MPIP: Melanoma Patients Information Page

The MPIP is the oldest and largest community of people affected by melanoma hosted through the Melanoma Research Foundation. It is designed to provide support and information to caregivers, patients, family and friends. Once you have been touched by melanoma—either as a patient or as a family member or friend of a patient—you become part of a community. It is not a community anyone joins willingly. But if you must be part of this group, you will find no better place to find the tools you need in your journey with this cancer, and the friends who can make that journey more bearable.

The information on the bulletin board is open and accessible to everyone. To add a new topic or to post a reply, you must be a registered user. Please note that you will be able to post both topics and replies anonymously even though you are logged in. All posts must abide by MRF posting policies.

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Mat's picture
Replies 1
Last reply 1/3/2014 - 1:41pm
Replies by: tschmith

From Seeking Alpha (investor website):

Merck Vs. Bristol In PD-1 Cancer Drug Race

Dec 18 2013, 18:48  | 7 commentsby: Peter Geschek  |  about: MRK, BMY, includes: RHHBY Disclosure: I have no positions in any stocks mentioned, and no plans to initiate any positions within the next 72 hours. I wrote this article myself, and it expresses my own opinions. I am not receiving compensation for it (other than from Seeking Alpha). I have no business relationship with any company whose stock is mentioned in this article. (More...)

In November Merck (MRK) reported additional data about its lambrolizumab (previously known as MK-3475) trial, an experimental anti-PD-1 immunotherapy, conducted in 135 patients with advanced melanoma.


The results from Merck's trial were almost identical to the results from the Bristol-Myers' (BMY) trial which tested a combination of Yervoy and its experimental drug, nivolumab.


The objective response rate in the Merck trial across all doses was 38 percent, as evaluated by a blinded central review committee. Objective response rate includes all the patients who had either a complete or partial response.


In Bristol-Myers Squibb' presentation at ASCO in May, its drug nivolumab, in combination with Yervoy, achieved an objective response rate of 40 percent among the 53 patients treated.


Merck's lambrolizumab trial has also showed an estimated overall survival rate of 81 percent at one year across all dosing groups. This is the first time overall survival data have been reported from the Phase 1b clinical trial which is still ongoing.


Merck's clinical trials


Merck is running a huge network of clinical trials to expand its immunotherapy effort.


Lambrolizumab has eight clinical trials running with a total enrollment of 3,000 patients across a broad range of cancer types, including bladder, colorectal, gastric, head and neck, melanoma, non-small cell lung, triple negative breast and hematological malignancies. Additional trials are also planned.


The expansion of the lambrolizumab clinical development program is based on preliminary evidence from Merck's foundational Phase 1b trial which included 1,000 patients with late-stage metastatic carcinoma.


Lambrolizumab was intravenously applied at a dose of 10 mg per kilogram of body weight every 2 or 3 weeks or 2 mg per kilogram every 3 weeks in patients who had received prior treatment with Yervoy as well as those who had not.


The confirmed response rate as evaluated by an independent radiologic review according to the Response Evaluation Criteria in Solid Tumors (RECIST) was 38 percent.


The highest confirmed response rate was observed in the group that received 10 mg per kilogram every 2 weeks.


Responses were durable in the majority of patients during a median follow-up of 11 months. 81 percent of the patients who had a response were still receiving treatment at the time of the analysis cut-off date in March 2013.


The overall median progression-free survival among the 135 patients was longer than 7 months.


The bottom line is that in patients with advanced melanoma, including those who had disease progression while receiving Yervoy, treatment with lambrolizumab resulted in a high rate of sustained tumor regression.


Bristol's trials


Bristol-Myers isn't wasting any time extending the range of its own drug, nivolumab.


It has 6 late-stage studies underway, with FDA designated fast-track status in place for melanoma, lung cancer and kidney cancer. If the data continues to support the early results, Bristol-Myers will have a major new therapy in its portfolio.


The blockbuster Yervoy disables an immune system brake called CTLA-4, but it shrinks tumors in only about 10 percent of patients. Even though the effect in that small percentage of patients can be long-lasting and highly effective, that still leaves an urgent need for new drugs for patients with advanced melanoma.




Roche (OTCQX:RHHBY) targets PD-L1, which the company believes may be a safer approach. Early data from a small study showed that investigators could use the maximum dose safely, making this a strong candidate in mid-stage studies.


Roche's compound is known as MPDL3280A, developed by its Genentech subsidiary. Overall, tumors in 29 patients, or 21 percent, responded to the drug in an early trial.


In the future it may be possible to test tumors for the presence of PD-L1, and use the drugs mainly for those patients, where it is expected to work more effectively.


Roche is also in a hurry, it recently rushed the drug into Phase 3.




Bristol's nivolumab, and Merck's lambrolizumab are antibodies that bind to PD-1, while Roche's drug binds to PD-L1. It is not clear yet which approach is better.


The key is the interaction between the PD-1 (programmed death) protein and PD-L1 (programmed death ligand) protein that allows cancer cells to escape and multiply.


By giving a patient the correct antibody protein to block either the PD-1 or PD-L1 from interacting, the immune system will destroy the cancer cells.


For decades scientists have been trying to understand why the body's immune system doesn't see cancer cells as the enemy and attack them.


Recent discoveries found that tumors create a sort of cloak of invisibility from the immune system. The new class of drugs lifts the cloaking device and allows the immune system to attack.


"You're setting up a fair fight" with the disease, said Nils Lonberg, a senior vice president at Bristol-Myers, in an interview. "The immune system is just as adaptable as the cancer."


It is not clear yet how many types of tumors the drugs will work for. All the companies are targeting melanoma because there is evidence that it is sometimes controlled spontaneously by the immune system. The companies also have data for lung and kidney cancer. Roche's study showed some effect in colorectal and head and neck cancer as well.


Some immunotherapy agents hold particular promise in being paired with drugs that specifically target genetic mutations driving the tumors. Since immunotherapy agents are treating the immune system, and not the cancer itself, this sort of approach should work against different kinds of cancer.


Even companies that don't have any PD-1 or PD-L1 drugs in their pipeline, like Pfizer, are interested studying them in combination with their own targeted cancer drugs.


For PD-1 and PD-L1, the most important interaction is at the tumor site as opposed to the broader impact across the immune system, which is what Yervoy does by targeting CTLA-4.


Investor summary


In the third quarter Merck's pharmaceutical sales declined 4 percent to $9.5 billion.


Sales of Singulair, Maxalt, Temodar and Cozaar declined following loss of market exclusivity. The losses were partially offset by growth in Remicade, Gardasil vaccine, Simponi and Isentress.


Singulair, a once-daily oral medicine for the chronic treatment of asthma and the relief of symptoms of allergic rhinitis, declined 53 percent in sales to $280 million in the third quarter. The patents for Singulair expired in the U.S. in 2012 and in major European markets in early 2013. A rapid fall in sales followed the patent expiry.


Combined sales of Remicade and Simponi, treatments for inflammatory diseases, increased 22 percent to $700 million in the third quarter.


Global sales of the combined diabetes franchise of Januvia and Janumet decreased 1 percent to $1.4 billion.


Sales of Zetia and Vytorin (a combination of Zetia and Zocor), medicines for lowering LDL cholesterol, decreased 1 percent to $1.1 billion in the third quarter. The decrease reflects lower sales of Vytorin, partially offset by growth of Zetia in the U.S.


Merck's sales of Gardasil, a vaccine to help prevent diseases caused by four types of human papillomavirus, were $665 million, an increase of 15 percent for the quarter. The increase was driven by continued strong uptake of its use in males in the U.S., and higher public sector sales of $60 million.


The company's gross margin declined to 62.8 percent in the third quarter of 2013 from 64.0 percent for the third quarter of 2012, reflecting primarily the impact of patent expiries.


Merck has lowered its non-GAAP earnings forecast to a range of $3.48 - $3.52 per share.


The company has increased its quarterly dividend to $0.44, up $0.01 from $0.43 per share paid last quarter. Payment will be made on January 8, 2014, to stockholders of record on December 16, 2013.


Over the past few years Merck has gained a reputation of having a hugely expensive research program coupled with a growing roster of setbacks in the clinic.


There is an air of urgency and excitement around lambrolizumab, which is demonstrated by the sheer size of the clinical trials, unprecedented for the company. Merck badly needs a winner from its pipeline and lambrolizumab has a clear promise to become one.

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kab07011's picture
Replies 5
Last reply 1/3/2014 - 8:05am

Hi everyone,

I was diagnosed with stage 1B (.97) ulcerated in Oct 2009 and had a WLE and SNB negative then on my lower back. They took lots of fat and muscle tissue from under there. Only follow-ups are derm appts every 6 months. I have had 2 children since then. Baby is 7 months old now and I do carry her a good bit of the day..however, MAJOR back pain started on Christmas, I had a little here and there that would go away up until then, but nothing like this. I can't even sleep at night. I am nursing and Tylenol did not touch the pain.

I also have some bruising and itching the few days before the severe pain. I did not fall or do anything in that area and those are the only symptoms I have had.

So now here I am with bad low back pain, right in area of origiinal mel, which radiates to front pelvic region. I am thinking the worst and having a hard time functioning.

Who do I even talk to about this the gynecologist, dermatologist, family doctor or chiropractor? Should I just take an antibiotic to see if it is something infected in the pelvic region. Blood work? CAT scan? What else can it be before thinking the worst? Nerve issues/bladder infection. It hurts even relaxing or sitting. Sigh..

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Jahendry12's picture
Replies 10
Last reply 1/2/2014 - 5:33pm
Replies by: Janner, Anonymous, JerryfromFauq, Jahendry12

Hi - I am fairly new to this site.  My husband was diagnosed with Nodular Melanoma in April 2011.  He had surgery to remove the melanoma from his leg as well as SNB.  The SNB came back with 'traces' of melanoma.  Our melanoma doctor advised a groin dissection and all lymph nodes were removed.  NONE came back with melanoma.  He was doing good, following up with scans, body checks, etc.  March of this year they found a nodule on his lung.  He was sent for a PET and then surgery to remove the nodule.  It came back as melanoma.  He just had another surgery to remove 3 more nodes from his lung as well as some lymph nodes that were enlarged.  Our Christmas present this year, was the pathology coming back as NO MELANOMA. 

So, my question.  I have never asked what 'stage' my husband is at because I knew it was bad from the beginning, but I just didn't want to live life thinking about a stage.  Since the melanoma has been found on the lung, does that mean he is automatically at stage 4?   I know I should know the Tumor thickness & Mitotic rate, but I do not.  I do know that it was ulcerated & he had had it on his leg for about 8 months.  My guess is that he was Stage  IIIc or 4.  He has blood taken every 3 months and it has always come back near perfect.  He is healthy & has been asymptomatic from day 1. 

Is there a way to tell what stage he is without knowing the exact thickness?

Thanks for any information any one can provide.

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Mat's picture
Replies 8
Last reply 1/2/2014 - 5:13pm

As I approach my resolutions for 2014--a surreal experience this year given my Stage IV diagnosis a few months ago--I'm thinking about diet.  Admittedly, other than avoiding eye contact with the vending machine at my office, I haven't made many changes since my diagnosis.  I try to stay away from red meat, eat more and organic fruits and veggies, etc.  I've done a poor job of cutting out desserts--I enjoy them too much.  So, I'm thinking about my diet and wondering if I should be making more significant changes.  I looked through prior posts and it appears that opinions on diets are about as mild and in agreement as those on politics, religion, creation versus evolution, etc.  I also did some independent internet research and found nothing terribly convincing.  In the end, I've decided to skip major changes.  Wishing you all a happy, healthy (relatively speaking) and prosperous New Year.

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Anonymous's picture
Replies 4
Last reply 1/2/2014 - 5:11pm
Replies by: JerryfromFauq, Anonymous, casagrayson

The counts went crazy, so that feature was apparently removed.  Now we are speaking to a blank wall. 

Couldn't we have this feature fixed?  It gives a sense of community to know people are out there.  Otherwise, there are only a few replies, or none at all and you wonder: Is anyone there?  Without these counts, who knows?

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Michelem's picture
Replies 11
Last reply 1/2/2014 - 3:58pm
Replies by: JerryfromFauq, kylez, Michelem, arthurjedi007, SABKLYN, Anonymous

My husband had surgery in October -removal of melanoma on the bottom of his foot, and 8 lymph nodes in the groin area. Subsequently another melanoma appeared near the first, and was removed in an in-office procedure.

As he healed, we began screening for the interferon-ipi randomized trial. But that PET scan, just 90 days after the first, showed cancer has now spread to more lymph nodes. This kicks us from the trial - so disappointing. In two weeks he will have surgery to remove more lymph nodes. We are told a two-hour procedure and at least one night hospital stay. So it seems like a serious procedure. 

What next? Does anyone know what this quick recurrence means in terms of possible further spread? I assume we may get back in line for the randomized trial once he is healed from this surgery. Based on previously experience, that is likely to be at least a couple of months - which seems like a long time to wait. 

Thanks so much for insights, thoughts . . . . and prayers!  mm


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Tina D's picture
Replies 5
Last reply 1/2/2014 - 3:44pm

First, I want to say Happy New Year to all. I am incredibly grateful to be alive here at the beginning of 2014. When I entered stage IV in 2005, that was a pretty unlikely scenario, so I thank God for each day I am gifted with.

I started Merck's PD1 back in July, initial scans showed a whopping 67% shrinkage! Next scans 6 weeks later were stable with no changes. I will be having scans again on the 12th of January. I am feeling pretty well overall. Biggest issue has been when my thryroid quit entirely, and that has caused some major fatigue, but synthroid is bringing levels back up, and I am def doing better. I do have quite a bit of vitiligo on face and arms; halos around many moles.Eyelashes and brows turning white. I am trusting the Lord with the outcome, but do feel a little anxious about the upcoming scans since the previous ones had no shrinkage at all. My days are in His hands, and I am thankful... so very thankful for all the years He has blessed me with. I will turn 50 this year in April and there never was a woman more happy to be hitting the big five-o.

When I was diagnosed with breast cancer in Jan 2002, and melanoma in March of 02 ... our kiddos were still so young ( 2,5,10,11 and 14) and I was only 37. When I had that first mel recurrence in 2005, I knew my days could be short with my precious family. Thanking the Lord that now our children are 14,17,22,23 and 26 and I am glad for each extra day with them and with my wonderful hubby of 30 years. May each day of this New Year be one you cherish, and make memories with loved ones. Some days are much more trying than others for each of us, and this is not an easy road... but, as I look back, I have so many amazing wonderful memories of blessed days by the scores over these past 12 years since my initial diagnosis.

With a thankful heart, and wishes for a blessed New Year for each of you,


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JerryfromFauq's picture
Replies 5
Last reply 1/2/2014 - 3:30am
Replies by: BrianP, JerryfromFauq, Anonymous, JoshF, POW

What You Need to Know About Interleukin-2 for Metastatic Melanoma.

"Melanoma." National Comprehensive Cancer Network. V.1.2009. 27 January 2009.

"Proleukin Prescribing Information." Novartis Pharmaceuticals Corp. 27 January 2009.

Smith FO, Downey SG, Klapper JA, et al. Treatment of metastatic melanoma using interleukin-2 alone or in conjunction with vaccines. Clin Cancer Res 2008 14:5610-5618. 27 January 2009.

This overview will arm you with the critical information you need to understand how it works, its effectiveness and its side effects.

Other Names (United States)
Proleukin, aldesleukin


IL-2 was approved by the Food and Drug Administration for the treatment of metastatic melanoma in 1998.

IL-2 is different than a chemotherapy drug -- it is actually a natural part of your body's immune system. It is a type of messenger molecule called a "cytokine" that is secreted from certain cells to alert other cells about an infectious invader. At least 15 different kinds of interleukins have been discovered since the 1970s: IL-2 is known to specifically stimulate the growth and maturation of two kinds of white blood cells, called "T and B lymphocytes." The IL-2 used to treat metastatic melanoma doesn't come from the body but rather is mass produced, using the techniques of genetic engineering. It has the same properties as the natural version, but it has a slightly different name, aldesleukin.

Evidence for the Effectiveness of Interleukin-2

In the studies that led to approval, 6% of selected patients (those in good physical and mental condition) with metastatic melanoma had a complete response to high-dose IL-2, and 10% had a partial response. A complete response is defined as a long-lasting (10+ years and counting) elimination of the disease, although it is not technically a "cure." Regardless of the terminology, it is the only drug available that even has the possibility of such a profoundly positive and lengthy effect. Responses were observed in patients with a variety of metastases, including in the lung, liver, lymph nodes, soft tissue, adrenal glands and subcutaneous (deep) layers of the skin. IL-2, however, has not previously been recommended for patients with existing brain metastases.

Many clinical trials have been conducted (and are still being conducted) in an attempt to increase the response rates of IL-2 by combining it with other medicines. For example, a study demonstrated higher response rates when IL-2 was given in combination with a vaccine (22%) compared to IL-2 alone (13%). Unfortunately, many attempts to combine IL-2 with various chemotherapy drugs (cisplatin, vinblastine, dacarbazine and others) -- an approach called "biochemotherapy" -- as well as with other drugs (interferon-alfa2b, etc), have thus far shown no significant improvement in the statistic that really counts: survival time.

Use of Interleukin-2

IL-2 is given by a 15-minute IV infusion every 8 hours for 5 days. Each treatment course consists of two 5-day treatment cycles separated by a 9-day rest period, and multiple courses are the norm. You will typically be imaged about a month after finishing your first treatment. If you are responding, you'll likely be offered a second course of treatment for 6 to 12 weeks after finishing the first course. To be eligible for IL-2 treatment, you must be in relatively good physical condition, with good heart, lung, liver and kidney function.

Potential Side Effects

IL-2 has frequent, often serious and sometimes fatal side effects. It should be given in a hospital under the supervision of a qualified physician experienced in the use of anticancer agents. An intensive care facility and specialists skilled in cardiopulmonary or intensive care medicine must be available. The rate of drug-related deaths in clinical trials of metastatic melanoma patients who received IL-2 was 2%.

Many of the side effects are due to "capillary leak," which begins immediately after treatment is started. Capillary leak results in the leakage of proteins out of blood that then causes a decrease in blood pressure. The most common side effects are as follows:

    nausea, vomiting, diarrhea, loss of appetite
    weakness and fatigue
    flu-like symptoms (fever, chills, headache and muscle aches)
    low blood pressure
    general pain, chest pain (angina)
    breathing problems due to fluid in the lungs
    weight gain, fluid retention
    mental effects (paranoia, hallucinations, insomnia)
    itching, peeling skin
    anemia (low red blood cell count)
    low platelet count (increasing the risk of bleeding)
    low white blood cell count
    kidney damage
    mouth sores

These side effects are rarer but have been reported in some people taking IL-2:

    abnormal heart rhythm, heart attack
    respiratory failure
    severe infections
    gastrointestinal bleeding
    thyroid problems
    liver problems
    severe dizziness, fainting


IL-2 can make the side effects of other drugs and diseases much worse, so tell your doctor if you have:

    kidney problems
    heart disease
    liver disease
    lung disease
    a seizure disorder
    thyroid disorder
    any allergies
    any immune disorders

Also let your doctor know about any over-the-counter or prescription medications you use, especially corticosteroids, indomethacin, blood pressure drugs, antidepressants, anti-anxiety drugs or other anticancer medications. Do not start or stop any medicine without doctor approval.



I'm me, not a statistic. Praying to not be one for years yet.

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Pink's picture
Replies 3
Last reply 1/2/2014 - 2:12am
Replies by: JerryfromFauq, POW, Momrn5

2006 diagnoses with Mel on leg, wide excision. Now I have nodules in my leg and went for isolated infusion in my leg, the nodules in leg responded well but foll up PET showers mets to shoulder and back and brain mets. Going back to Moffit next week for consultation for stereotactic radiation and to get started on Ipi. How are the results with the radiation I have 3small ones and worried about getting rid of them.

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JoshF's picture
Replies 15
Last reply 1/1/2014 - 9:10pm

I got the call from surgical oncologist on lung nodule today. It was positive for melanoma.He is postponing surgery indefinitely and called medical oncologist. So, I have an appointment with medical oncologist this afternoon. Not sure what this fight is going to look like but whatever it is I'm ready. What are my options? Not sure if lung met is braf positive or negative yet....though reoccurrence on cheek was negative. Advice on any questions I should you know my brain is scrambled.



Let's work for better treatments....for a cure!!!!

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blden2186's picture
Replies 3
Last reply 1/1/2014 - 8:14pm
Replies by: johnbil, POW, Anonymous

I had my 3rd recurrence of melanoma in my left leg this past year.  Went through a month of interferon infusions,  radiation, and am week 18 of the 48 week self injections.   I am so tired, headaches, pin point rash, GI issues, dizziness.  Still working 30-36 hours a week.   Thinking of quitting injections - has anyone else been through this and made decision to quit early?  My oncologists (Humphrey CA Center) know I am considering stopping. 

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lll.ll.lll.ll.lll's picture
Replies 3
Last reply 1/1/2014 - 9:51am

So even tho I struggle with being tired I'm still trying to make it to the gym a few times a week, especially now that I'm off for a bit. And stretching for my upcoming back workout I feel the muscle under where my biopsy was taken is sore.. not necessarily the entire muscle (my left lat) but just underneath the area. Not thinking I slept wrong, I generally sleep on my stomach. It only hurts twisting so Im just going to limit any exercises that involve that and see how it plays out the next couple days I think.

Anyway have a great and safe new year

thanks for reading

Adam McCurry

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Brendan's picture
Replies 3
Last reply 1/1/2014 - 9:09am
Replies by: ReginaTink, Anonymous, POW

Hi Everyone,

I hope the holidays are treating you well.  

I am happy to report that I am now in a PD-1 trial.  I am receiving nivolumab every other Friday for at least five more doses. If I respond then I will receive six additional doses.  The clinical trial is in Tampa and I live in Philadelphia.  I have flown down twice and the bills are already adding up.  USAir and Southwest fly daily and I am going to look into their medical travel programs.

Does anyone know of any agencies, non-profits, etc., that help cancer patients with travel expenses?  The primary expense is obviously airfare, but car rental adds up too.

Thanks and good luck to you,



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arthurjedi007's picture
Replies 4
Last reply 1/1/2014 - 7:34am
Replies by: Anonymous, buffcody, arthurjedi007, ecc26

Got my blood work today before my 3rd dose of ipi(yervoy). Anyone know what a large increase means in eosinophils? 3 weeks ago it was 2.7 with an absolute of .2. Today it is 8.0 with an absolute of .5.

I was also wondering if ipi is working should we also see an increase in our absolute lymphocytes? 3 weeks ago mine was 1.2 and now it is 1.1 so really no change.

Typically my numbers are closely the same so to see a number more than double is odd and has me wondering what's happening. I assume it is a reaction to ipi so that is great but I dunno. My dr did not mention anything about it just said my blood work looks good.

Thanks everyone and I hope the new year is great for all of us mel warriors.



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JerryfromFauq's picture
Replies 10
Last reply 1/1/2014 - 3:56am
Replies by: JerryfromFauq, Joannezaras, POW, Anonymous, JoshF

Tried to post the URL so that you could read the whole long article.  Here's the start.    This is in response to the Gal that has been telling people that one must kill their immunsystem before they can receive IL-2. 

2013 IL-2 & T-Regs   Does IL-2 require killinig Immune system (Which includes our T-cells)?

High-dose (HD) bolus IL-2 therapy is currently one of the most potent forms of immunotherapy and was approved by the FDA as a single-agent cytokine therapy for metastatic melanoma and renal cell carcinoma (1–3). Typical HD IL-2 therapy consists of bolus infusions of 600,000 or 720,000 IU/kg of aldesleukin (Novartis), and each cycle of therapy is aimed at giving up to 15 bolus infusions every 8 hours or as many as the patient can withstand due to toxicity (1, 4). The therapy cycle is then repeated approximately every 14 to 21 days for up to 6 to 8 cycles, depending on the clinical performance of each patient and toxicities associated with IL-2 therapy. Early single and multicenter clinical trials have consistently shown a 15%–16% partial and complete response rate in patients with stage IIIC or stage IV noncutaneous metastatic melanoma and in patients with renal cell carcinoma, among whom a smaller fraction of patients (about 5%) experience durable long-lasting complete remission for years (1, 2, 5). HD IL-2 has also been combined with other immunotherapies, including adoptive T cell therapy using ex vivo–expanded tumor-infiltrating lymphocytes (6–8) and tumor antigen peptide vaccines (9), where it may enhance antitumor T cell function. IL-2 is known to induce NK cell and CD8+ T cell proliferation, survival, and acquisition of effector function through STAT5 activation (10–12). Increased tumor-infiltrating and circulating perforin+ (PRF1+) NK cells and activated CD8+ T cells have been found in most patients undergoing HD IL-2 therapy, but this finding did not always correlate with tumor regression or clinical response (13–15).

One of the key problems with HD IL-2 therapy, which limits its more widespread use, is its adverse effects, including blood pressure changes, vascular leak syndrome, liver dysfunction, neurological changes (cognitive impairment), and high fever (1, 2). These toxic effects require some patients to withdraw from therapy after a limited number of therapy cycles. Nevertheless, HD IL-2 continues to be a treatment of choice for qualified patients, especially for those with metastatic melanoma, because it is one of the only therapies capable of inducing documented durable clinical remission lasting for many years. Thus, specific biomarkers that can identify subsets of patients who are responsive to HD IL-2, and thereby improve patient selection, are needed to refine this form of therapy and make it more attractive to more clinical centers.

Recently, a number of groups have reported that HD IL-2 markedly expands the classic Treg pool, consisting of CD4+CD25+Foxp3+ Tregs (16–19). Some of these studies have attempted to correlate the extent of Treg expansion during IL-2 therapy with clinical outcome and have suggested a negative correlation between a sustained increase in Tregs during multiple IL-2 therapy cycles and progressive disease (17). Tregs inhibit effector CD8+ and CD4+ T cells by suppressing their proliferation or inducing cell death. Moreover, Tregs can also antagonize NK cell–mediated antitumor activity (20–23). However, the exact role of Tregs in HD IL-2 therapy needs to be further defined.

Tregs exist in two main forms: the so-called natural Tregs, originally derived from the thymus, and induced Tregs, generated from peripheral naive CD4+ T cells in the presence of TGF-β and IL-2 (22, 24, 25). However, the phenotypic markers distinguishing these two main Treg types are still unclear. Although previous studies have tracked the appearance of Tregs during IL-2 therapy by using the classic markers CD25, Foxp3, cytotoxic T lymphocyte antigen 4 (CTLA4), glucocorticoid-induced tumor necrosis factor receptor (GITR), and CD127, Tregs may exist in various states of differentiation and activation that may be discernible with use of additional markers. For example, a subset of Tregs may be tumor antigen specific and activated through the TCR before HD IL-2 therapy; these cells may carry specific activation markers reflecting this ongoing antigenic stimulation that clearly separates them from the bulk circulating Treg population. Thus, these previously “activated” tumor-specific Tregs may be induced to further divide by IL-2 treatment.

In this article, we investigated which lymphoid and myeloid subsets were modulated upon HD IL-2 therapy and their possible association with clinical response to allow preidentification of patients who can benefit from this treatment. We performed comprehensive multiparameter flow cytometry analysis to determine the changes in more than 40 different lymphocyte subsets, including subpopulations of Tregs, DCs, and CD4+, CD8+, NK, and B cells in PBMCs from patients treated with HD IL-2 before IL-2 infusion and 2 days after the last infusion of cycle 1 of HD IL-2 therapy. After analyzing the fold changes of each cell subset, we found that CD4+ICOS+ T cell subset, consisting almost exclusively of CD25hi and Foxp3hi Tregs (ICOS+ Tregs), was one of the most rapidly expanding lymphocyte subsets in response to IL-2. We present data characterizing the phenotype of CD4+ICOS+ and ICOS+ Treg subsets during the first cycle of HD IL-2 therapy and their potential as predictive biomarkers.

Activated T cells within a CD4+ICOS+ subset greatly increase during IL-2 therapy. We developed a multicolor FACS staining panel to track changes in multiple lymphocyte subsets in peripheral blood of patients with melanoma during cycle 1 of HD IL-2 therapy. This panel allowed us to track the changes in multiple T cell, B cell, DC, and NK cell lineages before and after HD IL-2 therapy. First, we analyzed the first 9 patients consecutively treated with HD IL-2 (Supplemental Table 1; supplemental material available online with this article; doi: 10.1172/JCI46266DS1). Blood was collected immediately before the first bolus infusion of IL-2 and during the rebound period, which is 2 days after the last IL-2 infusion, when a rapid influx of lymphocytes back into the blood occurs (16, 26, 27). This sample 2 days after IL-2 treatment gives us a “window” into the immediate changes that are induced in patients during the first cycle of IL-2 therapy. A heat diagram of the FACS data shows the fold change in 46 lymphocyte subsets as a percentage of total live lymphocytes (Figure 1A). Strikingly, although minor changes occurred in a number of lymphocyte subsets, some major cell types consistently exhibited markedly high increases in all patients during IL-2 therapy, as indicated by the bright red regions in Figure 1A. One of these cell types was the CD4+ T cells, which consisted of ICOS+, CD25+ICOS+, and CD4+CD25+ICOS+ T cells that coexpressed Foxp3 (Figure 1A).
CD4+ T cells expressing ICOS with phenotypic characteristics of Tregs increFigure 1

CD4+ T cells expressing ICOS with phenotypic characteristics of Tregs increase the most in peripheral blood after HD IL-2 therapy. PBMCs isolated at baseline and 2 days after the last dose of IL-2 during cycle 1 of HD IL-2 therapy from 9 patients (nonresponders) were stained for multiple T, B, and NK cell and DC markers. The percentage of 46 cell subsets in the live lymphocyte gate were determined, and the fold change in the frequency of each indicated cell subset in the lymphocyte gate was calculated by dividing the frequency of cells before HD IL-2 therapy by the frequency after treatment. (A) Changes in the percentage of indicated cell subsets analyzed for all 9 patients (patient numbers are shown at the top of the heat map) were heat mapped based on the fold changes, with the use of an Excel conditional formatting program, as indicated at the bottom of the figure. The major lymphocyte subpopulations corresponding to the different phenotypic marker subsets (left side) are indicated on the right side of the heat diagram. (B) Total numbers of CD4+ICOS+, CD4+CD25+ICOS+, and CD4+CD25+Foxp3+ICOS+ cells before IL-2 and 2 days after cycle 1 of HD IL-2 therapy (after IL-2) are shown for these 9 patients. Total cell numbers were calculated by multiplying the percentage of each subset in the viable lymphocyte gate by the absolute lymphocyte count. Horizontal bars represent median values. Statistical analyses were performed with 2-tailed Wilcoxon matched paired test.

The second major cell type that showed a high increase in all patients was NK cells, with a predominantly CD56hiCD16loPRF1+ NK phenotype (Figure 1A) and more than an 80-fold increase in these cells in some patients (median, 25-fold increase; n = 9). Expansion of NK cells and acute sensitivity of these cells to IL-2, as these cells constitutively express CD25 (IL-2Rα), as well as perforin-induced expression by IL-2 were expected on the basis of previous studies on IL-2–treated patients (28–31). All other lymphocyte subsets exhibited either small increases after IL-2 therapy (less than 2 fold) or a decrease, as shown by the blue regions in Figure 1A. Increased frequency of CD11c+ DCs was seen in some patients (median, 3.6 fold), whereas the frequency of CD19+ B cells consistently decreased after IL-2 therapy by 3 fold to 4 fold.

The CD4+ICOS+ and CD4+CD25+ICOS+ cell subsets increased by a median of 13 fold and 27 fold, respectively. However, the most consistent and highest increase was in the frequency of CD4+CD25+Foxp3+ICOS+ T cells (median, 37 fold). We calculated the change in total number of ICOS+ cells in the CD4+ subset by multiplying the absolute lymphocyte counts per milliliter of blood by the percentage of each subset in the live lymphocyte gate. As shown in Figure 1B, the total number of CD4+ICOS+, CD4+CD25+ICOS+, and CD4+CD25+Foxp3+ICOS+ T cells increased greatly after HD IL-2 therapy. Similar results were seen with the .     .


I'm me, not a statistic. Praying to not be one for years yet.

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