumab or pembrolizumab and who underwent staging CT of the chest and abdomen were retrospectively included. Treatment response evaluation according to the RECIST 1.1 and iRECIST guidelines was performed for all patients. Response patterns, as well as overall response rate (ORR), disease control rate (DCR), and time to progression (TTP), were compared between RECIST 1.1 and iRECIST.

RESULTS

Out of 143 patients with progressive disease (PD) according to RECIST 1.1, 48 (33.6%) did not attain confirmation of progression (iCPD) as per iRECIST and six patients who were treated beyond RECIST 1.1 progression reached PD at a later point in time in iRECIST, resulting in a significant difference in TTP between iRECIST and RECIST 1.1 (618.3 ± 626.9 days vs. 538.1 ± 617.9 days, respectively (p < 0.05)). The number of non-responders as per RECIST 1.1 was 79, whereas it was 60 when using iRECIST. ORR was 28.5% for RECIST 1.1 and 34.1% for iRECIST, and corresponding DCR of 67.4% for RECIST 1.1 and 74.6% for iRECIST.

CONCLUSION

iRECIST was more suitable than RECIST 1.1 for capturing atypical response patterns to ICI therapy in patients with melanoma and NSCLC, resulting in differences in the assessment of treatment response.

CLINICAL RELEVANCE STATEMENT

Compared to RECIST 1.1, iRECIST may improve patient care and treatment decisions for patients with NSCLC or melanoma who are treated with immune checkpoint inhibitors in clinical routine.

KEY POINTS

RECIST 1.1 may incorrectly assess atypical treatment patterns to immune checkpoint inhibitors. iRECIST better captured atypical response patterns compared to RECIST 1.1. iRECIST was more suitable for assessing response to immune checkpoint inhibitors in non-small cell lung carcinoma and 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.

Polysialic acid is upregulated on activated immune cells and negatively regulates anticancer immune activity

Suppression of anticancer immune function is a key driver of tumorigenesis. Identifying molecular pathways that inhibit anticancer immunity is critical for developing novel immunotherapeutics. One such molecule that has recently been identified is the carbohydrate polysialic acid (polySia), whose expression is dramatically upregulated on both cancer cells and immune cells in breast cancer patient tissues. The role of polySia in the anticancer immune response, however, remains incompletely understood. In this study, we profile polySia expression on both healthy primary immune cells and on infiltrating immune cells in the tumour microenvironment (TME). These studies reveal polySia expression on multiple immune cell subsets in patient breast tumors. We find that stimulation of primary T-cells and macrophages in vitro induces a significant upregulation of polySia expression. We subsequently show that polySia is appended to a range of different carrier proteins within these immune cells. Finally, we find that selective removal of polySia can significantly potentiate killing of breast cancer cells by innate immune cells. These studies implicate polySia as a significant negative regulator of anticancer immunity.

Myeloid-Derived Suppressor Cells: Implications in Cancer Immunology and Immunotherapy

Myeloid-derived suppressor cells (MDSCs) are believed to be key promoters of tumor development and are recognized as a hallmark of cancer cells' ability to evade the immune system evasion. MDSC levels often increase in peripheral blood and the tumor microenvironment (TME). These cells exert immunosuppressive functions, weakening the anticancer immune surveillance system, in part by repressing T-cell immunity. Moreover, MDSCs may promote tumor progression and interact with cancer cells, increasing MDSC expansion and favoring an immunotolerant TME. This review analyzes the primary roles of MDSCs in cancer and T-cell immunity, discusses the urgent need to develop effective MDSC-targeted therapies, and highlights the potential synergistic combination of MDSC targeting with chimeric antigen receptors and immune checkpoint inhibitors.

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.