Regional Metastatic Melanoma Research Articles

A phase Ib clinical trial of neoadjuvant OrienX010, an oncolytic virus, in combination with toripalimab in patients with resectable stage IIIb to stage IVM1a acral melanoma.

9570 Background: Metastatic acral melanoma is very difficult to treat. Unlike cutaneous melanoma, acral melanoma responds poorly to checkpoint inhibitors in monotherapy. OrienX010 is a granulocyte-macrophage colony-stimulating factor expressing herpes simplex type-1 derived oncolytic virus. It has shown robust efficacy in metastatic acral melanoma, and may improve the response to checkpoint inhibitors. To evaluate the role of OrienX010 in combination with checkpoint inhibitors in acral melanoma, we conducted a Phase Ib neoadjuvant trial of OrienX010 in combination with the anti-PD-1 monoclonal antibody toripalimab in resectable stage IIIB-IVM1a acral melanoma (NCT04197882). Methods: Patients with resectable stage IIIB-IV M1a acral melanoma received neoadjuvant intratumoral OrienX010 up to 10 mL of 8 x 107 pfu/mL and intravenous toripalimab 3 mg/kg every 2 weeks for 4 – 6 doses prior to surgical resection. After resection, adjuvant toripalimab 3 mg/kg was administered every 3 weeks for up to 1 year. The primary endpoints were radiographic response rate per RECIST 1.1 and pathological response rate (pCR and pPR). The secondary endpoints were 1- and 2-year recurrence-free survival, and safety. Results: Between July 2019 and Jan 2021, 30 patients with regional metastatic acral melanoma were enrolled. Median age was 56.5 years, 14 (47%) were male, 19 (63%) had recurrent disease, and stage IIIB 12 (40%), IIIC 14 (47%), and IVM1a 4 (13%). Median tumor burden was 28mm (range, 10-80mm), and only 5 (17%) patients had melanoma mutations (2 cKIT, 1 NRAS, 2 BRAF). To date, of 24 patients who completed neoadjuvant treatment, 21 (88%) underwent surgery. Three (12%) patients did not undergo surgery due to disease progression prior to surgery and 6 patients are still receiving neoadjuvant treatment. Radiographic responses were seen in 10 (33%) patients. However, 17 of 21 (81%) patients showed pathologic responses in resected metastases, with 3 (14%) showing a pCR and 14 (67%) a pPR. Pathologic responses were associated with greater lymphoid infiltrate, hyaline fibrosis, and decrease in Ki-67 expression in the metastasis. At a median follow-up of 8.9 months, none of the patients who underwent resection have recurred. The neoadjuvant treatment was well tolerated, with all patients experiencing at least 1 treatment related adverse event (TRAE) and Grade 1 fever was most common. Three (10%) patients had a grade 3-4 TRAE, including 1 alanine aminotransferase increase and 2 wound infections. Conclusions: Neoadjuvant treatment with OrienX010 and toripalimab in resectable stage IIIB-IVM1a acral melanoma was well tolerated and produced a high pathologic response rate. To date, no patients have recurred, and recurrence-free survival evaluation is ongoing. This combination therapy warrants further evaluation in acral melanoma. Clinical trial information: NCT04197882.

Use Patterns and Costs of Isolated Limb Perfusion and Infusion in the Treatment of Regional Metastatic Melanoma: A Retrospective Database Analysis.

IntroductionIsolated limb perfusion and infusion (ILP/ILI) are therapies for regional metastatic melanoma that allow high doses of anticancer drugs to be delivered directly into the circulation of an affected limb, thereby minimizing systemic drug toxicity. This procedure can lead to high response rates and is recommended in patients with Stage III unresectable metastatic melanoma. However, limited information is available on patterns of use and costs. This study examined patterns of ILP/ILI use and associated costs in patients with melanoma in the United States (US).MethodsRetrospective, observational study, using administrative claims data from the MarketScan® databases, was performed in patients with a diagnosis of melanoma (ICD-9-CM: 172.xx, V10.82) who underwent ILP/ILI (CPT-4: 36823) between January 1, 2002 and March 31, 2013. Patient characteristics, use patterns, length of hospital stay, and costs (per 2014 US $) of ILP/ILI were assessed.ResultsOne hundred and thirteen patients met the study criteria and were included in the analysis. Mean age was 61.4 years (standard deviation [SD] 13.8) and 38.9% of patients were male; the mean baseline Charlson Comorbidity Index was 0.19; 34.5% of patients were Medicare beneficiaries. The majority of patients (87.6%) had melanoma of the lower limb, 11.5% of the upper limb, and 0.9% of both limbs; 60.2% had lymph node metastasis and 56.6% had skin metastasis. Four patients (3.5%) underwent multiple ILP/ILI. The mean (±SD) length of hospital stay was 5.6 (±3.5) days and the mean (±SD) cost was US$36,758 (±27,124) per ILP/ILI procedure.ConclusionsIsolated limb perfusion and infusion in patients with melanoma were associated with long hospital stays and high costs. These results provide useful source data for the economic evaluation of treatment options for regional metastatic melanoma.FundingThis study was funded by Amgen, Inc.Electronic supplementary materialThe online version of this article (doi:10.1007/s12325-016-0283-z) contains supplementary material, which is available to authorized users.

Treatment of Regional Metastatic Melanoma of Unknown Primary Origin.

(1) Background: The purpose of this retrospective study was to evaluate the recurrence and survival rates of metastatic melanoma of unknown primary origin (MUP), in order to further refine current recommendations for the surgical treatment; (2) Methods: Medical data of all MUP patients registered between 2000 and 2011, were analyzed. Seventy-eight patients were categorized in either lymph node (axilla, groin, head-and neck) or subcutaneous MUP. Axillary node MUPs were generally treated with dissections of levels I-III, inguinal node MUPs with combined superficial and deep groin dissections, and head-and-neck node MUPs with neck dissections to various extents, based on lymph drainage patterns. Subcutaneous lesions were excised with 1–2 cm margins. The primary outcome was treatment outcomes in terms of (loco)regional recurrence and survival rates; (3) Results: Lymph node MUP recurred regionally in 11% of patients, with an overall recurrence rate of 45%. In contrast, subcutaneous MUP recurred locally in 65% of patients with an overall recurrence rate of 78%. This latter group had a significantly shorter disease-free interval than patients with lymph node MUP (p = 0.000). In the entire study population, 5-year and 10-year overall survival rates were 56% and 47% respectively, with no differences observed between the various subgroups; (4) Conclusion: The relatively low regional recurrence rate after regional lymph node dissection (11%) supports its current status as standard surgical treatment for lymph node MUP. Subcutaneous MUP, on the contrary, appears to recur both locally (65%) and overall (78%) at a significantly higher rate, suggesting a different biological behavior. However, wide local excision remains the best available option for this specific group.

Use Patterns and Costs of Isolated Limb Perfusion and Infusion in the Treatment of Regionally Metastatic Melanoma: a Retrospective Database Analysis

Introduction Isolated limb perfusion and infusion (ILP/ILI) are therapies for regional metastatic melanoma that allow high doses of anticancer drugs to be delivered directly into the circulation of an affected limb, thereby minimizing systemic drug toxicity. This procedure can lead to high response rates and is recommended in patients with Stage III unresectable metastatic melanoma. However, limited information is available on patterns of use and costs. This study examined patterns of ILP/ILI use and associated costs in patients with melanoma in the United States (US).

Abstract 4557: Development of a melanocortin receptor 1 targeted probe for molecular imaging of melanoma

Abstract Melanoma is curable by means of surgical excision if diagnosed in early stages, but once the metastatic stage is reached, prognosis is poor because the tumor is resistant to most cures. Therefore, a melanoma targeted probe that can deliver therapy to metastases at high dosages could increase the chances of treatment. Melanocortin 1 receptor (MC1R) is overexpressed in most human melanoma metastases, thus making it a promising target for imaging and therapy of melanomas. To confirm that MC1R is a specific melanoma marker, mRNA and protein expression was confirmed and quantified in tumor and normal unaffected patient tissue samples. MC1R mRNA expression was highly and generally expressed among melanoma samples surveyed. In contrast, MC1R expression was not elevated in other skin cancers, normal skin and organs involved in toxicity and clearance, i.e. heart, spleen, liver and kidney. To determine MC1R protein expression in patient samples, immunohistochemistry was performed on a melanoma tissue microarray containing 267 samples. None of the normal skin samples (n = 19) had staining with a pathology score of α4. Benign lesions (n = 65), samples of local invasion to regional lymph nodes (n = 35) and metastatic melanoma (n=40) had moderate to high staining in 15, 33 and 47% of the samples, respectively. We have previously reported the development of a peptidomimetic ligand with high specificity and affinity for MC1R. In this study, we have conjugated this ligand to an infrared dye to generate a MC1R specific optical probe (named ML-800). Our whole-cell binding assay using A375/MC1R human melanoma engineered cells was used to determine the high binding affinity of ML-800 (0.4± 0.1 nM Ki). The cellular uptake of the probe was studied in A375/MC1R cells by fluorescence microscopy both in vitro and in vivo using a dorsal skin-fold window-chamber mouse model. The in vivo tumor targeting of ML-800 was evaluated by intravenous injection of probe into nude mice bearing bilateral subcutaneous tumors of A375 with low number of MC1R receptors and A375/MC1R with high expression of MC1Rs. Fluorescence imaging showed that the agent has higher uptake values in A375/MC1R tumors than those in A375M tumors (P, 0.05), demonstrating differentiation of probe retention in tumors with different levels of expression. In conclusion, the imaging probe designed in this study demonstrates the potential for the development of agents that can deliver imaging contrast and therapy to melanoma metastases that express MC1R. Since radiopeptides have proven their usefulness for diagnostic imaging and radiotherapy, in the future, this ligand could be developed as a targeted delivery vehicle for non-invasive nuclear imaging to detect regional lymph node involvement, or delivery of radiotherapy. Furthermore, by attachment to the MC1R ligand with a cleavable linker, cytotoxins may also be targeted to tumor cells for receptor mediated endocytosis and intracellular release. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4557. doi:1538-7445.AM2012-4557

Epigenetic regulation of microRNA-375 and its role in melanoma development in humans

To identify epigenetically regulated miRNAs in melanoma, we treated a stage 3 melanoma cell line WM1552C, with 5AzadC and/or 4-PBA. Several hypermethylated miRNAs were detected, one of which, miR-375, was highly methylated and was studied further. Minimal CpG island methylation was observed in melanocytes, keratinocytes, normal skin, and nevus but hypermethylation was observed in patient tissue samples from primary, regional, distant, and nodular metastatic melanoma. Ectopic expression of miR-375 inhibited melanoma cell proliferation, invasion, and cell motility, and induced cell shape changes, strongly suggesting that miR-375 may have an important function in the development and progression of human melanomas.

Pericardial effusion and tamponade following interferon alpha treatment for locally advanced melanoma

Regional Metastatic Melanoma has a relatively high mortality rate. Adjuvant interferon-alpha (IFN-α) has been shown to improve disease-free survival, post-resection. Cardiotoxicity associated with IFN-α use has been described previously in the literature, but here we describe the first case of pericardial effusion with cardiac tamponade secondary to IFN-α 2b treatment of melanoma. Clinicians should be aware of this potentially lethal complication and the possible acuity of its onset.

Pegylated interferon alpha-2b as adjuvant treatment of Stage III malignant melanoma: an evidence-based review

Stage III melanoma, also referred to as regional metastatic melanoma, has five-year survival rates ranging between 40% and 78%. In order to reduce the likelihood of recurrence in this high-risk population, patients undergo resection of primary tumors and all involved nodal basins. Systemic therapy is being pursued in an effort to improve outcome data, but the best strategy has yet to be defined. Interferon alpha-2b remains to date the most promising approach available. Toxicities and intensive intravenous administration, unfortunately, are major concerns. An alternative is the use of interferon in its pegylated subcutaneous form. The aim of this research was to review the evidence for the use of pegylated interferon alpha-2b in Stage III malignant melanoma. ECOG 1684 was the pivotal trial that first demonstrated a statistically significant benefit in relapse-free and overall survival for adjuvant interferon alpha-2b in high-risk melanoma. Other larger studies, such as ECOG 1690, confirmed a relapse-free survival benefit but did not achieve statistical significance for overall survival. The first study of the pegylated form of interferon alpha-2b in Stage III melanoma, EORTC 18991, is reviewed here. This trial showed a statistically significant improvement in relapse-free survival but not overall survival. Encouraging data of potential equivalent efficacy, easier administration, and fewer Grade 3 and 4 adverse reactions compared with high-dose intravenous interferon raises the question of its potential role in Stage III melanoma in the adjuvant setting.

Abstract 3299: Expression of exchange protein activated by cAMP (Epac) in melanoma and its role in cell migration

Abstract Background: We previously reported that Epac, a guanine nucleotide exchange factor directly activated by cAMP, increases cell migration in melanoma. Epac1, a major isoform of Epac, increases melanoma cell migration via production of heparan sulfate (HS), a major extracellular glycosaminoglycan. However, the frequency and level of expression of Epac1 in human melanoma tissues is largely unknown. Furthermore, it is still unclear if Epac1's role in heparan sulfate production and cell migration is universal among different melanomas. Methods: Epac1 mRNA expression was examined in melanoma cell lines at different melanoma progression stages, and in human fresh frozen tissue of four different stages, i.e., primary melanoma, regional dermal metastatic melanoma, lymph node metastatic melanoma and distant metastatic melanoma. Also, melanoma and melanocyte cell lines were subjected to cell migration assay with the Boyden chambers. Epac1 expression was ablated by shRNA to examine involvement of Epac1 in cell migration and HS production. Results: There was a tendency toward higher Epac1 mRNA expression with progression of melanoma stage, i.e., Epac1 mRNA was higher in metastatic melanoma (MM) and vertical growth phase (VGP) melanoma cell lines than in a melanocyte cell line. In human melanoma samples, Epac1 mRNA expression was higher in regional dermal (p=0.04, n=10) and lymph node (p=0.03, n=10) metastatic melanoma than in primary melanoma, but not in distant metastatic melanoma; however, 4 out of 10 distant metastatic melanoma showed more than 2-fold increase of Epac1 mRNA expression compared to primary melanoma. These data suggest that Epac1 expression correlates with melanoma stage. When cells were incubated with 8-pMeOPT-2′-O-Me-cAMP, an Epac-specific agonist, cell migration was increased in melanoma cell lines but not in melanocytes. Heparatinase, a heparan sulfate-degrading enzyme, inhibited 8-pMeOPT-2′-O-Me-cAMP-induced cell migration in 2 metastatic melanoma cell lines, SK-Mel-2 (64.6±7.5 vs. 35.2±5.5 cells/field, p<0.05, n=4) and SK-Mel-187 (70.2±6.6 vs 43.2±9 cells/field, p<0.05, n=4) in parallel with decreased HS production. When Epac1 expression was ablated by shRNA, cell migration was decreased (SK-Mel-2, 92.6±4 vs. 49.3±1 cells/field, p<0.05, n=4; SK-Mel-187, 77.9±9 vs. 31.6±5 cells/field, p<0.05, n=4) in parallel with decreased HS production (SK-Mel-2,13 vs. 6.8±0.6 μg/ml, p<0.05, n=4; SK-Mel-187, 46.6±6.2 vs. 26.1±8.2 μg/ml, p<0.05, n=4). These data suggest that Epac1 expression plays a major role in melanoma cell migration through heparan sulfate production, and Epac's role is universal in metastatic melanoma cells. Conclusion: Epac1 expression increases with the progression of melanoma. Epac1 mediates melanoma cell migration via HS production in different melanoma cell lines. These data suggest that Epac1 could be a target for treating patients with melanoma. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 3299.

Two Cases of Malignant Melanoma with Nodal Metastasis from Unknown Primary Site

About 1% of malignant melanoma is found in the head and neck region and among them, about 2-16% is presented with palpable regional metastatic melanoma with unknown primary lesion (MUP). We have experienced two cases of MUP which were diagnosed after excisional biopsy. MUP has better prognosis than that with known primary lesion. To get good prognosis, the initial treatment of MUP should be regional lymphadenectomy, indicating the importance of an accurate diagnosis. Although the radiologic finding for malignant melanoma may offer no specific findings, physicians should be aware of the possibility of melanoma in neck mass patients. We present two cases of MUP with a literature review. (Korean J Otorhinolaryngol-Head Neck Surg 2009;52:75-8)

Improved Survival After Lymphadenectomy for Nodal Metastasis From an Unknown Primary Melanoma

No primary lesion is identified in 10% to 20% of patients presenting with palpable evidence of regional metastatic melanoma. Because the prognostic significance of unknown primary melanoma (MUP) is unclear, we compared clinical outcomes of patients with MUP and known primary melanoma (MKP) with regional nodal metastases. We reviewed our 13,000-patient prospective melanoma database (1971 through 2005) to identify patients managed with regional lymphadenectomy for palpable nodal metastases from MUP or MKP. Multivariate analysis identified prognostic factors significant for survival. MUP and MKP were then matched by significant covariates. Overall survival (OS) was estimated by Kaplan-Meier method and compared by log-rank analysis. Multivariate analysis of data from 1,571 study patients identified four significant covariates associated with worse prognosis: age >or= 60 years (hazard ratio [HR] = 1.294; P = .0017), male sex (HR = 1.335; P = .0004), nodal tumor burden >or= one (HR = 1.256; P < .0001), and known primary (HR = 1.507; 95% CI, 1.220 to 1.862; P = .0001). Five-year OS was significantly higher for 262 patients with MUP than for 1,309 patients with MKP (55% +/- 6% v 44% +/- 3%; P = .0021). Computerized matching of MUP and MKP by four significant covariates (age, sex, nodal tumor burden, and decade of diagnosis) yielded 221 matched pairs. Median and 5-year OS rates were 165 months and 58% +/- 7%, respectively, for MUP as compared with 34 months and 40% +/- 7%, respectively, for MKP (P = .0006). Lymphadenectomy is effective for nodal metastasis from MUP. The significantly better postoperative survival for MUP versus MKP suggests a strong endogenous immune response against the primary melanoma. Immunologic studies to identify cell-mediated and antibody components of this response may lead to new approaches for determining melanoma prognosis and treatment.

Surveillance of the Eye and Vision in Clinical Trials of CP-675,206 for Metastatic Melanoma

To determine the ocular safety of CP-675,206 (Pfizer, New York, New York, USA), a fully human anti-cytotoxic T lymphocyte-associated antigen 4 monoclonal antibody in clinical trials of immunotherapy of metastatic melanoma. Prospective, nonrandomized study of the eye and vision in phase I/II clinical trials of CP-675,206 in metastatic melanoma conducted at the University of California, Los Angeles. Patients with regional or distant metastatic melanoma were enrolled in phase I/II clinical trials evaluating the safety and antitumor efficacy of CP-675,206 alone or in combination with melanoma antigen peptide-pulsed dendritic cell vaccines. Ophthalmic evaluation was performed at the onset of CP-675,206 immunotherapy (baseline evaluation), two months or more after the onset of CP-675,206 immunotherapy (end-study evaluation), and at two- to three-month intervals thereafter in patients who continued to receive CP-675,206 immunotherapy (poststudy evaluation). Baseline and end-study evaluations included comprehensive ophthalmic examination, psychophysical and electrophysiologic visual function assessment, fundus photography, fluorescein angiography, and visual function assessment. Twenty patients with metastatic melanoma arising from the skin, mucosa, eye, or unknown site were evaluated. Systemic toxicity attributed to CP-675,206 included dermatologic manifestations, diarrhea, and autoimmune hepatitis with panhypopituitarism. A subset of patients receiving CP-675,206 demonstrated antitumor efficacy with partial response or complete response of metastatic melanoma. Comparison of ophthalmic baseline with end-study evaluations in all 20 patients and limited-term poststudy evaluations showed no adverse effect of CP-675,206 immunotherapy on the eye or vision. In this study, CP-675,206 immunotherapy for metastatic melanoma did not adversely affect the eye or vision.

Can Surgical Therapy Alone Achieve Long-Term Cure of Melanoma Metastatic to Regional Nodes?

Anecdotal reports of melanoma recurrence 15 years after complete lymphadenectomy have led to claims that the onset of nodal metastasis invariably signals systemic metastases and a terminal diagnosis. Few series in the literature are able to refute this assertion. We therefore examined rates of long-term (> 15-25 years) survival for patients with regional (nodal) melanoma. We performed an analysis of patients with American Joint Committee on Cancer stage III melanoma entered into a prospective database for the last 30 years. All patients were seen at the treating institution within 4 months of their diagnosis and monitored thereafter. All patients underwent complete lymphadenectomy. Patients receiving melanoma vaccines were excluded. Statistical comparisons used Chi-square analysis and the log-rank test. At a maximum follow up of 386 months (32 years) for the population of 1422 patients, rates of 15-, 20-, and 25-year melanoma-specific survival were 36% +/- 1%, 35% +/- 1%, and 35% +/- 1%, respectively. When patients were stratified by clinical status of regional lymph nodes, survival rates were significantly lower (P = 0.001) if nodes were palpable. The number of tumor-positive nodes (P < 0.0001), the pathological primary tumor stage (P = 0.005), age (P = 0.0001), and gender (P = 0.002) also were significantly related to long-term survival. Long-term survivors of melanoma metastatic to regional lymph nodes are not uncommon, and the extremely low rate of recurrence beyond 15 years suggests that this disease-free interval is usually synonymous with cure. Although some risk factors decrease the likelihood of long-term survival, the high overall rates of extended survival in all risk groups clearly support surgical management as the primary treatment for regional metastatic melanoma.

Peripheral blood CD4+ T-cell response before postoperative active immunotherapy correlates with clinical outcome in metastatic melanoma.

Canvaxin polyvalent specific active immunotherapeutic (CancerVax Corp., Carlsbad, CA) is a minimally toxic adjuvant after resection of regional metastatic melanoma. Because Canvaxin immunotherapeutic requires induction of an immune response, we hypothesized that survival would be directly correlated with cellular immune responses to Canvaxin cells prior to immunization. We randomly selected 54 patients from a study of Canvaxin therapy after complete resection of American Joint Committee on Cancer (AJCC) stage III melanoma. Peripheral blood lymphocytes (PBLs) collected before immunotherapy were co-cultured with Canvaxin cells; cellular response was determined by flow cytometric measurement of the production of intracellular interleukin 4 (IL4) or interferon gamma (IFNgamma) by CD4(+) T-cells. Results were calculated as percent positive for double staining of CD4(+) plus IL4(+) or CD4(+) plus IFNgamma(+). The mean (+/- SD) increase in cytokine-producing CD4(+) T-cells after Canvaxin stimulation was 4.8 +/- 2.3% for an IFN response and 5.1 +/- 2.0% for an IL4 response. Both increases were significantly correlated with overall survival by univariate analysis (P = .0471 for IFNgamma and 0.002 for IL4). There was no significant correlation between unstimulated IFNgamma/IL4 responses and overall survival. Multivariate analysis showed that a CD4(+) T-cell IL4 response before Canvaxin therapy was a significant independent prognostic variable. In vitro cellular immune response to Canvaxin cells directly correlates with survival after subsequent initiation of immunotherapy for AJCC stage III melanoma. This finding will be evaluated in a multicenter phase III trial of Canvaxin plus bacille Calmette-Guerin (BCG) versus placebo plus BCG after resection of stage III melanoma.

Biochemotherapy of metastatic malignant melanoma. Predictive value of tumour-infiltrating lymphocytes.

The therapeutic efficacy of biochemotherapy in metastatic malignant melanoma still carries a low remission rate, but with some durable responses. It would therefore be of considerable importance if patients with a high probability of responding could be identified using predictive tests. The response to interferon-alpha (IFN-α) correlates with the occurrence of CD4+ lymphocytes identified by fine-needle aspirates from melanoma metastases (Håkansson et al, 1996). The present investigation studies a possible correlation between tumour-infiltrating CD4+ lymphocytes in malignant melanoma metastases and the therapeutic effect of biochemotherapy. A total of 25 patients with systemic and 16 with regional metastatic melanoma were analysed before initiation of biochemotherapy (cis-platinum 30 mg/m2 d.1–3, DTIC 250 mg/m2 d.1–3 i.v. and IFN-α2b 10 million IU s.c. 3 days a week, q. 28d.). A monoclonal antibody, anti-CD4, was used to identify tumour-infiltrating lymphocytes in fine-needle aspirates before start of treatment. The presence of these lymphocytes was correlated to response, time to progression and overall survival. A statistically significant correlation (P = 0.01) was found between the occurrence of CD4+ lymphocytes and tumour regression during biochemotherapy in patients with systemic disease. Out of 14 patients with moderate to high numbers of infiltrating CD4+ lymphocytes, 12 achieved tumour regression. In contrast, among patients with low numbers of these cells in metastatic lesions, 8 out of 11 had progressive disease. We also found a significantly longer time to progression (P < 0.003) and overall survival (P < 0.01) among patients with moderate to high numbers of these cells compared to patients with low numbers of these cells before initiation of biochemotherapy. Furthermore, in patients with regional disease, we found a significantly longer time to progression (P = 0.01) and a trend toward a longer overall survival time (P = 0.09). Based on these results and as previously shown with IFN-α therapy alone, there seems to be a need for CD4+ lymphocytes infiltrating the tumours before the start of biochemotherapy to make the treatment successful. Determination of these cells in fine-needle aspirates seems to be a method to predict responders to biochemotherapy, thus increasing the cost–benefit of this treatment strategy considerably, both in terms of patient adverse reactions and health care costs. © 2001 Cancer Research Campaign http://www.bjcancer.com

Management of regional metastases.

Treatment of regional melanoma metastases aims not only at local remission of the primary tumour but also at prevention or delay of distant metastases. Regional metastases can occur as satellite, in-transit and regional lymph node metastases. This is an overview of the current therapeutic modalities for regional metastatic melanoma: surgical management of relapse, satellite and in-transit metastases; therapeutic lymphadenectomy; development from elective lymph node dissection to sentinel lymph node dissection (SLND); radiotherapy and isolated limb perfusion. Instead of elective lymph node dissection the new microstaging technique by means of SLND is gaining particular importance. For this method prognostic relevance is expected and thus it is supposed to be an important staging parameter for adjuvant treatment planning.

Expression of ICAM-1 during IFN-alpha-based treatment of metastatic malignant melanoma: relation to tumor-infiltrating mononuclear cells and regressive tumor changes.

Intercellular adhesion molecule-1 (ICAM-1) plays an important role in cell to cell interactions. In malignant melanoma, ICAM-1 expression correlates with malignant behavior. We used monoclonal antibodies, anti-ICAM-1, anti-CD4+, anti-CD8+, and anti-CD11c+ to study the effect of interferon-alpha (IFN-alpha) on the expression of ICAM-1 by melanoma cells in regional metastases and its correlation to the occurrence of CD4+, CD8+, and CD11c+ cells close to tumor cells and in the tumor stroma. We also estimated the expression of ICAM-1 and regressive changes in malignant melanoma metastases, correlating the duration of treatment to these effects of IFN-alpha. Twenty-three IFN-alpha-treated and 10 untreated patients with regional metastatic malignant melanoma were studied. The duration of IFN-alpha treatment influenced the expression of ICAM-1. In metastases from patients treated for 1 week only, 1 of 5 showed high expression of ICAM-1 compared with 6 of 11 of those treated for 3 weeks (p = 0.01, chi-square test for trend comparing untreated patients and patients with various durations of IFN-alpha treatment). In IFN-alpha-treated patients with low expression of ICAM-1, none of 7 metastases showed CD4+ cells infiltrating close to tumor cells, in contrast to 6 of 10 metastases expressing high amounts of ICAM-1 (p = 0.03). Similarly, the expression of ICAM-1 was found to correlate with the occurrence of CD8+ cells close to the tumor cells (p = 0.04). We also showed a correlation between ICAM-1 expression and histologic evidence of tumor regression (p = 0.02).

IgM Anti-Ganglioside Antibodies Induced by Melanoma Cell Vaccine Correlate with Survival of Melanoma Patients

Melanoma cells express ganglioside antigens GM3, GD3, GM2, and GD2 on their surface. This study examined whether immunization with a melanoma cell vaccine induced anti-ganglioside antibody responses in melanoma patients and whether these responses were correlated with survival. Sixty-six patients who had received melanoma cell vaccine immunotherapy after surgical removal of regional metastatic melanoma were identified. Cryopreserved serum samples from these patients were used in an enzyme-linked immunsorbent assay to determine the IgM antibody levels to GM2, GD2, GM3, and GD3 prior to melanoma cell vaccine treatment and 4 wk after the first melanoma cell vaccine immunization. All antibody levels significantly increased by week 4 (p < 0.001 for all four antibodies) and all increases were significantly associated with survival (anti-GD2, p < 0.001; anti-GM2, p = 0.001; anti-GD3, p < 0.001; anti-GM3, p < 0.001). Anti-tumor activity of these antibodies was proved using five representative antibody-positive sera in a complement-dependent cytotoxicity assay with cultured melanoma cell lines. These studies suggest that GM2, GD2, GM2, and GD3 expressed by melanoma cells can induce specific IgM antibodies and that high levels of these antibodies might have a beneficial impact on survival.

Positron emission tomography plus serum TA90 immune complex assay for detection of occult metastatic melanoma

Background: Whole-body positron emission tomography (PET) using 18F-fluorodeoxyglucose is very sensitive for detection of metastatic melanoma. We previously reported the accuracy of a serum TA90 enzyme-linked immunosorbent assay (ELISA) in predicting the recurrence of early-stage melanoma. This serum ELISA measures a circulating immune complex composed of TA90 a tumor-associated 90-kD glycoprotein antigen, and its IgG antibody. We hypothesized that using PET examination in conjunction with our serum TA90 ELISA would increase the detection of occult melanoma lesions. Study Design: From November 1, 1993 to December 31, 1995, 87 patients underwent PET examination followed within 6 weeks by serum TA90 ELISA. All patients had undergone complete resection of local, regional, or distant metastatic melanoma and had no clinical evidence of disease at the time of PET examination. Each patient had complete followup for 12 months after PET examination. The clinical course was determined by chart review of clinical and radiographic findings. Results: Of the 25 patients who experienced recurrence of disease within 6 months of followup, 22 (88%) had a positive result on one or both tests. Of the 52 patients with a negative result on both tests, 49 (94%) remained disease-free at 6 months of followup. Of the 14 patients who developed distant metastases within 6 months after PET examination, 13 (93%) had a positive PET examination and/or a positive TA90 ELISA. Conclusions: The TA90 ELISA correlated well with PET examination for detection of metastatic melanoma. The high sensitivity of PET examination plus TA90 ELISA suggests that this combination may have a role in the surveillance of patients at high risk of developing metastatic melanoma.

Augmentation of IgM antibody to gp43 tumor-associated antigen peptide by melanoma cell vaccine.

We previously reported that gp43 tumor-associated antigen peptide (DLTMKYQIF; designated 810 antigen) on human melanoma cells is recognized by IgM human monoclonal antibody L92 and by cytotoxic T lymphocytes (CTL). In this study, we retrospectively tested sera of 44 patients with regional metastatic melanoma (22 who recurred within 1 year and 22 who survived longer than 5 years) to determine if antibody responses to 810 antigen could be induced by immunization with an allogeneic melanoma cell vaccine that contained 810 peptide. IgM and IgG antibodies were assessed by enzyme-linked immunosorbent assay using a synthetic 810 nonamer peptide. A significant augmentation of IgM antibody was demonstrated 4 weeks after initiation of vaccine therapy, and the IgM level was significantly higher in patients who survived more than 5 years. The antigen epitope recognized by antibodies was located within TMKYQI. Of this epitope sequence, K appears to play a central role in antigenicity. The 810 antigen recognized by antibody and CTL may have clinical relevance as a potential source of melanoma vaccine.