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Kuijpers AMJ, van Akkooi ACJ. Neo-Adjuvant Therapy for Metastatic Melanoma. Cancers (Basel) 2024; 16:1247. [PMID: 38610925 PMCID: PMC11010858 DOI: 10.3390/cancers16071247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 03/01/2024] [Indexed: 04/14/2024] Open
Abstract
Melanoma treatment is leading the neo-adjuvant systemic (NAS) therapy field. It is hypothesized that having the entire tumor in situ, with all of the heterogeneous tumor antigens, allows the patient's immune system to have a broader response to the tumor in all its shapes and forms. This translates into a higher clinical efficacy. Another benefit of NAS therapy potentially includes identifying patients who have a favorable response, which could offer an opportunity for the de-escalation of the extent of surgery and the need for adjuvant radiotherapy and/or adjuvant systemic therapy, as well as tailoring the follow-up in terms of the frequency of visits and cross-sectional imaging. In this paper, we will review the rationale for NAS therapy in resectable metastatic melanoma and the results obtained so far, both for immunotherapy and for BRAF/MEKi therapy, and discuss the response assessment and interpretation, toxicity and surgical considerations. All the trials that have been reported up to now have been investigator-initiated phase I/II trials with either single-agent anti-PD-1, combination anti-CTLA-4 and anti-PD-1 or BRAF/MEK inhibition. The results have been good but are especially encouraging for immunotherapies, showing high durable recurrence-free survival rates. Combination immunotherapy seems superior, with a higher rate of pathologic responses, particularly in patients with a major pathologic response (MPR = pathologic complete response [pCR] + near-pCR [max 10% viable tumor cells]) of 60% vs. 25-30%. The SWOG S1801 trial has recently shown a 23% improvement in event-free survival (EFS) after 2 years for pembrolizumab when giving 3 doses as NAS therapy and 15 as adjuvant versus 18 as adjuvant only. The community is keen to see the first results (expected in 2024) of the phase 3 NADINA trial (NCT04949113), which randomized patients between surgery + adjuvant anti-PD-1 and two NAS therapy courses of a combination of ipilimumab + nivolumab, followed by surgery and a response-driven adjuvant regimen or follow-up. We are on the eve of neo-adjuvant systemic (NAS) therapy, particularly immunotherapy, becoming the novel standard of care for macroscopic stage III melanoma.
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Affiliation(s)
- Anke M. J. Kuijpers
- Department of Surgical Oncology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
| | - Alexander C. J. van Akkooi
- Melanoma Institute Australia, Sydney, NSW 2060, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2050, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
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2
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Flaherty KT. A twenty year perspective on melanoma therapy. Pigment Cell Melanoma Res 2023; 36:563-575. [PMID: 37770281 DOI: 10.1111/pcmr.13125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/27/2023] [Accepted: 08/29/2023] [Indexed: 09/30/2023]
Abstract
Melanoma had long been considered to be particularly addressable with immunotherapy, but that reputation was built on modestly effective cytokine-based immunotherapy. CTLA-4 antibody therapy reinforced this legacy, but PD-1 antibodies transformed the melanoma treatment landscape and lead the way for immunotherapy to become standard treatment for more than half of the advanced cancer population. BRAF mutations were discovered in 8% of all cancer and nearly 50% of melanomas. Successful development of BRAF inhibitors and BRAF/MEK combination therapy in melanoma preceded regulatory approval across all cancer types. No cancer type saw outcomes improved by the same margin as melanoma in the decade of the 2010s.
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Affiliation(s)
- Keith T Flaherty
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
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3
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Pavlick AC, Ariyan CE, Buchbinder EI, Davar D, Gibney GT, Hamid O, Hieken TJ, Izar B, Johnson DB, Kulkarni RP, Luke JJ, Mitchell TC, Mooradian MJ, Rubin KM, Salama AK, Shirai K, Taube JM, Tawbi HA, Tolley JK, Valdueza C, Weiss SA, Wong MK, Sullivan RJ. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of melanoma, version 3.0. J Immunother Cancer 2023; 11:e006947. [PMID: 37852736 PMCID: PMC10603365 DOI: 10.1136/jitc-2023-006947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2023] [Indexed: 10/20/2023] Open
Abstract
Since the first approval for immune checkpoint inhibitors (ICIs) for the treatment of cutaneous melanoma more than a decade ago, immunotherapy has completely transformed the treatment landscape of this chemotherapy-resistant disease. Combination regimens including ICIs directed against programmed cell death protein 1 (PD-1) with anti-cytotoxic T lymphocyte antigen-4 (CTLA-4) agents or, more recently, anti-lymphocyte-activation gene 3 (LAG-3) agents, have gained regulatory approvals for the treatment of metastatic cutaneous melanoma, with long-term follow-up data suggesting the possibility of cure for some patients with advanced disease. In the resectable setting, adjuvant ICIs prolong recurrence-free survival, and neoadjuvant strategies are an active area of investigation. Other immunotherapy strategies, such as oncolytic virotherapy for injectable cutaneous melanoma and bispecific T-cell engager therapy for HLA-A*02:01 genotype-positive uveal melanoma, are also available to patients. Despite the remarkable efficacy of these regimens for many patients with cutaneous melanoma, traditional immunotherapy biomarkers (ie, programmed death-ligand 1 expression, tumor mutational burden, T-cell infiltrate and/or microsatellite stability) have failed to reliably predict response. Furthermore, ICIs are associated with unique toxicity profiles, particularly for the highly active combination of anti-PD-1 plus anti-CTLA-4 agents. The Society for Immunotherapy of Cancer (SITC) convened a panel of experts to develop this clinical practice guideline on immunotherapy for the treatment of melanoma, including rare subtypes of the disease (eg, uveal, mucosal), with the goal of improving patient care by providing guidance to the oncology community. Drawing from published data and clinical experience, the Expert Panel developed evidence- and consensus-based recommendations for healthcare professionals using immunotherapy to treat melanoma, with topics including therapy selection in the advanced and perioperative settings, intratumoral immunotherapy, when to use immunotherapy for patients with BRAFV600-mutated disease, management of patients with brain metastases, evaluation of treatment response, special patient populations, patient education, quality of life, and survivorship, among others.
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Affiliation(s)
| | - Charlotte E Ariyan
- Department of Surgery Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Diwakar Davar
- Hillman Cancer Center, University of Pittsburg Medical Center, Pittsburgh, Pennsylvania, USA
| | - Geoffrey T Gibney
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Omid Hamid
- The Angeles Clinic and Research Institute, A Cedars-Sinai Affiliate, Los Angeles, California, USA
| | - Tina J Hieken
- Department of Surgery and Comprehensive Cancer Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Benjamin Izar
- Department of Medicine, Division of Hematology/Oncology, Columbia University Medical Center, New York, New York, USA
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rajan P Kulkarni
- Departments of Dermatology, Oncological Sciences, Biomedical Engineering, and Center for Cancer Early Detection Advanced Research, Knight Cancer Institute, OHSU, Portland, Oregon, USA
- Operative Care Division, VA Portland Health Care System (VAPORHCS), Portland, Oregon, USA
| | - Jason J Luke
- Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tara C Mitchell
- Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Meghan J Mooradian
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Krista M Rubin
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - April Ks Salama
- Department of Medicine, Division of Medical Oncology, Duke University, Durham, Carolina, USA
| | - Keisuke Shirai
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Janis M Taube
- Department of Dermatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hussein A Tawbi
- Department of Melanoma Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - J Keith Tolley
- Patient Advocate, Melanoma Research Alliance, Washington, DC, USA
| | - Caressa Valdueza
- Cutaneous Oncology Program, Weill Cornell Medicine, New York, New York, USA
| | - Sarah A Weiss
- Department of Medical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Michael K Wong
- Patient Advocate, Melanoma Research Alliance, Washington, DC, USA
| | - Ryan J Sullivan
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
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4
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Haist M, Stege H, Kuske M, Bauer J, Klumpp A, Grabbe S, Bros M. Combination of immune-checkpoint inhibitors and targeted therapies for melanoma therapy: The more, the better? Cancer Metastasis Rev 2023; 42:481-505. [PMID: 37022618 PMCID: PMC10348973 DOI: 10.1007/s10555-023-10097-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/27/2023] [Indexed: 04/07/2023]
Abstract
The approval of immune-checkpoint inhibitors (CPI) and mitogen activated protein kinase inhibitors (MAPKi) in recent years significantly improved the treatment management and survival of patients with advanced malignant melanoma. CPI aim to counter-act receptor-mediated inhibitory effects of tumor cells and immunomodulatory cell types on effector T cells, whereas MAPKi are intended to inhibit tumor cell survival. In agreement with these complementary modes of action preclinical data indicated that the combined application of CPI and MAPKi or their optimal sequencing might provide additional clinical benefit. In this review the rationale and preclinical evidence that support the combined application of MAPKi and CPI either in concurrent or consecutive regimens are presented. Further, we will discuss the results from clinical trials investigating the sequential or combined application of MAPKi and CPI for advanced melanoma patients and their implications for clinical practice. Finally, we outline mechanisms of MAPKi and CPI cross-resistance which limit the efficacy of currently available treatments, as well as combination regimens.
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Affiliation(s)
- Maximilian Haist
- Department of Dermatology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, 94305, USA.
- Department of Microbiology & Immunology, Stanford University School of Medicine, Stanford, CA, 94305, USA.
| | - Henner Stege
- Department of Dermatology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Michael Kuske
- Department of Dermatology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Julia Bauer
- Department of Dermatology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Annika Klumpp
- Department of Dermatology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Stephan Grabbe
- Department of Dermatology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Matthias Bros
- Department of Dermatology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
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5
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Bogani G, Cinquini M, Signorelli D, Pizzutilo EG, Romanò R, Bersanelli M, Raggi D, Alfieri S, Buti S, Bertolini F, Bonomo P, Marandino L, Rizzo M, Monforte M, Aiello M, Tralongo AC, Torri V, Di Donato V, Giannatempo P. A systematic review and meta-analysis on the Optimal Treatment duration of cHEckpoint inhibitoRS in solid tumors: the OTHERS study. Crit Rev Oncol Hematol 2023; 187:104016. [PMID: 37156405 DOI: 10.1016/j.critrevonc.2023.104016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 04/19/2023] [Accepted: 05/02/2023] [Indexed: 05/10/2023] Open
Abstract
No clear evidence supports the advantage of fixed (up to two years (2yICI)) or continuous treatment (more than two years (prolonged ICI)) in cancer patients achieving stable disease or response on immune checkpoint inhibitors (ICIs). We performed a systematic review and meta-analysis of randomized controlled trials reporting the duration of ICIs (alone or in combination with standard of care (SoC)) across various solid tumors. Overall, we identified 28,417 records through database searching. Based on the eligibility criteria, 57 studies were identified for the quantitative synthesis, including 22,977 patients receiving ICIs (with or without SoC). Prolonged ICI correlated with better overall survival (OS) than 2yICI in patients with melanoma (HR:1.55; 95%CI: 1.22,1.98), while 2yICI-SoC led to better OS than prolonged ICI-SoC in patients with NSCLC (HR: 0.84; 95%CI: 0.68,0.89). Prospective randomized trials are needed to assess the most appropriate duration of ICIs. OBJECTIVE: No clear evidence supports the advantage of fixed (up to two years (2yICI)) or continuous treatment (more than two years (prolonged ICI)) in cancer patients achieving stable disease or response on immune checkpoint inhibitors (ICIs). Here, we assessed the optimal treatment duration for ICIs in solid tumors. CONCLUSIONS: Prolonged ICIs administration does not seem to improve the outcomes of patients with NSCLC an RCC.
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Affiliation(s)
- Giorgio Bogani
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Roma, Italy.
| | - Michela Cinquini
- Oncology Department, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy Italy
| | - Diego Signorelli
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Elio G Pizzutilo
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milano, Italy; Department of Hematology & Oncology, University of Milan, Milan, Italy
| | - Rebecca Romanò
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milano, Italy; Department of Hematology & Oncology, University of Milan, Milan, Italy
| | - Melissa Bersanelli
- Medical Oncology Unit, University of Parma, Parma, Italy; Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Daniele Raggi
- Department of Medical Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Salvatore Alfieri
- Department of Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milano, Italy
| | - Sebastiano Buti
- Medical Oncology Unit, University of Parma, Parma, Italy; Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Federica Bertolini
- Department of Oncology, Azienda Ospedaliera - Universitaria di Modena, Modena, Italy
| | - Pierluigi Bonomo
- Department of Oncology, Azienda Ospedaliera - Universitaria Careggi, Firenze, Italy
| | - Laura Marandino
- Department of Medical Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Mimma Rizzo
- A.O.U. Consorziale Policlinico di Bari, Bari, Italy
| | - Marta Monforte
- Oncology Department, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy Italy
| | - Marco Aiello
- Medical Oncology Unit, A.O.U. Policlinico San Marco, Catania, Italy
| | - Antonio C Tralongo
- Oncology Department, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy Italy
| | - Valter Torri
- Oncology Department, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy Italy
| | - Violante Di Donato
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Roma, Italy
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6
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Trojaniello C, Sparano F, Cioli E, Ascierto PA. Sequencing Targeted and Immune Therapy in BRAF-Mutant Melanoma: Lessons Learned. Curr Oncol Rep 2023; 25:623-634. [PMID: 36995534 PMCID: PMC10164000 DOI: 10.1007/s11912-023-01402-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE OF REVIEW The treatment strategy for BRAF-mutated melanoma remains unsatisfactory, although the advent of immune checkpoint inhibition has improved the prognosis of advanced melanoma. This article reports current evidence on the efficacy and safety of sequential immunotherapy with targeted therapy in patients with BRAF-mutated melanoma. It discusses criteria for the use of available options in clinical practice. RECENT FINDINGS Targeted therapy provides rapid disease control in a relatively high proportion of patients, although the development of secondary resistance limits the duration of responses; in contrast, immunotherapy may induce slow but more durable responses in a subset of patients. Therefore, the identification of a combination strategy for the use of these therapies seems a promising perspective. Currently, inconsistent data have been obtained, but most studies indicate that the administration of BRAFi/MEKi prior to immune checkpoint inhibitors appears to reduce the efficacy of immunotherapy. On the contrary, several clinical and real-life studies suggest that frontline immunotherapy with subsequent targeted therapy may be associated with better tumor control than immunotherapy alone. Larger clinical studies are ongoing to confirm the efficacy and safety of this sequencing strategy for treating BRAF-mutated melanoma with immunotherapy followed by targeted therapy.
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Affiliation(s)
- Claudia Trojaniello
- Melanoma, Cancer Immunotherapy, and Development Therapeutics Unit, Istituto Nazionale Tumori IRCCS Fondazione "G. Pascale", Naples, Italy
| | - Francesca Sparano
- Melanoma, Cancer Immunotherapy, and Development Therapeutics Unit, Istituto Nazionale Tumori IRCCS Fondazione "G. Pascale", Naples, Italy
| | - Eleonora Cioli
- Melanoma, Cancer Immunotherapy, and Development Therapeutics Unit, Istituto Nazionale Tumori IRCCS Fondazione "G. Pascale", Naples, Italy
| | - Paolo Antonio Ascierto
- Melanoma, Cancer Immunotherapy, and Development Therapeutics Unit, Istituto Nazionale Tumori IRCCS Fondazione "G. Pascale", Naples, Italy.
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7
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Real-world outcomes of different lines and sequences of treatment in BRAF-positive advanced melanoma patients. Melanoma Res 2023; 33:38-49. [PMID: 36545921 DOI: 10.1097/cmr.0000000000000856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The objective of this study is to compare efficacy with different treatment sequences and lines of treatment among BRAF V600 mutated (BRAF+) advanced melanoma patients with immunotherapies (IO) and targeted therapies (TT) using real-world data. This was a retrospective cohort study using the Novartis BRAF+ meLanoma patients ObsErvational database, the harmonized customized data from Flatiron and ConcertAI. The study included BRAF+ advanced unresectable melanoma patients treated with first-line (1L) IO or TT between 1 January 2014 and 31 May 2020. Patient characteristics and treatment patterns were described. Kaplan-Meier curves and propensity score-adjusted Cox models were used for analyzing progression-free survival (PFS) and overall survival (OS). A total of 1961 patients were included, of which, 57.2% received IO and 42.8% received TT on 1L therapy. Overall, 603 patients initiated a 2L therapy: 56.2% IO and 43.8% TT. Regardless of treatment sequence, patients progressed at a relatively similar rate with no significant difference between groups (median PFS: 12.9 months for 1L TT/2L IO and 13.1 months for 1L IO/2L TT; HR, 0.84; P = 0.137). The 2-year OS rate was also similar with 1L TT/2L IO and 1L IO/2L TT (78% vs. 80%; HR, 1.09; P = 0.730). PFS was worse on 2L therapy compared with 1L (median 4.7 vs. 6.5 months). Efficacy on 2L therapy was poor compared with 1L. Among patients who received 2L therapy, regardless of treatment sequences, outcomes were comparable between 1L TT/2L IO and 1L IO/2L TT in this study that reflects real-world experiences beyond clinical trial selective eligibility criteria.
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8
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Immune checkpoint blockade in melanoma: Advantages, shortcomings and emerging roles of the nanoparticles. Int Immunopharmacol 2022; 113:109300. [DOI: 10.1016/j.intimp.2022.109300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022]
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9
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Corrie P, Meyer N, Berardi R, Guidoboni M, Schlueter M, Kolovos S, Macabeo B, Trouiller JB, Laramée P. Comparative efficacy and safety of targeted therapies for BRAF-mutant unresectable or metastatic melanoma: Results from a systematic literature review and a network meta-analysis. Cancer Treat Rev 2022; 110:102463. [PMID: 36099854 DOI: 10.1016/j.ctrv.2022.102463] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/30/2022] [Accepted: 08/30/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The objective of this study was to estimate the relative efficacy and safety of targeted therapies for the treatment of metastatic melanoma using a network meta-analysis (NMA). METHODS A systematic literature review (SLR) identified studies in Medline, Embase and Cochrane published until November 2020. Screening used prespecified eligibility criteria. Following a transitivity assessment across included studies, Bayesian NMA was conducted. RESULTS A total of 43 publications reporting 15 targeted therapy trials and 42 reporting 18 immunotherapy trials were retained from the SLR and considered for the NMA. Due to substantial between-study heterogeneity with immunotherapy trials, the analysis considered a network restricted to targeted therapies. Among combination therapies, encorafenib + binimetinib was superior to dabrafenib + trametinib for overall response rate (OR = 1.86; 95 % credible interval [CrI] 1.10, 3.17), superior to vemurafenib + cobimetinib with fewer serious adverse events (SAEs) (OR = 0.51; 95 % CrI 0.29, 0.91) and fewer discontinuations due to AEs (OR = 0.45; 95 % CrI 0.21, 0.96), and superior to atezolizumab + vemurafenib + cobimetinib with fewer SAEs (OR = 0.41; 95 % CrI 0.21, 0.82). Atezolizumab + vemurafenib + cobimetinib and encorafenib + binimetinib were generally comparable for efficacy endpoints. Among double combination therapies, encorafenib + binimetinib showed high probabilities of being better for all efficacy and safety endpoints. CONCLUSIONS This NMA confirms that combination therapies are more efficacious than monotherapies. Encorafenib + binimetinib has a favourable efficacy profile compared to other double combination therapies and a favourable safety profile compared to both double and triple combination therapies.
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Affiliation(s)
- Pippa Corrie
- Oncology Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Nicolas Meyer
- Institut Universitaire du Cancer et CHU de Toulouse, Toulouse, France; Inserm UMR 1037 - CRCT, Toulouse, France
| | - Rossana Berardi
- Clinica Oncologica, AOU Ospedali Riuniti, Ancona, Università Politecnica delle Marche, Ancona, Italy
| | - Massimo Guidoboni
- Experimental and Clinical Oncology of Immunotherapy and Rare Tumors, IRCCS IRST "Dino Amadori", Meldola, FC, Italy
| | | | | | - Bérengère Macabeo
- Aix-Marseille Université, Marseille, France; Pierre Fabre Laboratories, Paris, France
| | | | - Philippe Laramée
- Aix-Marseille Université, Marseille, France; Pierre Fabre Laboratories, Paris, France.
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Poulikakos PI, Sullivan RJ, Yaeger R. Molecular Pathways and Mechanisms of BRAF in Cancer Therapy. Clin Cancer Res 2022; 28:4618-4628. [PMID: 35486097 PMCID: PMC9616966 DOI: 10.1158/1078-0432.ccr-21-2138] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/08/2022] [Accepted: 03/30/2022] [Indexed: 01/24/2023]
Abstract
With the identification of activating mutations in BRAF across a wide variety of malignancies, substantial effort was placed in designing safe and effective therapeutic strategies to target BRAF. These efforts have led to the development and regulatory approval of three BRAF inhibitors as well as five combinations of a BRAF inhibitor plus an additional agent(s) to manage cancer such as melanoma, non-small cell lung cancer, anaplastic thyroid cancer, and colorectal cancer. To date, each regimen is effective only in patients with tumors harboring BRAFV600 mutations and the duration of benefit is often short-lived. Further limitations preventing optimal management of BRAF-mutant malignancies are that treatments of non-V600 BRAF mutations have been less profound and combination therapy is likely necessary to overcome resistance mechanisms, but multi-drug regimens are often too toxic. With the emergence of a deeper understanding of how BRAF mutations signal through the RAS/MAPK pathway, newer RAF inhibitors are being developed that may be more effective and potentially safer and more rational combination therapies are being tested in the clinic. In this review, we identify the mechanics of RAF signaling through the RAS/MAPK pathway, present existing data on single-agent and combination RAF targeting efforts, describe emerging combinations, summarize the toxicity of the various agents in clinical testing, and speculate as to where the field may be headed.
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Affiliation(s)
- Poulikos I. Poulikakos
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Ryan J. Sullivan
- Department of Medicine, Massachusetts General Hospital, Boston, MA 02114
| | - Rona Yaeger
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065
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11
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Frazer R, Gupta A, Herbert C, Payne M, Diaz-Mendoza S, Vincent SA, Kovaleva E. Delphi panel for consensus on the optimal management of dabrafenib plus trametinib-related pyrexia in patients with melanoma. Ther Adv Med Oncol 2022; 14:17588359221127681. [PMID: 36339928 PMCID: PMC9629565 DOI: 10.1177/17588359221127681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 09/02/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose: Dabrafenib and trametinib combination therapy (dab + tram) is indicated to treat BRAF V600 mutation–positive unresectable/metastatic melanoma and as adjuvant treatment for resected stage III disease. Dab + tram–related pyrexia may require early therapy discontinuation. A modified Delphi panel was conducted to develop consensus on the optimal management of dab + tram–related pyrexia in patients with melanoma. Methods: In all, 10 UK oncologists experienced in melanoma management participated in a three-round modified Delphi study (Round 1: one-to-one interview; Rounds 2 and 3: email survey). In each round, participants rated the extent of their agreement with statements about defining and managing dab + tram–related pyrexia. Consensus was defined as >80% agreement for critical management (CM) and >60% for non-critical management (NCM) statements. Results: All 10 participants completed Round 1; 9 completed Rounds 2 and 3. Consensus was reached on 42/66 statements (20 CM and 22 NCM). Drug-related pyrexia was agreed as being strictly an elevation of body temperature, although other symptoms may be present (89% agreement). Panelists agreed on the need for simple and generic guidance on dab + tram–related pyrexia management that does not differentiate between patient groups (100%), and that management of first and second dab + tram–related pyrexia episodes should be the same regardless of treatment intent (100%). Regarding CM, participants agreed that both dab and tram should be interrupted for pyrexia (100%) without considering the use of steroids (89%); patients on dab + tram presenting to non-oncology services with pyrexia should be directed to an oncology-specific service as soon as possible and assessed for infection (100%). NCM statements on steroid use following dab + tram interruption and when to restart dab + tram did not reach consensus. Conclusions: These consensus statements provide a framework on optimal management of dab + tram–related pyrexia in patients with melanoma which should inform future guidelines.
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Affiliation(s)
| | - Avinash Gupta
- The Christie NHS Foundation Trust, Manchester, England
| | | | - Miranda Payne
- Oxford University Hospitals NHS Trust, Oxford, England
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12
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Atkins MB, Abu-Sbeih H, Ascierto PA, Bishop MR, Chen DS, Dhodapkar M, Emens LA, Ernstoff MS, Ferris RL, Greten TF, Gulley JL, Herbst RS, Humphrey RW, Larkin J, Margolin KA, Mazzarella L, Ramalingam SS, Regan MM, Rini BI, Sznol M. Maximizing the value of phase III trials in immuno-oncology: A checklist from the Society for Immunotherapy of Cancer (SITC). J Immunother Cancer 2022; 10:jitc-2022-005413. [PMID: 36175037 PMCID: PMC9528604 DOI: 10.1136/jitc-2022-005413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2022] [Indexed: 11/03/2022] Open
Abstract
The broad activity of agents blocking the programmed cell death protein 1 and its ligand (the PD-(L)1 axis) revolutionized oncology, offering long-term benefit to patients and even curative responses for tumors that were once associated with dismal prognosis. However, only a minority of patients experience durable clinical benefit with immune checkpoint inhibitor monotherapy in most disease settings. Spurred by preclinical and correlative studies to understand mechanisms of non-response to the PD-(L)1 antagonists and by combination studies in animal tumor models, many drug development programs were designed to combine anti-PD-(L)1 with a variety of approved and investigational chemotherapies, tumor-targeted therapies, antiangiogenic therapies, and other immunotherapies. Several immunotherapy combinations improved survival outcomes in a variety of indications including melanoma, lung, kidney, and liver cancer, among others. This immunotherapy renaissance, however, has led to many combinations being advanced to late-stage development without definitive predictive biomarkers, limited phase I and phase II data, or clinical trial designs that are not optimized for demonstrating the unique attributes of immune-related antitumor activity-for example, landmark progression-free survival and overall survival. The decision to activate a study at an individual site is investigator-driven, and generalized frameworks to evaluate the potential for phase III trials in immuno-oncology to yield positive data, particularly to increase the number of curative responses or otherwise advance the field have thus far been lacking. To assist in evaluating the potential value to patients and the immunotherapy field of phase III trials, the Society for Immunotherapy of Cancer (SITC) has developed a checklist for investigators, described in this manuscript. Although the checklist focuses on anti-PD-(L)1-based combinations, it may be applied to any regimen in which immune modulation is an important component of the antitumor effect.
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Affiliation(s)
- Michael B Atkins
- Georgetown Lombardi Comprehensive Cancer Center, Washington, District of Columbia, USA
| | | | - Paolo A Ascierto
- Istituto Nazionale Tumori IRCCS Fondazione "G Pascale", Napoli, Italy
| | - Michael R Bishop
- The David and Etta Jonas Center for Cellular Therapy, University of Chicago, Chicago, Illinois, USA
| | - Daniel S Chen
- Engenuity Life Sciences, Burlingame, California, USA
| | - Madhav Dhodapkar
- Center for Cancer Immunology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - Leisha A Emens
- UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Marc S Ernstoff
- DCTD/DTP-IOB, ImmunoOncology Branch, NCI, Bethesda, Maryland, USA
| | | | - Tim F Greten
- Gastrointestinal Malignancies Section, National Cancer Institue CCR Liver Program, Bethesda, Maryland, USA
| | - James L Gulley
- Center for Immuno-Oncology, National Cancer Institute, Bethesda, Maryland, USA
| | | | | | | | - Kim A Margolin
- St. John's Cancer Institute, Santa Monica, California, USA
| | - Luca Mazzarella
- Experimental Oncology, New Drug Development, European Instititue of Oncology IRCCS, Milan, Italy
| | | | - Meredith M Regan
- Dana-Farber/Harvard Cancer Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Mario Sznol
- Yale School of Medicine, New Haven, Connecticut, USA
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13
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Kato S, Fujiwara Y, Hong DS. Targeting KRAS: Crossroads of Signaling and Immune Inhibition. JOURNAL OF IMMUNOTHERAPY AND PRECISION ONCOLOGY 2022; 5:68-78. [PMID: 36034582 PMCID: PMC9390702 DOI: 10.36401/jipo-22-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/15/2022] [Accepted: 06/18/2022] [Indexed: 11/09/2022]
Abstract
ABSTRACT
Mutations of RAS are commonly seen in human cancers, especially in lung, colorectal, and pancreatic adenocarcinoma. Despite huge effort for decades, targeting RAS mutations has been “undruggable” because of the molecular instability of RAS protein inhibition. However, the recent discovery of the KRAS G12C inhibitor paved the way to expand therapeutic options for patients with cancer harboring the KRAS G12C mutation. At the same time, the successful development of immune checkpoint inhibitors (ICIs) drastically changed the paradigm of cancer treatment and resulted in a better understanding of the tumor immune microenvironment in patients with KRAS-mutant cancer. This review describes the following: the clinical characteristics of cancer with KRAS mutation; successful development of the KRAS G12C inhibitor and its impact on the tumor immune microenvironment; and potential new avenues such as the combination strategy using KRAS inhibitor and ICI, with preclinical and clinical rationales for overcoming resistance to inhibition of KRAS to improve therapeutic efficacy for patients with cancer harboring KRAS mutations.
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Affiliation(s)
- Shumei Kato
- 1 Center for Personalized Cancer Therapy and Division of Hematology and Oncology, Department of Medicine, UC San Diego Moores Cancer Center, La Jolla, CA, USA
| | - Yu Fujiwara
- 2 Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, USA
| | - David S. Hong
- 3 Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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14
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Schadendorf D, Dummer R, Robert C, Ribas A, Sullivan RJ, Panella T, McKean M, Santos ES, Brill K, Polli A, Pietro AD, Ascierto PA. STARBOARD: encorafenib + binimetinib + pembrolizumab for first-line metastatic/unresectable BRAF V600-mutant melanoma. Future Oncol 2022; 18:2041-2051. [PMID: 35272485 DOI: 10.2217/fon-2021-1486] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Despite the significant progress in the treatment of unresectable or metastatic BRAF V600-mutant melanoma, there remains two primary treatment options: targeted therapy and immunotherapy. Targeted therapy or immunotherapy alone is associated with efficacy limitations including efficacy limited to select patient subsets. With separate mechanisms of action and different response patterns, the combination of targeted agents and immunotherapy to treat patients with BRAF V600-mutant melanoma may further improve patient outcomes. Current treatment guidelines recommend treatment with targeted agents alone, immunotherapy, or the combination of targeted agents and immunotherapy. The randomized, double-blind STARBOARD trial aims to evaluate efficacy and safety of encorafenib, binimetinib and pembrolizumab in treatment-naive patients with metastatic or unresectable locally advanced BRAF V600-mutant melanoma in comparison to pembrolizumab.
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Affiliation(s)
- Dirk Schadendorf
- Department of Dermatology, University Hospital Essen, 45122 Essen, Germany & German Cancer Consortium, Partner Site Essen, Germany
| | - Reinhard Dummer
- Department of Dermatology, University Hospital Zürich & University Zurich, Zurich, 8091, Switzerland
| | - Caroline Robert
- Melanoma Research Unit, Institut Gustave Roussy, Villejuif, 94805, France
| | - Antoni Ribas
- Department of Medicine, Division of Hematology-Oncology, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Ryan J Sullivan
- Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115 USA
| | - Timothy Panella
- Department of Medicine, Division of Hematology & Oncology, University of Tennessee, Knoxville, TN 37996, USA
| | - Meredith McKean
- Sarah Cannon Research Institute at Tennessee Oncology, Nashville, TN 37203, USA
| | - Edgardo S Santos
- Florida Precision Oncology/A Division of Genesis Care USA, Florida Atlantic University, Aventura, FL 33180, USA
| | | | | | | | - Paolo A Ascierto
- Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, 80131, Italy
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15
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Marconcini R, Pezzicoli G, Stucci LS, Sergi MC, Lospalluti L, Porta C, Tucci M. Combination of immunotherapy and other targeted therapies in advanced cutaneous melanoma. Hum Vaccin Immunother 2022; 18:1980315. [PMID: 34613889 PMCID: PMC9302493 DOI: 10.1080/21645515.2021.1980315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 08/22/2021] [Accepted: 09/08/2021] [Indexed: 12/20/2022] Open
Abstract
Cutaneous Melanoma (CM) is an aggressive cancer whose incidence is increasing worldwide. However, the knowledge of its biology and genes driving cell growth and survival allowed to develop new drugs that have improved PFS and OS of advanced disease. Both BRAF targeting agents and immune checkpoint inhibitors (ICIs) have been adopted for the treatment of metastatic disease and the adjuvant setting. Several melanoma patients show innate or acquired drug-resistance and thus new strategies are required for overcoming this complication. New ICIs have been developed, and strategies of combination or sequencing are under investigation in ongoing clinical trials. In addition, pre-clinical data have demonstrated that many strategies induce the release of neoantigens within the tumor microenvironment, thus suggesting the combination of new agents with ICIs. Here, we review the ongoing strategies in advanced CM including a dedicated section on treatment of brain metastases.
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Affiliation(s)
- Riccardo Marconcini
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Gaetano Pezzicoli
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy
- Dermatology Unit, Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy
| | - Luigia Stefania Stucci
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy
| | - Maria Chiara Sergi
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy
| | - Lucia Lospalluti
- Dermatology Unit, Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy
| | - Camillo Porta
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy
- Department of Biomedical Sciences and Human Oncolog, University of Bari ‘Aldo Moro’, Bari, Italy
| | - Marco Tucci
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy
- Department of Biomedical Sciences and Human Oncolog, University of Bari ‘Aldo Moro’, Bari, Italy
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16
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Navani V, Graves MC, Mandaliya H, Hong M, van der Westhuizen A, Martin J, Bowden NA. Melanoma: An immunotherapy journey from bench to bedside. Cancer Treat Res 2022; 183:49-89. [PMID: 35551656 DOI: 10.1007/978-3-030-96376-7_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Melanoma gave science a window into the role immune evasion plays in the development of malignancy. The entire spectrum of immune focused anti-cancer therapies has been subjected to clinical trials in this disease, with limited success until the immune checkpoint blockade era. That revolution launched first in melanoma, heralded a landscape change throughout cancer that continues to reverberate today.
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Affiliation(s)
| | - Moira C Graves
- Centre for Drug Repurposing and Medicines Research, University of Newcastle and Hunter Medical Research Institute, University Dr, Callaghan, NSW, 2308, Australia
| | - Hiren Mandaliya
- Calvary Mater Hospital Newcastle, Edith St, Waratah, NSW, 2298, Australia
| | - Martin Hong
- Calvary Mater Hospital Newcastle, Edith St, Waratah, NSW, 2298, Australia
| | - Andre van der Westhuizen
- Centre for Drug Repurposing and Medicines Research, University of Newcastle and Hunter Medical Research Institute, University Dr, Callaghan, NSW, 2308, Australia.,Calvary Mater Hospital Newcastle, Edith St, Waratah, NSW, 2298, Australia
| | - Jennifer Martin
- Centre for Drug Repurposing and Medicines Research, University of Newcastle and Hunter Medical Research Institute, University Dr, Callaghan, NSW, 2308, Australia.,John Hunter Hospital, Newcastle, NSW, Australia
| | - Nikola A Bowden
- Centre for Drug Repurposing and Medicines Research, University of Newcastle and Hunter Medical Research Institute, University Dr, Callaghan, NSW, 2308, Australia
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17
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Melanoma Brain Metastases: An Update on the Use of Immune Checkpoint Inhibitors and Molecularly Targeted Agents. Am J Clin Dermatol 2022; 23:523-545. [PMID: 35534670 DOI: 10.1007/s40257-022-00678-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 11/01/2022]
Abstract
Brain metastases from melanoma are no longer uniformly associated with dismal outcomes. Impressive tumor tissue-based (craniotomy) translational research has consistently shown that distinct patient subgroups may have a favorable prognosis. This review provides a historical overview of the standard-of-care treatments until the early 2010s. It subsequently summarizes more recent advances in understanding the biology of melanoma brain metastases (MBMs) and treating patients with MBMs, mainly focusing upon prospective clinical trials of BRAF/MEK and PD-1/CTLA-4 inhibitors in patients with previously untreated MBMs. These additional systemic treatments have provided effective complementary treatment approaches and/or alternatives to radiation and craniotomy. The current role of radiation therapy, especially in conjunction with systemic therapies, is also discussed through the lens of various retrospective studies. The combined efficacy of systemic treatments with radiation has improved overall survival over the last 10 years and has sparked considerable research interest regarding optimal dosing and sequencing of radiation treatments with systemic treatments. Finally, the review describes ongoing clinical trials in patients with MBMs.
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18
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Aroldi F, Middleton MR. Long-Term Outcomes of Immune Checkpoint Inhibition in Metastatic Melanoma. Am J Clin Dermatol 2022; 23:331-338. [PMID: 35359259 DOI: 10.1007/s40257-022-00681-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2022] [Indexed: 12/14/2022]
Abstract
Increasing knowledge about the biology of melanoma and of immunology has led to the development and regulatory approval of the immune checkpoint inhibitors ipilimumab, nivolumab, and pembrolizumab, which are indicated for the treatment of melanoma irrespective of the B-Raf proto-oncogene mutation status of the tumour. Only a subset of patients will respond, but those who do can expect long-lasting, previously unheard-of responses. Long-term survival results for the registration trials, including CheckMate 067, Keynote-006, and Keynote-001, have recently been published. In particular, the combination of ipilimumab and nivolumab showed an impressive 5-year overall survival of just over 50%. However, toxicity remains a significant concern, with some of the side effects being life threatening and/or life changing. In this review, we discuss the safety and efficacy data of all the agents currently approved for the first-line treatment of advanced melanoma, identifying factors that influence the choice of a single agent rather than combination therapy. We highlight the potential biomarkers of response, effects of long-term toxicity, and options after progression.
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19
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Bari S, Muzaffar J, Eroglu Z. Combination targeted and immune therapy in the treatment of advanced melanoma: a valid treatment option for patients? Ther Adv Med Oncol 2022; 14:17588359221090306. [PMID: 35478991 PMCID: PMC9036333 DOI: 10.1177/17588359221090306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 03/10/2022] [Indexed: 11/16/2022] Open
Abstract
Melanomas harboring an activating BRAFV600 mutation account for 50% of all advanced melanomas. The approval of BRAF-targeted therapy revolutionized treatment of these patients with achievement of impressive responses. However, development of resistance to these drugs is a significant problem, and as such, duration of response remains low, with median progression free survival of around 11–15 months. Immune checkpoint blockers exploit the immune system to eradicate cancer and can produce durable disease control that results in long-term, treatment-free survival in some patients. These drugs have shown very impressive survival in patients with BRAF-mutated melanoma. Thus, there is a need to continue to utilize emerging data to achieve long-term disease control for patients with advanced melanoma. Combining targeted therapy with immune therapy may be one possible way to achieve this goal. In this review, the mechanisms of action of these two pathways, including the mechanistic basis of this combination, are summarized, along with results of completed and ongoing trials in triple therapy.
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Affiliation(s)
- Shahla Bari
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jameel Muzaffar
- Department of Head and Neck Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Zeynep Eroglu
- Department of Cutaneous Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
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20
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Dixon-Douglas JR, Patel RP, Somasundram PM, McArthur GA. Triplet Therapy in Melanoma - Combined BRAF/MEK Inhibitors and Anti-PD-(L)1 Antibodies. Curr Oncol Rep 2022; 24:1071-1079. [PMID: 35366166 PMCID: PMC9249697 DOI: 10.1007/s11912-022-01243-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2021] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW We provide an updated review of clinical trials evaluating the combination of BRAF/MEK inhibitors with anti-PD-(L)1 therapy (triplet therapy) for patients with advanced BRAF-mutant melanoma, accompanied by a summary of the biological evidence supporting this combination. RECENT FINDINGS Resistance to BRAF/MEK inhibition and comparatively low response rates to immune checkpoint inhibitors remain clinical challenges in the treatment of melanoma. Preclinical data demonstrates that targeted therapy is immune-modulatory and synergises with immune checkpoint inhibition. Several randomised controlled trials have evaluated the combination of targeted therapy with immune checkpoint inhibition. Triplet therapy has shown improvements in progression-free survival and durability of response compared to BRAF/MEK inhibition alone; however, questions remain regarding the best clinical scenario for implementation of this regimen in the era of front-line immunotherapy.
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Affiliation(s)
- Julia R Dixon-Douglas
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Riyaben P Patel
- Cancer Research Division, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Pretashini M Somasundram
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia
| | - Grant A McArthur
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia. .,Cancer Research Division, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia. .,Department of Oncology, Sir Peter MacCallum, University of Melbourne, Parkville, VIC, Australia.
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21
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Ritter N, Peeken L, Schultz ES, Debus D. Die Systemtherapie des malignen Melanoms. AKTUELLE DERMATOLOGIE 2022. [DOI: 10.1055/a-1700-9298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungIn den vergangenen 10 Jahren wurde die Systemtherapie des malignen Melanoms durch die Zulassung neuer Substanzen revolutioniert. In der vorliegenden Übersicht werden zunächst die aktuellen adjuvanten Therapiemöglichkeiten beschrieben, anschließend werden der Kenntnisstand zur neoadjuvanten Therapie dargestellt und schließlich die Behandlungsoptionen im inoperablen Stadium beleuchtet.
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Affiliation(s)
- Nathalie Ritter
- Klinikum Nürnberg, Hautklinik, Universitätsklinik für Dermatologie der Paracelsus Medizinischen Privatuniversität, Nürnberg
| | - Lucia Peeken
- Klinikum Nürnberg, Hautklinik, Universitätsklinik für Dermatologie der Paracelsus Medizinischen Privatuniversität, Nürnberg
| | - Erwin S. Schultz
- Klinikum Nürnberg, Hautklinik, Universitätsklinik für Dermatologie der Paracelsus Medizinischen Privatuniversität, Nürnberg
| | - Dirk Debus
- Klinikum Nürnberg, Hautklinik, Universitätsklinik für Dermatologie der Paracelsus Medizinischen Privatuniversität, Nürnberg
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22
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Kartolo A, Deluce J, Hopman WM, Liu L, Baetz T, Ernst S, Lenehan JG. Real-World Evidence of Systemic Therapy Sequencing on Overall Survival for Patients with Metastatic BRAF-Mutated Cutaneous Melanoma. Curr Oncol 2022; 29:1501-1513. [PMID: 35323326 PMCID: PMC8947206 DOI: 10.3390/curroncol29030126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/09/2022] [Accepted: 02/23/2022] [Indexed: 11/18/2022] Open
Abstract
Aim: To evaluate optimal systemic therapy sequencing (first-line targeted therapy (1L-TT) vs. first-line immunotherapy (1L-IO)) in patients with BRAF-mutated metastatic melanoma. Methods: Nation-wide prospective data of patients with newly diagnosed BRAF-mutated metastatic melanoma were retrieved from the Canadian Melanoma Research Network. Results: Our study included 79 and 107 patients in the 1L-IO and 1L-TT groups, respectively. There were more patients with ECOG 0−1 (91% vs. 72%, p = 0.023) in the 1L-IO group compared to the 1L-TT group. Multivariable Cox analysis suggested no OS differences between the two groups (HR 0.838, 95%CI 0.502−1.400, p = 0.500). However, patients who received 1L-TT then 2L-IO had the longest OS compared to 1L-IO without 2L therapy, 1L-IO then 2L-TT, and 1L-TT without 2L therapy (38.3 vs. 32.2 vs. 16.9 vs. 6.3 months, p < 0.001). For patients who received 2L therapy, those who received 2L-IO had a trend towards OS improvement compared with the 2L-TT group (21.7 vs. 8.9 months, p = 0.053). Conclusions: Our nation-wide prospective study failed to establish any optimal systemic therapy sequencing in advanced BRAF-mutant melanoma patients. Nevertheless, we provided evidence that immunotherapy has durable efficacy in advanced BRAF-mutant melanoma patients, regardless of treatment line, and that Canadian medical oncologists were selecting the appropriate treatment sequences in a real-world setting, based on patients’ clinical and tumour characteristics.
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Affiliation(s)
- Adi Kartolo
- Department of Oncology, Queen’s University, Kingston, ON K7L 2V7, Canada; (A.K.); (T.B.)
| | - Jasna Deluce
- Department of Oncology, University of Western Ontario, London, ON N6A 5W9, Canada; (J.D.); (S.E.)
| | - Wilma M. Hopman
- Department of Public Health Sciences, Queen’s University, Kingston, ON K7L 2V7, Canada;
| | - Linda Liu
- Pulse Infoframe, London, ON N5X 4E7, Canada;
| | - Tara Baetz
- Department of Oncology, Queen’s University, Kingston, ON K7L 2V7, Canada; (A.K.); (T.B.)
| | - Scott Ernst
- Department of Oncology, University of Western Ontario, London, ON N6A 5W9, Canada; (J.D.); (S.E.)
| | - John G. Lenehan
- Department of Oncology, University of Western Ontario, London, ON N6A 5W9, Canada; (J.D.); (S.E.)
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23
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Adams R, Coumbe JEM, Coumbe BGT, Thomas J, Willsmore Z, Dimitrievska M, Yasuzawa-Parker M, Hoyle M, Ingar S, Geh J, MacKenzie Ross A, Healy C, Papa S, Lacy KE, Karagiannis SN. BRAF inhibitors and their immunological effects in malignant melanoma. Expert Rev Clin Immunol 2022; 18:347-362. [PMID: 35195495 DOI: 10.1080/1744666x.2022.2044796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The treatment of cutaneous melanoma has been revolutionised by the development of small molecule inhibitors targeting the MAPK pathway, including inhibitors of BRAF (BRAFi) and MEK (MEKi), and immune checkpoint blockade antibodies, occurring in tandem. Despite these advances, the 5-year survival rate for patients with advanced melanoma remains only around 50%. Although not designed to alter immune responses within the tumour microenvironment (TME), MAPK pathway inhibitors (MAPKi) exert a range of effects on the host immune compartment which may offer opportunities for therapeutic interventions. AREAS COVERED We review the effects of MAPKi especially BRAFi, on the TME, focussing on alterations in inflammatory cytokine secretion, the recruitment of immune cells and their functions, both during response to BRAFi treatment and as resistance develops. We outline potential combinations of MAPKi with established and experimental treatments. EXPERT OPINION MAPKi in combination or in sequence with established treatments such as checkpoint inhibitors, anti-angiogenic agents, or new therapies such as adoptive cell therapies, may augment their immunological effects, reverse tumour-associated immune suppression and offer the prospect of longer-lived clinical responses. Refining therapeutic tools at our disposal and embracing "old friends" in the melanoma treatment arsenal, alongside new target identification, may improve the chances of therapeutic success.
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Affiliation(s)
- Rebecca Adams
- St. John's Institute of Dermatology, School of Basic & Medical Biosciences, King's College London, Guy's Hospital, London SE1 9RT, United Kingdom
| | - Jack E M Coumbe
- St. John's Institute of Dermatology, School of Basic & Medical Biosciences, King's College London, Guy's Hospital, London SE1 9RT, United Kingdom
| | - Ben G T Coumbe
- St. John's Institute of Dermatology, School of Basic & Medical Biosciences, King's College London, Guy's Hospital, London SE1 9RT, United Kingdom
| | - Jennifer Thomas
- The Royal Marsden, Downs Road, Sutton, Surrey, United Kingdom
| | - Zena Willsmore
- St. John's Institute of Dermatology, School of Basic & Medical Biosciences, King's College London, Guy's Hospital, London SE1 9RT, United Kingdom
| | - Marija Dimitrievska
- St. John's Institute of Dermatology, School of Basic & Medical Biosciences, King's College London, Guy's Hospital, London SE1 9RT, United Kingdom
| | - Monica Yasuzawa-Parker
- St. John's Institute of Dermatology, School of Basic & Medical Biosciences, King's College London, Guy's Hospital, London SE1 9RT, United Kingdom
| | - Maximilian Hoyle
- St. John's Institute of Dermatology, School of Basic & Medical Biosciences, King's College London, Guy's Hospital, London SE1 9RT, United Kingdom
| | - Suhaylah Ingar
- St. John's Institute of Dermatology, School of Basic & Medical Biosciences, King's College London, Guy's Hospital, London SE1 9RT, United Kingdom
| | - Jenny Geh
- Department of Plastic Surgery at Guy's, King's, and St. Thomas' Hospitals, London, United Kingdom
| | - Alastair MacKenzie Ross
- Department of Plastic Surgery at Guy's, King's, and St. Thomas' Hospitals, London, United Kingdom
| | - Ciaran Healy
- Department of Plastic Surgery at Guy's, King's, and St. Thomas' Hospitals, London, United Kingdom
| | - Sophie Papa
- Department of Medical Oncology, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.,ImmunoEngineering, School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Katie E Lacy
- St. John's Institute of Dermatology, School of Basic & Medical Biosciences, King's College London, Guy's Hospital, London SE1 9RT, United Kingdom
| | - Sophia N Karagiannis
- St. John's Institute of Dermatology, School of Basic & Medical Biosciences, King's College London, Guy's Hospital, London SE1 9RT, United Kingdom.,Breast Cancer Now Research Unit, School of Cancer & Pharmaceutical Sciences, King's College London, Guy's Cancer Centre, London SE1 9RT, United Kingdom
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Biomarkers of treatment benefit with atezolizumab plus vemurafenib plus cobimetinib in BRAFV600 mutation–positive melanoma. Ann Oncol 2022; 33:544-555. [DOI: 10.1016/j.annonc.2022.01.076] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 01/20/2022] [Accepted: 01/25/2022] [Indexed: 01/01/2023] Open
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Dummer R, Long GV, Robert C, Tawbi HA, Flaherty KT, Ascierto PA, Nathan PD, Rutkowski P, Leonov O, Dutriaux C, Mandalà M, Lorigan P, Ferrucci PF, Grob JJ, Meyer N, Gogas H, Stroyakovskiy D, Arance A, Brase JC, Green S, Haas T, Masood A, Gasal E, Ribas A, Schadendorf D. Randomized Phase III Trial Evaluating Spartalizumab Plus Dabrafenib and Trametinib for BRAF V600-Mutant Unresectable or Metastatic Melanoma. J Clin Oncol 2022; 40:1428-1438. [PMID: 35030011 PMCID: PMC9061149 DOI: 10.1200/jco.21.01601] [Citation(s) in RCA: 73] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
PURPOSE Preclinical data suggest the combination of an anti-programmed death receptor 1 antibody plus dabrafenib and trametinib to have superior antitumor activity compared with dabrafenib plus trametinib alone. These observations are supported by translational evidence suggesting that immune checkpoint inhibitors plus targeted therapy may improve treatment outcomes in patients with BRAF V600-mutant metastatic melanoma. COMBI-i is a phase III trial evaluating spartalizumab, an anti-programmed death receptor 1 antibody, in combination with dabrafenib and trametinib (sparta-DabTram), versus placebo plus dabrafenib and trametinib (placebo-DabTram) in patients with BRAF V600-mutant unresectable or metastatic melanoma. METHODS Patients received spartalizumab 400 mg intravenously every 4 weeks plus dabrafenib 150 mg orally twice daily and trametinib 2 mg orally once daily or placebo-DabTram. Participants were age ≥ 18 years with unresectable or metastatic BRAF V600-mutant melanoma. The primary end point was investigator-assessed progression-free survival. Overall survival was a key secondary end point (ClinicalTrials.gov identifier: NCT02967692). RESULTS At data cutoff (July 1, 2020), the median progression-free survival was 16.2 months (95% CI, 12.7 to 23.9 months) in the sparta-DabTram arm versus 12.0 months (95% CI, 10.2 to 15.4 months) in the placebo-DabTram arm (hazard ratio, 0.82 [95% CI, 0.66 to 1.03]; P = .042 [one-sided; nonsignificant]). The objective response rates were 69% (183 of 267 patients) versus 64% (170 of 265 patients), respectively. Grade ≥ 3 treatment-related adverse events occurred in 55% (146 of 267) of patients in the sparta-DabTram arm and 33% (88 of 264) in the placebo-DabTram arm. CONCLUSION The study did not meet its primary end point; broad first-line use of sparta-DabTram is not supported by these results. Further biomarker-driven investigation may identify patient subpopulations who could benefit from checkpoint inhibitor plus targeted therapy combinations.
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Affiliation(s)
- Reinhard Dummer
- University Hospital Zürich Skin Cancer Center, Zürich, Switzerland
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, and Royal North Shore and Mater Hospitals, Sydney, New South Wales, Australia
| | - Caroline Robert
- Gustave Roussy, Villejuif, and Paris-Saclay University, Orsay, France
| | - Hussein A Tawbi
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Keith T Flaherty
- Dana-Farber Cancer Institute/Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - Paolo A Ascierto
- Istituto Nazionale Tumori, IRCCS, Fondazione "G. Pascale," Naples, Italy
| | - Paul D Nathan
- Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Piotr Rutkowski
- Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Oleg Leonov
- Clinical Oncological Dispensary, Omsk, Russia
| | - Caroline Dutriaux
- Centre Hospitalier Universitaire de Bordeaux, Hôpital Saint-André, Bordeaux, France
| | - Mario Mandalà
- Unit of Medical Oncology, University of Perugia, Perugia, Italy.,Unit of Medical Oncology, Papa Giovanni XXIII Cancer Center Hospital, Bergamo, Italy
| | - Paul Lorigan
- University of Manchester and The Christie NHS Foundation Trust, Manchester, United Kingdom
| | | | - Jean Jacques Grob
- Timone Hospital AP-HM and Aix-Marseille University, Marseille, France
| | - Nicolas Meyer
- Université Toulouse III-Paul Sabatier, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1037-CRCT, Toulouse, France
| | - Helen Gogas
- Laiko General Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | | | - Ana Arance
- Hospital Clinic of Barcelona, Barcelona, Spain
| | | | | | | | - Aisha Masood
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | - Eduard Gasal
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | - Antoni Ribas
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, CA
| | - Dirk Schadendorf
- University Hospital Essen, Essen, and German Cancer Consortium, Heidelberg, Germany
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Wang J, Tawbi HA. Emergent immunotherapy approaches for brain metastases. Neurooncol Adv 2021; 3:v43-v51. [PMID: 34859232 PMCID: PMC8633738 DOI: 10.1093/noajnl/vdab138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Brain metastases from solid tumors are increasing in incidence, especially as outcomes of systemic therapies continue to extend patients’ overall survival. The long-held notion that the brain is an immune sanctuary has now been largely refuted with increasing evidence that immunotherapy can induce durable responses in brain metastases. Single agent immune checkpoint inhibition with anti-CTLA4 and anti-PD1 antibodies induces durable responses in 15%–20% in melanoma brain metastases as long as patients are asymptomatic and do not require corticosteroids. The combination of anti-CTLA4 with anti-PD-1 antibodies induces an intracranial response in over 50% of asymptomatic melanoma patients, and much lower rate of otherwise durable responses (20%) in symptomatic patients or those on steroids. Data in other cancers, such as renal cell carcinoma, are accumulating indicating a role for immunotherapy. Emerging immunotherapy approaches will have to focus on increasing response rates, decreasing toxicity, and decreasing steroid dependency. The path to those advances will have to include a better understanding of the mechanisms of response and resistance to immunotherapy in brain metastases, the use of novel agents such as anti-LAG3 checkpoint inhibitors, targeted therapy (oncogene directed or TKIs), and possibly surgery and SRS to improve the outcomes of patients with brain metastases.
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Affiliation(s)
- Jianbo Wang
- Department of Genitourinary Malignancies, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Hussein A Tawbi
- Department of Melanoma Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
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Ferrucci PF, Lens M, Cocorocchio E. Combined BRAF-Targeted Therapy with Immunotherapy in BRAF-Mutated Advanced Melanoma Patients. Curr Oncol Rep 2021; 23:138. [PMID: 34735635 DOI: 10.1007/s11912-021-01134-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2021] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW To review evidence on the efficacy and safety of combined BRAF-targeted therapy and immune checkpoint inhibitors in patients with BRAF-mutated metastatic melanoma. RECENT FINDINGS Programmed death-1 pathway inhibitors administered with BRAF/MEK inhibitors showed promising anti-tumour activity in BRAF-mutated advanced melanoma and were investigated for safety and efficacy in three large international clinical trials. Although, in two out of those three randomized phase III studies, progression-free survival (PFS) did not reach statistical significance, results showed that duration of response (DOR) and overall survival (OS) were improved using combined therapy, sustaining the scientific rationale for its use at least in a subset of metastatic melanomas. However, the frequent occurrence of autoimmunity-induced toxicities should be considered since it is limiting the continuity and the wide application of these regimens. Novel treatment modalities combining targeted therapy with checkpoint inhibitors require further clinical investigation and elucidation of their effect on the immune system and cancer cell modulation.
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Affiliation(s)
- Pier Francesco Ferrucci
- Tumor Biotherapy Unit, Department of Experimental Oncology, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141, Milan, Italy.
| | | | - Emilia Cocorocchio
- Department of Hemato-Oncology, European Institute of Oncology IRCCS, Milan, Italy
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Katsandris A, Ziogas DC, Kontouri M, Staikoglou S, Gogas H. Atezolizumab plus vemurafenib and cobimetinib for the treatment of BRAF V600-mutant advanced melanoma: from an hypothetic triplet to an approved regimen. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2021. [DOI: 10.1080/23808993.2021.1976637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Aikaterini Katsandris
- First Department of Medicine, National and Kapodistrian University of Athens, School of Medicine, Laiko General Hospital, Athens, Greece
| | - Dimitrios C. Ziogas
- First Department of Medicine, National and Kapodistrian University of Athens, School of Medicine, Laiko General Hospital, Athens, Greece
| | - Maria Kontouri
- First Department of Medicine, National and Kapodistrian University of Athens, School of Medicine, Laiko General Hospital, Athens, Greece
| | - Stavroula Staikoglou
- First Department of Medicine, National and Kapodistrian University of Athens, School of Medicine, Laiko General Hospital, Athens, Greece
| | - Helen Gogas
- First Department of Medicine, National and Kapodistrian University of Athens, School of Medicine, Laiko General Hospital, Athens, Greece
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Ferrucci PF, Di Giacomo AM, Del Vecchio M, Atkinson V, Schmidt H, Schachter J, Queirolo P, Long GV, Stephens R, Svane IM, Lotem M, Abu-Amna M, Gasal E, Ghori R, Diede SJ, Croydon ES, Ribas A, Ascierto PA. KEYNOTE-022 part 3: a randomized, double-blind, phase 2 study of pembrolizumab, dabrafenib, and trametinib in BRAF-mutant melanoma. J Immunother Cancer 2021; 8:jitc-2020-001806. [PMID: 33361337 PMCID: PMC7768966 DOI: 10.1136/jitc-2020-001806] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 12/13/2022] Open
Abstract
Background In the KEYNOTE-022 study, pembrolizumab with dabrafenib and trametinib (triplet) improved progression-free survival (PFS) versus placebo with dabrafenib and trametinib (doublet) without reaching statistical significance. Mature results on PFS, duration of response (DOR), and overall survival (OS) are reported. Methods The double-blind, phase 2 part of KEYNOTE-022 enrolled patients with previously untreated BRAFV600E/K-mutated advanced melanoma from 22 sites in seven countries. Patients were randomly assigned 1:1 to intravenous pembrolizumab (200 mg every 3 weeks) or placebo plus dabrafenib (150 mg orally two times per day) and trametinib (2 mg orally one time a day). Primary endpoint was PFS. Secondary endpoints were objective response rate, DOR, and OS. Efficacy was assessed in the intention-to-treat population, and safety was assessed in all patients who received at least one dose of study drug. This analysis was not specified in the protocol. Results Between November 30, 2015 and April 24, 2017, 120 patients were randomly assigned to triplet (n=60) or doublet (n=60) therapy. With 36.6 months of follow-up, median PFS was 16.9 months (95% CI 11.3 to 27.9) with triplet and 10.7 months (95% CI 7.2 to 16.8) with doublet (HR 0.53; 95% CI 0.34 to 0.83). With triplet and doublet, respectively, PFS at 24 months was 41.0% (95% CI 27.4% to 54.2%) and 16.3% (95% CI 8.1% to 27.1%); median DOR was 25.1 months (95% CI 14.1 to not reached) and 12.1 months (95% CI 6.0 to 15.7), respectively. Median OS was not reached with triplet and was 26.3 months with doublet (HR 0.64; 95% CI 0.38 to 1.06). With triplet and doublet, respectively, OS at 24 months was 63.0% (95% CI 49.4% to 73.9%) and 51.7% (95% CI 38.4% to 63.4%). Grade 3–5 treatment-related adverse events (TRAEs) occurred in 35 patients (58%, including one death) receiving triplet and 15 patients (25%) receiving doublet. Conclusion In BRAFV600E/K-mutant advanced melanoma, pembrolizumab plus dabrafenib and trametinib substantially improved PFS, DOR, and OS with a higher incidence of TRAEs. Interpretation of these results is limited by the post hoc nature of the analysis.
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Affiliation(s)
- Pier Francesco Ferrucci
- Cancer Biotherapy Unit, Department of Experimental Oncology, European Institute of Oncology IRCCS, Milan, Italy
| | - Anna Maria Di Giacomo
- Center for Immuno-Oncology, University Hospital of Siena; University of Siena, Siena, Italy
| | - Michele Del Vecchio
- Unit of Melanoma Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Victoria Atkinson
- University of Queensland, and Gallipoli Medical Research Foundation, Greenslopes Private Hospital, Woolloongabba, Queensland, Australia
| | - Henrik Schmidt
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jacob Schachter
- Division of Oncology, Sheba Medical Centre, Tel HaShomer Hospital, Tel Aviv, Israel
| | - Paola Queirolo
- Divisione di Oncologia Medica del Melanoma, Sarcoma e Tumori Rari, European Institute of Oncology IRCCS, Milan, Italy
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, and Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Medical Oncology and Translational Research, Mater Hospital, North Sydney, New South Wales, Australia
| | | | - Inge Marie Svane
- Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - Michal Lotem
- Sharett Institute of Oncology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | - Eduard Gasal
- Global Drug Development, Oncology, Novartis, East Hanover, New Jersey, USA
| | - Razi Ghori
- Department of Clinical Oncology, Merck & Co Inc, Kenilworth, New Jersey, USA
| | - Scott J Diede
- Department of Clinical Oncology, Merck & Co Inc, Kenilworth, New Jersey, USA
| | - Elizabeth S Croydon
- Department of Clinical Oncology, Merck & Co Inc, Kenilworth, New Jersey, USA
| | - Antoni Ribas
- Department of Medicine, University of California Los Angeles and the Jonsson Comprehensive Cancer Center, Los Angeles, California, USA
| | - Paolo Antonio Ascierto
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori IRCCS Fondazione "G. Pascale", Naples, Italy
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Mao L, Ding Y, Bai X, Sheng X, Dai J, Chi Z, Cui C, Kong Y, Fan Y, Xu Y, Wang X, Tang B, Lian B, Yan X, Li S, Zhou L, Wei X, Li C, Guo J, Zhang X, Si L. Overall Survival of Patients With Unresectable or Metastatic BRAF V600-Mutant Acral/Cutaneous Melanoma Administered Dabrafenib Plus Trametinib: Long-Term Follow-Up of a Multicenter, Single-Arm Phase IIa Trial. Front Oncol 2021; 11:720044. [PMID: 34504796 PMCID: PMC8422804 DOI: 10.3389/fonc.2021.720044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/03/2021] [Indexed: 01/22/2023] Open
Abstract
Objectives To examine the long-term survival outcome of dabrafenib in combination with trametinib in Chinese patients with unresectable or metastatic acral/cutaneous melanoma with BRAF-V600 mutation and to explore potential predictors of effectiveness. Methods This was a long-term follow-up of Chinese patients with unresectable or metastatic BRAF V600-mutant acral/cutaneous melanoma administered dabrafenib (150 mg twice daily) plus trametinib (2 mg once daily) in an open-label, multicenter, single-arm, phase IIa study (NCT02083354). Efficacy endpoints included objective response rate (ORR), duration of response (DOR), progression-free survival (PFS), and overall survival (OS). The impacts of baseline characteristics on PFS and OS were analyzed. Results A total of sixty patients were included. The median age was 48 years, and 24 patients (40.0%) were male. Totally 12 individuals (20.0%) had acral melanoma, and 45 (75.0%) had failed previous systemic therapy. Up to July 2020, the median duration of follow-up was 37.0 (95% confidence interval [CI] 29.1-44.9) months. The updated ORR was 71.7% (95%CI 60.3%-83.1%). The 3-year OS rate was 28.8% (95%CI 19.1-43.6%) in the overall population, and 35.7% (95%CI 15.5–82.4%) in acral melanoma patients. The median DOR was 7.5 months (95%CI 4.5 to 10.5). Baseline normal lactic dehydrogenase (LDH), metastatic organ sites<3 and complete response to combination therapy with dabrafenib plus trametinib were associated with improved PFS and OS. Conclusion Dabrafenib combined with trametinib confer long-term survival in Chinese patients with BRAF V600-mutant, unresectable or metastatic acral/cutaneous melanoma. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT02083354, identifier NCT02083354.
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Affiliation(s)
- Lili Mao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Melanoma, Peking University Cancer Hospital & Institute, Beijing, China
| | - Ya Ding
- Department of Biotherapy, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Xue Bai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Melanoma, Peking University Cancer Hospital & Institute, Beijing, China
| | - Xinan Sheng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Genitourinary Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Jie Dai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Melanoma, Peking University Cancer Hospital & Institute, Beijing, China
| | - Zhihong Chi
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Melanoma, Peking University Cancer Hospital & Institute, Beijing, China
| | - Chuanliang Cui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Melanoma, Peking University Cancer Hospital & Institute, Beijing, China
| | - Yan Kong
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Melanoma, Peking University Cancer Hospital & Institute, Beijing, China
| | - Yun Fan
- Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Yanjun Xu
- Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Xuan Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Melanoma, Peking University Cancer Hospital & Institute, Beijing, China
| | - Bixia Tang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Melanoma, Peking University Cancer Hospital & Institute, Beijing, China
| | - Bin Lian
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Melanoma, Peking University Cancer Hospital & Institute, Beijing, China
| | - Xieqiao Yan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Genitourinary Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Siming Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Genitourinary Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Li Zhou
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Genitourinary Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Xiaoting Wei
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Melanoma, Peking University Cancer Hospital & Institute, Beijing, China
| | - Caili Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Melanoma, Peking University Cancer Hospital & Institute, Beijing, China
| | - Jun Guo
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Melanoma, Peking University Cancer Hospital & Institute, Beijing, China
| | - Xiaoshi Zhang
- Department of Biotherapy, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Lu Si
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Melanoma, Peking University Cancer Hospital & Institute, Beijing, China
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Carlino MS, Larkin J, Long GV. Immune checkpoint inhibitors in melanoma. Lancet 2021; 398:1002-1014. [PMID: 34509219 DOI: 10.1016/s0140-6736(21)01206-x] [Citation(s) in RCA: 434] [Impact Index Per Article: 144.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/30/2021] [Accepted: 05/19/2021] [Indexed: 12/14/2022]
Abstract
Immune checkpoint inhibitors target the dysfunctional immune system, to induce cancer-cell killing by CD8-positive T cells. Immune checkpoint inhibitors, specifically anti-CTLA4 and anti-PD-1 antibodies, have revolutionised the management of many cancers, particularly advanced melanoma, for which tumour regression and long-term durable cancer control is possible in nearly 50% of patients, compared with less than 10% historically. Despite the absence of adequately powered trial data, combined anti-CTLA4 and anti-PD-1 checkpoint inhibition has the highest 5-year overall survival rate of all therapies in advanced melanoma, and has high activity in melanoma brain metastases. A phase 3 study has shown the addition of an anti-LAG3 antibody to nivolumab improves progression-free survival, but its effect on overall survival and how this combination compares to combined anti-CTLA4 and anti-PD-1 checkpoint inhibition is unknown. At present, there are no highly sensitive and specific biomarkers of response to immune checkpoint inhibitors, and clinical factors, such as volume and sites of disease, serum lactate dehydrogenase, and BRAF mutation status, are used to select initial therapy for patients with advanced melanoma. Immune checkpoint inhibitors can induce autoimmune toxicities by virtue of their mechanism of action. These toxicities, termed immune-related adverse events, occur most frequently with combined anti-CTLA4 and anti-PD-1 checkpoint inhibition; can have a variety of presentations; can affect any organ system (most often the skin, colon, endocrine system, and liver); and appear to mimic classic autoimmune diseases. Immune-related adverse events require prompt recognition and management, which may be different from the autoimmune disease it mimics. Immune checkpoint inhibitors appear to be safe for use in patients with HIV, viral hepatitis, and patients with mild-to-moderate pre-existing autoimmune diseases. Patients with organ transplants can respond to immune checkpoint inhibitors but have a high chance of transplant loss. PD-1 inhibitors are now an established standard of care as adjuvant therapy in high-risk resected stage III or IV melanoma. Neoadjuvant checkpoint inhibition for resectable stage III melanoma, which is currently limited to clinical trials, is emerging as a highly effective therapy.
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Affiliation(s)
- Matteo S Carlino
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Department of Medical Oncology Blacktown and Westmead Hospitals, Sydney, NSW, Australia
| | - James Larkin
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Royal North Shore and Mater Hospitals, North Sydney, Sydney, NSW, Australia.
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Giugliano F, Crimini E, Tarantino P, Zagami P, Uliano J, Corti C, Trapani D, Curigliano G, Ascierto PA. First line treatment of BRAF mutated advanced melanoma: Does one size fit all? Cancer Treat Rev 2021; 99:102253. [PMID: 34186441 DOI: 10.1016/j.ctrv.2021.102253] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 06/13/2021] [Accepted: 06/16/2021] [Indexed: 02/07/2023]
Abstract
In the last decade, immunotherapy and target therapy have revolutionized the prognosis of patients with BRAF-V600 mutation-positive metastatic melanoma. To date, three different combinations of BRAF/MEK inhibitors have been approved for this population, showing comparable efficacy and unique toxicity profiles. Several immune-checkpoint inhibitors, including pembrolizumab, nivolumab and the combination of nivolumab plus ipilimumab, are also available options for untreated metastatic melanoma patients. A novel approach has emerged by combining immune-checkpoint inhibitors and targeted agents, based on preclinical hints of synergy, prompting clinical results from large randomized trials. Specifically, the triplet of atezolizumab, vemurafenib and cobimetinib has been recently approved by FDA for patients with untreated BRAF-mutant metastatic melanoma. With a wide variety of available treatment options in this setting, it is paramount to establish criteria to select the most effective and safe frontline tailored approaches, for each patient. Results from ongoing studies are awaited, to maximise the benefits in survival outcomes and quality of life for patients, balancing adverse events and clinical benefit. The purpose of this review is to summarize the current landscape of standard and experimental treatment strategies for the first line treatment of patients with BRAF-mutated advanced melanoma and discuss the best patient-centered tailored strategies in the first-line setting.
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Affiliation(s)
- Federica Giugliano
- European Institute of Oncology, IRCCS, 20141 Milan, Italy; Department of Oncology and Hematology (DIPO), University of Milan, 20122 Milan, Italy
| | - Edoardo Crimini
- European Institute of Oncology, IRCCS, 20141 Milan, Italy; Department of Oncology and Hematology (DIPO), University of Milan, 20122 Milan, Italy
| | - Paolo Tarantino
- European Institute of Oncology, IRCCS, 20141 Milan, Italy; Department of Oncology and Hematology (DIPO), University of Milan, 20122 Milan, Italy
| | - Paola Zagami
- European Institute of Oncology, IRCCS, 20141 Milan, Italy; Department of Oncology and Hematology (DIPO), University of Milan, 20122 Milan, Italy
| | - Jacopo Uliano
- European Institute of Oncology, IRCCS, 20141 Milan, Italy; Department of Oncology and Hematology (DIPO), University of Milan, 20122 Milan, Italy
| | - Chiara Corti
- European Institute of Oncology, IRCCS, 20141 Milan, Italy; Department of Oncology and Hematology (DIPO), University of Milan, 20122 Milan, Italy
| | - Dario Trapani
- European Institute of Oncology, IRCCS, 20141 Milan, Italy
| | - Giuseppe Curigliano
- European Institute of Oncology, IRCCS, 20141 Milan, Italy; Department of Oncology and Hematology (DIPO), University of Milan, 20122 Milan, Italy.
| | - Paolo A Ascierto
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
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Liu Y, Zhang X, Wang G, Cui X. Triple Combination Therapy With PD-1/PD-L1, BRAF, and MEK Inhibitor for Stage III-IV Melanoma: A Systematic Review and Meta-Analysis. Front Oncol 2021; 11:693655. [PMID: 34195094 PMCID: PMC8236832 DOI: 10.3389/fonc.2021.693655] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 05/17/2021] [Indexed: 12/14/2022] Open
Abstract
Triple combination of anti-PD-1/PD-L1 immunotherapy and anti-BRAF plus anti-MEK targeted therapy is a promising antitumor strategy and is increasingly being used in clinical trials. To evaluate the safety and efficacy of triple combination of PD-1/PD-L1, BRAF, and MEK inhibition in patients diagnosed with stage III-IV melanoma, we performed a systematic review and meta-analysis of randomized controlled trials (RCTs). The PubMed, EMBASE, and Cochrane Library were searched for all studies published from inception to January 2021. The progression free survival (PFS), overall survival (OS), overall response rate (ORR), and risk of adverse events (AEs) were extracted by two independent investigators and pooled hazard ratio (HR) or risk ratio (RR) with 95% CI were determined using the random-effects model for data synthesis. Overall, five randomized controlled trials encompassing 1,266 patients with stage III-IV melanoma were selected. Triple combination therapy significantly improved PFS (HR = 0.71; 95% CI = 0.59 to 0.86; P = 0.0005) and 2-year OS (RR = 1.12; 95% CI = 1.03 to 1.23; P = 0.01), but had no impact on ORR (RR = 1.09; 95% CI = 0.91 to 1.30; P = 0.37) when compared with controlled treatment group. In addition, triple combination therapy was associated with increased risks of hypothyroidism, arthralgia, myalgia, ALT increased, AST increased, asthenia, and pyrexia compared with control group. Triple combination therapy of PD-1/PD-L1, BRAF, and MEK inhibition achieved better survival benefits but had higher incidence of some adverse events over two-drug combination or monotherapy. Further randomized controlled clinical trials are needed to verify our results.
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Affiliation(s)
- Ye Liu
- School of Pharmaceutical Sciences, Tsinghua University, Beijing, China
| | - Xilan Zhang
- Department of Pathology, The Second People's Hospital of Dongying, Dongying, China
| | - Guoying Wang
- Department of Oncology, The Second People's Hospital of Dongying, Dongying, China
| | - Xinchang Cui
- Department of Oncology, The Second People's Hospital of Dongying, Dongying, China
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Trojaniello C, Luke JJ, Ascierto PA. Therapeutic Advancements Across Clinical Stages in Melanoma, With a Focus on Targeted Immunotherapy. Front Oncol 2021; 11:670726. [PMID: 34178657 PMCID: PMC8222774 DOI: 10.3389/fonc.2021.670726] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/10/2021] [Indexed: 12/31/2022] Open
Abstract
Melanoma is the most fatal skin cancer. In the early stages, it can be safely treated with surgery alone. However, since 2011, there has been an important revolution in the treatment of melanoma with new effective treatments. Targeted therapy and immunotherapy with checkpoint inhibitors have changed the history of this disease. To date, more than half of advanced melanoma patients are alive at 5 years; despite this breakthrough, approximately half of the patients still do not respond to treatment. For these reasons, new therapeutic strategies are required to expand the number of patients who can benefit from immunotherapy or combination with targeted therapy. Current research aims at preventing primary and acquired resistance, which are both responsible for treatment failure in about 50% of patients. This could increase the effectiveness of available drugs and allow for the evaluation of new combinations and new targets. The main pathways and molecules under study are the IDO inhibitor, TLR9 agonist, STING, LAG-3, TIM-3, HDAC inhibitors, pegylated IL-2 (NKTR-214), GITR, and adenosine pathway inhibitors, among others (there are currently about 3000 trials that are evaluating immunotherapeutic combinations in different tumors). Other promising strategies are cancer vaccines and oncolytic viruses. Another approach is to isolate and remove immune cells (DCs, T cells, and NK cells) from the patient's blood or tumor infiltrates, add specific gene fragments, expand them in culture with growth factors, and re-inoculate into the same patient. TILs, TCR gene transfer, and CAR-T therapy follow this approach. In this article, we give an overview over the current status of melanoma therapies, the clinical rationale for choosing treatments, and the new immunotherapy approaches.
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Affiliation(s)
- Claudia Trojaniello
- Unit of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy
| | - Jason J. Luke
- Cancer Immunotherapeutics Center, University of Pittsburgh Medical Center and Hillman Cancer Center, Pittsburgh, PA, United States
| | - Paolo A. Ascierto
- Unit of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy
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Krishnan T, Menzies AM, Roberts-Thomson R. Recent advancements in melanoma management. Intern Med J 2021; 51:327-333. [PMID: 33738950 DOI: 10.1111/imj.15228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/11/2020] [Accepted: 11/11/2020] [Indexed: 01/11/2023]
Abstract
The treatment options for patients with melanoma have expanded significantly over the past decade. In particular, the use of targeted therapy and immunotherapy has dramatically transformed the outlook for patients with advanced disease. These treatments are now being utilised as adjuvant therapy for patients with earlier stage melanoma after surgical resection. We review the latest updates for melanoma staging, surgical resection, radiotherapy and systemic therapies.
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Affiliation(s)
- Tharani Krishnan
- Medical Oncology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Alexander M Menzies
- Medical Oncology Department, Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia.,Medical Oncology Department, Royal North Shore and Mater Hospitals, Sydney, New South Wales, Australia
| | - Rachel Roberts-Thomson
- Medical Oncology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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Lelliott EJ, McArthur GA, Oliaro J, Sheppard KE. Immunomodulatory Effects of BRAF, MEK, and CDK4/6 Inhibitors: Implications for Combining Targeted Therapy and Immune Checkpoint Blockade for the Treatment of Melanoma. Front Immunol 2021; 12:661737. [PMID: 34025662 PMCID: PMC8137893 DOI: 10.3389/fimmu.2021.661737] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 04/12/2021] [Indexed: 12/12/2022] Open
Abstract
The recent advent of targeted and immune-based therapies has revolutionized the treatment of melanoma and transformed outcomes for patients with metastatic disease. The majority of patients develop resistance to the current standard-of-care targeted therapy, dual BRAF and MEK inhibition, prompting evaluation of a new combination incorporating a CDK4/6 inhibitor. Based on promising preclinical data, combined BRAF, MEK and CDK4/6 inhibition has recently entered clinical trials for the treatment of BRAFV600 melanoma. Interestingly, while BRAF- and MEK-targeted therapy was initially developed on the basis of potent tumor-intrinsic effects, it was later discovered to have significant immune-potentiating activity. Recent studies have also identified immune-related impacts of CDK4/6 inhibition, though these are less well defined and can be both immune-potentiating and immune-inhibitory. BRAFV600 melanoma patients are also eligible to receive immunotherapy, specifically checkpoint inhibitors against PD-1 and CTLA-4. The immunomodulatory activity of BRAF/MEK-targeted therapies has prompted interest in combination therapies incorporating these with immune checkpoint inhibitors, however recent clinical trials investigating this approach have produced variable results. Here, we summarize the immunomodulatory effects of BRAF, MEK and CDK4/6 inhibitors, shedding light on the prospective utility of this combination alone and in conjunction with immune checkpoint blockade. Understanding the mechanisms that underpin the clinical efficacy of these available therapies is a critical step forward in optimizing novel combination and scheduling approaches to combat melanoma and improve patient outcomes.
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Affiliation(s)
- Emily J Lelliott
- Cancer Research Division, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
| | - Grant A McArthur
- Cancer Research Division, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
| | - Jane Oliaro
- Cancer Research Division, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia.,Department of Immunology, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Karen E Sheppard
- Cancer Research Division, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia.,Department of Biochemistry and Pharmacology, University of Melbourne, Parkville, VIC, Australia
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Ziogas DC, Konstantinou F, Bouros S, Theochari M, Gogas H. Combining BRAF/MEK Inhibitors with Immunotherapy in the Treatment of Metastatic Melanoma. Am J Clin Dermatol 2021; 22:301-314. [PMID: 33765322 DOI: 10.1007/s40257-021-00593-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 12/11/2022]
Abstract
The management and prognosis of BRAF-mutant metastatic melanoma have changed drastically following the introduction of immune checkpoint inhibitors and molecularly targeted agents. These treatment options present different mechanisms of action and toxicities but also totally distinct kinetics of their response, including a "relatively" short-lasting benefit in subsets of patients treated with BRAF/MEK inhibitors and a lower response rate in patients treated with immune checkpoint inhibitors. BRAF/MEK inhibitors, when administered prior to or concurrently with immune checkpoint inhibitors, at least transiently alter some immunosuppressive parameters of the tumor microenvironment and theoretically improve sensitivity to immunotherapy. Preclinical data from mouse models with oncogene-addicted melanoma confirmed this beneficial immune/targeted synergy and supported the clinical testing of combinations of BRAF/MEK inhibitors and immune checkpoint inhibitors to improve the activity of upfront anti-melanoma therapies. The first positive phase III results were published in 2020, and triggered the discussion about the benefits, the limitations, as well as the possible implications of combining or sequencing targeted therapies with immune checkpoint inhibitors in everyday practice. Beginning from the interplay of immune/targeted agents within the melanoma microenvironment, this review outlines available information from the retrospective experience up to the late-stage randomized evidence on combinatorial treatments. Many clinical trials are currently underway exploring open questions about optimal timing, new immune biomarkers, and eligible patient subsets for these immune/targeted regimens. Awaiting these results, decision making in the first-line setting for BRAF-mutant melanoma is still guided by the patients' characteristics and the biological aspects of melanoma.
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Affiliation(s)
- Dimitrios C Ziogas
- School of Medicine, First Department of Medicine, National and Kapodistrian University of Athens, Laiko General Hospital, 75, Mikras Asias str., Goudi, 11527, Athens, Greece
| | - Frosso Konstantinou
- School of Medicine, First Department of Medicine, National and Kapodistrian University of Athens, Laiko General Hospital, 75, Mikras Asias str., Goudi, 11527, Athens, Greece
| | - Spyros Bouros
- School of Medicine, First Department of Medicine, National and Kapodistrian University of Athens, Laiko General Hospital, 75, Mikras Asias str., Goudi, 11527, Athens, Greece
| | - Maria Theochari
- School of Medicine, First Department of Medicine, National and Kapodistrian University of Athens, Laiko General Hospital, 75, Mikras Asias str., Goudi, 11527, Athens, Greece
| | - Helen Gogas
- School of Medicine, First Department of Medicine, National and Kapodistrian University of Athens, Laiko General Hospital, 75, Mikras Asias str., Goudi, 11527, Athens, Greece.
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Wiesweg M, Preuß C, Roeper J, Metzenmacher M, Eberhardt W, Stropiep U, Wedeken K, Reis H, Herold T, Darwiche K, Aigner C, Stuschke M, Schildhaus HU, Schmid KW, Falk M, Heukamp L, Tiemann M, Griesinger F, Schuler M. BRAF mutations and BRAF mutation functional class have no negative impact on the clinical outcome of advanced NSCLC and associate with susceptibility to immunotherapy. Eur J Cancer 2021; 149:211-221. [PMID: 33872981 DOI: 10.1016/j.ejca.2021.02.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/17/2021] [Accepted: 02/22/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE BRAF mutations have been subtyped in three functional classes with different oncogenic modes of action. The clinical impact of BRAF mutational subtypes in non-small-cell lung cancer (NSCLC) remains to be defined. So far, ambiguous results were reported from analyses of heterogeneous patient cohorts. METHODS We studied patients with metastatic or recurrent NSCLC who were sequentially enrolled in precision oncology programs at two large German lung cancer centres from 2009 to 2019. The study period allowed evaluating the specific impact of BRAF V600E-targeting. RESULTS In a cohort of 72 patients, BRAF mutation subtyping revealed p.V600E mutations in 31 cases (43%), whereas 41 cases (57%) harboured 18 different BRAF mutational subtypes of functional classes II/III. Functionally relevant comutations were observed in 6.4% of class I, and 24.4% of class II/III BRAF mutations. Most patients were treated with chemotherapy. Targeted therapy was administered in 11 patients with a response rate of 72.7%. PD-1/PD-L1-immunotherapy was given in 14 patients with a response rate of 28.6%. Overall survival of patients with BRAF-mutated NSCLC was inferior (HR 1.38, p = 0.048) as compared to patients with BRAF wild-type cancers. Median time-to-treatment-failure with BRAF-targeting agents was shorter as compared to approved targeted therapy of other oncogenic drivers (HR 1.97, p = 0.05). Survival outcomes were not impacted by BRAF mutation subtype functional class. CONCLUSIONS Patients with BRAF-mutated NSCLC have an inferior prognosis, which is not determined by BRAF mutation functional class. In contrast to NSCLC with other tractable driver mutations, BRAF-mutated NSCLC exhibit high susceptibility to immune checkpoint inhibitors.
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Affiliation(s)
- Marcel Wiesweg
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Germany; Division of Thoracic Oncology, West German Cancer Center, University Medicine Essen - Ruhrlandklinik, University Duisburg-Essen, Germany.
| | - Cedric Preuß
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Germany
| | - Julia Roeper
- Department of Hematology and Oncology, University Department Internal Medicine-Oncology, Pius Hospital, Medical Campus University of Oldenburg, Oldenburg, Germany; Lung Cancer Network NOWEL, Oldenburg, Germany
| | - Martin Metzenmacher
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Germany; Division of Thoracic Oncology, West German Cancer Center, University Medicine Essen - Ruhrlandklinik, University Duisburg-Essen, Germany
| | - Wilfried Eberhardt
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Germany; Division of Thoracic Oncology, West German Cancer Center, University Medicine Essen - Ruhrlandklinik, University Duisburg-Essen, Germany
| | - Ursula Stropiep
- Department of Hematology and Oncology, University Department Internal Medicine-Oncology, Pius Hospital, Medical Campus University of Oldenburg, Oldenburg, Germany; Lung Cancer Network NOWEL, Oldenburg, Germany
| | - Katrin Wedeken
- Department of Hematology and Oncology, University Department Internal Medicine-Oncology, Pius Hospital, Medical Campus University of Oldenburg, Oldenburg, Germany; Lung Cancer Network NOWEL, Oldenburg, Germany
| | - Henning Reis
- Institute of Pathology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Germany
| | - Thomas Herold
- Institute of Pathology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Germany
| | - Kaid Darwiche
- Department of Pulmonary Medicine, Section of Interventional Pneumology, West German Cancer Center, University Medicine Essen - Ruhrlandklinik, University Duisburg-Essen, Germany
| | - Clemens Aigner
- Department of Thoracic Surgery and Endoscopy, West German Cancer Center, University Medicine Essen - Ruhrlandklinik, University Duisburg-Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - Martin Stuschke
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - Hans-Ulrich Schildhaus
- Institute of Pathology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Germany
| | - Kurt W Schmid
- Institute of Pathology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - Markus Falk
- Institute for Hematopathology Hamburg, Hamburg, Germany; Lung Cancer Network NOWEL, Oldenburg, Germany
| | - Lukas Heukamp
- Institute for Hematopathology Hamburg, Hamburg, Germany; Lung Cancer Network NOWEL, Oldenburg, Germany
| | - Markus Tiemann
- Institute for Hematopathology Hamburg, Hamburg, Germany; Lung Cancer Network NOWEL, Oldenburg, Germany
| | - Frank Griesinger
- Department of Hematology and Oncology, University Department Internal Medicine-Oncology, Pius Hospital, Medical Campus University of Oldenburg, Oldenburg, Germany; Lung Cancer Network NOWEL, Oldenburg, Germany
| | - Martin Schuler
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Germany; Division of Thoracic Oncology, West German Cancer Center, University Medicine Essen - Ruhrlandklinik, University Duisburg-Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
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Ascierto PA, Atkins MB, Eggermont AM, Gershenwald JE, Grob JJ, Hamid O, Sondak VK, Sosman JA, Tawbi HA, Weber JS, Caracò C, Osman I, Puzanov I. The "Great Debate" at Melanoma Bridge 2020: December, 5th, 2020. J Transl Med 2021; 19:142. [PMID: 33827575 PMCID: PMC8028182 DOI: 10.1186/s12967-021-02808-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/24/2021] [Indexed: 01/11/2023] Open
Abstract
The Great Debate session at the 2020 Melanoma Bridge virtual congress (December 3rd-5th, Italy) featured counterpoint views from experts on five specific controversial issues in melanoma. The debates considered whether or not innate immunity is important in the response to cancer and immunotherapy, how useful are the revised American Joint Committee on Cancer (AJCC) classification for the staging of patients, the use of sentinel node biopsy for staging patients, the use of triplet combination of targeted therapy plus immunotherapy versus combined immunotherapy, and the respective benefits of neoadjuvant versus adjuvant therapy. As is usual with Bridge congresses, the debates were assigned by meeting Chairs and positions taken by experts during the debates may not have necessarily reflected their own personal opinion.
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Affiliation(s)
- Paolo A Ascierto
- Department of Melanoma, Cancer Immunotherapy and Innovative Therapy, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy.
| | - Michael B Atkins
- Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Alexander M Eggermont
- Princess Maxima Center and University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeffrey E Gershenwald
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Jacques Grob
- Service de Dermatologie et Cancérologie CutanéeHôpital de la Timone, Aix-Marseille Université, Marseille Cedex 5, France
| | - Omid Hamid
- The Angeles Clinic and Research Institute, Los Angeles, CA, USA
| | - Vernon K Sondak
- Department of Cutaneous Oncology, Richard M. Schulze Family Foundation, Moffitt Cancer Center , Tampa, FL, USA
- Departments of Oncologic Sciences and Surgery, University of South Florida Morsani School of Medicine, Tampa, FL, USA
| | - Jeffrey A Sosman
- Robert H Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA
| | - Hussein A Tawbi
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey S Weber
- Laura and Isaac Perlmutter Cancer Center, NYU School of Medicine, New York, NY, USA
| | - Corrado Caracò
- Unit of Melanoma and Skin Tumor Surgery, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Iman Osman
- New York University Langone Medical Center, New York, NY, USA
| | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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Yap TA, Parkes EE, Peng W, Moyers JT, Curran MA, Tawbi HA. Development of Immunotherapy Combination Strategies in Cancer. Cancer Discov 2021; 11:1368-1397. [PMID: 33811048 DOI: 10.1158/2159-8290.cd-20-1209] [Citation(s) in RCA: 129] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 01/03/2021] [Accepted: 02/01/2021] [Indexed: 12/11/2022]
Abstract
Harnessing the immune system to treat cancer through inhibitors of CTLA4 and PD-L1 has revolutionized the landscape of cancer. Rational combination strategies aim to enhance the antitumor effects of immunotherapies, but require a deep understanding of the mechanistic underpinnings of the immune system and robust preclinical and clinical drug development strategies. We review the current approved immunotherapy combinations, before discussing promising combinatorial approaches in clinical trials and detailing innovative preclinical model systems being used to develop rational combinations. We also discuss the promise of high-order immunotherapy combinations, as well as novel biomarker and combinatorial trial strategies. SIGNIFICANCE: Although immune-checkpoint inhibitors are approved as dual checkpoint strategies, and in combination with cytotoxic chemotherapy and angiogenesis inhibitors for multiple cancers, patient benefit remains limited. Innovative approaches are required to guide the development of novel immunotherapy combinations, ranging from improvements in preclinical tumor model systems to biomarker-driven trial strategies.
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Affiliation(s)
- Timothy A Yap
- Investigational Cancer Therapeutics (Phase I Program), The University of Texas MD Anderson Cancer Center, Houston, Texas. .,Institute for Applied Cancer Science, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Khalifa Institute for Personalized Cancer Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eileen E Parkes
- Oxford Institute of Radiation Oncology, University of Oxford, Oxford, United Kingdom
| | - Weiyi Peng
- Department of Biology and Biochemistry, University of Houston, Houston, Texas
| | - Justin T Moyers
- Investigational Cancer Therapeutics (Phase I Program), The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael A Curran
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hussein A Tawbi
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Ottaviano M, Giunta EF, Tortora M, Curvietto M, Attademo L, Bosso D, Cardalesi C, Rosanova M, De Placido P, Pietroluongo E, Riccio V, Mucci B, Parola S, Vitale MG, Palmieri G, Daniele B, Simeone E. BRAF Gene and Melanoma: Back to the Future. Int J Mol Sci 2021; 22:ijms22073474. [PMID: 33801689 PMCID: PMC8037827 DOI: 10.3390/ijms22073474] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/20/2021] [Accepted: 03/22/2021] [Indexed: 12/13/2022] Open
Abstract
As widely acknowledged, 40-50% of all melanoma patients harbour an activating BRAF mutation (mostly BRAF V600E). The identification of the RAS-RAF-MEK-ERK (MAP kinase) signalling pathway and its targeting has represented a valuable milestone for the advanced and, more recently, for the completely resected stage III and IV melanoma therapy management. However, despite progress in BRAF-mutant melanoma treatment, the two different approaches approved so far for metastatic disease, immunotherapy and BRAF+MEK inhibitors, allow a 5-year survival of no more than 60%, and most patients relapse during treatment due to acquired mechanisms of resistance. Deep insight into BRAF gene biology is fundamental to describe the acquired resistance mechanisms (primary and secondary) and to understand the molecular pathways that are now being investigated in preclinical and clinical studies with the aim of improving outcomes in BRAF-mutant patients.
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Affiliation(s)
- Margaret Ottaviano
- Department of Clinical Medicine and Surgery, Università Degli Studi di Napoli “Federico II”, 80131 Naples, Italy; (P.D.P.); (E.P.); (V.R.); (B.M.); (S.P.)
- Oncology Unit, Ospedale del Mare, 80147 Naples, Italy; (L.A.); (D.B.); (C.C.); (M.R.); (B.D.)
- CRCTR Coordinating Rare Tumors Reference Center of Campania Region, 80131 Naples, Italy; (M.T.); (G.P.)
- Correspondence:
| | - Emilio Francesco Giunta
- Department of Precision Medicine, Università Degli Studi della Campania Luigi Vanvitelli, 80131 Naples, Italy;
| | - Marianna Tortora
- CRCTR Coordinating Rare Tumors Reference Center of Campania Region, 80131 Naples, Italy; (M.T.); (G.P.)
| | - Marcello Curvietto
- Unit of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, 80131 Naples, Italy; (M.C.); (M.G.V.); (E.S.)
| | - Laura Attademo
- Oncology Unit, Ospedale del Mare, 80147 Naples, Italy; (L.A.); (D.B.); (C.C.); (M.R.); (B.D.)
| | - Davide Bosso
- Oncology Unit, Ospedale del Mare, 80147 Naples, Italy; (L.A.); (D.B.); (C.C.); (M.R.); (B.D.)
| | - Cinzia Cardalesi
- Oncology Unit, Ospedale del Mare, 80147 Naples, Italy; (L.A.); (D.B.); (C.C.); (M.R.); (B.D.)
| | - Mario Rosanova
- Oncology Unit, Ospedale del Mare, 80147 Naples, Italy; (L.A.); (D.B.); (C.C.); (M.R.); (B.D.)
| | - Pietro De Placido
- Department of Clinical Medicine and Surgery, Università Degli Studi di Napoli “Federico II”, 80131 Naples, Italy; (P.D.P.); (E.P.); (V.R.); (B.M.); (S.P.)
| | - Erica Pietroluongo
- Department of Clinical Medicine and Surgery, Università Degli Studi di Napoli “Federico II”, 80131 Naples, Italy; (P.D.P.); (E.P.); (V.R.); (B.M.); (S.P.)
| | - Vittorio Riccio
- Department of Clinical Medicine and Surgery, Università Degli Studi di Napoli “Federico II”, 80131 Naples, Italy; (P.D.P.); (E.P.); (V.R.); (B.M.); (S.P.)
| | - Brigitta Mucci
- Department of Clinical Medicine and Surgery, Università Degli Studi di Napoli “Federico II”, 80131 Naples, Italy; (P.D.P.); (E.P.); (V.R.); (B.M.); (S.P.)
| | - Sara Parola
- Department of Clinical Medicine and Surgery, Università Degli Studi di Napoli “Federico II”, 80131 Naples, Italy; (P.D.P.); (E.P.); (V.R.); (B.M.); (S.P.)
| | - Maria Grazia Vitale
- Unit of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, 80131 Naples, Italy; (M.C.); (M.G.V.); (E.S.)
| | - Giovannella Palmieri
- CRCTR Coordinating Rare Tumors Reference Center of Campania Region, 80131 Naples, Italy; (M.T.); (G.P.)
| | - Bruno Daniele
- Oncology Unit, Ospedale del Mare, 80147 Naples, Italy; (L.A.); (D.B.); (C.C.); (M.R.); (B.D.)
| | - Ester Simeone
- Unit of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, 80131 Naples, Italy; (M.C.); (M.G.V.); (E.S.)
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Systemic Therapy of Metastatic Melanoma: On the Road to Cure. Cancers (Basel) 2021; 13:cancers13061430. [PMID: 33804800 PMCID: PMC8003858 DOI: 10.3390/cancers13061430] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/11/2021] [Accepted: 03/15/2021] [Indexed: 12/22/2022] Open
Abstract
Simple Summary Malignant melanoma is more dangerous than most other skin cancers due to its ability to spread early and aggressively. Until the development of new therapeutic strategies, the median survival of patients with metastatic melanoma was just a few months. Immunotherapy, the first regimen, leading to significant improvement, blocks immune checkpoints, which normally dampen immune responses, enabling our defense cells to recognize and destroy cancer cells again. Immunotherapy achieves long-term survival in about 50% of metastatic melanoma patients. Besides, targeted therapy has also significantly improved the survival of melanoma patients, blocking cell-signaling proteins, which are altered in about 50% of melanomas and lead to uncontrolled tumor cell growth. In addition to the approved regimens, there are numerous new treatment strategies, ranging from modified viruses to personalized immune cells that attack and destroy tumor cells. This review shall give an insight into both already approved regimens and upcoming developments. Abstract This decade has brought significant survival improvement in patients with metastatic melanoma with targeted therapies and immunotherapies. As our understanding of the mechanisms of action of these therapeutics evolves, even more impressive therapeutic success is being achieved through various combination strategies, including combinations of different immunotherapies as well as with other modalities. This review summarizes prospectively and retrospectively generated clinical evidence on modern melanoma therapy, focusing on immunotherapy and targeted therapy with BRAF kinase inhibitors and MEK kinase inhibitors (BRAF/MEK inhibitors), including recent data presented at major conference meetings. The combination of the anti-PD-1 directed monoclonal antibody nivolumab and of the CTLA-4 antagonist ipilimumab achieves unprecedented 5-year overall survival (OS) rates above 50%; however, toxicity is high. For PD-1 monotherapy (nivolumab or pembrolizumab), toxicities are in general well manageable. Today, novel combinations of such immune checkpoint inhibitors (ICIs) are under investigation, for example with cytokines and oncolytic viruses (i.e., pegylated interleukin-2, talimogene laherparepvec). Furthermore, current studies investigate the combined or sequential use of ICIs plus BRAF/MEK inhibitors. Several studies focus particularly on poor prognosis patients, as e.g., on anti-PD-1 refractory melanoma, patients with brain metastases, or uveal melanoma. It is hoped, on the road to cure, that these new approaches further improve long term survival in patients with advanced or metastatic melanoma.
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Fattore L, Ruggiero CF, Liguoro D, Castaldo V, Catizone A, Ciliberto G, Mancini R. The Promise of Liquid Biopsy to Predict Response to Immunotherapy in Metastatic Melanoma. Front Oncol 2021; 11:645069. [PMID: 33816298 PMCID: PMC8013996 DOI: 10.3389/fonc.2021.645069] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/01/2021] [Indexed: 12/12/2022] Open
Abstract
Metastatic melanoma is the deadliest form of skin cancer whose incidence has been rising dramatically over the last few decades. Nowadays, the most successful approach in treating advanced melanoma is immunotherapy which encompasses the use of immune checkpoint blockers able to unleash the immune system's activity against tumor cells. Immunotherapy has dramatically changed clinical practice by contributing to increasing long term overall survival. Despite these striking therapeutic effects, the clinical benefits are strongly mitigated by innate or acquired resistance. In this context, it is of utmost importance to develop methods capable of predicting patient response to immunotherapy. To this purpose, one major step forward may be provided by measuring non-invasive biomarkers in human fluids, namely Liquid Biopsies (LBs). Several LB approaches have been developed over the last few years thanks to technological breakthroughs that have allowed to evaluate circulating components also when they are present in low abundance. The elements of this so-called "circulome" mostly encompass: tumor DNA, tumor and immune cells, soluble factors and non-coding RNAs. Here, we review the current knowledge of these molecules as predictors of response to immunotherapy in metastatic melanoma and predict that LB will soon enter into routine practice in order to guide clinical decisions for cancer immunotherapy.
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Affiliation(s)
- Luigi Fattore
- SAFU Laboratory, Department of Research, Advanced Diagnostics and Technological Innovation, Translational Research Area, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Ciro Francesco Ruggiero
- Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Domenico Liguoro
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Vittorio Castaldo
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Angiolina Catizone
- Department of Anatomy, Histology, Forensic- Medicine and Orthopedics, Sapienza University of Rome, Rome, Italy
| | - Gennaro Ciliberto
- Scientific Directorate, IRCSS Regina Elena National Cancer Institute, Rome, Italy
| | - Rita Mancini
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
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Abstract
About half of all cutaneous melanomas harbor activating mutations in the BRAF oncogene. Dependence on this pathway makes the tumors vulnerable to BRAF (and downstream MEK) inhibition, and three drug combinations are approved to target this vulnerability in advanced melanomas with BRAFV600 mutations. Responses to BRAF/MEK inhibitors are usually fast, but durability of response can be limited. Five-year data from BRAF/MEK inhibitors show long-term survival benefit for a third of the patients. There is a wide variety of known mechanisms of resistance to BRAF/MEK inhibition, such as mitogen-activated protein kinase reactivation, activation of parallel pathways, alterations in cell-cycle regulation, and non-genetic resistance mechanisms. Strategies that have been explored to overcome these mechanisms include alternative dosing regimens, addition of another kinase inhibitor, and use of anti-PD-1 immunotherapy either in combination or post-relapse on BRAF/MEK inhibitor therapies.
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van Doorn DJ, Takkenberg RB, Klümpen HJ. Immune Checkpoint Inhibitors in Hepatocellular Carcinoma: An Overview. Pharmaceuticals (Basel) 2020; 14:3. [PMID: 33374927 PMCID: PMC7821931 DOI: 10.3390/ph14010003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/15/2020] [Accepted: 12/19/2020] [Indexed: 12/24/2022] Open
Abstract
Patients with hepatocellular carcinoma (HCC) face a common type of cancer, which is amongst the most deadly types of cancer worldwide. The therapeutic options range from curative resection or ablation to loco regional therapies in palliative setting and last but not least, systemic treatment. The latter group underwent major changes in the last decade and a half. Since the introduction of sorafenib in 2007, many other systemic treatments have been investigated. Most without success. It took more than ten years before lenvatinib could be added as alternative first-line treatment option. Just recently a new form of systemic treatment, immunotherapy, entered the field of therapeutic options in patients with HCC. Immune checkpoint inhibitors are becoming the new standard of care in patients with HCC. Several reviews reported on the latest phase 1/2 studies and discussed the higher response rates and better tolerability when compared to current standard of care therapies. This review will focus on elaborating the working mechanism of these checkpoint inhibitors, give an elaborate update of the therapeutic agents that are currently available or under research, and will give an overview of the latest trials, as well as ongoing and upcoming trials.
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Affiliation(s)
- Diederick J. van Doorn
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (D.J.v.D.); (R.B.T.)
| | - Robert Bart Takkenberg
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (D.J.v.D.); (R.B.T.)
| | - Heinz-Josef Klümpen
- Department of Medical Oncology, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Quoi de neuf en oncodermatologie ? Ann Dermatol Venereol 2020; 147:12S33-12S42. [DOI: 10.1016/s0151-9638(20)31106-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Pisapia P, Pepe F, Iaccarino A, Sgariglia R, Nacchio M, Russo G, Gragnano G, Malapelle U, Troncone G. BRAF: A Two-Faced Janus. Cells 2020; 9:E2549. [PMID: 33260892 PMCID: PMC7760616 DOI: 10.3390/cells9122549] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 11/18/2020] [Accepted: 11/25/2020] [Indexed: 12/12/2022] Open
Abstract
Gain-of-function of V-Raf Murine Sarcoma Viral Oncogene Homolog B (BRAF) is one of the most frequent oncogenic mutations in numerous cancers, including thyroid papillary carcinoma, melanoma, colon, and lung carcinomas, and to a lesser extent, ovarian and glioblastoma multiforme. This mutation aberrantly activates the mitogen-activated protein (MAP) kinase extracellular signal-regulated kinase (MEK)/extracellular signal-regulated kinase (ERK) signaling pathway, thereby eliciting metastatic processes. The relevance of BRAF mutations stems from its prognostic value and, equally important, from its relevant therapeutic utility as an actionable target for personalized treatment. Here, we discuss the double facets of BRAF. In particular, we argue the need to implement diagnostic molecular algorithms that are able to detect this biomarker in order to streamline and refine diagnostic and therapeutic decisions.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Giancarlo Troncone
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (P.P.); (F.P.); (A.I.); (R.S.); (M.N.); (G.R.); (G.G.); (U.M.)
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