Failure of adjuvant treatment for malignant melanoma - what next?

Background: The possibilities of adjuvant therapy of malignant melanoma have significantly expanded in recent years. Based on the results of clinical studies, immunotherapy represented by checkpoint inhibitors (ipilimumab, pembrolizumab, nivolumab) and targeted therapies (dabrafenib plus trametinib) in patients with a proven mutation in the BRAF gene were included in the treatment protocols. In the Czech Republic, nivolumab and combination therapy of dabrafenib with trametinib are currently available for clinical practice. However, the question remains how to proceed if relapse or generalization occurs after the adjuvant treatment. The following case study describes one of possible solutions.

Case Report: The article presents the failure of adjuvant nivolumab immunotherapy in a patient with locally advanced stage IIIC malignant melanoma. Ipilimumab has been selected as a treatment choice and demonstrated its efficacy. However, its administration was associated with immune-related side effects. These were dia-gnosed and successfully treated in the internal department in close cooperation with our department of oncology.

Conclusion: Although adjuvant therapy has significantly reduced a risk of disease relapse, there is a cohort of patients in whom adjuvant therapy fails. Failure may occur after the end of the therapy or, as in our case, during the therapy. Based on currently available data, it is not possible to unambiguously choose the optimal procedure after adjuvant therapy failure. Currently, there is no other way than following clinical experience and reimbursement regulations, or enrolling the patient in a clinical trial. Immune-related adverse effects require particular attention as they are unique due to their mechanism of origin and often require a multidisciplinary approach.