Neo-adjuvant care for melanoma patients with BRAFi or immunotherapy continues to show good results!

As I mentioned in regard to adjuvant therapy in melanoma a couple of posts ago - initially, CLND (complete lymph node dissection - the removal of all lymph nodes in the area of a positive node) was recommended for melanoma patients.  Gradually, we learned that such a procedure merely increased the rate of complications like lymphedema, but did NOT extend overall survival in patients.  (Review the posts and articles that pop up when you enter 'CLND' in the search bubble at the top right if you want to check out tons of research that went into that decision over time.)  As the data was revealed, changes in the standard of care followed.  Today, SLND (sentinel lymph node dissection - the removal of only the node - occasionally 2 or 3 - that 'light up' nearest the initial lesion when the area is injected with radiographic material) is the recommended procedure.  Standard of care also recommends that these patients are then treated with adjuvant therapy (treatment provided once all gross evidence of tumor has been removed) utilizing either targeted or immunotherapy.  This standard of care, led to the approval of immunotherapy for adjuvant use in 2017 and for targeted therapy in 2018.  

That said - there is a "new" methodology in town!  NEO-adjuvant therapy ~ Therapy for melanoma patients with either targeted or immunotherapy when affected nodes are left IN PLACE!  I began reporting the data on this method in 2015. Find reports addressing it here:  Neoadjuvant treatment in melanoma 

Now, there's this:

Pathological response and survival with neoadjuvant therapy in melanoma: a pooled analysis from the International Neoadjuvant Melanoma Consortium (INMC).  Menzies, Amaria, Rozeman, et al.  Nature Medicine.  Feb 2021.

The association among pathological response, recurrence-free survival (RFS) and overall survival (OS) with neoadjuvant therapy in melanoma remains unclear. In this study, we pooled data from six clinical trials of anti-PD-1-based immunotherapy or BRAF/MEK targeted therapy. In total, 192 patients were included; 141 received immunotherapy (104, combination of ipilimumab and nivolumab; 37, anti-PD-1 monotherapy), and 51 received targeted therapy. A pathological complete response (pCR) occurred in 40% of patients: 47% with targeted therapy and 33% with immunotherapy (43% combination and 20% monotherapy). pCR correlated with improved RFS (pCR 2-year 89% versus no pCR 50%,) and OS (pCR 2-year OS 95% versus no pCR 83%). In patients with pCR, near pCR or partial pathological response with immunotherapy, very few relapses were seen (2-year RFS 96%), and, at this writing, no patient has died from melanoma, whereas, even with pCR from targeted therapy, the 2-year RFS was only 79%, and OS was only 91%. Pathological response should be an early surrogate endpoint for clinical trials and a new benchmark for development and approval in melanoma.

The positive nature of this data is even making it to the lay press for medical advances.  This link takes you to - Melanoma breakthrough: New treatment saving lives - Published in Medical X-press today.

It seems data collected for over 6-plus years indicates that if you find yourself in the position of a Stage III melanoma patient, consideration of leaving any positive node(s) in place and availing yourself of treatment with either BRAFi or immunotherapy BEFORE that node is removed is one worth discussing with your oncologist. 

For what it's worth.  Perhaps a new way of looking at melanoma treatment, especially for Stage III patients, may be in the offing. - c