Patient with generalized malignant melanoma treated with nivolumab in the first line

A 75-year-old patient was referred for examination at the dermato-oncology clinic of the Dermatology Clinic of VFN in September 2016. He was being treated for ICHS and had undergone prostate surgery for hyperplasia in 2013.

In April 2016, he was examined at the local dermatology department for a newly emerging rapidly growing nodular lesion on the lateral side of the neck. In May 2016, the lesion was excised at the local surgical department. Histology revealed an unusual nodular melanoma with spitz-like features, Breslow 4.48, without regression or ulceration, reaching the lower edge. The patient traveled to Cuba for four months immediately after the excision, where he was informed of the histology results. Upon returning from abroad in September 2016, the patient was referred to our clinic for further management. At the first examination on September 29, 2016, resistance was detected over the scar, and a sonographic examination indicated an activated lymph node. The patient was referred to the ENT clinic at FN Motol for scar excision.

On October 10, 2016, a control ultrasound of the resistance in the neck scar area was performed, describing an enlarged infiltrated node. The patient was indicated for scar excision and block dissection of the cervical nodes. The surgery was performed in November 2016 at the ENT department in Motol. Thirteen nodes were removed, and a partial parotidectomy was performed. Metastases were confirmed in two nodes, but the parotid was unaffected.

Adjuvant immunotherapy with Roferon 9 million IU s.c. was started on January 2, 2017. During therapy, there was a slight elevation in liver tests, but otherwise, the patient tolerated the treatment without significant issues.

On October 31, 2017, during a regular examination, three spherical lesions were detected in the liver by ultrasonography. Immunotherapy was discontinued, and a PET CT scan on November 10, 2017, revealed metastatic liver involvement with multiple lesions and a solitary lesion in the left lower lobe of the lung measuring 8 mm, as well as a thickened bladder wall. The patient was referred to a urological examination, where cystoscopy showed normal results. We requested a BRAF mutation test from the infiltrated node.

On December 1, 2017, we were informed that the patient was BRAF V600 negative. Therefore, we requested Opdivo therapy. On December 5, 2017, we received additional information that the patient was positive for the V600K variant, which is less common. Since BRAF inhibitors could only be administered as monotherapy and we had already approved anti-PD-1 antibody treatment, we started Opdivo therapy on December 8, 2017, at a dose of 3 mg/kg every two weeks. Control CT scans of the chest, abdomen, and pelvis on February 19, 2018, after the sixth administration of Opdivo, showed complete regression of the metastatic lesion in the left lung. The liver lesions had significantly decreased in size, and two dense nuchal lesions were noted. Sonographic verification of the lesion character was recommended, performed on August 23, 2018. The nodes were reported as reactive and not infiltrated. The patient tolerates the therapy without issues and has had no side effects throughout the treatment. The last chest, abdomen, and pelvis CT scan on May 17, 2018, after the twelfth Opdivo dose, concluded further partial regression of the liver lesions and no focal changes in the lung parenchyma. The patient continues with the therapy.

MUDr. Taťána Šuková

Dermatovenerology Clinic, VFN Prague