case_images: PMC11079628_01
case_images: Timeline from all case reports. Course of the disease, expressed in months, and treatments received by each patient are illustrated with a swimmer plot. Relevant dates are indicated within the timeline. Color references for each kind of event are indicated in the legend. Case#1: after pembrolizumab treatment, this patient attained complete remission in 04/2018 (POST) and remained NED until present. Case#2: After pembrolizumab treatment, this patient attained complete remission (04/2021) and remained NED until present. Case#3: Although this patient achieved a rapid CR to nivolumab (05/2018), had to shift to dabrafenib/trametinib, because of a supraventricular arrhythmia (12/2018), with further progression. Case#4: After pembrolizumab treatment, this patient attained complete remission (05/2020) and remained NED until present (09/2023). Case#5: this patient remained NED 46 months after CR to nivolumab (12/2016), further described. CR, Complete Response; NED, no evidence of disease.
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case_images: PMC11079628_01_fimmu-15-1354710-g001.jpg
case_images: f1
case_images: The details of the disease course and treatments received are summarized in a swimmer plot ( Figure 1 , timeline). In 04/2009 ( Figure 1 , timeline) she started vomiting, and in 05/2009 a segmentary resection of the small intestine was performed. Starting in 09/2015 she received five courses of Ipilimumab (3 mg/kg every three weeks), and in 06/2016 she started treatment with pembrolizumab (2 mg/kg every three weeks), which she continued until 09/2019, without significant toxicity (see timeline in  Figure 1 ). In 04/2016 he signed the informed consent to enter the CASVAC-0401 study ( Figure 1 , timeline). In 08/2016 two cutaneous metastatic lesions close to the primary tumor scar appeared and were excised. On 26/04/2010 the patient entered the CASVAC 0401 study, and he was randomized to the vaccine arm ( Figure 1 , timeline). Case #4 is a 56 years-old white Caucasian male to whom in 2006 a melanoma in the retro-auricular right pavilion was excised ( Figure 1 , timeline). On 07/10 the patient entered the CASVAC 0401 study and she was randomized to the VACCIMEL arm ( Figure 1 , timeline).
case_images: Patient #1 and #4 cases. (A) IHC of an inguinal LN metastasis excised from case#1 intra-VACCIMEL treatment; CD8+ and CD11c+ populations are shown. IHC was performed as previously described. Original magnification 400X; scale bars 50microm. (B) PET/CAT scan from case#1 (PRE, 01/2015) showed hypercaptating right lung nodules and a parasplenic nodule. After pembrolizumab treatment, this patient attained complete remission in 04/2018 (POST) and remained NED until present (09/2023). (C) CT from case#4, dated 04/2019 (PRE) showing lung right lung hilar metastases- (indicated by green lines), not detectable after treatment with Pembrolizumab (POST; dated 07/2020).
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case_images: PMC11079628_01_fimmu-15-1354710-g002.jpg
case_images: f2
case_images: Histologic analysis revealed a metastatic lymph node with brisk tumor infiltration with CD8+ lymphocytes and a high number of CD11c+ DC ( Figure 2A ). In 01/2015 a PET/CT scan revealed several hypercaptating nodules at both lungs and two hypermetabolic para-splenic and para-pancreatic nodules ( Figure 2B  PRE). The patient attained CR in 04/2018 and remains disease-free until 09/2023 (65 months+) ( Figure 2B  POST). Due to the COVID-19 pandemic, this patient could only start on 02/2020 treatment with pembrolizumab (200 mg every 3 weeks), of which he could only receive three infusions because of travel restrictions ( Figure 2C , PRE). In 07/2020 a new CAT-Scan was performed and revealed CR of the hilar adenopathy ( Figure 2C , POST).
case_images: Patient #2 case. (A) Histopathological analysis of a tumor draining LN and a cutaneous metastases excised throughout VACCIMEL immunization and 4 years before anti-PD-1 treatment; CD8+ populations as determined by IHC are shown. Original magnification 400X; scale bars 50microm. (B) IFN-gamma ELISPOT to analyze T-cell response induced by VACCIMEL. PRE: blood extracted at the selection process; POST-3: blood extracted 24 months after protocol start; unspecific: corresponds to PBMC only stimulated with culture medium. Bars indicate quantification of the spots normalized to 105 stimulated PBMC (effector cells). Peptides tested for this case are shown in the table. (C) PRE: CAT scan showing a lung metastasis (red arrow), non-detectable after ICI treatment with pembrolizumab (POST).
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case_images: PMC11079628_01_fimmu-15-1354710-g003.jpg
case_images: f3
case_images: In 03/2017, a dermic nodule in the upper right scapular area and an enlarged right axillary LN were detected and biopsied ( Figure 3A ). TAA following immunization ( Figure 3B ). In 1/2021, a CAT-Scan revealed a right paracardiac nodule (17 mm diameter) and a micronodule (3 mm diameter) in the upper left lung lobule. In 05/2021 the right paracardiac nodule reached 2.4 cm diameter and the pulmonary nodule increased to 1.2 cm, as detected by PET-CAT scan ( Figure 3C  PRE). After 12 infusions, a new CAT-Scan was performed in 09/2021 and a CR of the lung ( Figure 3C  POST) and paracardiac nodules was observed.
case_images: Patient #3 case. (A) Histopathological analysis of a LN metastasis excised prior to VACCIMEL immunization (03/2010). HLA-I+ and CD11c+ populations determined by IHC are shown. Original magnification 200X; scale bars 100microm. (B) T-cell response induced by VACCIMEL protocol to HLA-restricted peptides from shared melanoma associated antigens detected by IFN-gamma ELISPOT was performed as described. Pre: blood extracted at the selection process; Post 1, 2 and 3 (P1, P2, P3): blood extracted 6, 12 and 24 months after protocol start; unspecific: corresponds to PBMC only stimulated with culture medium. Bars indicate quantification of the spots normalized to 105 stimulated PBMC (effector cells). Peptides tested for this case are shown in the table. (C) A PET/CAT scan performed in 03/2018 showed multiple metastatic lesions (PRE), non-detectable after ICI treatment with nivolumab (09/2018) (POST).
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case_images: PMC11079628_01_fimmu-15-1354710-g004.jpg
case_images: f4
case_images: Histological analysis of the LN metastasis revealed scarce infiltration of tumor nests by CD8+ cells (not shown); HLA-I negative tumor cells were abundant ( Figure 4A  left) and CD11C+ cells were scarce ( Figure 4A  right). Reactivity to TAA increased throughout immunization, as determined by IFN-gamma release from PBMC response in ELISPOT assays, thus revealing immune capabilities ( Figure 4B ). He remained NED until 03/2018 (52 months later), when clinical progression with left supraclavicular adenopathies, muscular and subcutaneous metastases, a nodule in the basal right lung and several small brain metastases were detected ( Figure 4C , PRE). A new PET/CAT Scan performed in 09/2018 revealed that the patient achieved a CR of the previous lesions ( Figure 4C  POST); the etiology of an increased isotope uptake observed at the root of the ascending aorta and the right atrium was not ascertained.