Could Active Surveillance Help Prevent Advanced Melanoma in CLL Patients?

Patients with chronic lymphocytic leukemia (CLL) have an increased risk for melanoma and could benefit from screening. A new study analyzing management of these melanomas found a higher rate of invasive disease, and that active surveillance could help lead to early excision and thus better outcomes.

Previous research has shown that patients with CLL are at increased risk of skin cancer, including melanoma, and also have an approximately two-fold increased risk of dying from these secondary malignancies. Treatment of melanoma has evolved in recent years, though, especially with the use of immune checkpoint inhibition in metastatic disease; studies of these agents have excluded patients with secondary malignancies.

In a new observational study, researchers led by William J. Archibald, MD, of the University of Rochester Medical Center, examined how melanomas were detected and managed in patients with CLL. The results were published in Leukemia Research.

The study included a total of 470 patients with CLL at a single center, covering 2,849.3 years of follow-up. Of those, 18 patients developed 22 melanomas; 14 patients had non-advanced disease, and 4 had metastatic melanoma. The median age at CLL diagnosis for the entire cohort was 62 years; those with advanced melanoma were older at CLL diagnosis, at 68 years.

The median time to first melanoma was 1.8 years for those with non-advanced disease, compared with 7.4 years for those with advanced disease. Most of the patients who developed melanoma were male, including all 14 of those with non-advanced disease and three of the four with metastatic melanoma.

Overall, the risk of developing melanoma in this CLL population was significantly higher than that of the general population, according to an age- and sex-matched analysis, with a standardized incidence ratio of 6.32 (95% CI, 3.45–10.60). Melanomas were most often detected based on evaluation at a dermatology clinic.

Nineteen patients underwent surgical management of their melanoma with a wide local excision; one underwent Mohs surgery, and six had sentinel lymph node biopsies. Of the four patients who were diagnosed with metastatic disease, one received dacarbazine, along with palliative radiation therapy; one patient elected to receive only comfort care measures; one elected for palliative care and observation; and one was treated with the immune checkpoint inhibitor ipilimumab followed by pembrolizumab after recurrence. That patient remained in a stable response after 23 cycles of pembrolizumab, at 29 months since the diagnosis of metastatic melanoma.

“As early detection of melanoma is essential to improving outcomes, our data strongly support larger prospective studies to determine the value of concomitant CLL follow-up and skin care to provide the highest-quality active surveillance and early intervention for CLL patients,” the authors concluded. They note that this study provides the first data suggesting that immune checkpoint inhibitor therapy could be effective for CLL patients with metastatic melanoma, though further studies are needed for confirmation.