Adjuvant Pembrolizumab versus Placebo in Resected Stage III Melanoma

Circulating cytokine associations with clinical outcomes in melanoma patients treated with combination nivolumab plus ipilimumab

Nivolumab plus ipilimumab (aCTLA-4/aPD-1) combination therapy has significantly improved clinical outcomes in patients with metastatic melanoma, with 50%-60% of patients responding to treatment, but predictors of response are poorly characterized. We hypothesized that circulating cytokines and peripheral white blood cells may predict response to therapy and evaluated 15 cytokines and complete blood counts (CBC with differentials) from 89 patients with advanced melanoma treated with combination therapy from three points in time: pre-treatment, one month and approximately three months after starting therapy. Clinical endpoints evaluated included durable clinical benefit (DCB), progression-free survival (PFS), and overall survival (OS). A parsimonious predictive model was developed to identify cytokines predictors of response to combination therapy. In this study, we found that pre-treatment, patients with DCB had higher IL-23, lower CXCL6, and lower IL-10 levels. Lower NLR one month after starting therapy predicted better PFS and OS, primarily driven by an increase in absolute lymphocytes. A multivariate model demonstrated that baseline CXCL6, IL-10, IL-23 were independent predictors of therapy response, and the combined model has reached an area under the curve (AUC) of 0.79 in prediction of response to combination therapy. Our study identified baseline CXCL6, IL-23, and IL-10 as predictors of response to aCTLA4/aPD1 combination therapy among patients with metastatic melanoma. This study also provides a framework for identifying patients who are likely to respond to combination ICB, as well as a subset of patients with high risk of developing resistance and are thus in need of alternative therapeutic options, such as clinical trials.

Efficacy and safety of adjuvant systemic therapies in trial non-eligible resected stages III and IV melanoma patients

BACKGROUND

Adjuvant immunotherapy and targeted therapy are now the standard of care for patients with resected stage IIIA-IV melanoma. However, little is known regarding its efficacy in real-world patients who were not represented in these landmark trials.

METHODS

This retrospective study included all patients with resected stage IIIA-IV melanoma who received adjuvant systemic therapy between January 1 2018 and December 31 2020, in two Canadian academic cancer. Primary outcome was the proportion of trial non-eligible patients in the real-world setting. Survival and safety analyses were also conducted.

RESULTS

Of the total 113 patient, 99 (88%) were trial non-eligible patients. Most common reasons for trial non-eligible criteria was having no baseline CLND (72%), followed by outside of treatment window >12 weeks (30%), stage IIIA (14%), unknown primary (9%), stage IV (14%), and baseline AD on immunosuppressants (3%). There were no significant RFS (P = 0.731) or OS (P = 0.110) differences in the overall population of trial eligible vs. non-eligible. Safety profiles were similar between the trial eligible vs. non-eligible groups.

CONCLUSION

Our study suggested a high proportion of real-world patients would have been deemed non-eligible for clinical trials. Regardless, adjuvant systemic therapy delivered similar survival and toxicity outcomes in both groups.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

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

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

Is One Year Enough? Extended Adjuvant Dabrafenib Plus Trametinib for Chinese Patients With Resected Stage III Melanoma

BACKGROUND

Pathogenic BRAF mutations drive constitutive MAPK pathway activation in melanoma, and targeted therapies with dabrafenib plus trametinib have improved outcomes in the adjuvant setting. However, the optimal duration of adjuvant therapy remains unclear. This retrospective study examined whether extending dabrafenib plus trametinib beyond 1 year offers additional clinical benefit in Chinese patients with resected Stage III melanoma.

METHODS

Medical records from six centers were reviewed for adults with BRAF V600E/K-positive, completely resected Stage III melanoma who received at least 12 months of adjuvant dabrafenib plus trametinib. Patients were divided into a 1-year therapy group and a more-than-1-year therapy group. Relapse-free survival (RFS) was the primary end point; adverse events were also assessed.

RESULTS

Of the 122 patients included, 77 received more than 1 year of adjuvant therapy. The more-than-1-year group experienced significantly better RFS (log-rank p = 0.04), and longer therapy independently reduced recurrence risk in multivariate analysis (HR, 2.42; p = 0.035). Adverse event profiles did not differ between groups, and toxicity-related treatment modifications occurred primarily within the first year.

CONCLUSIONS

Extending dabrafenib plus trametinib beyond 1 year may provide improved RFS without increasing toxicity. Further prospective trials are warranted to confirm the impact on overall survival and identify optimal patient subsets for prolonged therapy.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Interventions

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Trial Registration

ClinicalTrials.gov Identifier: NCT03427827.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Reduction in surgical interventions in melanoma

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL TRIAL INFORMATION

NCT04099251.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

PROCEDURE

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

RESULTS

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

CONCLUSIONS

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

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.

Lactylation-Driven NUPR1 Promotes Immunosuppression of Tumor-Infiltrating Macrophages in Hepatocellular Carcinoma

While checkpoint immunotherapy effectively mobilizes T-cell responses against tumors, its success in hepatocellular carcinoma (HCC) is frequently undermined by immunosuppressive myeloid cells within the tumor microenvironment. This study investigates the role of nuclear protein 1 (NUPR1), a gene prominently expressed in tumor-associated macrophages (TAMs), in mediating this suppression and influencing immunotherapy outcomes. Through comprehensive analysis of single-cell RNA sequencing (scRNA-seq) datasets and functional assays in vitro and in vivo, NUPR1 is identified as a critical regulator within TAMs. The upregulation of NUPR1 is associated with enhanced M2 macrophage polarization and increased expression of immune checkpoints PD-L1 and SIRPA, resulting in CD8+ T cell exhaustion and a diminished response to immunotherapy. Mechanistically, NUPR1 inhibits the ERK and JNK signaling pathways, thereby creating an immunosuppressive milieu conducive to tumor progression. Additionally, tumor-derived lactate is shown to upregulate NUPR1 expression in macrophages via histone lactylation, perpetuating a feedback loop that intensifies immune suppression. Pharmacological targeting of NUPR1 reverses M2 polarization, curtails tumor growth, and augments the efficacy of PD-1 blockade in preclinical models, positioning NUPR1 as both a potential biomarker for immunotherapy responsiveness and a therapeutic target to boost immunotherapy efficacy in HCC.

A Pan-Cancer Comparative Analysis of The Cancer Genome Atlas Transcriptomic TIL-Immune Signatures

Efforts to understand the tumor microenvironment (TME) through basic science research and The Cancer Genome Atlas (TCGA) data analysis have led to the creation of unique immune transcriptomic signatures from tumor-infiltrating lymphocytes (TIL). However, no pan-cancer analysis has been conducted to compare the prognostic performance of these signatures using overall survival (OS) or progression-free interval (PFI) as endpoints. We compiled a library of 146 TIL-immune signatures and evaluated gene signature score correlation with OS and PFI for 9,961 available TCGA samples across 33 cancer types. Zhang CD8 TCS demonstrated higher accuracy in prognosticating both OS and PFI across the pan-cancer landscape, however, variability was seen across cancer types and germ cell origin. Cluster analysis compiled a group of six signatures (Oh.Cd8.MAIT, Grog.8KLRB1, Oh.TIL_CD4.GZMK, Grog.CD4.TCF7, Oh.CD8.RPL, Grog.CD4.RPL32) whose association with OS and PFI could potentially be conserved across multiple cancer types.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

CONCLUSION

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

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

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

PD-L1 Inhibitor Cosibelimab for Cutaneous Squamous Cell Carcinoma: Comprehensive Evaluation of Efficacy, Mechanism, and Clinical Trial Insights

Cutaneous squamous cell carcinoma (CSCC) is one of the most common non-melanoma skin cancers, and particularly challenging to treat in advanced or metastatic stages. Traditional therapies, including chemotherapy and radiation, often result in limited efficacy and severe side effects. Cosibelimab, a fully human monoclonal antibody targeting PD-L1, has emerged as a promising immunotherapy for advanced CSCC. In this review, we evaluate the therapeutic potential of cosibelimab by analyzing its mechanism of action, clinical trial data, and its role compared to other PD-1/PD-L1 inhibitors, such as pembrolizumab and cemiplimab. We synthesized the available preclinical and clinical data on cosibelimab, focusing on published Phase I and II trial results involving 76 patients. Objective response rates (ORRs), progression-free survival (PFS), overall survival (OS), and safety profiles were compared between cosibelimab, pembrolizumab, and cemiplimab. Mechanistic insights into cosibelimab's dual action, including PD-L1 blockade and antibody-dependent cellular cytotoxicity (ADCC), were also explored. Phase II trials demonstrated an ORR of 47.5%, with a median PFS of 12.9 months in advanced CSCC patients. Cosibelimab demonstrated a favorable safety profile, with predominantly mild to moderate adverse events. Comparative analysis with pembrolizumab and cemiplimab showed similar efficacy, although long-term survival data for cosibelimab is still emerging. Given its efficacy and safety, cosibelimab holds promise not only as a monotherapy but also for future exploration in combination regimens and broader oncologic indications. Future trials are required to validate its long-term outcomes, including overall survival, and to explore its use in combination therapies and neoadjuvant/adjuvant settings.

Immune-Based Strategies for Pancreatic Cancer in the Adjuvant Setting

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

Efficacy of adjuvant therapy in patients with stage IIIA cutaneous melanoma

BACKGROUND

Patients with resected American Joint Committee on Cancer 8th edition (AJCC v8) stage IIIA melanoma have been under-represented in clinical trials of adjuvant drug therapy. The benefit of adjuvant targeted therapy and immunotherapy in this population is unclear.

PATIENTS AND METHODS

In this multicenter, retrospective study, patients with stage IIIA melanoma (AJCC v8) who received adjuvant pembrolizumab or nivolumab (anti-PD1), BRAF/MEK-targeted therapy dabrafenib + trametinib (TT), or no adjuvant treatment (OBS) were included. Recurrence-free survival (RFS), distant metastasis-free survival (DMFS), and toxicity rates were examined.

RESULTS

A total of 628 patients from 34 centers across Australia, Europe and USA were identified - 256 in anti-PD1, 80 in TT and 292 in OBS. The median follow-up was 2.6 years (IQR, 1.6-3.4 years). The presence of some key poor prognostic variables was significantly higher in anti-PD1 compared to OBS. The two-year RFS was 79.3% (95% CI, 74.1-84.8) for anti-PD1, 98.6% (95% CI, 96.0-100) for TT and 84.3% (95% CI, 79.9-89.0) for OBS. The two-year DMFS was 88.4% (95% CI, 84.3-92.8) in anti-PD1, 100% in TT and 91.1% (95% CI, 87.7-94.7) in OBS. Higher Breslow thickness and higher mitotic rate were associated with higher risk of recurrence in the anti-PD1 and OBS (P<0.05). Rates of ≥ Grade 3 toxicities were 10.9% with anti-PD1 and 17.5% with TT; discontinuation due to toxicity occurred in 13.3% and 21.2%, respectively. Rates of unresolved toxicity at last follow-up were 26.9% in anti-PD1 and 12.5% in TT groups.

CONCLUSIONS

Stage IIIA melanoma has a modest risk of recurrence. Adjuvant anti-PD1 did not significantly improve RFS or DMFS compared to OBS alone. Adjuvant TT appears promising over anti-PD1 or OBS. Outcomes after adjuvant therapy in this population needs further study in larger datasets with longer follow up or prospective randomised trials.

Vitiligo-like hypopigmentation secondary to adjuvant checkpoint inhibitor therapy in patients with resectable stage III melanoma: a cohort from two tertiary hospitals

Vitiligo-like hypopigmentation induced by immune checkpoint inhibitors (ICIs) has been largely associated with improved survival outcomes in metastatic melanoma. However, its development during adjuvant ICI therapy and its role as a prognostic factor in this setting remain unclear. We aimed to describe ICI-induced vitiligo in a cohort of patients with resected stage III melanoma treated with adjuvant ICI and to identify differences in progression-free survival (PFS) and distant metastasis-free survival (DMFS) between those who developed vitiligo and those who did not. Patients and data were collected from two institutions, both retrospectively and prospectively, from January 2018 to February 2024. Patients were divided into 'vitiligo' and 'non-vitiligo' groups for comparisons. Of 40 patients, 22.5% developed ICI-induced vitiligo [median follow-up: 23 months (1-73)]. Treatments received were nivolumab (70%) and pembrolizumab (30%). Fifty-five percent of the patients completed 1 year of treatment, 37.5% discontinued and 7.5% were still ongoing. Vitiligo and non-vitiligo groups differed in the cause of treatment discontinuation (severe toxicity in vitiligo vs. progression in non-vitiligo, P  = 0.005) and the occurrence of progression (none in vitiligo vs. 52% in non-vitiligo, P  = 0.001). Survival analyses showed longer PFS in vitiligo group ( P  = 0.013) and no differences in DMFS ( P  = 0.111). ICI-induced vitiligo typically affected photo-exposed areas, with a median time to onset of 4 months (1-27). These preliminary results on ICI-induced vitiligo in adjuvant treatment are in agreement with those reported in advanced melanoma treatment, so its development in the adjuvant setting could be a sign of good prognosis as well.

Rate of response to immune checkpoint inhibitor therapy in patients with conjunctival melanoma

Our primary objective was to estimate the overall response rate to immune checkpoint inhibitors (ICIs) in patients with locally advanced, multiply recurrent, or metastatic conjunctival melanoma treated with ICIs. A retrospective review of all consecutive conjunctival melanoma patients who were treated with ICI between October 2017 and January 2024 was carried out. The study included 16 patients with a median age of 66 years. The indications for ICI were locally extensive conjunctival melanoma in the eye/orbital area without nodal or distant metastasis in 10 patients, local recurrence of conjunctival melanoma and simultaneous nodal or distant metastasis in four patients, and metastatic conjunctival melanoma without local recurrence in two patients. Five patients received PD-1 inhibitor monotherapy with nivolumab or pembrolizumab; the other 11 received ipilimumab (CTLA-4 inhibitor) and nivolumab for several cycles and were then continued on nivolumab monotherapy ( n = 6) or not given additional ICI therapy ( n = 3). The number of cycles of ICI ranged from 2 to 25 (median, 13). Eight patients achieved a complete response. Six patients had progressive disease. The overall rate of objective response to ICI therapy was 63% (10 of 16), and for the subset of patients with local disease only, the objective response rate was 70% (7 of 10). In 14 patients (88%), orbital exenteration or additional extensive surgery was avoided; two patients had progression despite ICI and eventually needed an orbital exenteration. Future studies should aim to correlate biomarker data with response to ICI therapy in patients with conjunctival melanoma.

Melanoma neoadjuvant treatment: review and update of recent trials

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Immunotherapy for treatment of female genital tract melanoma: National Cancer Database analysis

Goal of this study was to examine the impact of immunotherapy on overall survival (OS) in patients with female genital tract melanoma (GTM). This retrospective cohort study utilized the National Cancer Database to identify individuals with invasive vulvar or vaginal melanoma diagnosed between 2004 and 2019. Kaplan-Meier plots and multivariate Cox regression were used to describe the impact of immunotherapy on OS and to examine predictors of OS among those who received immunotherapy for those with vulvar or vaginal melanoma. Of the 870 patients with vaginal melanoma, 23.6% received immunotherapy. Receiving immunotherapy for treatment of vaginal melanoma was associated with improved OS (median: 21.8 versus 18.9 months; P = 0.01); this association remained after adjustment for other prognostic factors [hazard ratio (HR), 0.77; 95% confidence interval (CI), 0.62-0.95; P = 0.01]. The survival advantage was more pronounced among those who did not receive primary surgical resection (median: 18.6 versus 12.2 months; P = 0.0009). Among 3123 patients with vulvar melanoma, 15.3% received immunotherapy. Receiving immunotherapy for treatment of vulvar melanoma was associated with an improvement in OS (median: 43.6 versus 57.7 months; P = 0.06; HR, 0.86; 95% CI, 0.74-1.00; P = 0.04). Survival benefit was more pronounced when restricted to patients with advanced or unknown stage disease (median OS, 31.6 versus 24.2 months; P = 0.002; adjusted HR, 0.74; 95% CI, 0.61-0.89; P = 0.002) and among the small subset who did not receive primary surgical resection (median: 19.8 versus 9.6 months; P = 0.0005). Immunotherapy was associated with improved OS in patients with female GTM, with some subsets particularly benefitting.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Steroid-refractory severe immune-related mucositis following adjuvant anti-PD-1 therapy for resectable melanoma: a case report

Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment and are increasingly used, also in the adjuvant and neoadjuvant settings. ICIs, however, can induce immune-related adverse events (irAEs), which range from mild to life-threatening. As the use of ICIs expands, prompt identification and management of especially severe and life-threatening irAEs are crucial. We report a case of grade 4 steroid-refractory immune-related mucositis in a 60-year-old male treated with pembrolizumab following complete resection of stage IIIC melanoma. The patient received seven courses of adjuvant pembrolizumab without adverse events until 2 weeks after the seventh dose, when he presented with acute respiratory distress, dysphagia, and dyspnea. Examination revealed significant throat swelling and mucosal edema. Despite initial treatment with high-dose steroids, the patient's condition deteriorated, and he was admitted to the ICU for intubation and close monitoring. Infliximab was administered for steroid-refractory mucositis, resulting in rapid symptom resolution and successful extubation 5 days later. This case highlights the challenges in managing severe steroid-refractory irAEs. The rapid response to infliximab suggests the benefit of early intervention with alternative immunosuppressive agents in severe irAEs. Increased awareness of rare irAEs is essential for optimizing treatment and improving outcomes for patients receiving ICIs.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Applications and challenges of immunotherapy in the management of gastric adenocarcinoma: current status and future perspectives

Gastric adenocarcinoma (GAC) remains a significant global public health challenge, characterized by high incidence and mortality rates. Progress in tumor immunology has introduced immune checkpoint inhibitors (ICIs) targeting the programmed cell death-1 (PD-1)/programmed cell death-ligand 1 (PD-L1) and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) pathways, demonstrating substantial potential in GAC therapy. Clinical research indicates that ICIs, particularly when combined with chemotherapy or targeted therapies, significantly enhance treatment efficacy in advanced GAC and specific molecular subtypes, including microsatellite instability-high (MSI-H) and human epidermal growth factor receptor 2 (HER2)-positive patients. However, immunotherapy is also associated with a range of immune-related adverse events (irAEs), necessitating effective management strategies to ensure treatment safety and maintain patients' quality of life. Future studies should focus on identifying new therapeutic targets, optimizing patient selection, and developing personalized treatment approaches to further improve the efficacy and safety of immunotherapy in GAC.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Late-Onset Immune-Related Adverse Events After Immune Checkpoint Inhibitor Therapy

Importance

The use of immune checkpoint inhibitors (ICIs) is increasing. Little is known about the frequency of late-onset immune-related adverse events (irAEs) and the patient-specific risk factors associated with their development.

Objectives

To assess the incidence of persistent or de novo late-onset irAEs requiring hospitalization and identify patient factors associated with risk of late-onset irAEs.

Design, Setting, and Participants

This retrospective observational cohort study conducted from January 2011 to October 2022 included patients who received ICIs and were hospitalized with irAEs at an academic medical center. Exclusion criteria included ICI therapy outside of the hospital system and no irAE diagnosis during admission. Data were analyzed from November 15, 2022, to January 8, 2025.

Exposure

Late-onset irAEs.

Main Outcomes and Measures

The main study outcomes were (1) incidence of irAE hospitalization at 0 to 6 months (early), more than 6 to 12 months (intermediate), and more than 12 months (late) after ICI initiation and (2) patient factors associated with risk of late-onset irAEs.

Results

Among the 795 patients hospitalized with irAEs, the median age was 67.3 years (IQR, 58.3-74.8 years); 476 (59.9%) were male. Most patients (n = 517 [65.0%]) received anti-programmed death ligand 1 (PD-L1) and anti-programmed cell death 1 monotherapy, with the most common indications being melanoma (n = 335 [42.1%]) and lung cancer (n = 167 [21.0%]). The median time from start of ICI therapy to hospital admission was 2.7 months (IQR, 1.2-6.1 months), with 14.7% of patients (n = 117 of 795) presenting 6 to 12 months after initial ICI exposure and 10.8% of patients (86 of 795) presenting more than 12 months after initial exposure. The irAEs most likely to present late included those involving the kidney (10 of 32 [31.3%]) and hematologic (5 of 23 [21.7%]) organ systems. In univariate analysis, ICI type was significantly associated with the timing of hospital admission for irAEs; of the 517 patients receiving anti-PD-L1-based therapy, 13.5% (n = 70) presented late compared with 5.4% (9 of 167) receiving dual therapy with anti-cytotoxic T-lymphocyte-associated protein 4 (P < .001). Patients receiving perioperative ICI therapy were significantly more likely to be admitted at the intermediate interval (16 of 68 [23.5%]) compared with those with metastatic disease (87 of 678 [12.8%]) (P = .03). Timing of irAE was also significantly associated with active ICI exposure; among the patients presenting late, 7.4% (48 of 651) had received ICI therapy within the last 60 days compared with 26.4% (38 of 144) who had not had recent ICI exposure (P < .001).

Conclusions and Relevance

The findings of this retrospective observational cohort study suggest that late irAEs are possible, with a subset of patients presenting years after the start of ICI therapy. Clinicians must remain vigilant for irAEs regardless of elapsed time from ICI therapy, especially as patients live longer and ICIs become more widely used. Future investigations are needed to better understand the risk factors for late-onset irAEs and the distinct immunologic pathways that underlie such events.

Sequencing of Immunotherapy and Outcomes in Operable Clinical Stage III Melanoma: A National Cohort Study

BACKGROUND AND OBJECTIVES

The impact of neoadjuvant immunotherapy (NIT) on overall survival (OS) in patients with resectable stage III melanoma remains unknown. We sought to identify factors associated with receipt of NIT and survival outcomes in patients with clinical stage III melanoma undergoing surgery.

METHODS

The National Cancer Database (2016-2020) was used to identify patients with clinical stage III melanoma who underwent surgery and received either NIT or adjuvant immunotherapy (AIT) only. Multivariable regression, Kaplan-Meier, and Cox proportional hazard methods were used to analyze variables of interest.

RESULTS

Patients with clinical N3 disease had 2.5 times the odds of NIT compared to those with N1 disease (95% CI 1.74-3.49). There was no difference in 3-year OS between the two cohorts: 79% (95% CI 73%-85%) for NIT patients and 75% (95% CI 73%-76%) for AIT patients (p = 0.078). Patients with N2/N3 disease had improved 3-year OS of 79% with NIT versus 71% for AIT-only (HR 0.61, 95% CI 0.38-0.97, p = 0.037).

CONCLUSIONS

NIT is given more selectively to clinical stage III patients with more advanced N category disease. Despite significant differences in N category between groups, there was no difference in OS observed at 3 years, and NIT was associated with a survival advantage among N2/N3 patients.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PATIENTS

Seven patients undergoing pelvic exenteration for pelvic mucosal melanoma.

MAIN OUTCOME MEASURES

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

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

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

Impact of Adjuvant Interferon Therapy on Survival Outcomes for Cutaneous Melanoma With Parotid Involvement

OBJECTIVES

To determine the relative 5-year overall survival (OS) and 5-year recurrence-free survival (RFS) outcomes for adjuvant interferon therapy in the treatment of head and neck cutaneous melanoma (HNCM) with parotid gland involvement.

METHODS

A retrospective cohort study was conducted at a single tertiary care institution to analyze patients undergoing parotidectomy for cutaneous head and neck melanoma involving the parotid gland from 2000 to 2014. Time-to-event analyses were performed using Kaplan-Meier curves with log-rank p-values and Cox proportional hazards models.

RESULTS

The sample consisted of 82 patients who underwent surgical resection of stage III HNCM with parotid involvement. The mean follow-up was 67.8 months (SD 65) after diagnosis. Twenty-one patients received adjuvant interferon therapy, 12 patients received adjuvant radiation therapy, and 49 patients received no adjuvant therapy. Crude 5-year OS rates were 95.0% for interferon therapy, 33.3% for adjuvant RT, and 40.4% for no adjuvant therapy. Crude 5-year RFS rates were 75.2%, 19.5%, and 40.8% respectively. In the fully adjusted model, adjuvant interferon therapy was associated with improved 5-year OS compared to adjuvant RT (HR 0.10, 95% CI 0.011-0.837; p = 0.034). There was no significant association between adjuvant interferon therapy and 5-year RFS in the fully adjusted model.

CONCLUSION

Adjuvant interferon therapy for surgically resected stage III cutaneous melanoma with parotid gland involvement may be associated with improved survival outcomes. These findings support the growing evidence for the use of immunotherapy in melanoma, and potentially a unique role for when melanoma involves the lymphatic-rich parotid gland.

LEVEL OF EVIDENCE

3 Laryngoscope, 135:1098-1104, 2025.

Radiation therapy in combination with immune checkpoint inhibitors in metastatic lung cancer: Effect of fractionation

Immunotherapy with checkpoint inhibitors has improved the outcomes of patients with metastatic lung cancer in recent years. Despite improved prognosis, not all patients respond to treatment. Therapeutic interventions to build on the success of immune checkpoint inhibitors are needed. A retrospective review of patient records for patients who had received immune checkpoint inhibitors in a single cancer center over 4 years was undertaken. Demographic and disease characteristics of patients with metastatic non-small cell lung cancer were recorded. Data on other treatments including chemotherapy and radiation therapy were extracted, and survival outcomes were calculated. Most (81.8%) of the 77 metastatic lung cancer patients examined had received palliative radiation therapy within 3 months of starting immune checkpoint inhibitors. While the survival outcomes of these patients did not differ from patients who had not received radiotherapy, patients who had undergone hypofractionated radiotherapy (defined as one or more fractions of 700 cGy or higher) displayed a better overall survival (OS) than the rest of the cohort. Palliative radiation therapy administered in proximity with immune checkpoint inhibitors immunotherapy had no effect on the OS of metastatic lung cancer patients. However, patients receiving palliative radiotherapy with fractions above 700 cGy showed better OS. Further studies are needed to optimize a combination strategy.

Real-Life Cohort of Patients With Resected High-Risk Melanoma Treated by Adjuvant Anti-PD1 Therapy

BACKGROUND

Programmed cell death protein-1 (PD1) antibodies are currently the standard treatment for resected high-risk melanoma, yet recurrence rate remains high.

OBJECTIVES

This real-life observational study aimed to describe the outcomes of patients with resected high-risk melanoma following adjuvant anti-PD1 immunotherapy and identify factors associated with recurrence risk.

MATERIALS AND METHODS

A total of 235 patients with resected stage III/IV melanoma treated with adjuvant nivolumab or pembrolizumab were included. Imaging scans and cerebral imaging were performed every 12 weeks to detect recurrences. Adverse events were collected. Univariate and multivariate analyses were performed to identify predictive factors of recurrence. Overall survival (OS) and recurrence-free survival (RFS) were estimated.

RESULTS

Among the 235 patients, 103 experienced at least one recurrence (43%); first recurrences were predominantly locoregional (47%). The predictive factor for recurrence identified by multivariate analysis was ulceration (RR 2,03, 95% CI [1,20; 2,86]). RFS was estimated at 75% [70-81] at 12 months and at 64% [58-71] at 24 months. RFS at 12 months was significantly lower in patients with ulcerations (RFS at 83%) compared to those without ulceration (RFS at 66%), p < 0.01. Overall survival (OS) was estimated at 91% [87%-94%] at 12 months and 84% [79%-89%] at 24 months. The OS after a first recurrence was estimated at 69% [60%-80%] at 12 months and decreased to 43% [32%-57%] at 24 months. After a first locoregional recurrence, surgery with a year of adjuvant immunotherapy (40%) was the favoured therapeutic approach. For distant recurrences, clinical trial enrolment was preferred (21%). Double curative immunotherapy was the preferred strategy for cerebral recurrences (30%).

CONCLUSIONS

In this cohort, nearly half of the patients underwent recurrences and RFS at 24 months was 64%. The RFS and OS data were comparable o those reported in the pivotal study Ulceration was the only significant predictive factor for recurrence, associated with decreased RFS at 24 months.

Changes in the surgical management of melanoma and measures to implement change

BACKGROUND

Cutaneous malignant melanoma has traditionally been a surgically managed disease. Recent clinical trials highlight major shifts in surgical management of this disease, emphasizing a multidisciplinary approach.

METHODS

Clinical trials evaluating the role of completion lymph node dissection (CLND) in the management of sentinel lymph node positive patients and more recent trials evaluating the impact of neoadjuvant immunotherapy on patients presenting with clinically advanced but surgically resectable melanoma are reviewed, as well as ongoing trial evaluating surgical margins.

RESULTS

Both DeCOG and MSLT-II trials confirmed that CLND is no longer standard management of the sentinel node positive patient. CLND offers no melanoma-specific survival benefit. Associated surgical morbidity justifies a surveillance and observation approach, combined with adjuvant therapy. Patients presenting with clinically advanced surgically resectable disease are best served by neoadjuvant therapy. This approach demonstrates significantly improved melanoma-specific survival compared to upfront surgery, underscoring the need for rapid adoption by surgeons.

CONCLUSIONS

Changes in surgical management of melanoma have been dramatic and offer patients improved outcomes though both reduction in the magnitude of surgery, as well as improved disease specific survival for patients with advanced surgically resectable disease.

Outcomes of Immunotherapy Treatment in Sinonasal Mucosal Melanoma

BACKGROUND

Sinonasal mucosal melanoma has poor survival despite multimodality treatment. While the impact of immunotherapy (IT) on metastatic cutaneous melanoma is well-defined, there are relatively little data on sinonasal mucosal melanoma.

OBJECTIVE

We sought to define immunotherapy outcomes in patients with sinonasal mucosal melanoma.

METHODS

A retrospective cohort study evaluated patients treated with IT during their overall treatment strategy for SNMM. Patient demographics, treatment, and survival outcomes were recorded.

RESULTS

52 patients had IT treatment for SNMM from 2000 to 2022, with an average age of 69.1 ± 11.9 years. The most common treatment was surgery with radiation and IT (n = 26, 50%). Most regimens consisted of a combination of Nivolumab and Ipilimumab (n = 17, 32.7%) or pembrolizumab (n = 14, 26.9%). 44.2% of patients experienced reported complications. Overall survival at 1-, 2-, and 5 years was 86.9%, 74.1%, and 39.1%, respectively.

CONCLUSION

Approximately half of patients will have a local response following immunotherapy, but it is rare to have improvement at metastatic locations. Further research within our group will assess optimal timing and markers that are predictive of response.

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

Background

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

Methods

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

Results

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

Conclusions

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

Molecular biology of the novel anticancer medications: a focus on kinases inhibitors, biologics and CAR T-cell therapy

INTRODUCTION

Cancer treatment underwent significant changes in the last few years with the introduction of novel treatments targeting the immune system.

OBJECTIVES

The objective of this review is to discuss novel anticancer drugs including kinase inhibitors, biologics and cellular therapy with CAR-T cells.

METHODS

Most recent research articles were extracted from PubMed using keywords such as "kinases inhibitors", "CAR-T cell therapy".

RESULTS AND DISCUSSION

The number of kinase inhibitors is significantly increasing due to their demonstrated effectiveness in combination with biologics. CAR-T represented a major breakthrough in the field. Also, it focused on their mechanisms of action and the rational of their use either alone or in combination in relation to their modes of action.

Tumor infiltrating lymphocytes in primary melanoma are associated with a better prognosis

BACKGROUND

The relationship between tumor infiltrating lymphocytes (TIL) and survival in melanoma is poorly understood. We present a large multicenter study assessing the association between TIL and survival.

METHODS

The Sentinel Lymph Node Working Group database was queried from 1993 to 2024 for cases with known TIL and survival data. TIL was analyzed dichotomously and stratified as non-brisk, brisk, and absent. Clinicopathologic factors were correlated with melanoma-specific survival (MSS), overall survival (OS), and recurrence-free survival (RFS).

RESULTS

Among 4957 patients, TIL was present in 3980 (80.2 ​%) of patients. TIL was prognostic of MSS (p ​= ​0.0033), OS (p ​= ​0.0053), and RFS (p ​= ​0.0011). In the stratified analysis, brisk TIL was more strongly associated with MSS, OS, and RFS than non-brisk TIL (all p ​< ​0.04). Among patients with a positive sentinel lymph node, TIL was prognostic of MSS, OS, and RFS (all p ​< ​0.03).

CONCLUSIONS

TIL is strongly predictive of survival in melanoma and may be useful in risk stratification when deciding whether risks of adjuvant therapy outweigh benefits for certain patients.

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

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

Adjuvant Proton Beam Radiation Therapy for Sinonasal Mucosal Melanoma

BACKGROUND

Head and neck mucosal melanoma (HNMM) is rare and carries a poor prognosis with high rates of disease progression. There is little data regarding the use of adjuvant proton radiation therapy in the management of sinonasal HNMM.

AIMS

We performed a retrospective review of patients with nonmetastatic sinonasal HNMM treated with adjuvant proton radiation from 2012 to 2022 at a single academic institution. Kaplan-Meier estimates were used for survival analyses.

METHODS AND RESULTS

Eight patients with sinonasal HNMM were treated with surgery and adjuvant proton radiation, and six received systemic therapy. Median follow-up was 15 months (range: 3-68 months). Only one local failure was observed, and two patients developed distant metastases. Kaplan-Meier 1-year results were as follows: local control 88%, distant metastasis-free survival 75%, and overall survival 88%. No Grade 3 or higher late toxicities were observed.

CONCLUSION

Surgical resection and adjuvant proton radiation provided early favorable local control and toxicity profiles in our cohort of patients with sinonasal HNMM. Further multi-institutional work is needed to study this rare malignancy.

DNA damage response and repair gene mutations predict clinical outcomes in biliary tract cancer

BACKGROUND

This study aims to explore the genetic characteristics of biliary tract cancer (BTC), with a particular focus on the impact of DNA damage response and repair (DDR) genes on clinical outcomes.

METHODS

A total of 180 patients with BTC and next-generation sequencing data were retrospectively analyzed. Clinical outcomes were compared between DDR-positive and DDR-negative groups.

RESULTS

DDR mutations were found in 28.3% of patients, with ATM (7.8%), BAP1 (5.6%), and BRCA2 (3.3%) being the most common. DDR-positive patients receiving first-line platinum-based chemotherapy (n = 73) had a significantly higher objective response rate (50.0% vs. 14.9 %; p = .001), longer median progression-free survival (mPFS) (7.7 vs. 3.8 months; p = .001) and longer median overall survival (28.6 vs. 11.9 months; p < .001). Multivariate analysis confirmed that deleterious DDR gene mutations were independently associated with prolonged mPFS (hazard ratio [HR], 0.37; 95% CI, 0.20-0.67; p < .001) and median overall survival (mOS) (HR, 0.19; 95% CI, 0.08-0.46; p < .001). In 56 patients receiving immunotherapy combined with chemotherapy, DDR-positive patients had a significantly higher overall response rate (45% vs. 8.3%; p = .001), longer mPFS (7.7 vs. 3.8 months; p = .009), and longer mOS (12.7 vs. 8.8 months; p = .011). Multivariate analysis showed that the presence of deleterious DDR gene mutations was associated with significantly longer mPFS (HR, 0.34; 95% CI, 0.16-0.73); p = .005] and mOS (HR, 0.23; 95% CI, 0.08-0.62; p = .004).

CONCLUSION

Deleterious DDR gene mutations are associated with improved clinical outcomes in patients with BTC treated with platinum-based chemotherapy or immunotherapy combined with chemotherapy.

Impact of Adopting a Multidisciplinary Care Delivery Model on Treatment Effectiveness and Outcomes in Stage III Melanoma Patients at a Community-Based Academic Institution: A Retrospective Study

Purpose Stage III melanoma represents a high-risk patient population, highlighting the need to implement strategies to prevent the onset of metastatic disease. This study evaluates the impact of systems of care, incorporating multidisciplinary care (MDC), nurse navigation, clinical trials, and early anti-PD1 immunotherapy use, on outcomes for this patient population. Patients and methods We conducted a retrospective chart review to evaluate the impact of an updated melanoma MDC program implemented at our institution in late 2016. This program facilitated access to nurse navigation, along with early PD-1 immunotherapy use and clinical trial enrollment, with the expectation of improved outcomes for our melanoma patients. Data were collected from 121 stage III melanoma patients treated at our institution between 2014 and 2019, divided into two cohorts: 2014-2016 (n = 66) and 2017-2019 (n = 55). Primary outcomes included three-year disease-free survival (DFS) and overall survival (OS). Secondary outcomes included disease recurrence rates and melanoma-related mortality. Results Implementation of an MDC model led to a significant increase in immunotherapy use, multidisciplinary visits, and nurse navigation. These combined factors resulted in a 30% increase in three-year DFS (from 48% to 78%, p = 0.001) and a 17% increase in three-year OS (from 63% to 80%, p = 0.04). There was a 30% decrease in stage III melanoma mortality (39% vs. 9%, p < 0.001). Conclusion Systematic sub-specialized care, nurse navigation, access to clinical trials, MDC care, and rapid adoption of advancements in the standard of care led to improved patient outcomes at our institution.

Cardiotoxicity associated with immune checkpoint inhibitors: Systematic review and meta-analysis

BACKGROUND AND AIMS

The aim of this systematic review was to assess the risk of cardiac toxicity in patients undergoing approved PD-1 (nivolumab, pembrolizumab, cemiplimab, dostarlimab), PD-L1 (atezolizumab, avelumab, durvalumab), and CTLA-4 (ipilimumab) inhibitors.

RESULTS

Among a total of 2272 articles, 11 phase II and III clinical trials included: 5463 patients and 175 cardiac adverse events. The most common cardiac disorder was atrial fibrillation (12 %), while cardiac arrest and cardiac failure (6 %) led to death in three cases. Overall, ICI treatment increased the risk of cardiotoxicity compared with control groups (RR=1.62, 95 %-CI= 1.18-2.24, p-value=0.0033; OR=1.71, 95 %-CI= 1.20-2.42, p-value=0.0027).

CONCLUSIONS

This study proved that the recognition of frequency and severity of all grade cardiotoxicity associated with ICIs is still underestimated. Thus, a systematic cardiological screening becomes necessary, in order to intercept the potential cardiological complications beforehand and optimize the outcomes of the respective treatment with PD-1, PD-L1 and CTLA-4 inhibitors.

Acral Melanoma in Skin of Color: Current Insights and Future Directions: A Narrative Review

Acral melanoma (AM), also known as acral lentiginous melanoma (ALM), is a rare subtype of melanoma that predominantly occurs on the palms, soles, and nail beds (Figure 1) [...].

Adjuvant Atezolizumab for Early Triple-Negative Breast Cancer: The ALEXANDRA/IMpassion030 Randomized Clinical Trial

Importance

Triple-negative breast cancer is an aggressive subtype with a high incidence in young patients, a high incidence in non-Hispanic Black women, and a high risk of progression to metastatic cancer, a devastating sequela with a 12- to 18-month life expectancy. Until recently, one strategy for treating early-stage triple-negative breast cancer was chemotherapy after surgery. However, it was not known whether the addition of immune therapy to postsurgery chemotherapy would be beneficial.

Objective

To evaluate the addition of immune therapy in the form of atezolizumab to postoperative chemotherapy in patients with the high-risk triple-negative breast cancer subtype.

Design, Setting, and Participants

In this open-label international randomized phase 3 trial conducted in more than 330 centers in 31 countries, patients undergoing surgery as initial treatment for stage II or III triple-negative breast cancer were enrolled between August 2, 2018, and November 11, 2022. The last patient follow-up was on August 18, 2023.

Interventions

Patients were randomized (1:1) to receive standard chemotherapy for 20 weeks with (n = 1101) or without (n = 1098) the immune therapy drug atezolizumab for up to 1 year.

Main Outcomes and Measures

The primary end point was invasive disease-free survival (time between randomization and invasive breast cancer in the same or opposite breast, recurrence elsewhere in the body, or death from any cause).

Results

The median age of enrolled patients was 53 years and most self-reported as being of Asian or White race and neither Latino nor Hispanic ethnicity. The study independent data monitoring committee halted enrollment at 2199 of 2300 planned patients. All patients stopped atezolizumab following a planned early interim and futility analysis. The trial continued to a premature final analysis. With invasive disease-free survival events in 141 patients (12.8%) treated with atezolizumab-chemotherapy and 125 (11.4%) with chemotherapy alone (median follow-up, 32 months), the final stratified invasive disease-free survival hazard ratio was 1.11 (95% CI, 0.87-1.42; P = .38). Compared with chemotherapy alone, the regimen of atezolizumab plus chemotherapy was associated with more treatment-related grade 3 or 4 adverse events (54% vs 44%) but similar incidences of fatal adverse events (0.8% vs 0.6%) and adverse events leading to chemotherapy discontinuation. Chemotherapy exposure was similar in the 2 treatment groups.

Conclusions and Relevance

The addition of the immune therapy drug atezolizumab to chemotherapy after surgery did not provide benefit among patients with triple-negative breast cancer who are at high risk of recurrent disease.

Trial Registration

ClinicalTrials.gov Identifier: NCT03498716.