NCDB Analysis of Melanoma 2004-2015: Epidemiology and Outcomes by Subtype, Sociodemographic Factors Impacting Clinical Presentation, and Real-World Survival Benefit of Immunotherapy Approval.

Background: The incidence of invasive melanoma is rising, and approval for the first immune checkpoint inhibitor (ICI) to treat metastatic melanoma occurred in 2011. We aim to describe the epidemiology and outcomes in recent years, sociodemographic factors associated with the presence of metastasis at diagnosis, and the real-world impact of ICI approval on survival based on melanoma subtype and race. Methods: This is a retrospective analysis of the National Cancer Database (NCDB) from the years 2004-2015. The primary outcome was the overall survival of metastatic melanoma by subtype. Secondary outcomes included sociodemographic factors associated with the presence of metastasis at diagnosis and the impact of treatment facility type and ICI approval on the survival of metastatic melanoma. Results: Of the 419,773 invasive melanoma cases, 93.80% were cutaneous, and 4.92% were metastatic at presentation. The odds of presenting with metastatic disease were higher in African Americans (AA) compared to Caucasians (OR 2.37; 95% CI 2.11-2.66, p < 0.001). Treatment of metastatic melanoma at an academic/research facility was associated with lower mortality versus community cancer programs (OR 0.75, 95 % CI 0.69-0.81, p-value < 0.001). Improvement in survival of metastatic melanoma was noted for Caucasians after the introduction of ICI (adjusted HR 0.80, 95% CI 0.78-0.83, p < 0.001); however, this was not statistically significant for AA (adjusted HR 0.80, 95% CI 0.62-1.02, p-value = 0.073) or ocular cases (HR 1.03, 95% CI 0.81-1.31, p-value = 0.797). Conclusion: Real-world data suggest a 20% improvement in survival of metastatic melanoma since the introduction of ICI. The disproportionately high odds of metastatic disease at presentation in AA patients with melanoma suggest the need for a better understanding of the disease and improvement in care delivery.

Treatment of Bleeding Diathesis Associated with a Heparin-Like Anticoagulant in Plasma Cell Neoplasia Using Protamine.

The development of a heparin-like anticoagulant (HLAC) in plasma cell neoplasia has previously been described in clinical literature. Testing of this HLAC, primarily in vitro, has demonstrated that neutralization may be achieved with protamine sulfate, owing to antithrombin III cofactor activity. We report a case in which intravenous protamine sulfate was administered to a patient with IgG-kappa monotypic multiple myeloma, which resulted in resolution of bleeding and coagulopathy, confirmed via objective laboratory data. Our case is intended to demonstrate that intravenous protamine sulfate should be considered in acute bleeding with plasma cell neoplasia. We review the literature to observe past experiences about this phenomenon. We postulate that chemotherapy, targeted therapies, and immunotherapies may also disrupt production of a HLAC. With further investigation, this strategy could be applicable in other hematological malignancies with bleeding diathesis, chiefly if the pathophysiology of the HLAC is precisely defined.