Systemic Therapy for Melanoma: ASCO Guideline Update

Complete color vision loss in a patient with metastatic melanoma of the skin treated with nivolumab-relatlimab

IntroductionThe combination nivolumab-relatlimab has demonstrated therapeutic benefits for patients with metastatic melanoma. However, its adverse effects can affect various organs, including the eye.Case reportWe present the case of an 80-year-old man who developed complete color blindness after the 2nd dose of nivolumab-relatlimab for advanced cutaneous melanoma. He also had significant blurry vision. Fundoscopy identified bilateral serous macular detachment. Ocular coherence tomography confirmed serous infiltration within the macula. After a thorough investigation, causality assessment linked this retinal effect to nivolumab-relatlimab (probable relationship via Naranjo criteria).Management and outcomeThe patient was treated with corticosteroids, intravenous immunoglobulin (IVIG), rituximab, and plasmapheresis, with improvement in blurry vision. However, he continued to experience persistent absence of color perception ("black and white vision") at a follow-up visit six months later.Discussion/conclusionFurther studies are necessary to understand the exact pathophysiology of this process. We hypothesize that it involves direct toxicity to the photoreceptors or retinal ganglion cells, leading to irreversible color vision loss. Effective strategies for preventing this significant, life-changing toxic effect of nivolumab-relatlimab should be sought.

Risk stratification using the Merlin Assay (CP-GEP) in an independent cohort of 930 patients with clinical stage I/II melanoma who did not undergo sentinel lymph node biopsy

PURPOSE

More than 80 % of patients with melanoma are diagnosed without nodal metastasis, but most of those who relapse or die from melanoma are initially diagnosed as low risk early-stage. Here we investigate the ability of the Merlin Assay to stratify patients who did not undergo sentinel lymph node biopsy (SLNB) for their risk of recurrence.

PATIENTS AND METHODS

930 patients with clinical stage I/II primary cutaneous melanoma from the University of Tuebingen diagnosed between 2000 and 2020 were analyzed. None of the patients included underwent SLNB. The Merlin Assay combines patient age at diagnosis, Breslow thickness, and gene expression of eight specific genes from the primary tumor. Risk output labels are High Risk and Low Risk.

RESULTS

Clinicopathological gene expression profile (CP-GEP) identified 879 patients as Low Risk and 51 patients as High Risk. The 10-year RFS (HR 20.07; p < 0.001) and DMFS (HR 19.39; p < 0.001) were significantly higher in CP-GEP Low Risk versus High Risk patients. Similar results were observed in 10-year MSS (HR 35.85; p < 0.001). CP-GEP analysis of lentigo maligna melanoma and acral lentiginous melanoma showed that the performance of assay was independent of melanoma histological subtypes.

CONCLUSION

This study shows that CP-GEP has the potential to stratify patients with early-stage melanoma who did not undergo SLNB based on their risk of recurrence. Patients with CP-GEP Low Risk have a significantly better long-term survival. CP-GEP shows to be promising for guiding SLNB referral and may support melanoma care by optimizing personalized treatment plans and potential surveillance regimens.

Pembrolizumab versus placebo as adjuvant therapy in resected stage IIB or IIC melanoma: Long-term follow-up, crossover, and rechallenge with pembrolizumab in the phase III KEYNOTE-716 study

BACKGROUND

Adjuvant pembrolizumab prolonged recurrence-free survival (RFS) and distant metastasis-free survival (DMFS) in patients with resected stage IIB/IIC melanoma in KEYNOTE-716. Results of a post hoc 4-year analysis are reported, including progression/recurrence-free survival 2 (PRFS2).

METHODS

Patients were randomly assigned 1:1 to pembrolizumab 200 mg or placebo intravenously every 3 weeks (part 1). RFS was the primary end point; DMFS was secondary. Patients with recurrence following placebo or 17 cycles of pembrolizumab could cross over to or be rechallenged with pembrolizumab (part 2).

RESULTS

Median follow-up (n = 976) was 52.8 months (range, 39.4-64.8). RFS (HR, 0.62 [95 % CI, 0.50-0.78]) and DMFS (HR, 0.59 [0.45-0.77]) favored pembrolizumab. At 48 months, RFS rates were 71.3 % for pembrolizumab and 58.3 % for placebo, and DMFS rates were 81.0 % and 70.1 %, respectively. The HR for PRFS2 was 0.75 (95 % CI, 0.56-1.01); 48-month PRFS2 rates were 82.5 % for pembrolizumab and 76.7 % for placebo. In the crossover population, median follow-up was 36.9 months; median RFS was not reached (NR; 95 % CI, 16.8-NR; 48-month RFS, 50.6 %) in patients with resectable disease (n = 41) and median progression-free survival was 22.0 months (4.5-NR) in patients with unresectable disease (n = 30). Among patients rechallenged, median follow-up was 21.9 months; none with resectable disease had recurrence (n = 6) and 1 with unresectable disease had best response of stable disease (n = 3). No new safety signals were observed.

CONCLUSIONS

With > 4 years follow-up, pembrolizumab continued to prolong RFS and DMFS and had antitumor activity in patients who crossed over to pembrolizumab.

TRIAL REGISTRATION

NCT03553836.

pTERT mutational status is associated with survival in stage IV melanoma patients receiving first-line immune therapy

BACKGROUND

TERT promoter mutations are the most prevalent mutations in melanoma. In this study, we investigated clinical characteristics and survival after first line therapies in a cohort of melanoma patients with known TERT promoter (pTERT) mutation status.

METHODS

Sequencing data from 2013 to 2021 covering 29 genes and the pTERT status was assessed and 774 melanomas patients with known pTERT status and clinical data were analyzed. Progression free survival (PFS) and overall survival (OS) of 374 melanoma patients in AJCC-stage IV who received first-line immune checkpoint inhibitors (ICI, anti-CTLA4 /anti-PD1 combination therapy or anti-PD1 monotherapy) or targeted therapy (TT) were assessed applying Cox uni-/ multivariable analyses and Kaplan-Meier curves.

RESULTS

The cohort included 573 cutaneous, 69 mucosal, 37 acral and 95 MUP (melanomas of unknown primary) melanoma patients with a median observational time from first diagnosis to patient death or censoring of 38.5 months. TERT promoter mutations were identified in 476 melanomas (61.5 %). Survival analysis of 374 patients with stage IV disease undergoing first-line systemic therapy (ICI or TT) suggested prolonged PFS and OS for patients with pTERT mutation positive tumors (pTERT(+)). Particularly, pTERT(+) patients receiving anti-CTLA4/anti-PD1 therapy showed mPFS of 14.8 months (95 % CI: 7.1-40.3) and mOS of 105.2 months (95 % CI: 27.6-not reached) compared to pTERT(-) patients with mPFS of 5.5 months (95 % CI: 2.7-10.0) and mOS of 14.7 months (95 % CI: 11.7-24.1).

CONCLUSIONS

Our findings suggest that presence of a pTERT mutation in melanomas might favor PFS and OS after first line ICI with the greatest improvement after receiving anti-CTLA4 / anti-PD1. If validated in larger prospective studies, pTERT mutation status may be a valuable prognostic marker for stage IV melanoma patients.

CRKL silencing inhibits melanoma growth and enhances its chemotherapy sensitivity through the PI3K/AKT and NLRP3/GSDMD pathways

Great advances have been made in malignant melanoma treatments, whereas drug resistance still limits many drug applications. CRKL has been reported to be overexpressed in various tumors and showed poor prognosis. However, its specific function and mechanism in melanoma remain unclear. In the present study, we investigated the expression of CRKL and its clinical association by bioinformatics and clinical analysis, and then performed a series of in vitro and in vivo experiments to demonstrate its function and mechanism. Results showed that CRKL increased during melanoma progression and was strongly associated with poor prognosis. CRKL silencing effectively inhibited melanoma cell growth and invasion via ERK/MMP9 and PI3K/AKT signaling pathways both in vitro and in vivo. Moreover, CRKL silencing induced pyroptosis in melanoma cells by upregulating the levels of pyroptosis-associated proteins, such as NLRP3, cleaved Caspase-1, and GSDMD-N. Importantly, our study demonstrated that interfering with CRKL expression enhanced the chemotherapy sensitivity of melanoma cells to cisplatin by regulating PI3K/AKT and NLRP3/GSDMD signaling pathways. In conclusion, our study uncovers a novel molecular mechanism by which CRKL functions in melanoma and highlights potential therapeutic strategies for improving chemotherapy sensitivity in melanoma patients.

Soluble CD27 differentially predicts resistance to anti-PD1 alone but not with anti-CTLA-4 in melanoma

Metastatic melanoma can be treated with anti-PD-1 monotherapy or in combination with anti-CTLA-4 or anti-Lag3. However, combination therapy is associated with a high risk of toxicity. Recently, we reported that high plasma soluble CD27 (sCD27) levels reflect the intratumoral interaction of CD70-CD27 and dysfunctional T cells in the tumor microenvironment of renal cell carcinoma. In this study, we first characterized the intratumoral expression of CD70 and CD27 in melanoma tumors and their interaction in vivo. We then reported a significant association between baseline sCD27 and anti-PD-1 resistance as assessed by progression-free survival, overall survival, or 12-month complete response in two prospective cohorts of melanoma patients. Multivariate analysis confirmed that sCD27 was independently associated with clinical outcomes. Notably, sCD27 did not predict clinical response to combination therapy in either cohort. This differential predictive value of sCD27 for the two therapeutic options was later confirmed by propensity score analysis. Our results suggest that high plasma sCD27 levels predict poorer efficacy of anti-PD1 monotherapy in metastatic melanoma, justifying therapeutic escalation with a combination of anti-PD1 and anti-CTLA-4.

Clinical Applications of the Molecular Landscape of Melanoma: Integration of Research into Diagnostic and Therapeutic Strategies

The molecular landscape of cutaneous melanoma is complex and heterogeneous, and a deeper understanding of the genesis and progression of the tumor driven by genetic alterations is essential for the development of effective diagnostic and therapeutic strategies. Molecular diagnostics and the use of biomarkers are increasingly playing a role in treatment decisions. However, further research is urgently needed to elucidate the relationships between complex genetic alterations and the effectiveness of target therapies (although BRAF mutation is still the only targeted genetic alteration). Further research is required to exploit other targetable genetic alterations such as NRAS, KIT or rare mutations. Treatment guidelines for cutaneous melanoma are continually evolving based on data from recent and ongoing clinical trials. These advancements reflect changes mainly in the optimal timing of systemic therapy and the choice of combination therapies increasingly tailored to molecular profiles of individual tumors. Mono- or combination immunotherapies demonstrated unprecedented success of melanoma treatment; still, there is room for improvement: though several factors of primary or acquired resistance are known, they are not part of patient management as biomarkers. The novel developments of cancer vaccines to treat melanoma (melanoma-marker-based or personalized neoantigen-based) are encouraging; introduction of them into clinical practice without proper biomarkers would be the same mistake made in the case of first-generation immunotherapies.

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.

Molecular Analysis of Cutaneous Sarcomatoid Neoplasms Frequently Identifies Melanoma Driver Variants

Primary cutaneous neoplasms that lack definitive histologic and immunophenotypic evidence of differentiation are a heterogeneous group of tumors with diverse prognoses and management options. These include undifferentiated and dedifferentiated melanoma (UM/DM), atypical fibroxanthoma (AFX), pleomorphic dermal sarcoma (PDS), and sarcomatoid squamous cell carcinoma. Diagnosis requires careful correlation between the clinicopathologic and molecular features, and the finding of a MAPK pathway variant commonly associated with melanoma may support the diagnosis of melanoma over other tumors in this group. To examine the frequency of typical melanoma-associated MAPK pathway-related variants (BRAF, NRAS, KIT, GNAQ, GNA11) among a cohort of primary cutaneous sarcomatoid neoplasms, we conducted a retrospective analysis of 37 cases of immunohistologically unclassifiable primary cutaneous neoplasms, submitted for targeted NGS analysis. All cases lacked a history of a prior relevant tumor, were negative for melanocytic markers (S100, SOX10, HMB45, and Melan-A), or showed <5% staining with 1 or 2 of these markers. Other lineage markers were negative. We identified typical melanoma driver variants in 7 cases (7/37, 19%), including NRAS (5/37, 14%), KIT (1/37, 3%), and GNAQ (1/37, 3%). There were no significant differences in age, sex, tumor site, or mitotic rate between patients with and without a melanoma driver variant. Melanoma cases were thicker (16.3 vs. 9.25 mm, P=0.041) and more likely to show epithelioid cell phenotype (P=0.008). In our cohort, nearly 20% of patients with immunohistologically unclassifiable cutaneous tumors could be reclassified as having primary UM/DM after molecular testing, thereby opening alternative management pathways.

Post-marketing surveillance of encorafenib in combination with binimetinib in Japanese patients with BRAF-mutant melanoma

BACKGROUND

A BRAF inhibitor, encorafenib, combined with a MEK inhibitor, binimetinib, was approved in Japan in early 2019 for the treatment of BRAF V600-mutant, unresectable malignant melanoma based on results of the global phase III trial, COLUMBUS, conducted in various countries including Japan. This post-marketing surveillance (PMS) assessed the combination in real-world clinical practice in Japan.

METHODS

We performed a prospective, multicentre, 12-month PMS of the safety and effectiveness of encorafenib plus binimetinib for radically unresectable, BRAF-mutant malignant melanoma in Japan.

RESULTS

Among 174 survey forms collected from 85 centres between February 2019 and August 2020, 172 were included for safety and effectiveness analysis. Patients (male [52.3%], median age 62.0 years) had Eastern Cooperative Oncology Group Performance Status 0 or 1 (91.8%) and comorbidities (55.2%). Respective encorafenib and binimetinib median dosages were 450 mg/day and 90 mg/day; median treatment duration, 24.1 and 24.2 weeks, and discontinuation, 71.5% for each, primarily for disease progression (56.9%) and adverse drug reactions (ADRs, 38.2%). Safety assessment ADRs occurred in 99 patients (57.6%), including eye disorders (40.7%), hepatic dysfunction (20.3%), rhabdomyolysis (4.7%), haemorrhage (2.3%), palmar-plantar erythrodysaesthesia syndrome (1.7%), and hypertension (1.7%); 19.8% were grade ≥ 3, none were grade 5, most resolved with/without treatment modification. At 12 months, the objective response rate was 48.8% (95% CI 41.2, 56.6; complete [19.2%], partial [29.7%]), overall survival was 40.1%.

CONCLUSION

The safety and effectiveness of encorafenib plus binimetinib in Japanese patients with BRAF-mutant malignant melanoma were similar to data reported in COLUMBUS; no new safety concerns were identified.

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.

EPS-8 regulates human malignant melanoma development by activating the Hedgehog pathway via degradation of Ptch1

BACKGROUND

The epidermal growth factor receptor pathway substrate 8 (EPS-8) is a tumor-associated antigen that is frequently overexpressed in various types of human solid tumors and is associated with aggressiveness and poor prognosis. The role of EPS-8 in cutaneous malignant melanoma and its potential mechanism remains unknown.

METHODS

EPS-8 expression, mutation immune infiltration, and the tumor microenvironment in melanoma were analyzed using various databases. Clinical samples were collected and melanoma cell viability, apoptosis and protein levels were detected using cell counting kit-8, colony formation, Hoechst 33258 staining, and Western blot. Meanwhile, xenograft tumor models in nude mice were produced to evaluate the effect of EPS-8 on malignant melanoma in vivo.

RESULTS

EPS-8 levels were highly expressed in melanoma and correlated with immune-infiltrating cells, immune-related scores, and immunotherapy. Additionally, in clinical malignant melanoma samples, the EPS-8 level was significantly higher in the malignant melanoma samples compared with adjacent normal tissue, and patients with a high expression of EPS-8 had significantly poor tumor differentiation and a high clinical stage. The overexpression of EPS-8 promoted the proliferation but inhibited the apoptosis of malignant melanoma cells. The knockdown of EPS-8 markedly inhibited the activation of the Hedgehog (Hh) pathway. Notably, the knockdown of Patched-1 (Ptch1) could attenuate the changes in proteins and mRNA level, cell proliferation, apoptosis, and tumor growth induced by the knockdown of EPS-8.

CONCLUSION

The overexpression of EPS-8 had impacts on the proliferation and apoptosis of cutaneous malignant melanoma cells. The degradation of Ptch1 contributed to the activation of the Hh pathway induced by EPS-8.

High-dose Vitamin C inhibits PD-L1 expression by activating AMPK in colorectal cancer

Vitamin C (VitC) has elicited considerable interest regarding its potential role in cancer therapy; however, its effects on tumor immunity remain unclear. In colorectal cancer (CRC), although anti-PD-1/PD-L1 therapies demonstrate promise, their efficacy is still constrained. Our prior research demonstrated that VitC can inhibit tumor growth by suppressing the Warburg effect. This study aims to explore the effects of high-dose VitC on PD-L1 expression in CRC, focusing on its underlying mechanisms and potential for enhancing immunotherapy. We found that VitC inhibits aerobic glycolysis in HCT116 cells while also downregulating PD-L1 expression. Further investigations indicated that this process is mediated by VitC's activation of AMPK, which downregulates HK2 and NF-κB, ultimately resulting in reduced PD-L1 expression and increased T cell infiltration. Notably, we observed that VitC and the PD-L1 monoclonal antibody atezolizumab exhibit comparable tumor-inhibiting abilities, and their combined use further enhances this efficacy. In conclusion, our results demonstrate that high-dose VitC activates AMPK, downregulates PD-L1 expression, mitigates immune evasion, and suppresses tumor growth. This provides a promising strategy for optimizing immunotherapy in CRC.

Size-specific clonidine-loaded liposomes: Advancing melanoma microenvironment suppression with safety and precision

The immunosuppressive tumor microenvironment (TME) plays a crucial role in the progression and treatment resistance of melanoma. Modulating the TME is thus a key strategy for enhancing therapeutic outcomes. Previousstudies have identified clonidine (CLD), an α2-adrenergic receptor agonist, as a promising agent that enhances T lymphocyte infiltration and reduces myeloid-derived suppressor cells within the TME, thereby promoting antitumor immune responses. In this study, we discovered that CLD reshaped the melanoma immune microenvironment, facilitating T-cell activation and exerting antitumor effects. However, the high doses of CLD required for effective TME modulation pose significant toxicity concerns, limiting its clinical applicability. To address this, we employed the controllable cavitation-on-a-chip (CCC) platform to formulate CLD-loaded liposomes and optimize their size. This approach aimed to enhance the precision and efficacy of drug delivery while reducing systemic side effects. Our results demonstrated that size-specific CLD liposomes, particularly those at 50 nm, significantly improved tumor growth inhibition and immune cell infiltration within the TME. Moreover, these optimized liposomes mitigate adverse effects associated with high-dose CLD treatment. This study indicates the potential of CCC-optimized CLD liposomes as a safer and more effective melanoma therapy, highlighting the critical interplay between liposome size control and therapeutic outcomes in cancer treatment.

Melanoma in pregnancy

Cutaneous melanoma is a malignant neoplasm of melanocytes that most frequently affects the skin. It is the most common malignancy in women of childbearing age, and accounts for almost one-third of all malignancies diagnosed during gestation. The pathophysiology of melanoma, particularly during pregnancy, is not well understood, but there are several ways in which the physiologic state pregnancy may impact melanoma. Based on the available literature, pregnancy does not seem to worsen maternal outcomes with melanoma, and outside of placental and fetal metastases, melanoma does not seem to cause serious obstetric or fetal complications. Treatment of localized melanoma during pregnancy follows guidelines for the general population, but advanced melanoma in pregnancy poses unique challenges given the lack of unifying research and management recommendations. Herein, we review the current literature, highlighting diagnostic clinical pearls and key multidisciplinary management considerations with regard to melanoma in the child-bearing population.

Oronasal mucosal melanoma is defined by two transcriptional subtypes in humans and dogs with implications for diagnosis and therapy

Mucosal melanoma is a rare melanoma subtype associated with a poor prognosis and limited existing therapeutic interventions, in part due to a lack of actionable targets and translational animal models for preclinical trials. Comprehensive data on this tumour type are scarce, and existing data often overlooks the importance of the anatomical site of origin. We evaluated human and canine oronasal mucosal melanoma (OMM) to determine whether the common canine disease could inform the rare human equivalent. Using a human and canine primary OMM cohort of treatment-naive archival tissue, alongside clinicopathological data, we obtained transcriptomic, immunohistochemical, and microbiome data from both species. We defined the transcriptomic landscape in both species and linked our findings to immunohistochemical, microbiome, and clinical data. Human and dog OMM stratified into two distinctive transcriptional groups, which we defined using a species-independent 41-gene signature. These two subgroups are termed CTLA4-high and MET-high and indicate actionable targets for OMM patients. To guide clinical decision-making, we developed immunohistochemical diagnostic tools that distinguish between transcriptomic subgroups. We found that OMM had conserved transcriptomic subtypes and biological similarity between human and canine OMM, with significant implications for patient classification, treatment, and clinical trial design. © 2025 The Author(s). The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Personalized, autologous neoantigen-specific T cell therapy in metastatic melanoma: a phase 1 trial

New treatment approaches are warranted for patients with advanced melanoma refractory to immune checkpoint blockade (ICB) or BRAF-targeted therapy. We designed BNT221, a personalized, neoantigen-specific autologous T cell product derived from peripheral blood, and tested this in a 3 + 3 dose-finding study with two dose levels (DLs) in patients with locally advanced or metastatic melanoma, disease progression after ICB, measurable disease (Response Evaluation Criteria in Solid Tumors version 1.1) and, where appropriate, BRAF-targeted therapy. Primary and secondary objectives were evaluation of safety, highest tolerated dose and anti-tumor activity. We report here the non-pre-specified, final results of the completed monotherapy arm consisting of nine patients: three at DL1 (1 × 108-1 × 109 cells) and six at DL2 (2 × 109-1 × 1010 cells). Drug products (DPs) were generated for all enrolled patients. BNT221 was well tolerated across both DLs, with no dose-limiting toxicities of grade 3 or higher attributed to the T cell product observed. Specifically, no cytokine release, immune effector cell-associated neurotoxicity or macrophage activation syndromes were reported. A dose of 5.0 × 108-1.0 × 1010 cells was identified for further study conduct. Six patients showed stable disease as best overall response, and tumor reductions (≤20%) were reported for four of these patients. In exploratory analyses, multiple mutant-specific CD4+ and CD8+ T cell responses were generated in each DP. These were cytotoxic, polyfunctional and expressed T cell receptors with broad functional avidities. Neoantigen-specific clonotypes were detected after treatment in blood and tumor. Our results provide key insights into this neoantigen-specific adoptive T cell therapy and demonstrate proof of concept for this new therapeutic approach. ClinicalTrials.gov registration: NCT04625205 .

Adjuvant immunotherapy in the modern management of resectable melanoma: current status and outlook to 2028

BACKGROUND

Therapeutic advances have reshaped the treatment landscape for patients with resectable melanoma, particularly for those with stage IIB/C and stage III disease. In this article, we discuss the current status and future outlook of adjuvant immunotherapy for melanoma in Europe.

RESULTS

Adjuvant immunotherapy offers significant benefits in terms of recurrence-free survival and distant metastasis-free survival. Uncertainties regarding overall survival (OS) benefits, however, remain. Trials such as Keynote-054, which are expected to provide crucial OS information, have delayed their final analyses until 2027. Additionally, real-world studies have raised questions about the correlation between recurrence-free survival/distant metastasis-free survival improvements observed in clinical trials and OS outcomes in routine clinical practice. These uncertainties have led to ongoing debates about the cost-effectiveness of adjuvant therapies, with disparities in reimbursement policies across Europe reflecting these concerns.

CONCLUSION

Looking ahead to 2028, adjuvant immunotherapy will remain a key option of comprehensive melanoma care, particularly for patients with stage IIB/C and stage III with micrometastatic disease, where neoadjuvant immunotherapy is not feasible.

Unravelling the Regulatory Roles of lncRNAs in Melanoma: From Mechanistic Insights to Target Selection

Melanoma is the deadliest form of skin cancer, and its treatment poses significant challenges due to its aggressive nature and resistance to conventional therapies. Long non-coding RNAs (lncRNAs) represent a new frontier in the search for suitable targets to control melanoma progression and invasiveness. Indeed, lncRNAs exploit a wide range of regulatory functions along chromatin remodeling, gene transcription, post-transcription, transduction, and post-transduction to ultimately tune multiple cellular processes. The understanding of this intricate and flexible regulatory network orchestrated by lncRNAs in pathological conditions can strategically support the rational identification of promising targets, ultimately speeding up the setup of new therapeutics to integrate the currently available approaches. Here, the most recent findings on lncRNAs involved in melanoma will be analyzed. In particular, the functional links between their mechanisms of action and some frequently underestimated features, like their different subcellular localizations, will be highlighted.

Nivolumab and hypofractionated radiotherapy in patients with advanced melanoma: A phase 2 trial

BACKGROUND

Radiotherapy is thought to enhance anti-tumor immunity, particularly when delivered in a hypofractionated and multisite manner. Therefore, we investigated the effects of combining radiotherapy with nivolumab in patients with advanced melanoma.

METHODS

This was a multicenter, non-randomized, phase 2 trial that enrolled patients with treatment-naïve metastatic melanoma. They received nivolumab (240 mg / 2 weeks) plus radiotherapy (day 15, 6 Gy × 3). When feasible, one target from each organ was irradiated (no irradiation of all targets). The primary endpoint was 1-year overall survival (OS).

RESULTS

This trial included 64 patients between March 2017 and July 2019. The median follow-up was 23.5 (2.3-43.8) months. The median age was 68 (35-95) years, patients were mostly male (67 %) with an Eastern Cooperative Oncology Group Performance Status (ECOG-PS) score of 0 (72 %), stage IV-M1c disease (47 %), and were BRAF-wild-type (67 %). The 2-year OS and 1-year PFS rates were 65.2 % and 56 %, respectively (P = 0.22 and P = 0.03, vs. 58 % and 43 %, respectively, in the Checkmate 066 study). Thirty-seven (58 %) and twenty-seven (42 %) patients were irradiated at one and multiple targets, respectively. The ECOG-PS (1 vs. 0; HR = 3.5; P = 0.005) was an independent prognostic factor for OS. Irradiating more than one site and irradiating a smaller cumulative tumor volume tended to correlate with better outcome. Grade 3-4 treatment-related adverse events occurred in 21.9 % of the patients (no grade 5).

CONCLUSIONS

Combined immunotherapy and hypofractionated radiotherapy did not improve survival compared to historical cohorts. The radiotherapy schedule needs to be optimized in order to improve these results.

Clinical Approaches for the Management of Skin Cancer: A Review of Current Progress in Diagnosis, Treatment, and Prognosis for Patients with Melanoma

Melanoma represents a significant public health challenge due to its increasing incidence and potential for metastasis. This review will explore the current clinical approaches to the management of melanoma, focusing on advancements in diagnosis, treatment, and prognosis. Methods for early detection and accurate staging have been enhanced by new diagnostic strategies. Treatment modalities have expanded beyond traditional surgical excision to include targeted therapy and immunotherapy. Prognostic assessment has benefited from the development of novel biomarkers and genetic profiling. This review will highlight the progress made in the multidisciplinary management of melanoma, underscoring the importance of continuous research to improve patient outcomes.

An Evaluation of Sentinel Lymph Node Biopsy Guideline Adherence in Melanoma

BACKGROUND

Regional lymph nodes are a common first site of metastasis in patients diagnosed with invasive melanoma. Knowledge of sentinel lymph node status provides strong prognostic information in melanoma and is important for staging and treatment decisions. The National Comprehensive Cancer Network® (NCCN) recommends performance of sentinel lymph node biopsy (SLNB) for melanoma patients with a T category of ≥T2a. This study aims to assess our academic institution's guideline adherence to improve quality of care.

METHODS

Retrospective review of medical records from 2017 to 2023 identified 628 patients referred to our institution for invasive melanoma treatment. Adherence to guidelines was assessed using Chi-square analyses and Fisher's exact tests.

RESULTS

In total, 8.2% of cases did not follow the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for SLNB. When justification provided within the medical record was considered adherent to guidelines, our rate of discordance was 1.6%. Head and neck melanomas were more likely to have guideline-discordant SLNB management, regardless of whether or not a justification was provided.

CONCLUSION

Greater than 98% of melanoma cases at our institution aligned with the SLNB NCCN Guidelines®. We outlined the complex justifications physicians and patients may use to pursue care that is nonadherent to guidelines. Employment of SLNB may be limited by medical comorbidities, surgical risks, and when the management would not change based on the result. Our study provides a blueprint for institutional assessment of guideline adherence and highlights the importance of documentation and guideline dissemination.

Transvitreal Retinochoroidal Biopsies of Primary Uveal Melanoma Reveal an Association of Low HLA Class I and High NK Cell Abundance in Low-Risk Disease

Purpose

Immune cells in primary uveal melanoma (PUM) have mostly been studied in enucleated tissue, thereby precluding material from thinner, low-risk PUM tumors for research purposes. Here, we investigated the feasibility of using tumor tissue acquired by transvitreal retinochoroidal (TVRC) tumor biopsies to study the tumor immune microenvironment and relation to genetic risk class.

Methods

Collected tumor biopsies of 41 patients were tested for genetic aberrations to determine high-risk (n = 19), medium-risk (n = 12), and low-risk (n = 9) tumors and were digested for flow cytometry analysis of immune cell and tumor markers. In addition, 13 patient-matched enucleated tumors were stained using multiplex immunohistochemistry.

Results

Tumor biopsies showed a high variability in the degree of immune infiltration. The tumor-specific lymphocyte infiltration pattern correlated well with the infiltration pattern in patient-matched enucleations. High-risk tumors tended to have a higher abundance of CD8 T cells, which expressed activation markers CD39, CD69, and PD-1, with reduced CD127 expression. In general, low-risk tumors exhibited decreased human leukocyte antigen (HLA) class I expression, coinciding with a higher abundance of natural killer (NK) cells (P = 0.0049), indicating a different lymphocyte infiltration pattern between low-, medium- and high-risk tumors.

Conclusions

TVRC biopsies are a suitable and valuable source of PUM tissue for research purposes. An abundance of CD8 T cells was found in high-risk PUM tumors. Further, medium- and low-risk PUM tumors are characterized by decreased HLA class I expression with a concomitant increase in NK cell infiltration as compared to high-risk PUM tumors, correlating with decreased risk of disease recurrence.

Glycolysis regulated exosomal LINC01214 inhibited CD8+ T cell function and induced anti-PD1 resistance in melanoma via modulating miR-4492/PPP1R11 axis

Background

Long non-coding RNAs (lncRNAs) can be incorporated into exosomes to mediate the intercellular communication, regulating the occurrence, development, and immunosuppression of cancers. T cell dysfunction has been a hallmark of many cancers, including melanoma, which enables cancer cells escape from host immune surveillance. However, the molecular mechanism of exosome-transmitted lncRNAs in CD8+ T cell dysfunction in melanoma remains largely unclear.

Method

The expression of circulating LINC01214 (cirLINC01214) was detected by quantitative real-time polymerase chain reaction (RT-qPCR). Exosomes were isolation from the culture medium and plasma of melanoma patients via ultracentrifugation and characterized by transmission electronic microscopy. The regulation of exosomal LINC01214 on CD8+ T cell function was determined by ELISA. The molecular mechanism of exosomal LINC01214 in CD8+ T cells were assessed by the RNA immunoprecipitation and pull-down assay. A mouse model with reconstituted human immune system was used to explore the role of exosomal LINC01214 in the resistance to anti-PD1 therapy.

Results

LINC01214 was highly expressed in melanoma tissues compared with matched adjacent normal tissues. Increased levels of circulating LINC01214 (cirLINC01214) was observed in melanoma patient plasma and correlated with poor PD-1 immunotherapy response. The cirLINC01214 was predominantly released by melanoma cells in an exosome manner. Melanoma cell-derived exosomal LINC01214 inhibits the production of IFN-γ, TNF-α, Granzyme-B and Perforin by CD8+ T cells. Further mechanism study found that cirLINC01214 delivered by exosomes suppressed CD8+ T cell function by up-regulating the expression of Protein Phosphatase 1 Regulatory Inhibitor Subunit 11 (PPP1R11) through sponging miR-4492. CirLINC01214 conferred resistance to PD-1 immunotherapy in melanoma xenograft mouse model. Melanoma patients with poor prognosis after PD-1 treatment carried high levels of exosomal LINC01214. Additionally, the secretion of exosomal cirLINC01214 was enhanced by the Warburg effect, which was consistent with the reprogrammed glucose metabolism of melanoma.

Conclusions

Our results demonstrated that exosomal LINC01214 released by melanoma cells promoted immunotherapy resistance by inducing CD8+ T cell dysfunction via the miR-4492/PPP1R11 regulatory loop. Targeting cirLINC01214 might be a potential therapeutic strategy to enhance the outcome of immunotherapy in melanoma.

A Review and Comparison of Immune-Checkpoint Inhibitors in the Treatment of Metastatic Uveal Melanoma

Introduction: Metastatic uveal melanoma (mUM) is a rare and aggressive malignancy characterised by poor responsiveness to conventional chemotherapies, posing significant treatment challenges. Immune checkpoint inhibitor (ICI) therapies, including monotherapies with Ipilimumab, pembrolizumab, and nivolumab, as well as dual ICI therapy, have emerged as potential treatments. Whilst current research favours dual therapy over single therapy, comprehensive individualised comparisons of the efficacy and safety profiles of these therapies remain limited. This meta-analysis aims to evaluate the clinical outcomes of single ICI therapies individually and compare against combination therapy to guide optimal treatment strategies for mUM. Methods: A systematic literature review was conducted to identify studies reporting objective response rates (ORR), disease control rates (DCR), median progression-free survival (MPFS), and adverse event rates (AER) for Ipilimumab, pembrolizumab, nivolumab, and dual ICI therapy. Data were aggregated using forest plots and analysed to compare the efficacy and safety of each regimen. Results: Dual ICI therapy demonstrated the highest ORR and DCR but showed no statistically significant advantage over monotherapies. Dual therapy also had a lower MPFS than both pembrolizumab and nivolumab monotherapies. Furthermore, dual therapy was associated with a much greater AER compared to any single therapy, including pembrolizumab and nivolumab. Conclusions: While dual ICI therapy offers improved ORR and DCR on aggregate analyses, monotherapies like pembrolizumab provide comparable outcomes in specific metrics, particularly MPFS, with significantly reduced toxicity. These findings underscore the need for personalised ICI regimens tailored to individual patient profiles rather than defaulting to dual therapy. Further research is essential to refine treatment guidelines and optimise outcomes for mUM patients.

Prognostic factors and outcomes of adjuvant and first-line metastatic treatments in melanoma a Turkish oncology group study

Management of melanoma has changed significantly with the discovery of targeted therapies and immune checkpoint inhibitors (ICI). Our aim in the study is to determine which treatment alternatives, specifically dabrafenib plus trametinib and ICIs, are effective in adjuvant therapy and which treatment is effective as first-line metastatic therapy. This retrospective, multicenter study included 120 patients diagnosed with stage IIIB-IIID melanoma receiving both adjuvant and first-line metastatic treatment between 2007 and 2023. Data on clinicopathologic characteristics, treatment regimens and outcomes were collected. Objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS) and overall survival (OS) were analyzed. Patients treated with dabrafenib plus trametinib as adjuvant therapy had the longest relapse-free survival (RFS) (median: 8.3 months), followed by those treated with interferon (4.1 months) and nivolumab (1.9 months) (p = 0.002). Metastatically, the highest ORR was observed in patients treated with dabrafenib plus trametinib (54.5%), followed by ICI (52.0%) and chemotherapy (33.3%). Similarly, DCR was superior for dabrafenib plus trametinib (86.3%) compared to ICI (70.8%) and chemotherapy (66.6%). Median PFS was 9.7 months (95% CI 7.2-12.2 months) in the whole group. This was 14.3 months (95% CI 9.6-19.0 months) with ICI, 10.3 months (95% CI 4.2-16.4 months) with BRAF/MEK inhibitors and 6.3 months (95% CI 4.7-7.9 months) with chemotherapy, which was statistically significant (p < 0.001). Dabrafenib plus trametinib showed the longest median OS (53.5 months) in metastatic patients and was significantly better than chemotherapy (33.6 months) (p < 0.001). BRAF V600E mutation, RFS > 6 months, ORR are all independent factors for OS prognosis. In our study, dabrafenib plus trametinib combination was more effective in adjuvant treatment of melanoma, while immunotherapy was more effective in metastatic first-line treatment.

Female Oncofertility and Immune Checkpoint Blockade in Melanoma: Where Are We Today?

The incidence of melanoma among young adults has risen, yet mortality has declined annually since the introduction of immune checkpoint inhibitors (ICI). The utilization of peri-operative ICI has significantly altered the treatment landscape in melanoma, with PD-1 inhibitors showing promising efficacy in improving relapse-free survival rates in high-risk stage II-III disease. With the increasing use of ICI, secondary concerns have emerged regarding the impact of cancer drugs on fertility and reproductive health among women of childbearing potential, especially in early-stage cancer settings. The exclusion of pregnant women from trials contributes to limited human data and clinical uncertainties, such as maternal and fetal toxicities related to ICI exposure during pregnancy, as well as the value of fertility preservation before ICI therapy. Uncertainty persists regarding pregnancy post-adjuvant immunotherapy, given the potential detrimental effects of hormonal and immunological changes during pregnancy on melanoma relapse. There is additional uncertainty about whether pregnancy-associated melanoma (PAM) represents a distinct disease entity that warrants tailored management compared to non-pregnant cases. Our review aims to give an overview of oncofertility practices among female melanoma patients after immunotherapy. We also focus on the literature gap in the published evidence and synthesize summaries regarding ICI toxicities on reproductive health and fetal development, pregnancy planning, and recurrence risks after melanoma treatment.

Size matters: Early progression of melanoma brain metastases after treatment with immune checkpoint inhibitors

Background

Immune checkpoint inhibitors (ICIs) are effective treatments for patients with metastatic melanoma, including patients with brain metastasis (BM). However, half of patients with melanoma BM have intracranial progression within 6 months after the start of ICIs. We investigated whether size affects response to ICIs in patients with melanoma BM.

Methods

In this single-center cohort study, patients with melanoma BM who were treated with ICIs between 2012 and 2021 were included. Clinical and radiologic features were collected at baseline. Longest axial diameter of all BMs was measured on baseline and follow-up MRI, and segmentation was performed for all BMs on baseline MRI. Lesion-level logistic regression analysis and patient-level survival analysis were performed for early BM progression (ie, within 6 months after start of ICIs) and intracranial progression-free survival (PFS), respectively.

Results

A total of 82 patients were included with a total of 464 BMs. At baseline, 37.8% of patients had ≥ 4 BMs and 53.7% of patients had at least one BM with a diameter ≥ 10 mm. In multivariable analysis on the lesion level, baseline BM diameter was associated with early BM progression (odds ratio 1.10, 95%CI 1.05-1.15, P < .001). On the patient level, having at least one BM ≥ 10mm was associated with shorter intracranial PFS (hazard ratio 2.08, 95%CI 1.64-5.56, P < .001).

Conclusions

Large BM diameter was associated with a higher risk of early progression after the start of ICIs. Therefore, local therapy should be considered for patients who are treated with ICIs and who have melanoma BMs ≥ 10 mm.

Metastatic Melanoma to Ovary and Advances in Metastatic Melanoma Treatment: A Case Report

Metastatic lesions to the ovary from melanoma are very rare. There have been several published case reports over the years documenting melanoma metastasizing to the adnexa. Ovarian metastases may either be asymptomatic or present with pelvic pain. As with most adnexal masses, diagnosis can be challenging and depends on the quality of imaging. When present, the prognosis is very poor. Surgical excision can be offered for symptomatic management, confirmation or diagnosis, and for cytoreduction; however, advances in genetic testing and systemic therapy have shown promise in treating this disease. To add to the growing body of literature, we present a case of melanoma metastasizing to the ovary and will discuss the advances in systemic therapy as well as genetic testing for these patients.

Annals of Surgical Oncology Practice Guidelines Series: Adjuvant and Neoadjuvant Therapy for Melanoma

Surgery has always been the mainstay of melanoma treatment, but the risk of recurrence after curative-intent surgery remains high for some stages of the disease. In this Annals of Surgical Oncology Guidelines Review, we provide an overview of practice changing studies, review international guidelines, and highlight current recommendations and areas of controversy when treating melanoma patients in the adjuvant and neoadjuvant setting. Recent clinical trials have established important roles for adjuvant and neoadjuvant therapy in conjunction with surgery for selected patients with stage II, stage III, and even resectable stage IV melanoma. Patients with melanoma should be evaluated for multimodality therapy, including a combination of surgery, systemic therapy (i.e., BRAF-targeted therapy or checkpoint blockade immunotherapy), and at times radiotherapy. With the rapid pace of advances in the field, it is crucial for surgical oncologists to remain updated on the latest guidelines and recommendations for adjuvant and neoadjuvant therapy and to continue to be leaders in this paradigm shift. Given the complex and evolving nature of treatment, this report reviews the latest practice guidelines in the context of modern multidisciplinary management of melanoma.

Same-day molecular testing for targetable mutations in solid tumor cytopathology-The next frontier of the rapid on-site evaluation

INTRODUCTION

This study aimed to assess the feasibility of implementing the Idylla system, an ultra-rapid, cartridge-based assay, as an extension of rapid on-site evaluation (ROSE) in cytology. The authors conducted a pilot validation study on specimens from non-small cell lung carcinoma, thyroid carcinoma, and melanoma, evaluating four assays designed to detect alterations in KRAS, EGFR, BRAF, gene fusions, and expression imbalances in ALK, ROS1, RET, NTRK1/2/3, and MET exon 14 skipping transcripts. They investigated the feasibility of providing accurate biomarker molecular testing results in a cytopathology laboratory within hours of specimen collection.

METHODS

The authors evaluated the performance characteristics and turn-around-time of the Idylla system by testing a total of 144 cartridge assays across various specimen types, including fine-needle aspirate smears, formalin-fixed paraffin-embedded (FFPE) cell blocks, small tissue biopsy FFPE blocks, and control cell line FFPE scrolls.

RESULTS

The average time from specimen input to results output was 2-3 hours. Accuracy across the four cartridge types was: KRAS assay: 100%, EGFR assay: 94%, BRAF assay: 100%, and GeneFusion assay: 94%. Analytical sensitivity ranged from 1% to 5% variant allele frequency for all assays. Inter-assay precision and analytical specificity were both 100%.

CONCLUSION

Using the Idylla system, actionable genetic alterations can be reliably detected within 2-3 hours from cytology and small biopsy samples with minimal input requirements. The findings of this study demonstrate the feasibility of incorporating same-day molecular testing as part of ROSE procedures in the cytopathology laboratory, ultimately shortening the time from procedure to personalized treatment for cancer patients.

It Looks Like a Zebra but Is Not: [18F]FDG PET/CT in a Giant Cutaneous Malignant Melanoma Mimicking Squamous Cell Carcinoma

Cutaneous malignant melanoma (MM) is the most aggressive form of skin cancer, associated with high mortality and rising incidence rates in Europe despite prevention efforts. Nodular MM, the most aggressive subtype, often mimics other skin tumors, complicating diagnosis. We present the case of a 66-year-old woman with a large, ulcerated tumor beneath the left scapula, along with multiple nodular lesions on the left arm and chest. Initially suspected to be an aggressive squamous cell carcinoma, the diagnosis was confirmed as invasive cutaneous MM with a BRAF(V600) mutation via biopsy. Staging with PET/CT revealed extensive glucose metabolism in the tumors and surrounding tissues, as well as metastatic lymphadenopathy. The disease was classified as stage IV (T4bN3cM1a0). Neoadjuvant systemic therapy with BRAF and MEK inhibitors (Dabrafenib and Trametinib) was initiated to reduce tumor size. Remarkable regression was observed within a week, with further reduction in tumor size after one month. A follow-up PET/CT after 3 months showed significant decreases in tracer uptake and lesion size, with a ΔSUVmax of 51.9%, a ΔMTV of 74.5%, and a ΔTLG of 83.5%, indicating an excellent response to targeted therapy.

Safety of talimogene laherparepvec: a real-world retrospective pharmacovigilance study based on FDA Adverse Event Reporting System (FAERS)

BACKGROUND

Oncolytic virus therapy is a rapidly evolving emerging approach for the medical management of cancer. Talimogene laherparepvec (T-VEC) is the first and only Food and Drug Administration (FDA)-approved oncolytic virus therapy. Considering that exactly how T-VEC works is not known, there is a strong need for a comprehensive pharmacovigilance study to identify safety signals of potential risks with T-VEC.

OBJECTIVE

The objective of this study was to assess the risk of adverse events (AEs) related to T-VEC.

METHODS

We implemented a pharmacovigilance study utilizing individual case safety reports (ICSRs) reported to the FDA Adverse Event Reporting System (FAERS) database dated from 2004 quarter 1 to 2023 quarter 3. In this study, we used two algorithms, reporting odds ratio (ROR) and information component (IC), to assess the risk of AEs related to T-VEC.

RESULTS

A total of 1138 ICSRs of patients who received the T-VEC and reported to the FDA dated from 2004 quarter 1 to 2023 quarter 3 were available. A total of seven system organ classes (SOCs) demonstrated statistically significant signals, i.e. General disorders and administration site conditions, Injury, poisoning and procedural complication, Infections and infestations, Neoplasms benign, malignant and unspecified, Skin and subcutaneous tissue disorders, Hepatobiliary disorders, and Endocrine disorders. From the preferred term level perspective, the most reported AEs in T-VEC-treated patients were pyrexia, illness, influenza, influenza-like illness, and chills. Unexpected significant AEs were detected, such as sepsis, encephalitis, syncope, and lymphadenopathy.

CONCLUSIONS

Most AEs in T-VEC-treated patients have been previously mentioned in the prescriptive information or documented in other clinical trials. But safety signals were also be detected in 4 unexpected AEs (sepsis, encephalitis, syncope, and lymphadenopathy). Further clinical trials need to be undertaken to facilitate a more comprehensive comprehension of the safety profile of T-VEC.

Tumor-infiltrating lymphocytes in melanoma: from prognostic assessment to therapeutic applications

Malignant melanoma, the most aggressive form of skin cancer, is characterized by unpredictable growth patterns, and its mortality rate has remained alarmingly high over recent decades, despite various treatment approaches. One promising strategy for improving outcomes in melanoma patients lies in the early use of biomarkers to predict prognosis. Biomarkers offer a way to gauge patient outlook early in the disease course, facilitating timely, targeted intervention. In recent years, considerable attention has been given to the immune response's role in melanoma, given the tumor's high immunogenicity and potential responsiveness to immunologic treatments. Researchers are focusing on identifying predictive biomarkers by examining both cancer cell biology and immune interactions within the tumor microenvironment (TME). This approach has shed light on tumor-infiltrating lymphocytes (TILs), a type of immune cell found within the tumor. TILs have emerged as a promising area of study for their potential to serve as both a prognostic indicator and therapeutic target in melanoma. The presence of TILs in melanoma tissue can often signal a positive immune response to the cancer, with numerous studies suggesting that TILs may improve patient prognosis. This review delves into the prognostic value of TILs in melanoma, assessing how these immune cells influence patient outcomes. It explores the mechanisms through which TILs interact with melanoma cells and the potential clinical applications of leveraging TILs in treatment strategies. While TILs present a hopeful avenue for prognostication and treatment, there are still challenges. These include understanding the full extent of TIL dynamics within the TME and overcoming limitations in TIL-based therapies. Advancements in TIL characterization methods are also critical to refining TIL-based approaches. By addressing these hurdles, TIL-focused research may pave the way for improved diagnostic and therapeutic options, ultimately offering better outcomes for melanoma patients.

Therapeutic Immunomodulation of Tumor-Lymphatic Crosstalk via Intratumoral Immunotherapy

Intra- and peritumoral lymphatics and tumor-draining lymph nodes play major roles in mediating the adaptive immune response to cancer immunotherapy. Despite this, current paradigms of clinical cancer management seldom seek to therapeutically modulate tumor-lymphatic immune crosstalk. This review explores recent developments that set the stage for how this regulatory axis can be therapeutically manipulated, with a particular emphasis on tumor-localized immunomodulation. Building on this idea, the nature of tumor-lymphatic immune crosstalk and relevant immunotherapeutic targets and pathways are reviewed, with a focus on their translational potential. Engineered drug delivery systems that enhance intratumoral immunotherapy by improving drug delivery to both the tumor and lymph nodes are also highlighted.

Pembrolizumab versus ipilimumab for advanced melanoma: 10-year follow-up of the phase III KEYNOTE-006 study

BACKGROUND

Pembrolizumab significantly improved overall survival (OS) versus ipilimumab for unresectable advanced melanoma in KEYNOTE-006 (NCT01866319); 10-year follow-up data are presented.

PATIENTS AND METHODS

Patients with unresectable stage III or IV melanoma were randomly assigned (1:1:1) to pembrolizumab 10 mg/kg i.v. every 2 weeks or every 3 weeks for ≤2 years (pooled), or ipilimumab 3 mg/kg i.v. every 3 weeks for four cycles. After KEYNOTE-006, patients could transition to KEYNOTE-587 (NCT03486873) for long-term follow-up. Eligible patients could receive second-course pembrolizumab. The primary endpoint was OS; modified progression-free survival (PFS; censored at date last known alive), modified PFS on second-course pembrolizumab, and melanoma-specific survival were exploratory.

RESULTS

Of 834 patients randomly assigned in KEYNOTE-006 (pembrolizumab, n = 556; ipilimumab, n = 278), 333 (39.9%) were eligible for KEYNOTE-587; 211/333 patients (25.3%) transitioned to KEYNOTE-587 (pembrolizumab, n = 159; ipilimumab, n = 52) and 122 (14.6%) did not. For patients who transitioned to KEYNOTE-587 (n = 211), median time from randomization in KEYNOTE-006 to data cut-off for KEYNOTE-587 (1 May 2024) was 123.7 months (range, 122.0-127.3 months). Median OS was 32.7 months [95% confidence interval (CI) 24.5-41.6 months] for pembrolizumab and 15.9 months (95% CI 13.3-22.0 months) for ipilimumab [hazard ratio (HR), 0.71 (95% CI 0.60-0.85)]; 10-year OS was 34.0% and 23.6%, respectively. Among patients who completed ≥94 weeks of pembrolizumab, median OS from week 94 was not reached (NR; 95% CI NR-NR); 8-year OS rate was 80.8%. Median modified PFS was 9.4 months (95% CI 6.7-11.6 months) for pembrolizumab and 3.8 months (2.9-4.3 months) for ipilimumab [HR, 0.64 (95% CI 0.54-0.75)]. Among patients who received second-course pembrolizumab, median modified PFS from start of second course was 51.8 months (95% CI 11.0 months-NR); 6-year modified PFS was 49.2%. Median melanoma-specific survival was 51.9 months (95% CI 30.0-114.7 months) for pembrolizumab and 17.2 months (13.9-25.9 months) for ipilimumab [HR, 0.66 (95% CI 0.55-0.81)].

CONCLUSIONS

These results confirm that pembrolizumab provides long-term survival benefits in advanced melanoma, supporting it as a standard of care in this setting.

First-line encorafenib plus binimetinib and pembrolizumab for advanced BRAF V600-mutant melanoma: Safety lead-in results from the randomized phase III STARBOARD study

BACKGROUND

BRAF inhibitors plus MEK inhibitors (BRAFi/MEKi) and immune checkpoint inhibitors (CPIs) are approved for BRAF V600-mutant advanced melanoma. Combinations of BRAFi/MEKi with CPIs may further improve outcomes and could offer additional treatment strategies.

METHODS

STARBOARD (NCT04657991) is a phase III study with an initial safety lead-in (SLI) phase conducted to determine the recommended phase III dose (RP3D) for encorafenib in combination with binimetinib and pembrolizumab. Patients with untreated, unresectable locally advanced or metastatic BRAF V600E/K-mutant cutaneous melanoma received binimetinib 45 mg twice daily and pembrolizumab 200 mg every 3 weeks plus encorafenib 450 mg once daily (COMBO450 plus pembrolizumab) or 300 mg once daily (COMBO300 plus pembrolizumab). The primary endpoint was the incidence of dose-limiting toxicities (DLTs). Secondary endpoints included safety, objective response, time to response, and duration of response. Progression-free survival was assessed post hoc.

RESULTS

In the SLI, the median follow-up duration was 19.4 months. Twenty patients received COMBO450 plus pembrolizumab and 17 received COMBO300 plus pembrolizumab. DLTs occurred in 1 of 17 DLT-evaluable patients in the COMBO450 plus pembrolizumab arm and in 2 of 17 DLT-evaluable patients in the COMBO300 plus pembrolizumab arm. No treatment-related deaths occurred in either treatment arm. The overall response rate was 65.0 % in the COMBO450 plus pembrolizumab arm and 47.1 % in the COMBO300 plus pembrolizumab arm.

CONCLUSION

The STARBOARD SLI showed that safety across the cohorts was generally comparable to the known safety profile of each agent. The standard dose regimen of COMBO450 plus pembrolizumab was chosen as the RP3D.

High BRAF V600 Mutation Level Associated with Worse Outcome in Metastatic Melanoma Patients Receiving BRAF and MEK Inhibitors

The prognostic value of BRAF V600 mutation level on clinical outcomes in patients with BRAF V600-mutated metastatic melanoma treated with BRAF and MEK inhibitors remains uncertain. The association was retrospectively analysed between BRAF V600 mutation level (defined as the ratio of the quantification of the BRAF V600 allele to the percentage of tumoral cells in the sample analysed) and progression-free and overall survival (PFS and OS, respectively) and 3-month response rate in a cohort of 58 patients with metastatic melanoma who harboured BRAF V600E/K mutations and received dual targeted-therapy BRAF/MEK inhibitors. The BRAF mutation level cut-off determined by the area under the receiver operating characteristic curve after internal validation by bootstrap methods was 0.44. Risk of poor PFS and OS was associated with BRAF V600 mutation level > 0.44 on multivariate analysis (p = 0.02 and p = 0.02, respectively) after adjusting for major confounding factors (age, sex, lactate dehydrogenase level, brain metastasis, and treatment line). No association was found between BRAF mutation level and 3-month response rate. Our study shows that high BRAF V600 mutation level in melanoma tissue was associated with poor prognosis in patients with metastatic melanoma treated with BRAF and MEK inhibitors.

The meaning-making process in the re-entry phase: A qualitative focus group study with patients treated for breast cancer or melanoma

PURPOSE

After completion of curative cancer treatment patients enter the re-entry phase, which is characterized by the task to pick up life again. While having to resume their former roles, patients experience the loss of normality and face existential concerns. A sense of meaning and purpose may help in dealing with changes in life and existential concerns. The aim of this study is to gain insight in the meaning-making process of patients treated for breast cancer or melanoma in the re-entry phase in order to develop an intervention to support picking up life after a long treatment process including systemic treatment.

METHODS

We conducted six focus groups with 16 patients (11 breast cancer and five melanoma) to explore their experiences, challenges, and sources of meaning during the re-entry phase. The re-entry phase was defined as the point from completion of surgical and systemic treatment (except for hormonal therapy) up to 18 months in remission. A thematic content analysis was performed by two researchers.

RESULTS

We identified four themes pertaining to patients' use of sources of meaning in the meaning-making process: (1) use of existing, helpful sources; (2) distress due to impacted sources; (3) search for new sources; and (4) use of adapted or new sources. When patients drew upon existing sources of meaning that had been impacted by cancer and the aftermath of treatment, they experienced distress. This could instigate a search resulting in adapted, strengthened, or new sources of meaning.

CONCLUSIONS

Meaning-making in the re-entry phase is a versatile process involving the use of existing sources of meaning, and a search for, or use of new, strengthened, or adapted sources of meaning. An intervention increasing patients' awareness of their sources of meaning might strengthen the meaning-making process of patients treated for breast cancer or melanoma.

Exploring resistance to immune checkpoint inhibitors and targeted therapies in melanoma

Melanoma is the most aggressive form of skin cancer, characterized by a poor prognosis, and its incidence has risen rapidly over the past 30 years. Recent therapies, notably immunotherapy and targeted therapy, have significantly improved the outcome of patients with metastatic melanoma. Previously dismal five-year survival rates of below 5% have shifted to over 50% of patients surviving the five-year mark, marking a significant shift in the landscape of melanoma treatment and survival. Unfortunately, about 50% of patients either do not respond to therapy or experience early or late relapses following an initial response. The underlying mechanisms for primary and secondary resistance to targeted therapies or immunotherapy and relapse patterns remain not fully identified. However, several molecular pathways and genetic factors have been associated with melanoma resistance to these treatments. Understanding these mechanisms paves the way for creating novel treatments that can address resistance and ultimately enhance patient outcomes in melanoma. This review explores the mechanisms behind immunotherapy and targeted therapy resistance in melanoma patients. Additionally, it describes the treatment strategies to overcome resistance, which have improved patients' outcomes in clinical trials and practice.

The emergence of neoadjuvant immune- over BRAF therapy in melanoma

Neoadjuvant therapy has emerged in high-risk stage III melanoma with immunotherapy improving long-term outcomes when compared with BRAF and MEK inhibition. Unmet needs remain surrounding optimal immunotherapy combinations, selection biomarkers and deintensification of treatment.

Treatment strategies with electrochemotherapy for limb in-transit melanoma: Real-world outcomes from a European, retrospective, cohort study

BACKGROUND

This study analysed treatment strategies with electrochemotherapy (ECT) in melanoma with limb in-transit metastases (ITM).

METHODS

We audited AJCC v.8 stage IIIB-IIID patients treated across 22 centres (2006-2020) within the International Network for Sharing Practices of ECT (InspECT).

RESULTS

452 patients were included, 58 % pre-treated (93 % had lower limb ITM, 44 % had ≤10 metastases [median size 1.5 cm]. Treatment strategies included first-line ECT (n = 145, 32 %), ECT with concurrent locoregional/systemic treatment (n = 163, 36 %), and salvage ECT (n = 144, 32 %). The objective response rate was 63 % (complete response [CR], 24 %), increasing to 74 % (CR, 39 %) following retreatment (median two ECT, range 1-8). CR rate in treatment-naïve and pre-treated patients was 50 % vs 32 % (p < 0.001). Bleomycin de-escalation was associated with lower CR (p = 0.004). Small tumour number and size, hexagonal electrode, retreatment, and post-ECT skin ulceration predicted response in multivariable analysis. At a median follow-up of 61 months, local and locoregional recurrence occurred in 55 % and 81 % of patients. Median local progression-free, new lesions-free, and regional recurrence-free survival were 32.9, 6.9, and 7.7 months. Grade-3 toxicity was 15 %. Concurrent treatment and CR correlated with improved regional control and survival. Concomitant checkpoint inhibition did not impact toxicity or survival outcomes. The median overall survival was 5.7 years.

CONCLUSIONS

Among patients with low-burden limb-only ITM, standard-dose bleomycin ECT results in durable local response. Treatment naivety, low tumour volume, hexagonal electrode application, retreatment, and post-ECT ulceration predict response. CR and concurrent treatment correlate with improved regional control and survival outcomes. Combination with checkpoint inhibitors is safe but lacks conclusive support.

Neoadjuvant therapy for melanoma: past, present, and future

Modern systemic therapy has dramatically improved outcomes for many patients with advanced metastatic melanoma. The success of these therapies has attracted much scientific interest while these therapies have made their way into the treatment of earlier stages of disease. Randomized trials have led to the approval of adjuvant immunotherapy and targeted therapy for resected stage III melanoma. However, most recently, these therapies have gained traction in the neoadjuvant setting. Promising early results led to randomized controlled trials that have now established neoadjuvant therapy as standard of care in advanced melanoma patients. Questions remain regarding the optimal choice of therapy, duration and timing of neoadjuvant therapy, extent of surgery, and the need for additional adjuvant therapy for patients who received neoadjuvant therapy. Herein we provide an overview of neoadjuvant therapy for melanoma and dilemmas to its broader applications.

[Monoclonal antibodies for inflammatory, autoimmune and oncological skin diseases]

In 1997 rituximab, a genetically engineered chimeric monoclonal antibody (mAb) targeting CD20 expressed on B cells was approved for treatment of non-Hodgkin's lymphoma. Since then, pharmacological improvements combined with increased knowledge on the immunopathogenesis of diseases led to the development of specific mAb targeting different antigens (e.g., interleukins or transmembrane receptors). This approach reshaped the therapeutic methodology in many fields, including dermatology. Nowadays, the treatment of frequent and possibly impairing inflammatory disorders such as psoriasis, atopic dermatitis or hidradenitis suppurativa have different mAbs approved for both adult and pediatric patients. This class of drugs often shows a more favorable outcome and a better safety profile than routine immunosuppressants, such as steroids and steroid-sparing substances. For many years mAbs also represented a pillar of oncological treatment for severe diseases such as malignant melanoma or Merkel cell carcinoma. This review summarizes the current knowledge on already approved and promising new mAbs for the treatment of inflammatory and oncological skin diseases.

Circulating tumor DNA-based assessment of molecular residual disease in non-metastatic melanoma

In patients with resected non-metastatic melanoma, the liquid biopsy for the assessment of molecular residual disease (MRD) by circulating tumour DNA (ctDNA) represents a promising tool to stratify the risk and to monitor tumour evolution. However, its validation requires the demonstration of analytical validity, clinical validity and utility. Indeed, the development of sensitive and specific assays can optimize prognostication and eventually help clinicians to modulate adjuvant treatments, in order to improve clinical outcomes. Data about ctDNA-guided prognosis stratification is emerging, but clinical trials assessing ctDNA-guided therapeutic decisions are still ongoing. This review aims to depict the role of ctDNA-based MRD assessment in patients with non-metastatic melanoma and to provide a roadmap to face challenges for its introduction into clinical practice.

Targeting the MHC-I endosomal-lysosomal trafficking pathway in cancer: From mechanism to immunotherapy

Immune checkpoint blockade (ICB) therapy has achieved broad applicability and durable clinical responses across cancer types. However, the overall response rate remains suboptimal because some patients do not respond or develop drug resistance. The low infiltration of CD8+ cytotoxic T cells (CTLs) in the tumor microenvironment due to insufficient antigen presentation is closely related to the innate resistance to ICB. The duration and spatial distribution of major histocompatibility complex class I (MHC-I) expression on the cell surface is critical for the efficient presentation of endogenous tumor antigens and subsequent recognition and clearance by CTLs. Tumor cells reduce the surface expression of MHC-I via multiple mechanisms to impair antigen presentation pathways and evade immunity and/or develop resistance to ICB therapy. As an increasing number of studies have focused on membrane MHC-I trafficking and degradation in tumor cells, which may impact the effectiveness of tumor immunotherapy. It is necessary to summarize the mechanism regulating membrane MHC-I translocation into the cytoplasm and degradation via the lysosome. We reviewed recent advances in the understanding of endosomal-lysosomal MHC-I transport and highlighted the means exploited by tumor cells to evade detection and clearance by CTLs. We also summarized new therapeutic strategies targeting these pathways to enhance classical ICB treatment and provide new avenues for optimizing cancer immunotherapy.

A Retrospective Analysis of the Prognostic Factors and Adverse Events in the Treatment of Mucosal Melanoma in a Single Centre

Background: Despite the dramatic advances in the management of metastatic cutaneous melanoma, there remains no consensus-based, evidence-based strategy for the management of mucosal melanoma. The rare nature of the disease, its late clinical presentation, and distinct tumour biology all complicate efforts to optimise patient outcomes. Methods: To this end, we carried out a monocentric, retrospective analysis of all patients diagnosed with mucosal melanoma and treated between 2013 and 2021. Both tumour- and patient-specific characteristics were recorded, in addition to immune-related adverse events, in order to provide real-world data on disease progression, treatment efficacy, and the identification of prognostic markers. Results: A total of 20 patients were identified (14 females and 6 males), with a mean age at diagnosis of 65.9 years. The median follow-up was 3.9 years (95% CI 1.4-6.4 years) from the initiation of systemic therapy. The median OS in the entire cohort was 1.9 years (95% CI 0.5-3.3 years). Performance status, sex, body mass index, and the presence of brain metastases were not associated with poorer outcomes. However, serum lactate dehydrogenase levels (LDH) (p = 0.04) and an NRAS mutation were markers of a poor prognosis (p = 0.004). Conclusuion: There is a pressing need for real-world, prospective, and clinical trial data to inform the optimal management of mucosal melanoma, and data supporting the use of adjuvant and neo-adjuvant immunotherapy are currently lacking. However, an elevated LDH is a reliable, independent negative prognostic marker. Inter-disciplinary management remains essential in order to develop optimal treatment strategies.

Emerging Indications for Neoadjuvant Systemic Therapies in Cutaneous Malignancies

Patients with cutaneous malignancies and locoregional involvement represent a high-risk population for disease recurrence, even if they receive optimal surgery and adjuvant treatment. Here, we discuss how neoadjuvant therapy has the potential to offer significant advantages over adjuvant treatment, further improving outcomes in some patients with skin cancers, including melanoma, Merkel cell carcinoma, and cutaneous squamous-cell carcinoma. Both preclinical studies and in vivo trials have demonstrated that exposure to immunotherapy prior to surgical resection can trigger a broader and more robust immune response, resulting in increased tumor cell antigen presentation and improved targeting by immune cells, potentially resulting in superior outcomes. In addition, neoadjuvant approaches hold the possibility of providing a platform for evaluating pathological responses in the resected lesion, optimizing the prognosis and enabling personalized adaptive management, in addition to expedited drug development. However, more data are still needed to determine the ideal patient selection and the best treatment framework and to identify reliable biomarkers of treatment responses. Although there are ongoing questions regarding neoadjuvant treatment, current data support a paradigm shift toward considering neoadjuvant therapy as the standard approach for selecting patients with high-risk skin tumors.