Axel Hauschild, MD, Professor of Dermatology at the University Hospital Schleswig-Holstein, Campus Kiel, in Germany, discussed the evolving utility of intralesional approaches to melanoma in the ASCO Poster Highlights session.

In general, he maintained that the overall and complete response rates are impressive, especially the regression of untreated lesions, ie, the bystander effect, as is the lack of toxicity associated with intralesional injections. However, the current studies use unconventional response criteria, which makes interpretation difficult, and they are evaluating a highly selected subset of stage IIIB/IV patients (those with injectable lesions and no visceral metastasis), whose outcomes will be better.

Nevertheless, the durability of response and evidence of systemic immune augmentation is encouraging, is hypothesis-building, and “gives a hint to future combinatorial trials with other immunodulators, such as anti–PD-1 antibodies,” he said.

Major Questions

“The major questions are: How strong is the systemic response from an intralesional treatment? And what is the size and localization of responding metastases, ie, skin vs visceral organs?” he asked. “I have only seen a tiny 1-cm nodule in the lung respond; I have not seen major responses in visceral organs. The vast majority of stage IV melanoma patients have M1c disease.”

Dr. Hauschild also emphasized that with the growing numbers of drugs for unresectable advanced melanoma, intralesional therapy has some competition. “The most interesting of these studies is the one combining T-VEC with ipilimumab, which showed some benefit in M1c patients. Maybe this is a good compromise, and the setting where we need to move ahead…. The future lies in combinational approaches with drugs from the new melanoma landscape.” ■

Disclosure: Dr. Hauschild is either a member of the advisory board/consultant or received speaker’s honoraria or fees for clinical trials from Amgen, Bristol-Myers Squibb, Celgene, Eisai, GlaxoSmithKline, MedImmune, Melasciences, Merck/MSD, Merck Serono, Novartis, Oncosec, Roche, and SciBase.