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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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Low SSP, El-Shakankery K, Brown E, Christie A, McCormack S, Stares M. Case report: A rare case of immunotherapy induced isolated left CN VI palsy in a patient with unresectable melanoma. Front Oncol 2024; 14:1330271. [PMID: 38410107 PMCID: PMC10896602 DOI: 10.3389/fonc.2024.1330271] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/23/2024] [Indexed: 02/28/2024] Open
Abstract
Introduction Immune checkpoint inhibitors are the mainstay of treatment in patients with unresectable or metastatic melanoma. Combination immunotherapy with ipilimumab and nivolumab has shown to improve survival outcomes as compared to single agent immunotherapy in these patients. Neurological immune-related adverse effects (irAEs) are uncommon and cranial nerve palsies are seen even more infrequently. Case presentation A 66-year-old woman with a background of metastatic, unresectable melanoma with supraclavicular and axillary lymph nodal involvement presented with a headache, photophobia and diplopia 3 weeks after her first cycle of ipilimumab and nivolumab. She was subsequently diagnosed with a left-sided cranial nerve VI palsy and treated with high dose oral steroids and steroid eye drops, with complete resolution of symptoms. She also experienced Grade 3 dermatitis requiring topical steroids, Grade 2 hypothyroidism and vitiligo. She continues to have an excellent clinical and radiological response, despite further immunotherapy being suspended. Conclusion This is the first reported UK case of immunotherapy-induced isolated cranial nerve VI palsy. Multiple irAEs are more common with combination immunotherapy and its occurrence is associated with more favourable outcomes in melanoma. Immunotherapy continues to revolutionise oncological care, but clinicians must be cognizant of unpredictable irAEs, which may require prompt assessment and intervention.
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Affiliation(s)
- Samantha Su Ping Low
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, United Kingdom
| | - Karim El-Shakankery
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, United Kingdom
| | - Ewan Brown
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, United Kingdom
| | - Alan Christie
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, United Kingdom
| | | | - Mark Stares
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, United Kingdom
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, United Kingdom
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