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The IGNYTE phase II trial evaluated RP1 (an HSV-1-based oncolytic immunotherapy) plus nivo in anti-PD-1-failed melanoma, showing an overall response rate (ORR) of 32.9% with 15.0% complete response (CRs) and deep, systemic responses in both injected and noninjected lesions. Median duration of response (DOR) was 33.7 months (14.1 to NR), progression-free survival (PFS) was modest overall at 3.6 months (2.0-5.0) but much longer in responders (35.5 months vs 1.9 months in nonresponders), and overall survival (OS) rates were encouraging at 1 and 2 years (75.3% and 63.3%, median OS NR). Safety was favorable, with mostly grade 1/2 TRAEs (77.1%) and low grade 3/4 rates (9.3%/3.6%), and biomarker data showed on-treatment immune activation. For our anti-PD-1-refractory melanoma patients, RP1+nivo looks like a practical, immunotherapy-only option with real durability in responders and manageable toxicity. This is definitely one to watch as we await randomized data.

I love this trial in that it advances science but also balances cost. Neoadjuvant therapy with ipilimumab + nivolumab (Ipi+Nivo) x 2 followed by surgery followed by adjuvant nivolumab. Patients with a major pathologic response went on to observation alone. Again, intact tumor-immune interactions are key to maximum treatment effectiveness. Another key to these patients is seeing a medical oncologist before surgery.

10-year survival data from Checkmate 067 on Ipi+Nivo, Nivo and Ipi alone in met-melanoma. The OS was twice as long in the Ipi+Nivo group compared to Nivo alone. Of note this was with Nivo-1 + Ipi-3, and most of us use the more tolerable Nivo-3 + Ipi-1 dosing based on Checkmate 511. This remains the SOC for good PFS met-melanoma in my opinion.

Combination vs. placebo improved PFS, where there was improvement in OS as the risk of death was 20% lower but was not significant, in BRAF V600E, the risk of death was reduced by 25%.
For BRAF V600E, NCCN recommends using this regimen in the adjuvant setting.

This was compared to adjuvant niovolumab for 12 months, patients who did not achieve complete response also received adjuvant nivo. Neoadjuvant therapy was for 2 cycles. 12-month event-free survival was 83.7% in the neoadjuvant group and 57.2% in the adjuvant group. 58% had major pathological response in the neoadjuvant group, less than 5% could not get the surgery. The estimated 12-month recurrence-free survival was 95.1% in patients in the neoadjuvant group who had a major pathological response, 76.1% among those with a partial response, and 57.0% among those with a nonresponse.

Interesting study showing a strong difference in EFS with neoadjuvant + adjuvant vs. adjuvant alone for stage III/IV melanoma. All patients had disease that was amenable to surgery; EFS at 24 months was 72% vs. 49% in favor of the neoadjuvant group. The hypothesis is that neoadjuvant therapy functionally inhibits the immune checkpoint before antitumor T-cells are surgically resected. This concept is also developing in other cancers, including NSCLC, breast and bladder cancers. This should affect clinical practice.

More may not always be better. Adjuvant Nivo q2-weeks + Ipi q6-weeks was not better than Nivo q4 weeks in reducing recurrences in fully resected stage III-IV melanoma.

Incredible development for a small population of patients with uveal melanoma but nonetheless a new standard of care. Initial infusions may be complex in terms of close monitoring, as inpatient, till more experience is acquired in community oncology practices.