Tuesday, November 12, 2019

Leptomeningeal melanoma and brain mets - a relationship?

As I've said many times, "Melanoma sucks great big green stinky hairy wizard balls!!!" (An expansion of the sentiment first expressed by dear Ruthie!) BUT...leptomeningeal disease sucks even more.  Here is an article posted earlier this year with additional links within:  Leptomeningeal disease and melanoma Now, there's this:

High-resolution MRI demonstrates that more than ninety percent of small intracranial melanoma metastases develop in close relationship to the leptomeninges.  Lasocki, Khoo, Lau, et al.  Neuro Oncol. 2019 Sep 9. 

Despite classic teaching that intracranial metastases typically arise at the grey-white matter junction, small intracranial melanoma metastases (IMM) are frequently observed at the interface between the cortex and leptomeninges (i.e. "corticomeningeal interface"), suggesting possible leptomeningeal origin.

MRI brain examinations of melanoma patients treated at a specialist oncology centre from July 2015 to June 2017 were retrospectively reviewed. The MRI examination on which IMM were first visible was identified, utilising 1mm volumetric post-contrast imaging prior to local therapy. Individual metastases (up to 10 per patient) were assessed for the presence of leptomeningeal contact, as well as their number, size and morphology. Lesions greater than/= to 10mm in long axis were excluded, in order to examine early metastatic disease.

75 patients had evidence of IMM. 15 patients had only lesion(s) measuring greater than/= to10mm at diagnosis, leaving 60 patients. 192 individual metastases were examined (median 2 per patient, interquartile range 1-4), 174 (91%) demonstrating leptomeningeal contact. A nodular morphology was observed in 154 of 192 (82%), 32 (17%) were ovoid but elongated along the cortex, and 6 (3%) were linear. Only three patients (5%) also exhibited a 'classic' linear leptomeningeal disease appearance.

Most IMM measuring between 2 and 9mm in diameter are corticomeningeal nodules. These data raise the hypothesis that deeper parenchymal extension of IMM occurs secondarily. If the leptomeninges provide a preferential site for establishment of IMM, further investigation of the underlying biology of this phenomenon may provide opportunities for novel therapeutic strategies for patients with IMM.

For what it's worth.  The more we can learn about how to deal with this most unfortunate of evolutions in melanoma, the better.  And as always, still holding dear Rob and his precious Adriana in my heart. ~ c

Saturday, November 9, 2019

Sew Chaotically! ~ Sashiko pillow cases, done!!!

Today I finally stitched together these pillow cases.  The sashiko embroidery was completed almost a year ago with sweet Ruthie, as a diversion from surgery and chemo miseries.  Mine is the wonky green basket weave design!!!  In my defense, I was stitching under the influence!  The embroidered portion is denim salvaged from some old jeans.  Thread and other fabric cobbled together from the remains of previous sewing projects.

A long time in the making.  I love them!  They are the perfect example of the power of sewing - and love.  Worthless remnants and difficult experiences reconfigured into moments and items of comfort and beauty.  Thanks, Ruthie!

Sew and live chaotically! - love, les

Thursday, November 7, 2019

What to do when that one melanoma tumor keeps growing?

For some melanoma patients, despite a pretty good response to targeted or immunotherapy, there remains that single lesion or one group of tumors that just won't respond!!!  What are they to do with that???  Localized treatment is becoming more clearly the answer!  This article noted the benefit of local surgery to excise the problem child:  When in doubt, cut it out!!!  Now there's this:

The Management of Oligoprogression in the Landscape of New Therapies for Metastatic Melanoma.  Guida, Bartolomeo, De Risi, et al.  Cancers (Basel). 2019 Oct 14. 

Background: A limited degree of progression after a response to treatment is labelled as oligoprogression and is a hot topic of metastatic melanoma (MM) management. Rogue progressive metastases could benefit from local treatment, which could allow the continuation of ongoing systemic therapy, also known as treatment beyond progression (TBP). 

Methods: We retrospectively reviewed 214 selected MM patients who developed oligoprogression during treatment with v-Raf murine sarcoma viral oncogene homolog B (BRAF)/mitogen-activated-extracellular signal-regulated kinase (MEK) or programmed cell death protein 1 (PD-1) inhibitors and received a local treatment continuing TBP. We performed univariate and multivariable analyses to assess the association between therapy outcomes and a series of clinical and biological features. 
Results: We identified 27 (10%) oligoprogressed patients treated locally with surgery (14), radiosurgery (11), and electrochemotherapy (2). TBP included PD-1 inhibitors (13) and BRAF/MEK inhibitors (14). The median progression-free survival post oligoprogression (PFSPO) was 14 months (5-19). In the univariate analysis, a significantly longer PFSPO was associated with complete response (CR), Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0, neutrophils/lymphocytes ratio (N/L) less than 2, and progression-free survival (PFS) at oligoprogression greater than 11 months. Nevertheless, in the multivariable analysis, only CR and N/L less than 2 were found to be associated with longer PFSPO. 
Conclusions: In selected patients, local treatments contribute to controlling oligoprogression for a long time, allowing the continuation of systemic treatment and prolongation of overall survival (OS). Increasing biological and clinical knowledge is improving the accuracy in identifying patients to apply for local ablative therapies.

So these researchers looked back on the records of 214 melanoma patients who developed oligoprogression.  They found 27, 13 of whom were treated with PD-1 inhibitors and 14 who were treated with BRAF/MEK.  Those patients then had their local non-responding lesions treated with either surgery (14), radiation (11), electrochemotherapy (2).  Average progression free survival after those therapies was 14 months.  Only complete response and a NLR less than 2 were factors that were significantly associated with a longer progression free survival after that treatment.

The article below, further corroborates the need for - and good responses from - localized treatment in patients who experience limited progression after treatment with checkpoint inhibitors:

Patterns of failure after immunotherapy with checkpoint inhibitors predict durable progression-free survival after local therapy for metastatic melanoma.  Klemen, Wang, Feingold, et al.   J Immunother Cancer. 2019 Jul 24.

Checkpoint inhibitors (CPI) have revolutionized the treatment of metastatic melanoma, but most patients treated with CPI eventually develop progressive disease. Local therapy including surgery, ablation or stereotactic body radiotherapy (SBRT) may be useful to manage limited progression, but criteria for patient selection have not been established. Previous work has suggested progression-free survival (PFS) after local therapy is associated with patterns of immunotherapy failure, but this has not been studied in patients treated with CPI.

We analyzed clinical data from patients with metastatic melanoma who were treated with antibodies against CTLA-4, PD-1 or PD-L1, either as single-agent or combination therapy, and identified those who had disease progression in 1 to 3 sites managed with local therapy. Patterns of CPI failure were designated by independent radiological review as growth of established metastases or appearance of new metastases. Local therapy for diagnosis, palliation or CNS metastases was excluded.

Four hundred twenty-eight patients with metastatic melanoma received treatment with CPI from 2007 to 2018. Seventy-seven have ongoing complete responses while 69 died within 6 months of starting CPI; of the remaining 282 patients, 52 (18%) were treated with local therapy meeting our inclusion criteria. Local therapy to achieve no evidence of disease (NED) was associated with three-year progression-free survival (PFS) of 31% and five-year disease-specific survival (DSS) of 60%. Stratified by patterns of failure, patients with progression in established tumors had three-year PFS of 70%, while those with new metastases had three-year PFS of 6%. Five-year DSS after local therapy was 93% versus 31%, respectively.

Local therapy for oligoprogression after CPI can result in durable PFS in selected patients. We observed that patterns of failure seen during or after CPI treatment are strongly associated with PFS after local therapy, and may represent a useful criterion for patient selection. This experience suggests there may be an increased role for local therapy in patients being treated with immunotherapy.

Though not listed in either of these articles, I would submit that intralesional therapy (if the lesion in question is accessible) as another good option to use in getting rid of a pesky melanoma remnant!  Wishing all of you my best! - c

Sunday, November 3, 2019

Moore Morris Trick-or-treat!!!!

She may have gotten married, but the minute Roo realized her daddy would be out of town leading up to and on Halloween, she was determine that her annual Daddy/Daughter pumpkin carving happened - NO MATTER WHAT!!!  So, it did!

The punkins became a bit more scary after a week of rain!!!
And for actual Halloween, there was this cute kit kat!!!
Sweet girl.  Fun punkins. Cute cat.  She's never missed carving pumpkins with her Daddy!!  Love my Daddy's girl!!! - les

Friday, October 25, 2019

Avoid meat, eggs and antibiotics for improved response to cancer therapy?????

Our microbiome has been getting lots of attention and legit research in regard to health generally, as well as cancer and response to cancer therapies (immunotherapy specifically) recently.  Here's a link to lots of reports:  Cooties!

And given that data and the importance of the right cooties being present in our gut, it makes sense that antibiotics would certainly throw a wrench in that balance.  Here's a link to some related posts:  Antibiotics, gut microbes, and decreased response to immunotherapy  It is interesting to note that years ago, doxycycline was found to be one of the things that killed melanoma:   Doxycycline kills melanoma - at least in a petri dish

Now, there's this:

Association of Prior Antibiotic Treatment With Survival and Response to Immune Checkpoint Inhibitor Therapy in Patients With Cancer.  Pinato, Howlett, Ottaviani, et al. JAMA Oncol. 2019 Sep 12. 

Gut dysbiosis impairs response to immune checkpoint inhibitors (ICIs) and can be caused by broad-spectrum antibiotic (ATB) therapy.  To evaluate whether there is an association between ATB therapy administered concurrently (cATB) or prior (pATB) to ICI therapy and overall survival (OS) and treatment response to ICI therapy in patients with cancer treated with ICIs in routine clinical practice.

This prospective, multicenter, cohort study conducted at 2 tertiary academic referral centers recruited 196 patients with cancer who received ICI therapy between January 1, 2015, and April 1, 2018, in routine clinical practice rather than clinical trials.

Overall survival calculated from the time of ICI therapy commencement and radiologic response to ICI treatment defined using the Response Evaluation Criteria in Solid Tumors, with disease refractory to ICI therapy defined as progressive disease 6 to 8 weeks after the first ICI dose without evidence of pseudoprogression.

Among 196 patients (137 men and 59 women; median [range] age, 68 [27-93] years) with non-small cell lung cancer (n = 119), melanoma (n = 38), and other tumor types (n = 39), pATB therapy, but not cATB therapy, was associated with worse OS (2 vs 26 months for pATB therapy vs no pATB therapy, respectively) and a higher likelihood of primary disease refractory to ICI therapy (21 of 26 [81%] vs 66 of 151 [44%]). Overall survival in patients with non-small cell lung cancer (2.5 vs 26 months), melanoma (3.9 vs 14 months), and other tumor types was consistently worse in those who received pATBs vs those who did not. Multivariate analyses confirmed that pATB therapy and response to ICI therapy  were associated with OS independent of tumor site, disease burden, and performance status.

Despite being limited by sample size, geographic origin, and the lack of correlative analyses on patients' gut microbiota, this study suggests that [prior] ATB therapy but not [concurrent] ATB therapy is associated with a worse treatment response and OS in unselected patients treated with ICIs in routine clinical practice. Mechanistic studies are urgently required to investigate ATB-mediated alterations of gut microbiota as a determinant of poorer outcome following ICI treatment.

Then there's this:

Can diet help cancer treatment? Study in mice offers clues

Which discusses an article published in July and notes:  "The study, published Thursday in the journal Nature, found restricting intake of an amino acid found in red meat and eggs significantly enhanced cancer treatment in mice, slowing tumour growth."

So, eat those veggies and take antibiotics only when you really need them!!!!  (Not that either of those recommendations are news!)  For what it's worth! - c

Monday, October 21, 2019

They DO!!!!!!!!!!!!!!!!! I present ~ Moore Love!

I cannot begin to find the words to describe all the sweet love and joy that was shared among so many over this weekend.  So, I will start with these two ~
Mr. and Mrs. Moore!!!
We were blessed to share lots of love, laughs and tender moments as witnesses with Bryan and Martha at their legal ceremony in Ringgold!!!!
Such sweetness and fun!
Selfie time!  Great thanks to Bryan for these pics as the "Chapel" had restrictions on photography!!!
Bridal traditions were sweetly maintained!  Something old = her cute dress that Jamie helped her find and purchase on their Paris adventure.  Something new = her bouquet.  Something borrowed = a blue opal ring Bentie got me years ago.  Something blue = covered by both the ring and dress!!!
I am so proud of these two.  They have worked hard to achieve lofty goals in their own lives, education and careers.  They have shared of themselves with their friends and family; ALWAYS making time to assist and brighten the days of those they love.  They have taken good care of each other through good times and bad.
Brent and I (and ever so many others) wish them every joy and happiness.  Congratulations, Jamie and Rose!!!  Moore Love, indeed!!

Stay tuned!  Their celebration with family and friends, party pics and even MOORE love to come! ~ les

Wednesday, October 16, 2019

So much bridal fun!!!!

Yep!  Baby girl gonna get herself hitched so we have been playing, celebrating, and having a great time generally!!!!

Our start to the "Bride's Day Out!"
Best peeps and brunch before shopping for supplies and sundries for her celebration!
Checking out McCoy Farms for the reception.
Bentie been gett'n set - with new kicks....
...and new shirts for himself and Fredo!
Getting to eat ALL the barbecue when planning the menu!!!
The cutest peeps in the cutest shirts for Roo's Bachelorette Party!
Of course there was DANCING!!!!
The BEST besties!!!
So happy for you, Roo and Jamie!!!  Moore Love!!! - les

P.S. She said, "Yes! To the dress (that I made)!!!"  But it's still under wraps for now!  Stay tuned! - c

Monday, October 14, 2019

Beauty in every season.

I mentioned my Blackberry lilies and the seed pods they form that give them their name in my Fav Things post.  I thought you might like to see them!  Are they not exquisite???

Incredible beauty.
In every season.
For my sewing sister, Denise - and all of us - when thinking about our space, our worth, our loveliness as we travel along the continuum of life.
May your days be beauty full. ~ les

Sunday, October 13, 2019

Intralesional IL-2 combined with anti-PD-1 for melanoma - and links to additional intel on intralesional/intratumoral therapies

From the moment I started seeing research about them, I've been a big fan of intralesional therapy ~  drugs injected directly into accessible melanoma tumors.  My Primer for Melanoma Treatment  contains a link that covers a great deal of what is known about them.  As I note there,

Intralesional drugs include (but are not limited to):

CAVATAK - derived from the Coxsackievirus
T-VEC - also called OncoVEX, Imlygic,  or Talimogene Laherparepvec - uses the herpes virus with GM-CSF
PV-10 - derived from Rose Bengal
HF10 - also derived from HSV
SD101 - a TLR9 agonist
IL-2 -  is also being used

From earlier this year:  In-transit melanoma metastases and PV-10 vs isolated limb perfusion, an update...

There was this update in 2018:  Reports on Intralesionals for melanoma - T-VEC, SD-101, and Dendritic cells

Here are two more reports from 2018:  T-VEC in melanoma, after progression on immunotherapy and BRAFi with good results! 3 case reports... and In-transit melanoma. Two "new" treatment options!

And from this summer, there is this:

Successful combination therapy of systemic checkpoint inhibitors and intralesional interleukin-2 in patients with metastatic melanoma with primary therapeutic resistance to checkpoint inhibitors alone.  Rafei-Shamsabadi, Lehr, von Bubnoff, and Meiss.  Cancer Immunol Immunother. 2019 Aug 17.   

Systemic immunotherapy with PD-1 inhibitors is established in the treatment of metastatic melanoma. However, up to 60% of patients do not show long-term benefit from a PD-1 inhibitor monotherapy. Intralesional treatments with immunomodulatory agents such as the oncolytic herpes virus Talimogene Laherparepvec and interleukin-2 (IL-2) have been successfully used in patients with injectable metastases. Combination therapy of systemic and local immunotherapies is a promising treatment option in melanoma patients. We describe a case series of nine patients with metastatic melanoma and injectable lesions who developed progressive disease under a PD-1 inhibitor monotherapy. At the time of progressive disease, patients received intratumoral IL-2 treatment in addition to PD-1 inhibitor therapy. Three patients showed complete, three patients partial response and three patients progressive disease upon this combination therapy. IHC stainings were performed from metastases available at baseline (start of PD-1 inhibitor) and under combination therapy with IL-2. IHC results revealed a significant increase of CD4+ and CD8+ T cells and a higher PD-1 expression in the inflammatory infiltrate of the tumor microenvironment in metastases from patients with subsequent treatment response. All responding patients further showed a profound increase of the absolute eosinophil count (AEC) in the blood. Our case series supports the concept that patients with initial resistance to PD-1 inhibitor therapy and injectable lesions can profit from an additional intralesional IL-2 therapy which was well tolerated. Response to this therapy is accompanied by increase in AEC and a strong T cell-based inflammatory infiltrate.

These are drugs I would certainly try, especially in combination with immunotherapy, should I have the need.  For what it's worth. ~ c

Thursday, October 10, 2019

Sew Chaotically! ~ The Mariana Jacket on our 'first' fall day!!!

I made this little linen-ish jacket a bit ago, but since my neck of the TN woods has been as hot as hell's front porch, today was the first day cool enough to need it!  The fabric is a funky 100% cotton canvas abstract print from fabric.com while the pattern is the FREE Mariana - unlined, notched collar jacket replete with its own tutorial on The --- Thread, all from Fabrics-store.com.  They have quite a collection of free patterns!  Check them out!

I made a straight size 4/6 as drafted.  My only adjustment was to use two buttons rather than the one the pattern prescribed.

Pretty stoked about my welt pockets!

I think it turned out really well!  I'm already planning one for Roo and another for myself in a more neutral fabric.  Happy fall, y'all!!!  Live and sew chaotically! - les

Monday, October 7, 2019

Internationally renowned melanoma specialists:

I've yelled for years that having a doctor (and institution) that is familiar with and provides lots of care to melanoma patients is ESSENTIAL in getting the best care for melanoma peeps.  It can mean the difference between life and death.  As such, I am often asked who and where these providers are.  So, I decided to create this post as a more accessible resource.  While by no means a complete list, it's a pretty darn good one!!!

Internationally renowned melanoma specialists include:
Antonio Ribas - UCLA (LA)
Stephen Hodi - Dana Farber Harvard  (MA)
Jason Luke - Hillman Cancer Center (PA)
John Thompson and Georgina Long - Australia
Those listed may be the lead melanoma physicians at their respective institutions, but seeking care from others in their groups allows for excellent care as well.  Furthermore, if travel is not something you can attain physically or financially, press your local oncologist to seek the opinion of these experts!!!  They can talk to these docs and attain advice on how to treat you over the phone!!!  YES!!!  It is something local docs can ask and expert docs can answer!!!  Many in this list attend and present lectures at cancer symposiums around the country and the world about the state of care in melanoma TO local oncologists!!  It is part of what they do.  It is a shame that you must push for such care while you or your loved one simultaneously deals with melanoma, but that is how it is.
Hope this helps.  Wishing you all my best! - c

Saturday, October 5, 2019

Ipi/Nivo combo 5 year overall survival report for peeps with advanced melanoma!

As a convenient follow-up to my September report Melanoma patients want to know! What do I choose? Targeted or immunotherapy? What happens then? in which I addressed the latest survival data for both targeted and immunotherapy, a report coming from some Melanoma Big Dogs on the 5 year OS of the ipi/nivo combo was just released. 

This ASCO 2019 report, linked my previous post noted:  Long-term follow-up of CA209-004: A phase I dose-escalation study of combined nivolumab (NIVO) and ipilimumab (IPI) in patients with advanced melanoma.  2019 ASCO.  Akins, Kirkwood, Wolchok, ..., Postow, ...Sznol.  J Clin Oncol 37, 2019. 

"Results: At a median follow-up of 43.1 months in all cohorts (N = 94), the 4- and 4.5-year OS rates were both 57%. The 4-year OS rates for pts with normal (n = 58) versus elevated LDH (n = 36) were 62% versus 49%; for pts with wild-type (n = 66) and mutant (n = 24) BRAF tumors, 4-year OS rates were 54% and 61%, respectively. Following the last dose of study drug (for any reason), overall post-treatment 1-, 2-, and 3-year OS rates were 74%, 65%, and 56%, respectively; in pts who discontinued due to study drug toxicity (n = 32), post-treatment 1-, 2-, and 3-year OS rates were 84%, 75%, and 65%, respectively, and in pts who discontinued for disease progression (n = 30), these were 52%, 34%, and 24%, respectively. Conclusions: This updated analysis from study CA209-004 showed favorable survival outcomes with NIVO+IPI, regardless of BRAF or LDH status, and provided evidence of long-term survival following discontinuation of treatment in pts with advanced melanoma. "

Now, there's this ~

Five-Year Survival with Combined Nivolumab and Ipilimumab in Advanced Melanoma.  Larkin, ..., Lebbe, ..., Ascierto, ...Long, ...Hodi, Wolchok.  N Engl J Med. 2019 Sep 28. 

Nivolumab plus ipilimumab or nivolumab alone resulted in longer progression-free and overall survival than ipilimumab alone in a trial involving patients with advanced melanoma. We now report 5-year outcomes in the trial.

We randomly assigned patients with previously untreated advanced melanoma to receive one of the following regimens: nivolumab (at a dose of 1 mg per kilogram of body weight) plus ipilimumab (3 mg per kilogram) every 3 weeks for four doses, followed by nivolumab (3 mg per kilogram every 2 weeks); nivolumab (3 mg per kilogram every 2 weeks) plus ipilimumab-matched placebo; or ipilimumab (3 mg per kilogram every 3 weeks for four doses) plus nivolumab-matched placebo. The two primary end points were progression-free survival and overall survival in the nivolumab-plus-ipilimumab group and in the nivolumab group, as compared with the ipilimumab group.

At a minimum follow-up of 60 months, the median overall survival was more than 60.0 months (median not reached) in the nivolumab-plus-ipilimumab group and 36.9 months in the nivolumab group, as compared with 19.9 months in the ipilimumab group. Overall survival at 5 years was 52% in the nivolumab-plus-ipilimumab group and 44% in the nivolumab group, as compared with 26% in the ipilimumab group. No sustained deterioration of health-related quality of life was observed during or after treatment with nivolumab plus ipilimumab or with nivolumab alone. No new late toxic effects were noted.

Among patients with advanced melanoma, sustained long-term overall survival at 5 years was observed in a greater percentage of patients who received nivolumab plus ipilimumab or nivolumab alone than in those who received ipilimumab alone, with no apparent loss of quality of life in the patients who received regimens containing nivolumab.

So - the ASCO report broke various factors down a bit, but generally noted:  "overall post-treatment 1-, 2-, and 3-year OS rates were 74%, 65%, and 56%, respectively".  In this new report the OS at 5 years for the ipi/nivo combo = 52%, for nivo alone = 44%, and ipi alone = 26%.  Given what we have been seeing in the research these numbers are pretty consistent with expectations.  The ipi/nivo combo peeps didn't quite hold onto the 3 year survival number of 56%, the data point where those who are fond of kaplan meier curves note things flatten out, but it is pretty close.  I do want to reiterate from the ASCO report, "pts who discontinued due to study drug toxicity (n = 32), post-treatment 1-, 2-, and 3-year OS rates were 84%, 75%, and 65%, respectively.   I think it is reasonable to assume that while the 5 year OS in that group may well decrease a bit, that would still be a good number! (Considering we are talking melanoma world y'all!!!)  

Pretty hopeful stuff when you consider that in 2010, NONE of the current therapies attaining these survival results for melanoma patients were FDA approved.  Not even ipi.  NOW!  Let's get some help for that other 50% of our melanoma peeps!!! - c

Monday, September 30, 2019

CheckMate 172 - nivo used after progression on ipi - report on those with acral,ocular and mucosal melanoma

As difficult as it is to treat cutaneous melanoma, folks with mucosal melanoma and other subtypes face even greater challenges.  Here are some previous reports:  Mucosal Melanoma 
Now, there's this:

Safety and efficacy of nivolumab in patients with rare melanoma subtypes who progressed on or after ipilimumab treatment: a single-arm, open-label, phase II study (CheckMate 172).  Nathan, Ascierto, Haanen, et al. Eur J Cancer. 2019 Aug 21.

Nivolumab has been widely studied in non-acral cutaneous melanoma; however, limited data are available in other melanoma subtypes. We report outcomes by melanoma subtype in patients who received nivolumab after progression on prior ipilimumab.

CheckMate 172 was a phase II, single-arm, open-label, multicentre study that evaluated nivolumab in patients with advanced melanoma who progressed on or after ipilimumab. Patients received 3 mg/kg of nivolumab, every 2 weeks for up to 2 years. The primary end-point was incidence of grade greater than/= to 3, treatment-related select adverse events (AEs).

Among 1008 treated patients, we report data on patients with non-acral cutaneous melanoma (n = 723 [71.7%]), ocular melanoma (n = 103 [10.2%]), mucosal melanoma (n = 63 [6.3%]), acral cutaneous melanoma (n = 55 [5.5%]) and other melanoma subtypes (n = 64 [6.3%]). There were no meaningful differences in the incidence of grade greater than/= to 3, treatment-related select AEs among melanoma subtypes or compared with the total population. No new safety signals emerged. At a minimum follow-up of 18 months, median overall survival was 25.3 months for non-acral cutaneous melanoma and 25.8 months for acral cutaneous melanoma, with 18-month overall survival rates of 57.5% and 59.0%, respectively. Median overall survival was 12.6 months for ocular melanoma and 11.5 months for mucosal melanoma, with 18-month overall survival rates of 34.8% and 31.5%, respectively.

The safety profile of nivolumab after ipilimumab is similar across melanoma subtypes. Compared with non-acral cutaneous melanoma, patients with acral cutaneous melanoma had similar survival outcomes, whereas those with ocular and mucosal melanoma had lower median overall survival.

Not the numbers we wish for...but it is something!  Let's make them better for everyone SOON!!! - c

Thursday, September 26, 2019

A few of my favorite things...

...when the treatment bites, and cancer stings, and I feel so sad ~ I simply remember my favorite things ~ and then I don't feel so bad!!!

This week a year ago, I was discharged after what was basically a 3 week hospital stay that included innumerable miseries, two surgeries, and a new cancer diagnosis of Stage II, ex-goblet cell adenocarcinoma of the appendix (GCC) to add to my existing Stage IV melanoma.  Once home, recovery was slow and followed by 3 months of adjuvant CAPOX chemotherapy treatment which created its own special hell.  It may seem strange having survived 16 years with melanoma, post brain and lung mets, along with a 2 1/2 year immunotherapy trial, to say that this year's insults have been the hardest to rally from. But it is so.  It has been physically exhausting; mentally demoralizing. Still, I am here.  I continue to work to gain strength and normalcy in my life and will be giving you updates on all of that very soon.  Though much in this year has been incredibly hard, I have also been blessed with love and beauty!!! As summer turns to fall, here are a few of what have been my favorite things...

Friends and loved ones near and far have made all the difference.  Hugs and laughter.  Amazing care packages of all stripes.  The best buttons and butt creams.  Bungee jumping workouts.  Calls, notes and emails - of encouragement, shared fears, and plain silliness have seen me through.

This guy!!!  (Seriously.  THIS GUY!!!)
Fun plans and laughs with this crew who never failed to make time to cheer me on no matter their personal challenges, work schedules, and all around busy lives!
Smiles and stories are never better than when shared with this boy!
Who knew his initials "FBM" would end up standing for Frederick Buttermilk Morris????
My personal perennial flower girl!  Bringing love, light and eternal blooms to life for all of us.
Belly laughs are seriously good for the soul!
Enthusiasm and love from friends like my dear Kay is worth more than any gold or medical potion.
My 55th birthday happened!  A surprise event in and of itself, was celebrated in the best ways...
Let them eat cake!!  Bentie hooked me up with apple pie and ice cream!  Yay, for 'warm fruit', right Char????  Plus the coolest little "note" book with a Sherlock motif!  Referencing another summer joy, along with the innumerable times I waxed enthusiastically about it to B, reading the complete collection by Arthur Conan Doyle ~ a literary work I had somehow missed all my life!  Should you indulge, which I highly recommend you do, know that I discovered I am very much aligned with Sherlock in my way of thinking.  Who knew?
I was blessed with surprise cards from many and this one from folks unknown!  Whoever you are, dear sender ~ know that you made my day!!!  Thank you!
Most folks would agree that I am a pretty great gift giver.  I know ALL would agree that I am a HORRIBLE gift wrapper!!!  Sometimes the paper is just too small and the bottom must go unwrapped!  I mean, how does one deal with that???  Ruthie, on the other hand is perfection on BOTH sides of the gift giving conundrum!  When the HAND DECORATED paper is this pretty, does there really need to be anything IN the package????????? 
You guessed it!  A perfect gift was wrapped within that amazing paper!!!  Look how her lovely dragonflies complete my porch!!!  Hope flies on dragonfly wings
Sewing and the sewing community, along with B's indulgence and participation in my efforts, have certainly been a huge part of my recovery this year.

My sewing space is just part of the sanctuary that is my sewing.
My inspiration board lifts my spirit - with cards and tokens from dear ones, my sweet little Granny's pin cushion, and yes, there's a little sewing inspo, too!!  It recently got a re-do!  Check that awesome background paper!
It's a bird!!  It's a plane!!!!  It's an incredible act of kindness!!!!!!

I cannot tell you how touched I was to learn that dear melanoma peep, Laurie, made a donation in my honor to Stand Up To Cancer and in so doing put my name on a plane!!!  Seriously, how cool is that?
And there WERE birds!!!!  As I sat looking out onto our back porch throughout my convalescence, B made sure I was medicated, fed, assisted, ensconced or uncovered with cozy blankets per my whim. Battery powered slippers were available to warm my feet (shaped like fierce dragons no less).  I was catered to in every way imaginable.  In the midst of all of that, he took care of the house, all the daily chores that life requires, AND made sure I had plenty of birds to watch.  He fed and called them daily.  (To the point that today, when he steps out on the porch and whistles, you see them gather in the branches of nearby trees!!!)  He rigged feeders and houses positioned just so, allowing me to watch them easily.  Look what happened...

We watched multiple sets of blue birds build their nests and hatch their chicks!  We even got to see this adventurous little one take his fledgling flight!!!
The poor parents were the hardest workers ever.  Sorry for the slightly sad photos.  Best I could do on my phone.  B's birds played a huge role in my recovery and have certainly been one of my favorite things.  Thanks, B!!
As I got stronger, I found relief and peace working in our garden.  Though a consistent comfort to me, gardening doesn't always turn out as you hope!  Initial enthusiasm for our gooseberries has been a bit dashed and one is even missing!!!  The birds I love ate more of our blueberries than we did and took pecks out of every tomato they could get to.  Whistle pigs pull any plant to the ground and chomp on it whenever they like.  Deer have given my beans and even some azaleas nice trim haircuts!  Still, my efforts to work with nature in all its forms soothed my jangled nerves and provided some successes of which I am inordinately proud.

Having planted my blackberry lilies in too much shade initially, not to mention in the chomping grounds of moles or voles, they were in serious danger of extinction!  Moving them to two sunnier locations this spring has reaped beautiful benefits!  Isn't the bloom lovely?  Glossy seed pods that look much like fat purple black berries are already forming.
But these coleus have been my most surprising favorite gardening thing!  Two bags of bulbs, purchased for a couple of bucks on a whim while in Wally World, then recklessly tossed into a dark spot of the garden under a dogwood, have provided bobbing light and color to what would have been dull shadows of the yard as well as the foggy, dim corners of my spirit.
These silly leaves have made me smile and been a balm to my wounded soul.
Sometimes the smallest gifts, the least effort, can provide the largest benefit to those in need.
There you have it my dear ones.  Know that all of you helped me find me ~ again.  You are always and forever, a few of my favorite things.  Much love, les