Metastatic melanoma is a devastating disease that has been increasing in incidence and until relatively recently had few effective treatment options. With the approval in 2011 of ipilimumab, a monoclonal antibody against cytotoxic T-lymphocyte associated protein 4 (CTLA-4), however, that has begun to change. Ipilimumab is an immune checkpoint inhibitor, a type of immunotherapy that can down-regulate inhibitory signals affecting T-cell activation to unleash more dramatic anti-tumoral responses and offer the possibility of deep and durable remissions in up to 20% of patients. Use of this and similar agents can lead to characteristic and varied immune-related adverse events (irAEs); however, experience has shown that these can be managed with patient education, early recognition, and judicious use of systemic steroids. Newer immune checkpoint inhibitors such as those that block PD-1 or PDL-1 have shown impressive results in early studies. Most recently, pembrolizumab, an anti-PD-1 antibody, was approved by the FDA for the treatment of patients with melanoma after progression on a CTLA-4 inhibitor and, if clinically relevant, a BRAF inhibitor. This supplement presents the case of a 60-year-old man with an enlarging right neck mass who was found to have disseminated metastatic melanoma. He was started on treatment with the CTLA-4 inhibitor ipilimumab (3 mg/kg intravenous). After the third dose, the patient developed grade 3 uveitis/retinitis and immune-mediated nephritis requiring hospitalization and systemic corticosteroids. Both conditions were considered irAEs secondary to ipilimumab. The patient recovered completely from all toxicities but did not receive further doses of ipilimumab. Nonetheless, the patient experienced a complete radiographic response and at time of writing was 19 months from diagnosis without evidence of disease.
Matthew Zibelman and Anthony J. Olszanski
Matthew Zibelman and Elizabeth R. Plimack
Before 2005, systemic treatment of metastatic renal cell carcinoma (RCC) was limited to a few minimally effective options. Since then, new agents have emerged targeting the vascular endothelial growth factor and mTOR pathways, which has improved outcomes for patients. Options increased even further beginning in 2015 with 3 new agents, including the addition of nivolumab, the first immune checkpoint inhibitor to demonstrate improved survival in RCC. RCC has long been considered a malignancy with immunogenic potential, and nivolumab offers the potential for durable responses in some patients with a generally tolerable toxicity profile. With so many drugs available to clinicians and patients, properly integrating immune checkpoint blockade (ICB) into the treatment paradigm is challenging. Additionally, emerging research with other ICB agents, as well as ongoing trials of combination strategies, is likely to further impact clinical decision-making. This article attempts to provide some context to inform systemic treatment decisions in the current landscape, with a particular emphasis on the role of immunotherapy, outlines the ongoing immunotherapy research in RCC, and discusses how treatment may evolve.