Two hundred and eighty patients were included in the study. The mean age of the patients at primary melanoma diagnosis was 62.9 years (standard deviation, SD = 14.9), with a median age of 65 years (interquartile range, IQR = 54–74). Most patients were males (60.7% versus 39.3%). Median follow-up time from melanoma diagnosis was 3.4 years (IQR = 1.8–6.2) for a total of 1286 person-years of follow-up. There were 144 deaths; five- and ten-year overall survival were 56.2% and 30.8%, respectively (Table 1).
Table 1
Characteristics of primary melanoma
Characteristics:
|
N.
|
%
|
Age, y
|
|
|
mean (SD)
|
62.9 (14.9)
|
median (IQR)
|
65 (54–74)
|
Sex
|
|
|
male
|
170
|
60.7
|
female
|
110
|
39.3
|
Localization of primary
|
|
|
skin
|
218
|
77.9
|
nodular
|
96
|
44.0
|
superficial spreading
|
94
|
43.1
|
other
|
28
|
12.8
|
mucosal
|
26
|
9.3
|
uveal
|
9
|
3.2
|
occult
|
12
|
4.3
|
unknown
|
15
|
5.4
|
Anatomic site
|
|
|
head/neck
|
52
|
18.6
|
upper limbs
|
42
|
15.0
|
trunk
|
100
|
35.7
|
lower limbs
|
59
|
21.1
|
unknown
|
27
|
9.6
|
Breslow thickness, mma
|
|
|
mean (SD)
|
3.9 (3.2)
|
median (IQR)
|
3 (2–5)
|
Ulcerationa
|
|
|
present
|
130
|
59.6
|
absent
|
65
|
29.8
|
unknown
|
23
|
10.6
|
Regressiona
|
|
|
yes
|
9
|
4.1
|
no
|
209
|
95.9
|
Presence of satellitosisa
|
|
|
yes
|
23
|
10.6
|
no
|
195
|
89.4
|
Lymphadenectomya
|
|
|
performed
|
102
|
46.8
|
positive
|
61
|
59.8
|
negative
|
41
|
40.2
|
not performed
|
116
|
53.2
|
Abbreviations: SD, standard deviation; IQR, Interquartile Range
a: only for cutaneous melanoma
|
Regarding the primary melanoma, 77.9% was of skin onset (of which 44.0% of nodular type, 43.1% of superficial diffusion, 12.8% of other histological type); 9.3% was mucosal; 3.2% was uveal and 4.3% was of unknown origin (occult melanoma). For 5.4% no data on primary melanoma were available. The most frequent location of the primary melanoma was the trunk (35.7%), followed by lower extremities (21.1%), head and neck (18.6%), and the upper extremities (15.0%). Breslow thickness was 3.9 mm (SD = 3.2), with a median of 3 mm (IQR = 2–5). Ulceration was present in 59.6% of cases, absent in the 29.8 %, unknown for a 10.6%. Regression was present only in 4.1% of cases and the presence of satellitosis in the 10.6% of cases. One hundred and two (102, 46.8%) patients had undergone lymphadenectomy, of which 59.8% were positive and 40.2% were negative for lymph node metastasis (Table 1).
As shown in Table 2, patients at the beginning of treatment with ICI had a mean age of 66.1 years (SD = 14.1), with a median age of 68 years (IQR = 58–77). Out of the 280 patients, 84 (30.0%) were in stage M1, 51 (18.2%) in stage M1b, 97 (34.6%) in stage M1c and 47 (16.8%) in stage M1d. Most of the patients showed the involvement of two metastatic organ sites (35.5%), followed by one (34.8%), and by three or more (29.7%). Serum LDH value was normal in 45.0% of patients and high in 26.8%. A BRAF mutation was present in 29.6% of patients (with V600E mutation in 86.7% of cases, V600K in 12.0% of cases, one case with K601E mutation), and was not present in 66.4% of patients; for 3.9% of patients this data was not available.
Table 2
Patient characteristics at Immune Checkpoint Inhibitors (ICI) therapy baseline
Characteristics:
|
N.
|
%
|
Age, y
|
|
|
mean (SD)
|
66.1 (14.1)
|
median (IQR)
|
68 (58–77)
|
Metastatic stage
|
|
|
M1a
|
84
|
30.0
|
M1b
|
51
|
18.2
|
M1c
|
97
|
34.6
|
M1d
|
47
|
16.8
|
unknown
|
1
|
0.4
|
Number of organs involved
|
|
|
1
|
97
|
34.8
|
2
|
99
|
35.5
|
≥ 3
|
83
|
29.7
|
Serum LDH
|
|
|
normal
|
126
|
45.0
|
higha
|
75
|
26.8
|
unknown
|
79
|
28.2
|
BRAF status
|
|
|
mutation
|
83
|
29.6
|
V600E
|
72
|
86.7
|
V600K
|
10
|
12.0
|
K601E
|
1
|
1.2
|
no mutation
|
186
|
66.4
|
unknown
|
11
|
3.9
|
Abbreviations: SD, standard deviation; IQR, Interquartile Range; LDH, Lactate Dehydrogenase.
a: > upper limit of normal (ULN)
|
As shown in Table 3, two hundred patients (71.4%) received ICI therapy as a first-line treatment, 76 (27.1%) as a second-line treatment, and only 4 patients (1.4%) as third- or fourth -line treatment. Among the patients who received ICI as a first line therapy, 103 patients (51.5%) received Nivolumab, 47 Pembrolizumab (23.5%), and 50 Ipilimumab (25.0%). Out of 280 patients, 248 (88.6%) did not receive any adjuvant therapy before ICI treatment. Among the 280 patients studied, 140 (50.0%) developed at least one type of toxicity. The following toxicities were observed: gastro-intestinal (19.3%); endocrinological (15.4%); VLL (15.4%); skin toxicity excluding VLL (11.4%); pulmonary (4.3%); skeletal muscle (2.5%); neurological (1.4%); cardiovascular (0.7%); hematological (0.7%); ocular (0.7%) and renal toxicity (0.4%). It is important to note that, among the 43 patients who developed VLL, 25 patients (58.1%) did not have any other toxicity. The median time of VLL onset after the start of Ipilimumab, Pembrolizumab and Nivolumab as a first-line treatment was 7 months (IQR = 3–14), 6 months (IQR = 4–8), and 10 months (4–17) respectively. No difference was found between ICI treatment types and onset of VLL (p = 0.713). From the start of ICI therapy, the median follow-up time was 9.9 months (ranging from 6 days to 81 months) for a total of 4651 months of follow-up.
Table 3
Type of therapies and toxicity
|
N.
|
%
|
ICI line of treatment
|
|
|
first-line
|
200
|
71.4
|
second-line
|
76
|
27.1
|
third or fourth line
|
4
|
1.4
|
First-line drug
|
|
|
Ipilimumab
|
50
|
25.0
|
Pembrolizumab
|
47
|
23.5
|
Nivolumab
|
103
|
51.5
|
Adjuvant therapy
|
|
|
no
|
248
|
88.6
|
yes
|
30
|
10.7
|
unknown
|
2
|
0.7
|
Toxicity
|
|
|
no
|
140
|
50.0
|
yes
|
140
|
50.0
|
Type of toxicity
|
|
|
leukoderma
|
43
|
15.4
|
only leukoderma
|
25
|
8.9
|
gastro-intestinal
|
54
|
19.3
|
endocrine
|
43
|
15.4
|
cutaneous (excluding leukoderma)
|
32
|
11.4
|
pulmonary
|
12
|
4.3
|
skeletal muscle
|
7
|
2.5
|
neurological
|
4
|
1.4
|
cardiovascular
|
2
|
0.7
|
hematological
|
2
|
0.7
|
ocular
|
2
|
0.7
|
renal
|
1
|
0.4
|
Abbreviations: ICI, Immune Checkpoint Inhibitors
|
A significant survival advantage in patients who developed VLL during ICI treatment compared to those who did not develop such a toxicity was observed (log-rank test, p < 0.0001; Fig. 1, panel A). Five-year overall survival for persons who developed VLL was 75.1% versus 24.2% for those who did not develop it. This effect was only observed for VLL and not for other toxicities, regardless of the toxicity grade. A significant poorer survival was found for patients with high LDH compared to those with normal serum LDH levels (log-rank test, p < 0.0001; Fig. 1, panel B); with metastatic disease M1c and M1d compared to M1a-M1b (log-rank test, p < 0.0001; Fig. 2, panel A); and in patients who did not undergo previous adjuvant treatment compared to those who did (log-rank test, p = 0.047; Fig. 2, panel B).
Table 4 shows the results of the multivariate analysis for mortality. After controlling for sex, age, staging, LDH levels, use of adjuvant therapy, first line use of ICIs, VLL development was associated with reduced mortality (hazard ratio, HR:0.32; 95%CI: 0.22–0.48, p < 0.0001). The protective effect was even greater if the analysis was restricted to patients with cutaneous melanoma who underwent treatment with ICI in first line (HR:0.24; 95%CI: 0.12–0.45, p < 0.0001). For patients in which ICI was the first line therapy and VLL was the only toxicity observed, mortality risk was 6 times lower than in patients with no toxicity (HR:0.15; 95% CI = 0.05–0.43, p < 0.0001). High serum LDH levels (HR:2.33; 95% CI:1.51–3.60, p < 0.0001), staging (M1d versus M1a-1b) (HR:2.25; 95% CI: 1.39–3.63, p = 0.001) and use of ICIs not as a first line treatment (HR:1.47; 95% CI:1.02–2.13, p = 0.040), were all independently associated with an increased risk of mortality in the multivariate model, while the use of adjuvant therapy was associated with a protective effect (HR:0.54; 95%CI: 0.29–0.99, p = 0.047).
Table 4
Prognostic factors for mortality: uni- and multi-variate Cox model
|
all melanoma
(N = 280)
|
only cutaneous melanoma
(N = 218)
|
only cutaneous melanoma and
first-line ICI
(N = 153)
|
|
HRcrude (95%CI)
|
P
|
HRadja (95%CI)
|
P
|
HRadja (95%CI)
|
P
|
HRadja (95%CI)
|
P
|
Sex
|
|
|
|
|
|
|
|
|
male
|
1
|
|
1
|
|
1
|
|
1
|
|
female
|
0.78 (0.56–1.10)
|
0.162
|
0.74 (0.51–1.07)
|
0.110
|
0.75 (0.49–1.16)
|
0.198
|
0.82 (0.45–1.48)
|
0.505
|
Age at start of ICI
|
1.00 (0.99–1.02)
|
0.658
|
1.01 (1.00-1.03)
|
0.076
|
1.01 (0.99–1.03)
|
0.190
|
1.04 (1.01–1.06)
|
0.002
|
Toxicity
|
|
|
|
|
|
|
|
|
none
|
1
|
|
1
|
|
1
|
|
1
|
|
leukoderma and other
|
0.26 (0.18–0.38)
|
< 0.0001
|
0.32 (0.22–0.48)
|
< 0.0001
|
0.28 (0.17–0.45)
|
< 0.0001
|
0.24 (0.12–0.45)
|
< 0.0001
|
only leukoderma
|
0.23 (0.12–0.44)
|
< 0.0001
|
0.23 (0.11–0.44)
|
< 0.0001
|
0.22 (0.11–0.46)
|
< 0.0001
|
0.15 (0.05–0.43)
|
< 0.0001
|
Serum LDH
|
|
|
|
|
|
|
|
|
normal
|
1
|
|
1
|
|
1
|
|
|
|
higha
|
2.75 (1.84–4.10)
|
< 0.0001
|
2.33 (1.51–3.60)
|
< 0.0001
|
2.76 (1.66–4.58)
|
< 0.0001
|
2.75 (1.46–5.16)
|
< 0.0001
|
Metastatic stage
|
|
|
|
|
|
|
|
|
1a-1b
|
1
|
|
1
|
|
1
|
|
1
|
|
1c
|
2.21 (1.51–3.23)
|
< 0.0001
|
1.44 (0.96–2.16)
|
0.075
|
1.52 (0.95–2.43)
|
0.084
|
1.92 (1.01–3.64)
|
0.047
|
1d
|
3.22 (2.08–4.99)
|
< 0.0001
|
2.25 (1.39–3.63)
|
0.001
|
1.76 (1.00-3.10)
|
0.051
|
2.80 (1.36–5.78)
|
0.005
|
Adjuvant therapy
|
|
|
|
|
|
|
|
|
yes vs. no
|
0.55 (0.31-1.00)
|
0.051
|
0.54 (0.29–0.99)
|
0.047
|
0.47 (0.25–0.91)
|
0.024
|
1.22 (0.57–2.61)
|
0.605
|
ICI line of treatment
|
|
|
|
|
|
|
|
|
first-line
|
1
|
|
1
|
|
1
|
|
-
|
|
second-line and beyond
|
1.94 (1.39–2.72)
|
< 0.0001
|
1.47 (1.02–2.13)
|
0.040
|
1.53 (1.00-2.33)
|
0.047
|
-
|
|
Abbreviations: HR, Hazard Ratio; adj, adjusted; CI, Confidence Intervals; LDH, Lactate Dehydrogenase; ICI, Immune Checkpoint Inhibitors
a: HR adjusted for all items in table
b: > upper limit of normal (ULN)
|
A subgroup analysis was conducted only for patients with ICIs as a first line therapy (N = 153). The median TTNT was 4.9 months. The occurrence of VLL was also an independent predictor factor for duration of clinical benefits measured by TTNT (only VLL), HR:0.17; 95%CI:0.06–0.44, p = < 0.0001; VLL and other toxicities HR:0.35; 95%CI:0.21–0.59, p = < 0.0001. Both high LDH serum levels and advance staging were associated with shorter TTNT (Table 5).
Table 5
Prognostic factors for time to the next treatment (TTNT): uni- and multi-variate Cox model
|
only cutaneous melanoma and first-line ICI
(N = 153)
|
|
HRcrude (95%CI)
|
P
|
HRadja (95%CI)
|
P
|
Sex
|
|
|
|
|
male
|
1
|
|
1
|
|
female
|
0.96 (0.61–1.49)
|
0.846
|
1.02 (0.63–1.66)
|
0.934
|
Age at start of ICI
|
1.00 (0.99–1.02)
|
0.564
|
1.01 (0.99–1.02)
|
0.513
|
Toxicity
|
|
|
|
|
none
|
1
|
|
1
|
|
leukoderma and other
|
0.32 (0.20–0.51)
|
< 0.0001
|
0.35 (0.21–0.59)
|
< 0.0001
|
only leukoderma
|
0.19 (0.07–0.48)
|
< 0.0001
|
0.17 (0.06–0.44)
|
< 0.0001
|
Serum LDH
|
|
|
|
|
normal
|
1
|
|
1
|
|
highb
|
1.95 (1.19–3.20)
|
0.008
|
2.06 (1.19–3.59)
|
0.010
|
Metastatic stage
|
|
|
|
|
M1a-1b
|
1
|
|
1
|
|
M1c
|
1.93 (1.15–3.24)
|
0.013
|
1.53 (0.88–2.65)
|
0.130
|
M1d
|
2.84 (1.66–4.88)
|
< 0.0001
|
2.08 (1.14–3.79)
|
0.017
|
Adjuvant therapy
|
|
|
|
|
yes vs. no
|
1.20 (0.65–2.22)
|
0.553
|
1.35 (0.70–2.60)
|
0.364
|
Abbreviations: HR, Hazard Ratio; adj, adjusted; CI, Confidence Intervals; LDH, Lactate Dehydrogenase.
a: HR adjusted for all items in table
b: > upper limit of normal (ULN)
|
All other factors considered in the study, such as Breslow thickness, ulceration, site of primary melanoma, presence of regression, presence of satellitosis, lymphadenectomy, BRAF status, and types of ICI used in first line (Ipilimumab, Pembrolizumab or Nivolumab), were not associated with mortality.
Demographic and clinical characteristics of patients who developed VLL and of the ones who do not developed it were examined (Table 6). No difference between groups were found for age, types of melanoma, anatomic site of the primary melanoma, BRAF status, use of adjuvant therapy, and type of ICI. However, statistically significant differences were observed for sex (p = 0.043), and LDH levels (p = 0.021). Most patients who developed VLL were females (53.5% versus 36.7%) and had normal serum LDH levels (80.0% versus 59.0%). For patients with ICI as first-line treatment, the best objective response was also analyzed. The rates of clinical complete responses (CR) (35.3% versus 9.1%) and partial responses (PR) (38.2% versus 28.0%) were higher in patients who developed VLL than in patients who did not have such a toxicity, while progressive disease (PD) was significantly lower in patients with VLL (5.9% versus 40.9%, p < 0.0001).
Table 6
Demographic and clinical characteristics of the patients and onset of leukoderma
|
leukoderma
(N = 43)
|
no leukoderma
(N = 237)
|
|
Characteristics:
|
N.*
|
%
|
N.*
|
%
|
Pa
|
Age at start of ICI
|
|
|
|
|
|
mean (SD)
|
66.2 (12.7)
|
66.1 (14.4)
|
0.831b
|
Sex
|
|
|
|
|
|
male
|
20
|
46.5
|
150
|
63.3
|
|
female
|
23
|
53.5
|
87
|
36.7
|
0.043
|
Localization of primary
|
|
|
|
|
|
Cutaneous
|
35
|
83.3
|
183
|
82.1
|
|
Mucosal
|
4
|
9.5
|
22
|
9.9
|
|
Uveal
|
0
|
…
|
9
|
4.0
|
|
Occult
|
3
|
7.1
|
9
|
4.0
|
0.537
|
Anatomic site
|
|
|
|
|
|
head/neck
|
5
|
13.2
|
47
|
21.9
|
|
upper limbs
|
3
|
7.9
|
39
|
18.1
|
|
trunk
|
16
|
42.1
|
84
|
39.1
|
|
lower limbs
|
14
|
36.8
|
45
|
20.9
|
0.089
|
Metastatic stage
|
|
|
|
|
|
M1a-1b
|
28
|
65.1
|
107
|
45.3
|
|
M1c
|
10
|
23.3
|
87
|
36.9
|
|
M1d
|
5
|
11.6
|
42
|
17.8
|
0.071
|
Serum LDH
|
|
|
|
|
|
normal
|
28
|
80.0
|
98
|
59.0
|
|
higha
|
7
|
20.0
|
68
|
41.0
|
0.021
|
BRAF status
|
|
|
|
|
|
mutation
|
29
|
69.0
|
157
|
69.2
|
|
no mutation
|
13
|
31.0
|
70
|
30.8
|
1.00
|
Adjuvant therapy
|
|
|
|
|
|
no
|
35
|
81.4
|
213
|
90.6
|
|
yes
|
8
|
18.6
|
22
|
9.4
|
0.104
|
First-line drug
|
|
|
|
|
|
Ipilimumab
|
7
|
20.6
|
43
|
25.9
|
|
Pembrolizumab
|
9
|
26.5
|
38
|
22.9
|
|
Nivolumab
|
18
|
52.9
|
85
|
51.2
|
0.801
|
Best objective responsed
|
|
|
|
|
|
Complete Response
|
12
|
35.3
|
15
|
9.1
|
|
Partial Response
|
13
|
38.2
|
46
|
28.0
|
|
Stable Disease
|
7
|
20.6
|
36
|
22.0
|
|
Progressive Disease
|
2
|
5.9
|
67
|
40.9
|
< 0.0001
|
Abbreviations: SD, Standard Deviation; LDH, Lactate Dehydrogenase; ICI, Immune Checkpoint Inhibitors
a: Fisher’s exact test
b: Mann-Whitney U test
c: > upper limit of normal (ULN)
d: to first-line therapy
|