Second-Line Treatments for Metastatic Melanoma

Case: A 62-Year-Old Female with Stage IV Melanoma

• A 62-year-old female consulted with her dermatologist for removal of a pigmented lesion that had recently become darker.
  • She noted that she had been experiencing persistent fatigue, shortness of breath, and a dry cough that she attributed to a prior COVID-19 infection.
  • LDH: 174 UI/L
• Excisional biopsy reveals melanoma with a Breslow depth of 1.2 mm, ulcerated, mitotic rate 4/mm2
  • The patient underwent wide local excision and sentinel node mapping
  • Staining was positive for melanoma in the right axillary node
  • CT of the chest, abdomen, and pelvis indicated multiple lesions in both lungs
  • The patient underwent core-needle biopsy of the largest lung lesion, measuring 1 cm
  • Pathology revealed metastatic melanoma, cutaneous nonacral with a positive BRAF V600E mutation
  • ECOG PS 1
• Diagnosis: Stage IV Melanoma, T2b N1a M1b

This is a video synopsis/summary of a Case-Based Peer Perspective, featuring Michael B. Atkins, MD.

For this patient progressing after first-line nivolumab plus ipilimumab, next treatment would undoubtedly be a BRAF/MEK inhibitor combination. The improved outcomes with immunotherapy first in the DREAMseq trial (NCT02224781) relate to 3 key factors: (1) longer duration of response to immunotherapy; (2) more CNS progressions on targeted therapy; and (3) BRAF/MEK inhibitors retain efficacy second-line after immunotherapy progression, whereas second-line immunotherapy is less effective following targeted therapy.

Targeted therapy is a critical component of the optimal treatment sequence following initial immunotherapy. BRAF/MEK inhibitors work as well second line as first line, overcoming the relatively poor second-line immunotherapy responses after disease progression on targeted therapy.

Video synopsis is AI-generated and reviewed by Targeted Oncology® editorial staff.