Marlene Garzarolli

Systemic therapy of metastatic melanoma

For patients with metastatic melanoma, there are currently several effective therapeutic options. The BRAF inhibitors vemurafenib and dabrafenib are characterized by rapid tumor control and high response rates. In combination with one of the two MEK inhibitors trametinib and cobimetinib, they achieve response rates (CR + PR, complete plus partial remissions) of 70 %, while delaying the development of treatment resistance, as well as a median overall survival of > 2 years with tolerable side effects.

Hirnmetastasen des malignen Melanoms

The majority of patients with metastatic melanoma will develop brain metastases, which are the most common cause of death. Until recently, local therapies (e. g., neurosurgery, radiotherapy) were the only options for brain metastases; however, effective systemic treatment options are now available. Upon suspicion of brain metastases, diagnostic staging with brain MRI and a neurological investigation are indicated. Prognostic factors such as number of cerebral metastases and symptoms, serum lactate dehydrogenase and S‑100 levels, extracerebral metastases, and ECOG status are considered during therapeutic planning. Treatment planning and therapeutic interventions should be based on an interdisciplinary and multimodal approach. Established treatments for singular brain metastases are neurosurgical resection and stereotactic radiotherapy, which can prolong survival. In patients with asymptomatic BRAF V600E-mutant brain metastases, the BRAF inhibitors dabrafenib, vemurafenib, and immunotherapy with ipilimumab are used. In the case of multiple symptomatic brain metastases, palliative whole-brain radiotherapy is used for treatment, although it has failed to show an overall survival benefit. Increased intracranial pressure and epileptic seizures are addressed with corticosteroids and anticonvulsants. Current clinical studies for melanoma patients with brain metastases are investigating new treatment options such as PD-1 antibodies, combined ipilimumab and nivolumab, combined BRAF inhibitors and MEK inhibitors, and stereotactic radiation in combination with immunotherapy or targeted therapy.ZusammenfassungHirnmetastasen treten bei der Mehrheit der Patienten mit metastasiertem Melanom auf und sind die häufigste Todesursache. Bis vor Kurzem war die Lokaltherapie die einzige Option für die Kontrolle von Hirnmetastasen. Inzwischen stehen wirksame systemische Therapieoptionen zur Verfügung. Bei Verdacht auf Hirnmetastasen sind eine Staging-Diagnostik mit Craniale Magnetresonanztomographie (cMRT) sowie eine neurologische Untersuchung indiziert. Für die Therapieplanung sollten prognostische Faktoren wie Anzahl und Symptomatik der zerebralen Metastasen, der LDH- und S100-Wert im Serum, die extrazerebrale Metastasierung sowie der ECOG (Eastern Cooperative Oncology Group)-Status einbezogen werden. Die Therapieentscheidung bzw. -durchführung sollte interdisziplinär bzw. multimodal erfolgen. Bei singulären Hirnmetastasen sind die neurochirurgische Resektion und die stereotaktische Radiatio etabliert. Das Behandlungsspektrum hat sich durch die Neuzulassung von wirksamen Immuntherapien (CTLA-4- und PD-1-Antikörper) sowie zielgerichteten Therapien (BRAF-und MEK-Inhibitoren) erheblich erweitert. Die palliative Ganzhirnradiatio wird bei multiplen symptomatischen Hirnmetastasen eingesetzt, wobei bisher kein signifikanter Vorteil für das Gesamtüberleben gezeigt werden konnte. Bei erhöhtem intrakraniellem Druck und epileptischen Anfällen sind Kortikosteroide und Antikonvulsiva indiziert. In aktuellen klinischen Studien werden für Melanompatienten mit Hirnmetastasen neue Therapieoptionen wie PD-1-Antikörper, Ipilimumab plus Nivolumab, BRAF-Inhibitoren plus MEK-Inhibitoren sowie stereotaktische Radiatio in Kombination mit Immuntherapie bzw. zielgerichteter Therapie untersucht.AbstractThe majority of patients with metastatic melanoma will develop brain metastases, which are the most common cause of death. Until recently, local therapies (e. g., neurosurgery, radiotherapy) were the only options for brain metastases; however, effective systemic treatment options are now available. Upon suspicion of brain metastases, diagnostic staging with brain MRI and a neurological investigation are indicated. Prognostic factors such as number of cerebral metastases and symptoms, serum lactate dehydrogenase and S‑100 levels, extracerebral metastases, and ECOG status are considered during therapeutic planning. Treatment planning and therapeutic interventions should be based on an interdisciplinary and multimodal approach. Established treatments for singular brain metastases are neurosurgical resection and stereotactic radiotherapy, which can prolong survival. In patients with asymptomatic BRAF V600E-mutant brain metastases, the BRAF inhibitors dabrafenib, vemurafenib, and immunotherapy with ipilimumab are used. In the case of multiple symptomatic brain metastases, palliative whole-brain radiotherapy is used for treatment, although it has failed to show an overall survival benefit. Increased intracranial pressure and epileptic seizures are addressed with corticosteroids and anticonvulsants. Current clinical studies for melanoma patients with brain metastases are investigating new treatment options such as PD-1 antibodies, combined ipilimumab and nivolumab, combined BRAF inhibitors and MEK inhibitors, and stereotactic radiation in combination with immunotherapy or targeted therapy.

An unusual case of Cowden syndrome associated with ganglioneuromatous polyposis

BackgroundGanglioneuromatous polyposis (GP) is a very rare disorder which may be associated with other clinical manifestations and syndromes, such as Cowden syndrome, multiple endocrine neoplasia (MEN) type II and neurofibromatosis (NF) 1. The risk for malignant transformation of ganglioneuromas is unknown, and the combination of GP with colon cancer has been only very seldom reported.Methods and resultsWe report the case of a 60-year old male patient with adenocarcinoma, adenomas and lipomas of the colon and multiple gastroduodenal lesions combined with generalised lipomatosis and macrocephaly. Based on the initial endoscopic and histological findings, a (restorative) proctocolectomy was recommended but declined by the patient. Instead, a colectomy was performed. The histological examination revealed an unforeseen GP in addition to the colon cancer. Extensive molecular diagnostics allowed for the differential diagnosis of the causes of the clinical manifestations, and the clinical suspicion of Cowden syndrome could not be confirmed using Sanger Sequencing and MLPA for the analysis of PTEN. Finally, a pathogenic germline mutation in PTEN (heterozygous stop mutation in exon 2: NM_000314 (PTEN):c.138C > A; p.Tyr46*) could be detected by next-generation sequencing (NGS), confirming an unusual presentation of Cowden syndrome with GP.ConclusionsCowden syndrome should be considered in cases of GP with extracolonic manifestation and verified by combined clinical and molecular diagnostics. Because GP may represent a premalignant condition, a surgical-oncological prophylactic procedure should be considered. Based on our experience, we recommend early implementation of Panel NGS rather than classical Sanger sequencing for genetic diagnostics, especially if various diagnoses are considered.

Systemtherapie des metastasierten malignen Melanoms

Für Patienten mit metastasiertem Melanom stehen aktuell mehrere wirksame Therapieoptionen zur Verfügung. Die BRAF‐Inhibitoren Vemurafenib und Dabrafenib zeichnen sich durch eine rasche Tumorkontrolle und hohe Ansprechraten aus. In Kombination mit den MEK‐Inhibitoren Trametinib bzw. Cobimetinib erreichen sie Ansprechraten (CR + PR, komplette plus partielle Remissionen) von 70 %, wobei die Entwicklung einer Therapieresistenz verzögert wird, sowie ein medianes Gesamtüberleben von > 2 Jahren bei tolerablen Nebenwirkungen.

[Melanoma brain metastases : Treatment options].

The majority of patients with metastatic melanoma will develop brain metastases, which are the most common cause of death. Until recently, local therapies (e. g., neurosurgery, radiotherapy) were the only options for brain metastases; however, effective systemic treatment options are now available. Upon suspicion of brain metastases, diagnostic staging with brain MRI and a neurological investigation are indicated. Prognostic factors such as number of cerebral metastases and symptoms, serum lactate dehydrogenase and S‑100 levels, extracerebral metastases, and ECOG status are considered during therapeutic planning. Treatment planning and therapeutic interventions should be based on an interdisciplinary and multimodal approach. Established treatments for singular brain metastases are neurosurgical resection and stereotactic radiotherapy, which can prolong survival. In patients with asymptomatic BRAF V600E-mutant brain metastases, the BRAF inhibitors dabrafenib, vemurafenib, and immunotherapy with ipilimumab are used. In the case of multiple symptomatic brain metastases, palliative whole-brain radiotherapy is used for treatment, although it has failed to show an overall survival benefit. Increased intracranial pressure and epileptic seizures are addressed with corticosteroids and anticonvulsants. Current clinical studies for melanoma patients with brain metastases are investigating new treatment options such as PD-1 antibodies, combined ipilimumab and nivolumab, combined BRAF inhibitors and MEK inhibitors, and stereotactic radiation in combination with immunotherapy or targeted therapy.ZusammenfassungHirnmetastasen treten bei der Mehrheit der Patienten mit metastasiertem Melanom auf und sind die häufigste Todesursache. Bis vor Kurzem war die Lokaltherapie die einzige Option für die Kontrolle von Hirnmetastasen. Inzwischen stehen wirksame systemische Therapieoptionen zur Verfügung. Bei Verdacht auf Hirnmetastasen sind eine Staging-Diagnostik mit Craniale Magnetresonanztomographie (cMRT) sowie eine neurologische Untersuchung indiziert. Für die Therapieplanung sollten prognostische Faktoren wie Anzahl und Symptomatik der zerebralen Metastasen, der LDH- und S100-Wert im Serum, die extrazerebrale Metastasierung sowie der ECOG (Eastern Cooperative Oncology Group)-Status einbezogen werden. Die Therapieentscheidung bzw. -durchführung sollte interdisziplinär bzw. multimodal erfolgen. Bei singulären Hirnmetastasen sind die neurochirurgische Resektion und die stereotaktische Radiatio etabliert. Das Behandlungsspektrum hat sich durch die Neuzulassung von wirksamen Immuntherapien (CTLA-4- und PD-1-Antikörper) sowie zielgerichteten Therapien (BRAF-und MEK-Inhibitoren) erheblich erweitert. Die palliative Ganzhirnradiatio wird bei multiplen symptomatischen Hirnmetastasen eingesetzt, wobei bisher kein signifikanter Vorteil für das Gesamtüberleben gezeigt werden konnte. Bei erhöhtem intrakraniellem Druck und epileptischen Anfällen sind Kortikosteroide und Antikonvulsiva indiziert. In aktuellen klinischen Studien werden für Melanompatienten mit Hirnmetastasen neue Therapieoptionen wie PD-1-Antikörper, Ipilimumab plus Nivolumab, BRAF-Inhibitoren plus MEK-Inhibitoren sowie stereotaktische Radiatio in Kombination mit Immuntherapie bzw. zielgerichteter Therapie untersucht.AbstractThe majority of patients with metastatic melanoma will develop brain metastases, which are the most common cause of death. Until recently, local therapies (e. g., neurosurgery, radiotherapy) were the only options for brain metastases; however, effective systemic treatment options are now available. Upon suspicion of brain metastases, diagnostic staging with brain MRI and a neurological investigation are indicated. Prognostic factors such as number of cerebral metastases and symptoms, serum lactate dehydrogenase and S‑100 levels, extracerebral metastases, and ECOG status are considered during therapeutic planning. Treatment planning and therapeutic interventions should be based on an interdisciplinary and multimodal approach. Established treatments for singular brain metastases are neurosurgical resection and stereotactic radiotherapy, which can prolong survival. In patients with asymptomatic BRAF V600E-mutant brain metastases, the BRAF inhibitors dabrafenib, vemurafenib, and immunotherapy with ipilimumab are used. In the case of multiple symptomatic brain metastases, palliative whole-brain radiotherapy is used for treatment, although it has failed to show an overall survival benefit. Increased intracranial pressure and epileptic seizures are addressed with corticosteroids and anticonvulsants. Current clinical studies for melanoma patients with brain metastases are investigating new treatment options such as PD-1 antibodies, combined ipilimumab and nivolumab, combined BRAF inhibitors and MEK inhibitors, and stereotactic radiation in combination with immunotherapy or targeted therapy.

Information-seeking and use of information resources among melanoma patients of German skin cancer centers: Information-seeking among melanoma patients

This study aimed to explore the information‐seeking behavior (ISB) of melanoma patients (MPs) and MP subgroups, in order to provide data for needs‐based adaptation of information provision.

Informationssuche und Nutzung von Informationsquellen durch Melanompatienten deutscher Hautkrebszentren: Informationssuche durch Melanompatienten

Mit dieser Studie sollte das Informationsverhalten (IV) von Melanompatienten (MP) und deren Subgruppen untersucht werden, um Daten für eine bedarfsgerechte Anpassung der Informationsversorgung zu erhalten.

Clinical, molecular, and immunological responses to pembrolizumab treatment of synchronous melanoma and acute myeloid leukemia

Key Points Pembrolizumab treatment of melanoma and concomitant sAML resulted in a significant platelet response and clearance of IDH1 mutation. Pembrolizumab therapy and response was associated with an increased PD-L1 expression on acute myeloid leukemia blasts and T cells.

Melanoma Brain Metastases: Local Therapies, Targeted Therapies, Immune Checkpoint Inhibitors and Their Combinations—Chances and Challenges

Recent phase II trials have shown that BRAF/MEK inhibitors and immune checkpoint inhibitors are active in patients with melanoma brain metastases (MBM), reporting intracranial disease control rates of 50–75%. Furthermore, retrospective analyses suggest that combining stereotactic radiosurgery with immune checkpoint inhibitors or BRAF/MEK inhibitors prolongs overall survival. These data stress the need for inter- and multidisciplinary cooperation that takes into account the individual prognostic factors in order to establish the best treatment for each patient. Although the management of MBM has dramatically improved, a substantial number of patients still progress and die from brain metastases. Therefore, there is an urgent need for prospective studies in patients with MBM that focus on treatment combinations and sequences, new treatment strategies, and biomarkers of treatment response. Moreover, further research is needed to decipher brain-specific mechanisms of therapy resistance.

Hirnmetastasen des malignen Melanoms: Therapiebesonderheiten

The majority of patients with metastatic melanoma will develop brain metastases, which are the most common cause of death. Until recently, local therapies (e. g., neurosurgery, radiotherapy) were the only options for brain metastases; however, effective systemic treatment options are now available. Upon suspicion of brain metastases, diagnostic staging with brain MRI and a neurological investigation are indicated. Prognostic factors such as number of cerebral metastases and symptoms, serum lactate dehydrogenase and S‑100 levels, extracerebral metastases, and ECOG status are considered during therapeutic planning. Treatment planning and therapeutic interventions should be based on an interdisciplinary and multimodal approach. Established treatments for singular brain metastases are neurosurgical resection and stereotactic radiotherapy, which can prolong survival. In patients with asymptomatic BRAF V600E-mutant brain metastases, the BRAF inhibitors dabrafenib, vemurafenib, and immunotherapy with ipilimumab are used. In the case of multiple symptomatic brain metastases, palliative whole-brain radiotherapy is used for treatment, although it has failed to show an overall survival benefit. Increased intracranial pressure and epileptic seizures are addressed with corticosteroids and anticonvulsants. Current clinical studies for melanoma patients with brain metastases are investigating new treatment options such as PD-1 antibodies, combined ipilimumab and nivolumab, combined BRAF inhibitors and MEK inhibitors, and stereotactic radiation in combination with immunotherapy or targeted therapy.ZusammenfassungHirnmetastasen treten bei der Mehrheit der Patienten mit metastasiertem Melanom auf und sind die häufigste Todesursache. Bis vor Kurzem war die Lokaltherapie die einzige Option für die Kontrolle von Hirnmetastasen. Inzwischen stehen wirksame systemische Therapieoptionen zur Verfügung. Bei Verdacht auf Hirnmetastasen sind eine Staging-Diagnostik mit Craniale Magnetresonanztomographie (cMRT) sowie eine neurologische Untersuchung indiziert. Für die Therapieplanung sollten prognostische Faktoren wie Anzahl und Symptomatik der zerebralen Metastasen, der LDH- und S100-Wert im Serum, die extrazerebrale Metastasierung sowie der ECOG (Eastern Cooperative Oncology Group)-Status einbezogen werden. Die Therapieentscheidung bzw. -durchführung sollte interdisziplinär bzw. multimodal erfolgen. Bei singulären Hirnmetastasen sind die neurochirurgische Resektion und die stereotaktische Radiatio etabliert. Das Behandlungsspektrum hat sich durch die Neuzulassung von wirksamen Immuntherapien (CTLA-4- und PD-1-Antikörper) sowie zielgerichteten Therapien (BRAF-und MEK-Inhibitoren) erheblich erweitert. Die palliative Ganzhirnradiatio wird bei multiplen symptomatischen Hirnmetastasen eingesetzt, wobei bisher kein signifikanter Vorteil für das Gesamtüberleben gezeigt werden konnte. Bei erhöhtem intrakraniellem Druck und epileptischen Anfällen sind Kortikosteroide und Antikonvulsiva indiziert. In aktuellen klinischen Studien werden für Melanompatienten mit Hirnmetastasen neue Therapieoptionen wie PD-1-Antikörper, Ipilimumab plus Nivolumab, BRAF-Inhibitoren plus MEK-Inhibitoren sowie stereotaktische Radiatio in Kombination mit Immuntherapie bzw. zielgerichteter Therapie untersucht.AbstractThe majority of patients with metastatic melanoma will develop brain metastases, which are the most common cause of death. Until recently, local therapies (e. g., neurosurgery, radiotherapy) were the only options for brain metastases; however, effective systemic treatment options are now available. Upon suspicion of brain metastases, diagnostic staging with brain MRI and a neurological investigation are indicated. Prognostic factors such as number of cerebral metastases and symptoms, serum lactate dehydrogenase and S‑100 levels, extracerebral metastases, and ECOG status are considered during therapeutic planning. Treatment planning and therapeutic interventions should be based on an interdisciplinary and multimodal approach. Established treatments for singular brain metastases are neurosurgical resection and stereotactic radiotherapy, which can prolong survival. In patients with asymptomatic BRAF V600E-mutant brain metastases, the BRAF inhibitors dabrafenib, vemurafenib, and immunotherapy with ipilimumab are used. In the case of multiple symptomatic brain metastases, palliative whole-brain radiotherapy is used for treatment, although it has failed to show an overall survival benefit. Increased intracranial pressure and epileptic seizures are addressed with corticosteroids and anticonvulsants. Current clinical studies for melanoma patients with brain metastases are investigating new treatment options such as PD-1 antibodies, combined ipilimumab and nivolumab, combined BRAF inhibitors and MEK inhibitors, and stereotactic radiation in combination with immunotherapy or targeted therapy.