Complete Remission of Metastatic Melanoma of the Scalp Following Treatment With Nivolumab Plus Relatlimab

Melanoma of the skin is the most aggressive form of skin cancer and is unlikely to be cured once metastasis occurs from the primary site. It is estimated to be the fifth most common type of cancer representing 5.0% of all new cancer diagnosis and 1.3% of cancer deaths. ¹ Patients have a better chance of survival if melanoma is diagnosed earlier and before it has metastasized. For those with distant melanoma of the skin, the 5-year survival rate is 35.1%. ¹ While surgical resection can contribute to immunotherapy efforts due to the immunosuppressive state caused by stage IV melanoma, ² an immunotherapy like nivolumab, an inhibitor of programmed death receptor-1 (PD-1), or ipilimumab, an inhibitor of cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4), is the standard of care. When using dual immune checkpoint inhibition, ipilimumab plus nivolumab is considered to be the most effective but also shown to result in immune-related toxicity. ³ In March of 2022, the FDA approved the use of the dual checkpoint inhibitor nivolumab plus relatlimab, a lymphocyte-activation gene 3 (LAG-3) antibody. One study showed the combination of the PD-1 and LAG-3 inhibitors at 12 months had a progression-free survival of 47.7% vs only 36.0% with nivolumab alone. ⁴ We describe the diagnosis and management of a patient with metastatic nodular melanoma which was treated with a palliative resection of the primary tumor followed by immunotherapy with nivolumab and relatlimab.

A 77-year-old man presented with a fungating melanoma of the right temple that had been changing over 18 months with continuous bleeding, as well as an unintentional thirty-pound weight loss. Unfortunately, the patient had been assured that no biopsy was needed until he was seen by dermatology. He underwent biopsy at that time which was consistent with nodular melanoma. He was referred to surgical oncology. The patient received a whole body PET scan and was found to have widespread fluorodeoxyglucose (FDG)—avid metastatic disease. He was offered palliative resection of the tumor to improve his quality of life secondary to ongoing bleeding and referred to a medical oncologist for systemic therapy. The patient underwent a wide local excision of the right temple lesion with a full-thickness skin graft from the left lower quadrant of his abdomen. Pathology identified the mass as an invasive nodular melanoma with lymphovascular invasion. The patient tolerated the procedure well and was discharged home. One month following surgery, he began systemic treatment with nivolumab plus relatlimab. The patient underwent 3 cycles of Opdualag over the course of 3 months. Four months after his first cycle of treatment, the patient had no evidence of disease on his PET scan. At last follow-up, he continued to have no evidence of disease.

Pigmented lesions of the skin which demonstrate any of the risk factors for melanoma should have an expedited biopsy. Delay in diagnosis leads to a greater chance of metastatic disease to develop. Following diagnosis, melanoma patients should be referred to a multidisciplinary group of practitioners who specialize in the most up-to-date management of melanoma for improved outcomes. Treatment of metastatic melanoma of the skin with nivolumab and relatlimab is an effective approach that is showing greater benefit to patients than nivolumab alone. We advocate for ongoing study in the field of immunotherapy in the treatment of metastatic melanoma.