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Hewitt DB, Beane JD, Grignol VP, Contreras CM. Association between surgical delay and outcomes among patients with invasive cutaneous melanoma. Am J Surg 2023; 226:631-639. [PMID: 37142517 DOI: 10.1016/j.amjsurg.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/11/2023] [Accepted: 04/28/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND The relationship between surgical delay and outcomes for patients with cutaneous melanoma is understudied. The objectives of this study were to determine the impact of surgical delay on regional nodal involvement and mortality in patients with cutaneous melanoma. METHODS Retrospective study of patients diagnosed with clinically node-negative invasive cutaneous melanoma from 2004 to 2018. Outcomes included regional lymph node disease and overall survival. Multivariable logistic regression and Cox proportional-hazards models were constructed to adjust for pertinent clinical factors. RESULTS Of 423,001 patients, 21.8% experienced a surgical delay (≥45 days). These patients were more likely to have nodal involvement (OR1.09; P = 0.01). Surgical delay (HR1.14; P < 0.001), Black race (HR1.34; P = 0.002), and Medicaid (HR1.92; P < 0.001) were associated with lower survival. Patients treated at academic/research (HR0.87; P < 0.001) or integrated network cancer programs (HR0.89; P = 0.001) had improve survival. CONCLUSIONS Surgical delay was frequent and resulted in higher rates of lymph node involvement and decreased overall survival.
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Affiliation(s)
- D Brock Hewitt
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Joal D Beane
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Valerie P Grignol
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Carlo M Contreras
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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2
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Young JN, Griffith‐Bauer K, Hill E, Latour E, Samatham R, Leachman S. The benefit of early-stage diagnosis: A registry-based survey evaluating the quality of life in patients with melanoma. SKIN HEALTH AND DISEASE 2023; 3:e237. [PMID: 37538330 PMCID: PMC10395626 DOI: 10.1002/ski2.237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/29/2023] [Accepted: 04/06/2023] [Indexed: 08/05/2023]
Abstract
Background The morbidity associated with advanced stage melanoma is an important consideration in the dialog surrounding early detection and overdiagnosis. Few studies have stratified melanoma patient quality of life (QoL) by stage at diagnosis. Objective We sought to investigate if melanoma stage is independently associated with changes in QoL within a large, community-based melanoma registry. Secondarily, we investigated whether demographic factors such as age, geographic location or level of education are associated with changes in QoL in the same population. Methods 1108 melanoma patients were surveyed over a three-month period using the QoL in Adult Cancer Survivors Survey, consisting of 47 items on a 7-point frequency scale. Data were analysed using both descriptive statistical models and adjusted multivariate logistic regression. Results There were 677 respondents generating a 61% response rate. Overall, higher stage at diagnosis correlated with the largest decreases in QoL as it pertained to both general (p = 0.001) and Cancer-Specific stressors (p < 0.001). Education level (p = 0.020), age (p < 0.001), rural area code designation (p = 0.020) and family history of melanoma (p = 0.017) were also independently associated with changes in QoL. Conclusion Earlier stage at melanoma diagnosis is associated with better QoL and thus represents a crucial intervention in patient care. Given our findings and the growing body of evidence surrounding morbidity in late-stage melanoma, it is essential that QoL be included in assessing the benefits of early detection.
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Affiliation(s)
- Jade N. Young
- Department of DermatologyOregon Health and Science UniversityPortlandOregonUSA
| | - Kelly Griffith‐Bauer
- Department of DermatologyOregon Health and Science UniversityPortlandOregonUSA
- The PolyclinicSeattleWashingtonUSA
| | - Emma Hill
- Department of DermatologyOregon Health and Science UniversityPortlandOregonUSA
| | - Emile Latour
- Department of DermatologyOregon Health and Science UniversityPortlandOregonUSA
- Biostatistics Shared ResourceKnight Cancer InstituteOregon Health and Science UniversityPortlandOregonUSA
| | - Ravikant Samatham
- Department of DermatologyOregon Health and Science UniversityPortlandOregonUSA
| | - Sancy Leachman
- Department of DermatologyOregon Health and Science UniversityPortlandOregonUSA
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3
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Dalamaga M, Nasiri-Ansari N, Spyrou N. Perspectives and Challenges of COVID-19 with Obesity-Related Cancers. Cancers (Basel) 2023; 15:cancers15061771. [PMID: 36980657 PMCID: PMC10046880 DOI: 10.3390/cancers15061771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/07/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023] Open
Abstract
The emergence of COVID-19 has created an unprecedented threat worldwide, involving overwhelmed health-care systems in the majority of countries [...]
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Affiliation(s)
- Maria Dalamaga
- Department of Biological Chemistry, School of Medicine, National and Kapodistrian University of Athens, 75 Mikras Asias, 11527 Athens, Greece
- Correspondence:
| | - Narjes Nasiri-Ansari
- Department of Biological Chemistry, School of Medicine, National and Kapodistrian University of Athens, 75 Mikras Asias, 11527 Athens, Greece
| | - Nikolaos Spyrou
- Tisch Cancer Institute Icahn School of Medicine at Mount Sinai, 1190 One Gustave L. Levy Place, New York, NY 10029, USA
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4
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Welti M, Cheng PF, Mangana J, Levesque MP, Dummer R, Imhof L. Impact of Covid-19 on the management of patients with metastatic melanoma. Oncotarget 2022; 13:1370-1379. [PMID: 36580495 PMCID: PMC9799324 DOI: 10.18632/oncotarget.28333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The Covid-19 pandemic created new uncertainties in the management of metastatic melanoma patients. In particular, the impact of immunotherapy, targeted therapy, or chemotherapy on the risk of Sars-CoV-2 infection and severity was debated. In this study, we analyzed all patients with metastatic melanoma receiving therapy who developed Covid-19 between February 2020 and February 2022. We retrospectively collected demographic data, cancer-specific parameters, melanoma treatment regimen, comorbidities and Covid-19-specific parameters in these patients. Of the 350 patients with metastatic melanoma, 25 had Covid-19. The median age at the time of Covid-19 diagnosis was 66 years (range 36-86), 10 patients were female, and 15 patients were male. The treatment regimen during infection was immunotherapy in 12 cases, followed by targeted therapy (n = 8), chemotherapy (n = 2), and TVEC injections, follow-up and palliative therapy in 1 case each. The severity was mild in 17 patients and 8 had a moderate to critical course. Patients with a severe Covid-19 course were often older and had more comorbidities than patients with a mild infection. Many of the patients had a mild Covid-19 course despite having metastatic melanoma and systemic therapy. We therefore recommend continuing systemic therapy whenever possible, even in such exceptional situations as the Covid-19 pandemic.
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Affiliation(s)
- Michèle Welti
- 1Department of Dermatology, University Hospital Zurich (USZ), Zurich 8091, Switzerland,2Faculty of Medicine, University of Zurich (UZH), Zurich 8032, Switzerland,Correspondence to:Michèle Welti, email:
| | - Phil F. Cheng
- 1Department of Dermatology, University Hospital Zurich (USZ), Zurich 8091, Switzerland,2Faculty of Medicine, University of Zurich (UZH), Zurich 8032, Switzerland
| | - Joanna Mangana
- 1Department of Dermatology, University Hospital Zurich (USZ), Zurich 8091, Switzerland,2Faculty of Medicine, University of Zurich (UZH), Zurich 8032, Switzerland
| | - Mitchell P. Levesque
- 1Department of Dermatology, University Hospital Zurich (USZ), Zurich 8091, Switzerland,2Faculty of Medicine, University of Zurich (UZH), Zurich 8032, Switzerland
| | - Reinhard Dummer
- 1Department of Dermatology, University Hospital Zurich (USZ), Zurich 8091, Switzerland,2Faculty of Medicine, University of Zurich (UZH), Zurich 8032, Switzerland
| | - Laurence Imhof
- 1Department of Dermatology, University Hospital Zurich (USZ), Zurich 8091, Switzerland,2Faculty of Medicine, University of Zurich (UZH), Zurich 8032, Switzerland,3Institute for Biomedical Engineering, ETH Zurich, Zurich 8092, Switzerland
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5
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Toma AO, Prodan M, Reddyreddy AR, Seclaman E, Crainiceanu Z, Bloanca V, Bratosin F, Dumitru C, Pilut CN, Alambaram S, Vasamsetti NG, Decean L, Pricop M. The Epidemiology of Malignant Melanoma during the First Two Years of the COVID-19 Pandemic: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:305. [PMID: 36612627 PMCID: PMC9819675 DOI: 10.3390/ijerph20010305] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 06/17/2023]
Abstract
It is hypothesized that the COVID-19 pandemic had a major impact on the epidemiology of malignant melanoma owing to diminished screening, diagnostic, and treatment capacities, resulting in a more advanced stage at initial presentation. The goal of this study is to undertake a systematic analysis of all epidemiological and clinical data on the trends and patient outcomes with malignant melanoma during the ongoing pandemic. Records were identified from PubMed, Cochrane, and Web of Science, selecting a total of 39 articles, narrative reviews, and editorial letters, following the PRISMA guidelines. The vast majority of the studies were published in Europe (28/39), and North America (7/39). A total of 99,860 patients were analyzed during 2020 and 2021 of the COVID-19 pandemic, and it was observed that malignant melanoma TNM staging increased significantly compared to the pre-pandemic period. Before the pandemic, 25.88% of patients had TNM stage II or above, compared to 36.25% during 2020-2021. During the COVID-19 pandemic, the malignant melanoma Breslow depth index grew from 1.59 mm before 2020 to 1.86 mm in 2020 and 2021. Patients decreased by 19.58% in 2020 and 2021 compared to pre-pandemic numbers. The patient-loss ratio indicated lower screening activity and patient addressability to dermatology and plastic surgery departments with skin cancer concerns during the COVID-19 pandemic. This systematic study shows that the identification and management of malignant melanoma during the COVID-19 pandemic faced major challenges which should alert medical systems to the high number of patients with advanced disease stages who may need emergency treatment and become incurable.
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Affiliation(s)
- Ana-Olivia Toma
- Department of Microbiology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Mihaela Prodan
- Department of Plastic Surgery, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Akash Reddy Reddyreddy
- School of General Medicine, Bhaskar Medical College, Amdapur Road 156-162, Hyderabad 500075, India
| | - Edward Seclaman
- Department of Biochemistry and Pharmacology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Center for Complex Networks Science, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Zorin Crainiceanu
- Department of Plastic Surgery, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Vlad Bloanca
- Department of Plastic Surgery, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Felix Bratosin
- Methodological and Infectious Diseases Research Center, Department of Infectious Diseases, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Catalin Dumitru
- Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Ciprian Nicolae Pilut
- Kaloji Narayana Rao University of Health Sciences, Nizampura, Warangal, Telangana 506007, India
| | - Satish Alambaram
- School of General Medicine, Bhaskar Medical College, Amdapur Road 156-162, Hyderabad 500075, India
| | | | - Luminita Decean
- Faculty of General Medicine, George Emil Palade University of Medicine, Pharmacy, Science and Technology, Strada Gheorghe Marinescu 38, 540139 Targu Mures, Romania
| | - Marius Pricop
- Discipline of Oral and Maxillo-Facial Surgery, Faculty of Dental Medicine, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
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Seretis K, Bounas N, Gaitanis G, Bassukas I. A Meta-Analysis on the Impact of the COVID-19 Pandemic on Cutaneous Melanoma Diagnosis in Europe. Cancers (Basel) 2022; 14:cancers14246085. [PMID: 36551570 PMCID: PMC9776971 DOI: 10.3390/cancers14246085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/05/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
The COVID-19 pandemic has been the epicenter of healthcare attention globally for the past two years, and large-scale adaptations in healthcare provision have been required. This study aimed to investigate the impact of the pandemic and the resulting lockdowns on cutaneous melanoma diagnosis and tumor burdens in Europe. A relevant literature search in electronic databases was conducted from inception to September 2022. The inclusion criteria were: controlled studies published in a peer-reviewed journal evaluating cutaneous melanoma in Europe and reporting data on melanoma characteristics from diagnoses. The quality of studies was evaluated using the Cochrane ROBINS-I tool for assessing bias in non-randomized studies. Meta-analysis was conducted utilizing a random effects model to synthesize the data. A total of 25 studies involving 32,231 patients were included in the data analysis models. Statistically significant increases in mean Breslow thickness (0.29 mm (0.03-0.55 mm)), ulceration rates (OR = 1.66 (1.29-2.13)), and resultant tumor staging were observed in the PostCovid group, with subgroup analysis revealing that lockdown-derived data were responsible for this trend. This meta-analysis reported on the impact of COVID-19 restrictions on melanoma diagnosis in Europe, emphasizing the higher tumor burden and disease progression state provoked by healthcare adaptations in the pandemic period.
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Affiliation(s)
- Konstantinos Seretis
- Department of Plastic Surgery, School of Health Sciences, University of Ioannina, 45100 Ioannina, Greece
- Correspondence: (K.S.); (I.B.); Tel.: +30-26-5109-9077 (K.S.); +30-26-5100-7425 (I.B.)
| | - Nikolaos Bounas
- Department of Plastic Surgery, School of Health Sciences, University of Ioannina, 45100 Ioannina, Greece
| | - Georgios Gaitanis
- Department of Skin and Venereal Diseases, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45100 Ioannina, Greece
| | - Ioannis Bassukas
- Department of Skin and Venereal Diseases, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45100 Ioannina, Greece
- Correspondence: (K.S.); (I.B.); Tel.: +30-26-5109-9077 (K.S.); +30-26-5100-7425 (I.B.)
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Ungureanu L, Apostu AP, Vesa ȘC, Cășeriu AE, Frățilă S, Iancu G, Bejinariu N, Munteanu M, Șenilă SC, Vasilovici A. Impact of the COVID-19 Pandemic on Melanoma Diagnosis in Romania-Data from Two University Centers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15129. [PMID: 36429847 PMCID: PMC9690697 DOI: 10.3390/ijerph192215129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/13/2022] [Accepted: 11/14/2022] [Indexed: 06/16/2023]
Abstract
The COVID-19 pandemic affected the healthcare system in our country and led non-COVID patients to postpone medical visits that were not urgent. The purpose of this study was to investigate the impact of the first year of the COVID-19 pandemic on the trends in melanoma diagnosis and to compare the pathological characteristics of melanoma patients before and during the pandemic. The number of primary cutaneous melanomas diagnosed each month between 1 March 2019 and 29 February 2020 (pre-COVID-19) and between 1 March 2020 and 28 February 2021 (COVID-19) in the North-Western Region of Romania (Cluj and Bihor counties) was determined. The pathological characteristics of melanomas diagnosed in the two intervals were compared. The number of melanoma diagnoses substantially decreased during the pandemic, with 66 (-19.3%) fewer cutaneous melanomas being diagnosed in the first year of the pandemic when compared with the previous year. The tumor thickness and mitotic rate were significantly higher in cases found during the COVID-19 pandemic. Our study suggests that COVID-19 has delayed diagnosis in patients with melanoma, leading to the detection of thicker melanomas that may increase morbidity and mortality. Further studies are needed to determine the consequences of this delay on outcomes.
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Affiliation(s)
- Loredana Ungureanu
- Department of Dermatology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
- Department of Dermatology, Emergency County Hospital, 400006 Cluj-Napoca, Romania
| | - Adina Patricia Apostu
- Department of Dermatology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Ștefan Cristian Vesa
- Department of Pharmacology, Toxicology and Clinical Pharmacology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania
| | - Alexandra Elena Cășeriu
- Department of Dermatology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Simona Frățilă
- Faculty of Medicine and Pharmacy, University of Oradea, 410068 Oradea, Romania
- Clinical Emergency County Hospital, 410039 Oradea, Romania
| | - Gabriela Iancu
- Department of Dermatology, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550169 Sibiu, Romania
- Clinic of Dermatology, County Emergency Hospital Sibiu, 550245 Sibiu, Romania
| | - Nona Bejinariu
- Santomar Oncodiagnostic Laboratory, 400350 Cluj-Napoca, Romania
| | - Maximilian Munteanu
- Department of Plastic and Reconstructive Surgery, “Prof Dr. I. Chiricuță” Institute of Oncology, 400015 Cluj-Napoca, Romania
| | - Simona C. Șenilă
- Department of Dermatology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
- Department of Dermatology, Emergency County Hospital, 400006 Cluj-Napoca, Romania
| | - Alina Vasilovici
- Department of Dermatology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
- Department of Dermatology, Emergency County Hospital, 400006 Cluj-Napoca, Romania
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Song X, Guo S, Han L, Wang L, Yang W, Wang G, Anil Baris C. Research on hair removal algorithm of dermatoscopic images based on maximum variance fuzzy clustering and optimization Criminisi algorithm. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2022.103967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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9
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Anastasopoulou A, Gkoufa A, Diamantopoulos P, Kazanas S, Eliadi I, Samarkos M, Gogas H. Clinical course of COVID-19 infection in a melanoma patient treated with nivolumab and bempegaldesleukin: a case report. Immunotherapy 2022; 14:1015-1020. [PMID: 35852114 PMCID: PMC9295713 DOI: 10.2217/imt-2021-0331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
The exact impact of immune checkpoint inhibitors in the course and outcome of COVID-19 in cancer patients is currently unclear. Herein, we present the first description of an elderly melanoma patient who developed COVID-19 pneumonia while under treatment with nivolumab and bempegaldesleukin in combination with an investigational PEGylated interleukin (IL-2). We present the clinical characteristics and the laboratory and imaging findings of our patient during the course of COVID-19 pneumonia. Moreover, we discuss the currently available data regarding the mechanism of action of immune checkpoint inhibitors and IL-2 analogs in the treatment of COVID-19. The administration of these agents did not have a negative effect on the outcome of COVID-19 pneumonia in an elderly melanoma patient. Immune checkpoint inhibitors represent a major advance in the treatment of several solid malignancies, including melanoma. Bempegaldesleukin is an investigational PEGylated IL-2 that is being evaluated, in combination with nivolumab, in the management of a variety of cancers. The immunomodulation caused by these agents may also modify the immune response in COVID-19. Currently available data regarding the impact of immune checkpoint inhibitors in reducing the severity of COVID-19 in patients with cancer are mixed, whereas no clinical data are available for bempegaldesleukin. Herein, we report the case of an elderly female melanoma patient who developed COVID-19 pneumonia while under treatment with nivolumab and bempegaldesleukin. The administration of these agents did not have a negative effect on the outcome of COVID-19 pneumonia in our patient.
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Affiliation(s)
- Amalia Anastasopoulou
- First Department of Internal Medicine, Laikon General Hospital, Medical School of National & Kapodistrian University of Athens, Athens, 11527, Greece
| | - Aikaterini Gkoufa
- First Department of Internal Medicine, Laikon General Hospital, Medical School of National & Kapodistrian University of Athens, Athens, 11527, Greece
| | - Panagiotis Diamantopoulos
- First Department of Internal Medicine, Laikon General Hospital, Medical School of National & Kapodistrian University of Athens, Athens, 11527, Greece
| | - Spyridon Kazanas
- First Department of Internal Medicine, Laikon General Hospital, Medical School of National & Kapodistrian University of Athens, Athens, 11527, Greece
| | - Irene Eliadi
- First Department of Internal Medicine, Laikon General Hospital, Medical School of National & Kapodistrian University of Athens, Athens, 11527, Greece
| | - Michael Samarkos
- First Department of Internal Medicine, Laikon General Hospital, Medical School of National & Kapodistrian University of Athens, Athens, 11527, Greece
| | - Helen Gogas
- First Department of Internal Medicine, Laikon General Hospital, Medical School of National & Kapodistrian University of Athens, Athens, 11527, Greece
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