Post on 14-Jun-2020
ESMO SUMMIT LATIN AMERICA 2019
Melanoma Clinical Cases
Ana Cláudia Galdino, MD
March, 2019
CONFLICT OF INTEREST DISCLOSURE
No conflict of interest
CASE 1
Male, 78 years old, ECOG PS 0 No allergies No comorbidities
2014 Diagnosis: Melanoma pT3a pN1b M0 in the right arm Management: Wide excision with safety margins and six-monthly follow up
CASE PRESENTATION CONT’D
2016 Recurrence as cutaneous metastasis Management: Resection only – BRAF WT; and six-monthly follow up
CASE PRESENTATION CONT’D
Oct/2017 Recurrence as brain and peri-pancreatic lymph nodes
CASE PRESENTATION CONT’D
Oct/2017 Recurrence as brain and peri-pancreatic lymph nodes
QUESTION FOR THE PANEL
How would you treat this patient?
a. SRS for brain metastasis, followed by anti-PD-1
b. Ipilimumab and anti-PD-1
c. Anti-PD-1 only
QUESTION FOR THE PANEL
How would you treat this patient?
a. SRS for brain metastasis, followed by anti-PD-1
b. Ipilimumab and anti-PD-1
c. Anti-PD-1 only
CASE PRESENTATION CONT’D
Nov/2017
Feb/2018
Nov/2017 SRS for brain metastasis, followed by anti-PD-1
CASE PRESENTATION CONT’D
Nov/2017
Feb/2018
CASE PRESENTATION CONT’D
Today Anti-PD-1 maintenance therapy
CASE 2
Male, 67 years old, ECOG PS 0 No allergies No comorbidities
Mar/2015 Due to dyspnea, clinical investigation revealed one suspected malignant lesion in
the right lower lobe. No primary tumor was found at that moment. Management: Right lower lobectomy Pathology report: Malignant Melanoma – BRAF V600E mutation Staging: PET/CT and Brain MRI – NED
Diagnosis: Metastatic Melanoma (lung) of unknown primary site – BRAF V600Emutation
Management: Three-monthly follow up
CASE PRESENTATION CONT’D
Jul/2016 PET/CT – No evidence of systemic disease
QUESTION FOR THE PANEL
How would you treat this patient?
a. Surgery + RT for surgical bed
b. BRAF/MEK inhibitors
c. BRAF/MEK inhibitors, followed by SRS for brain metastasis and then BRAF/MEKinhibitors
d. Ipilimumab and anti-PD-1, followed by anti-PD-1 only
QUESTION FOR THE PANEL
How would you treat this patient?
a. Surgery + RT for surgical bed
b. BRAF/MEK inhibitors
c. BRAF/MEK inhibitors, followed by SRS for brain metastasis and thenBRAF/MEK inhibitors
d. Ipilimumab and anti-PD-1, followed by anti-PD-1 only
CASE PRESENTATION CONT’D
Aug/17-21/2016 SRS for brain metastasis
CASE 3
Male, 64 years old, ECOG PS 0 No allergies No comorbidities
Jan/2015 Diagnosis: Melanoma pT4b pN0 M0 in the right leg Management: Wide excision + SNLB – 0/0
QUESTION FOR THE PANEL
How would you treat this patient? pT4b pN0
a. High-Dose Interferon
b. Low-Dose Interferon
c. Placebo-controlled trial for adjuvant therapy with PD1 or BRAF/MEK-I
d. Follow Up
QUESTION FOR THE PANEL
How would you treat this patient? pT4b pN0
a. High-Dose Interferon
b. Low-Dose Interferon
c. Placebo-controlled trial for adjuvant therapy with PD1 or BRAF/MEK-I
d. Follow Up - q 3 months for 2 years, and increasing intervals- CT Scan
CASE PRESENTATION CONT’D
Feb/2018 Recurrence as single site in right inguinal lymph node, between CT’s
QUESTION FOR THE PANEL
How would you treat this patient?
a. FNA – order BRAF to attempt neoadjuvant BRAF/MEK-I
b. FNA – to attempt neoadjuvant Ipi/Nivo
c. Nodal dissection and Adjuvant Therapy with anti PD1 (regardless of BRAF status)
d. Nodal dissection and Adjuvant Therapy with BRAF/MEK inhibitors if BRAF-mutated
QUESTION FOR THE PANEL
How would you treat this patient?
a. FNA – order BRAF to attempt neoadjuvant BRAF/MEK-I
b. FNA - to atempt neoadjuvant Ipi/Nivo
c. Nodal dissection and Adjuvant Therapy with anti PD1 (regardless of BRAFstatus)
d. Nodal dissection and Adjuvant Therapy with BRAF/MEK inhibitors if BRAF-mutated
CASE PRESENTATION CONT’D
Mar/2018 Nivolumab 3mg/kg q2w for three cycles and started with cough and fatigue SpO2
92% at rest
QUESTION FOR THE PANEL
Mar/2018
Diagnosis: Pneumonitis grade 2
Management: Nivolumab was interrupted and prednisone was started at 1mg/kg/dtaper during the next 30 days.
CASE PRESENTATION CONT’D
Abr/2018 Nivolumab 3mg/kg q2w is discontinued and prednisone 60mg PO is started
QUESTION FOR THE PANEL
How would you treat this patient?
a) Discontinue anti PD1 as adjuvant therapy
b) Resume Adjuvant Therapy with anti-PD1
c) Switch adjuvant therapy to BRAF/MEK - inhibitors
QUESTION FOR THE PANEL
How would you treat this patient?
a) Discontinue anti PD1 as adjuvant therapy
b) Resume Adjuvant Therapy with anti-PD1
c) Switch adjuvant therapy to BRAF/MEK - inhibitors
CASE 4
Female, 46 years old, ECOG PS 0 No allergies Comorbidities: hypothyroidism, bariatric surgery, hypertension
Jul/2018 Due to in the right axilla pain, she noted enlarged axillary lymph nodes. Normal
strength, but significant tingling USG revealed suspicious lymphadenopathy Incisional biopsy: Malignant Melanoma BRAF ordered Initial images identify only axillary lymph nodes with close contact with the right
brachial plexus
Diagnosis: Unresectable metastatic Melanoma (nodes) of unknown primary sitecTx cN3 M0 – BRAF ongoing
CASE PRESENTATION CONT’D
Jul/2018
QUESTION FOR THE PANEL
How would you treat this patient?
a. Wait for BRAF status (2 weeks, at least) and start neoadjuvant therapy withBRAF/MEK inhibitors
b. Neoadjuvant therapy with anti-PD1
c. Neoadjuvant therapy with Ipilimumab and Nivolumab
QUESTION FOR THE PANEL
How would you treat this patient?
a. Wait for BRAF status (2 weeks, ate least) and start neoadjuvant therapy withBRAF/MEK inhibitors
b. Neoadjuvant therapy with anti-PD1
c. Neoadjuvant therapy with Ipilimumab and Nivolumab
CASE PRESENTATION CONT’D
Aug2018 to Sep/2018 Ipilimumabe 3 + Nivolumabe 1 q3w for four cycles
CASE PRESENTATION CONT’D
Sep/2018 to date Nivolumabe 1 q3w for maintenance
QUESTION FOR THE PANEL
How would you treat this patient? - BRAF WT
a. Keep systemic therapy only (nivolumab, up to 2 years)
b. Surgery and discontinue systemic therapy
c. Surgery and adjuvant nivolumab, up to 2 years
QUESTION FOR THE PANEL
How would you treat this patient? - BRAF WT
a. Keep systemic therapy only (nivolumab, up to 2 years)
b. Surgery and discontinue systemic therapy
c. Surgery and adjuvant Nivolumabe, up to 2 years