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Staeger R, Martínez-Gómez JM, Turko P, Ramelyte E, Kraehenbuehl L, Del Prete V, Hasan Ali O, Levesque MP, Dummer R, Nägeli MC, Mangana J. Real-World Data on Clinical Outcomes and Treatment Management of Advanced Melanoma Patients: Single-Center Study of a Tertiary Cancer Center in Switzerland. Cancers (Basel) 2024; 16:854. [PMID: 38473216 DOI: 10.3390/cancers16050854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) and BRAF/MEK inhibitors (BRAF/MEKi) have drastically changed the outcomes of advanced melanoma patients in both the resectable/adjuvant and unresectable/metastatic setting. In this follow-up analysis of real-world data, we aimed to investigate the clinical management and outcomes of advanced melanoma patients in a tertiary referral center in Switzerland approximately a decade after the introduction of ICIs and BRAF/MEKi into clinical use. Moreover, we aimed to compare the results with seminal phase 3 trials and to identify areas of high unmet clinical need. METHODS This single-center retrospective cohort study analyzed the melanoma registry of the University Hospital Zurich, a tertiary cancer center in Switzerland, and included patients treated in the resectable/adjuvant (n = 331) or unresectable/metastatic setting (n = 375). RESULTS In the resectable setting, adjuvant anti-PD1 or BRAF/MEKi showed a 3-year relapse-free survival (RFS) of 53% and 67.6%, respectively, and the overall median RFS was 50 months. Patients with lymph node plus in-transit metastases or with distant metastases prior to commencing adjuvant treatment had a significantly reduced overall survival (OS). In 10.9% of patients, the treatment was stopped due to toxicity, which did not affect RFS/OS, unless the duration of the treatment was <3 months. Following a relapse of the disease during the first adjuvant treatment, the median progression-free survival (PFS2) was only 6.6 months; outcomes were particularly poor for relapses that were unresectable (median PFS2 3.9 months) or occurred within the first 2 months (median PFS2 2.7 months). A second adjuvant treatment for patients with resectable relapses still showed efficacy (median RFS2 43.7 months). Elevated LDH levels in patients with an unresectable relapse was correlated with a strong reduction in OS2 (HR 9.84, p = 0.018). In the unresectable setting, first-line anti-PD1, anti-CTLA4/PD1 combination, or BRAF/MEKi showed a 5-year OS of 46.5%, 52.4%, and 49.2%, respectively. In a multivariate analysis, elevated LDH levels or the presence of brain metastases substantially shortened OS (HR > 1.78, p < 0.035). There was a non-significant trend for the improved survival of patients treated with anti-CTLA4/PD1 compared to anti-PD1 (HR 0.64, p = 0.15). After a progression on first-line therapy, the median OS2 was reduced to below two years. Elevated LDH (HR 4.65, p < 0.001) levels and widespread disease with at least three metastatic sites, particularly bone metastases (HR 2.62, p = 0.026), affected OS2. CONCLUSION Our study offers real-world insights into the clinical management, treatment patterns, and outcomes of advanced melanoma patients in both the adjuvant and unresectable setting. Early relapses in patients undergoing adjuvant treatment pose a particular challenge but these patients are generally excluded from first-line trials. The approved first-line metastatic treatments are highly effective in the real-world setting with 5-year OS rates around 50%. However, outcomes remain poor for patients with brain metastases or who fail first-line treatment.
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Affiliation(s)
- Ramon Staeger
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Julia M Martínez-Gómez
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Patrick Turko
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Egle Ramelyte
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Lukas Kraehenbuehl
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Valerio Del Prete
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Omar Hasan Ali
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Mitchell P Levesque
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Reinhard Dummer
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Mirjam C Nägeli
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Joanna Mangana
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, 8091 Zurich, Switzerland
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Ferrándiz-Pulido C, Leiter U, Harwood C, Proby CM, Guthoff M, Scheel CH, Westhoff TH, Bouwes Bavinck JN, Meyer T, Nägeli MC, Del Marmol V, Lebbé C, Geusau A. Immune Checkpoint Inhibitors in Solid Organ Transplant Recipients With Advanced Skin Cancers-Emerging Strategies for Clinical Management. Transplantation 2023; 107:1452-1462. [PMID: 36706163 DOI: 10.1097/tp.0000000000004459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Use of immune checkpoint inhibitors (ICIs) in solid organ transplant recipients (SOTRs) with advanced skin cancers presents a significant clinical management dilemma. SOTRs and other immunosuppressed patients have been routinely excluded from ICI clinical trials with good reason: immune checkpoints play an important role in self- and allograft-tolerance and risk of acute allograft rejection reported in retrospective studies affects 10% to 65% of cases. These reports also confirm that cutaneous squamous cell carcinoma and melanoma respond to ICI therapy, although response rates are generally lower than those observed in immunocompetent populations. Prospective trials are now of critical importance in further establishing ICI efficacy and safety. However, based on current knowledge, we recommend that ICIs should be offered to kidney transplant recipients with advanced cutaneous squamous cell carcinoma, melanoma, or Merkel cell carcinoma if surgery and/or radiotherapy have failed. For kidney transplant recipients, this should be first line ahead of chemotherapy and targeted therapies. In SOTRs, the use of ICIs should be carefully considered with the benefits of ICIs versus risks of allograft rejection weighed up on a case-by-case basis as part of shared decision-making with patients. In all cases, parallel management of immunosuppression may be key to ICI responsiveness. We recommend maintaining immunosuppression before ICI initiation with a dual immunosuppressive regimen combining mammalian target of rapamycin inhibitors and either corticosteroids or calcineurin inhibitors. Such modification of immunosuppression must be considered in the context of allograft risk (both rejection and also its subsequent treatment) and risk of tumor progression. Ultimately, a multidisciplinary approach should underpin all clinical decision-making in this challenging scenario.
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Affiliation(s)
- Carla Ferrándiz-Pulido
- Department of Dermatology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ulrike Leiter
- Department of Dermatology, Eberhard-Karls University of Tuebingen, Tuebingen, Germany
| | - Catherine Harwood
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Charlotte M Proby
- Department of Dermatology, Ninewells Hospital and Medical School, Dundee, United Kingdom
| | - Martina Guthoff
- Department of Diabetology, Endocrinology, Nephrology, Section of Nephrology and Hypertension, Eberhard-Karls-University, Tuebingen, Germany
| | - Christina H Scheel
- Department of Dermatology, Skin Cancer Center, Ruhr-University Bochum, Bochum, Germany
| | - Timm H Westhoff
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Bochum, Germany
| | | | - Thomas Meyer
- Department of Dermatology, Skin Cancer Center, Ruhr-University Bochum, Bochum, Germany
| | - Mirjam C Nägeli
- Department of Dermatology, University Hospital of Zurich, Switzerland
| | - Veronique Del Marmol
- Service de Dermatologie, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Celeste Lebbé
- Dermato-Oncology Department, Université Paris Cite, AP-HP Hôpital Saint Louis, Cancer Institute APHP. Nord-Université Paris CiteINSERM U976, HIPI, Paris, France
| | - Alexandra Geusau
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
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Ramelyte E, Nägeli MC, Hunger R, Merat R, Gaide O, Navarini AA, Cozzio A, Wagner NB, Maul LV, Dummer R. Swiss Recommendations for Cutaneous Basal Cell Carcinoma. Dermatology 2022; 239:122-131. [PMID: 36137524 PMCID: PMC9808659 DOI: 10.1159/000526478] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 07/16/2022] [Indexed: 01/26/2023] Open
Abstract
Basal cell carcinoma (BCC) is the most common nonmelanoma skin cancer in Switzerland and worldwide. Most BCCs can be treated in a curative setting. However, patients can develop locally destructive and, rarely, metastatic tumors that require a different treatment approach. The clinical subtype of individual lesions provides prognostic information and influences management decisions. Surgical excision, topical therapies, and radiotherapy are highly effective in the majority of subtypes as well as in low- and high-risk diseases. For patients with low-risk diseases and superficial tumors not amenable to surgery, several nonsurgical alternatives are available. Systemic therapy is indicated for high-risk BCCs, which are not amenable to either surgery or radiotherapy. Hedgehog pathway inhibitors (HHI) are currently approved. Other therapeutic options such as immune checkpoint inhibitors show promising results in clinical trials. This first version of Swiss recommendations for diagnosis and management of BCC was prepared through extensive literature review and an advisory board consensus of expert dermatologists and oncologists in Switzerland. The present guidelines recommend therapies based on a multidisciplinary team approach and rate of recurrence for individual lesions. Based on the risk of recurrence, two distinct groups have been identified: low-risk (easy-to-treat) and high-risk (difficult-to-treat) tumors. Based on these classifications, evidence-based recommendations of available therapies are presented herein.
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Affiliation(s)
- Egle Ramelyte
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland,*Egle Ramelyte,
| | - Mirjam C. Nägeli
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland,**Mirjam C. Nägeli,
| | - Robert Hunger
- Department of Dermatology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Rastine Merat
- Division of Dermatology and Venereology, Geneva University Hospital, Geneva, Switzerland
| | - Olivier Gaide
- Department of Radiation Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Antonio Cozzio
- Clinic of Dermatology, Venereology and Allergology, St. Gallen Hospital, St. Gallen, Switzerland
| | - Nikolaus B. Wagner
- Clinic of Dermatology, Venereology and Allergology, St. Gallen Hospital, St. Gallen, Switzerland
| | - Lara Valeska Maul
- Department of Dermatology, University Hospital Basel, Basel, Switzerland
| | - Reinhard Dummer
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
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Kridin K, Brüggen MC, Chua SL, Bygum A, Walsh S, Nägeli MC, Kucinskiene V, French L, Tétart F, Didona B, Milpied B, Ranki A, Salavastru C, Brezinová E, Divani-Patel S, Lorentzen T, Nagel JL, Valiukeviciene S, Karpaviciute V, Tiplica GS, Oppel E, Oschmann A, de Prost N, Vorobyev A, Ingen-Housz-Oro S. Assessment of Treatment Approaches and Outcomes in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: Insights From a Pan-European Multicenter Study. JAMA Dermatol 2021; 157:1182-1190. [PMID: 34431984 DOI: 10.1001/jamadermatol.2021.3154] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe drug reactions associated with a high rate of mortality and morbidity. There is no consensus on the treatment strategy. Objective To explore treatment approaches across Europe and outcomes associated with the SJS/TEN disease course, as well as risk factors and culprit drugs. Design, Setting, and Participants A retrospective pan-European multicenter cohort study including 13 referral centers belonging to the ToxiTEN ERN-skin subgroup was conducted. A total of 212 adults with SJS/TEN were included between January 1, 2015, and December 31, 2019, and data were collected from a follow-up period of 6 weeks. Main Outcomes and Measures Risk factors for severe acute-phase complications (acute kidney failure, septicemia, and need for mechanical ventilation) and mortality 6 weeks following admission were evaluated using a multivariable-adjusted logistic regression model. One tool used in evaluation of severity was the Score of Toxic Epidermal Necrolysis (SCORTEN), which ranges from 0 to 7, with 7 the highest level of severity. Results Of 212 patients (134 of 211 [63.7%] women; mean [SD] age, 51.0 [19.3] years), the mean (SD) body surface area detachment was 27% (32.8%). In 176 (83.0%) patients, a culprit drug was identified. Antibiotics (21.2%), followed by anticonvulsants (18.9%), nonsteroidal anti-inflammatory drugs (11.8%), allopurinol (11.3%), and sulfonamides (10.4%), were the most common suspected agents. Treatment approaches ranged from best supportive care only (38.2%) to systemic glucocorticoids (35.4%), intravenous immunoglobulins (23.6%), cyclosporine (10.4%), and antitumor necrosis factor agents (3.3%). Most patients (63.7%) developed severe acute-phase complications. The 6-week mortality rate was 20.8%. Maximal body surface area detachment (≥30%) was found to be independently associated with severe acute-phase complications (fully adjusted odds ratio [OR], 2.49; 95% CI, 1.21-5.12; P = .01) and SCORTEN greater than or equal to 2 was significantly associated with mortality (fully adjusted OR, 10.30; 95% CI, 3.82-27.78; P < .001). Cyclosporine was associated with a higher frequency of greater than or equal to 20% increase in body surface area detachment in the acute phase (adjusted OR, 3.44; 95% CI, 1.12-10.52; P = .03) and an increased risk of infections (adjusted OR, 7.16; 95% CI, 1.52-33.74; P = .01). Systemic glucocorticoids and intravenous immunoglobulins were associated with a decreased risk of infections (adjusted OR, 0.40; 95% CI, 0.18-0.88; P = .02). No significant difference in 6-week mortality was found between treatment groups. Conclusions and Relevance This cohort study noted differences in treatment strategies for SJS/TEN in Europe; the findings suggest the need for prospective therapeutic studies to be conducted and registries to be developed.
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Affiliation(s)
- Khalaf Kridin
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Marie-Charlotte Brüggen
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland.,Medical Campus Davos, Davos, Switzerland.,ToxiTEN group, European Reference Network for Rare Skin Diseases, Paris, France
| | - Ser-Ling Chua
- ToxiTEN group, European Reference Network for Rare Skin Diseases, Paris, France.,Department of Dermatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Anette Bygum
- ToxiTEN group, European Reference Network for Rare Skin Diseases, Paris, France.,Department of Dermatology and Allergy Center, Odense University Hospital, Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Sarah Walsh
- ToxiTEN group, European Reference Network for Rare Skin Diseases, Paris, France.,Department of Dermatology, King's College Hospital, London, United Kingdom
| | - Mirjam C Nägeli
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Vesta Kucinskiene
- ToxiTEN group, European Reference Network for Rare Skin Diseases, Paris, France.,Department of Skin and Venereal Diseases, Lithuanian University of Health Sciences (LUHS), Hospital of LUHS Kauno Klinikos, European Reference Network for Rare and Complex Diseases of the Skin members, Kaunas, Lithuania.,Department of Skin and Venereal Diseases, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Lars French
- ToxiTEN group, European Reference Network for Rare Skin Diseases, Paris, France.,Department of Dermatology, University Hospital, Munich University of Ludwig Maximilian, Munich, Germany.,Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Florence Tétart
- ToxiTEN group, European Reference Network for Rare Skin Diseases, Paris, France.,Toxic Bullous Dermatoses and Severe Drug Reactions reference center, TOXIBUL FIMARAD network, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France.,Department of Dermatology, Inserm U519, Rouen University Hospital, Rouen, France
| | - Biagio Didona
- ToxiTEN group, European Reference Network for Rare Skin Diseases, Paris, France.,Rare Disease Unit, I Dermatology Division, Istituto Dermopatico dell'Immacolata, IRCCS, Rome, Italy
| | - Brigitte Milpied
- ToxiTEN group, European Reference Network for Rare Skin Diseases, Paris, France.,Toxic Bullous Dermatoses and Severe Drug Reactions reference center, TOXIBUL FIMARAD network, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France.,Department of Dermatology, Saint André Hospital, Bordeaux, France
| | - Annamari Ranki
- ToxiTEN group, European Reference Network for Rare Skin Diseases, Paris, France.,Department of Dermatology, Allergology and Venereology, University of Helsinki, Helsinki, Finland.,Helsinki University Hospital, Inflammation Center, Helsinki, Finland
| | - Carmen Salavastru
- ToxiTEN group, European Reference Network for Rare Skin Diseases, Paris, France.,Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Department of Pediatric Dermatology, Colentina Clinical Hospital, Bucharest, Romania
| | - Eva Brezinová
- ToxiTEN group, European Reference Network for Rare Skin Diseases, Paris, France.,First Department of Dermatovenereology, Masaryk University Faculty of Medicine, St Ann's Faculty Hospital in Brno, Brno, Czech Republic
| | - Sapna Divani-Patel
- Department of Dermatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Tine Lorentzen
- Department of Dermatology and Allergy Center, Odense University Hospital, Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Julie Loft Nagel
- Department of Dermatology and Allergy Center, Odense University Hospital, Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Skaidra Valiukeviciene
- Department of Skin and Venereal Diseases, Lithuanian University of Health Sciences (LUHS), Hospital of LUHS Kauno Klinikos, European Reference Network for Rare and Complex Diseases of the Skin members, Kaunas, Lithuania.,Department of Skin and Venereal Diseases, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Viktorija Karpaviciute
- Department of Skin and Venereal Diseases, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - George-Sorin Tiplica
- ToxiTEN group, European Reference Network for Rare Skin Diseases, Paris, France.,Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Department of Dermatology, Colentina Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Eva Oppel
- Department of Dermatology, University Hospital, Munich University of Ludwig Maximilian, Munich, Germany
| | - Anna Oschmann
- Department of Dermatology, University Hospital, Munich University of Ludwig Maximilian, Munich, Germany
| | - Nicolas de Prost
- Toxic Bullous Dermatoses and Severe Drug Reactions reference center, TOXIBUL FIMARAD network, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France.,Intensive care unit, AP-HP, Henri Mondor Hospital, Créteil, France
| | - Artem Vorobyev
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,ToxiTEN group, European Reference Network for Rare Skin Diseases, Paris, France.,Department of Dermatology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Saskia Ingen-Housz-Oro
- ToxiTEN group, European Reference Network for Rare Skin Diseases, Paris, France.,Toxic Bullous Dermatoses and Severe Drug Reactions reference center, TOXIBUL FIMARAD network, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France.,Dermatology Department, AP-HP, Henri Mondor Hospital, Créteil, France.,University Paris-Est Créteil EpiDermE, Créteil, France
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