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Gorry C, McCullagh L, O'Donnell H, Barrett S, Schmitz S, Barry M, Curtin K, Beausang E, Barry R, Coyne I. Neoadjuvant treatment for stage III and IV cutaneous melanoma. Cochrane Database Syst Rev 2023; 1:CD012974. [PMID: 36648215 PMCID: PMC9844053 DOI: 10.1002/14651858.cd012974.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Cutaneous melanoma is amongst the most aggressive of all skin cancers. Neoadjuvant treatment is a form of induction therapy, given to shrink a cancerous tumour prior to the main treatment (usually surgery). The purpose is to improve survival and surgical outcomes. This review systematically appraises the literature investigating the use of neoadjuvant treatment for stage III and IV cutaneous melanoma. OBJECTIVES To assess the effects of neoadjuvant treatment in adults with stage III or stage IV melanoma according to the seventh edition American Joint Committee on Cancer (AJCC) staging system. SEARCH METHODS We searched the following databases up to 10 August 2021 inclusive: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, LILACS and four trials registers, together with reference checking and contact with study authors to identify additional studies. We also handsearched proceedings from specific conferences from 2016 to 2020 inclusive. SELECTION CRITERIA Randomised controlled trials (RCTs) of people with stage III and IV melanoma, comparing neoadjuvant treatment strategies (using targeted treatments, immunotherapies, radiotherapy, topical treatments or chemotherapy) with any of these agents or current standard of care (SOC), were eligible for inclusion. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Primary outcomes were overall survival (OS) and adverse effects (AEs). Secondary outcomes included time to recurrence (TTR), quality of life (QOL), and overall response rate (ORR). We used GRADE to evaluate the certainty of the evidence. MAIN RESULTS We included eight RCTs involving 402 participants. Studies enrolled adults, mostly with stage III melanoma, investigated immunotherapies, chemotherapy, or targeted treatments, and compared these with surgical excision with or without adjuvant treatment. Duration of follow-up and therapeutic regimens varied, which, combined with heterogeneity in the population and definitions of the endpoints, precluded meta-analysis of all identified studies. We performed a meta-analysis including three studies. We are very uncertain if neoadjuvant treatment increases OS when compared to no neoadjuvant treatment (hazard ratio (HR) 0.43, 95% confidence interval (CI) 0.15 to 1.21; 2 studies, 171 participants; very low-certainty evidence). Neoadjuvant treatment may increase the rate of AEs, but the evidence is very uncertain (26% versus 16%, risk ratio (RR) 1.58, 95% CI 0.97 to 2.55; 2 studies, 162 participants; very low-certainty evidence). We are very uncertain if neoadjuvant treatment increases TTR (HR 0.51, 95% CI 0.22 to 1.17; 2 studies, 171 participants; very low-certainty evidence). Studies did not report ORR as a comparative outcome or measure QOL data. We are very uncertain whether neoadjuvant targeted treatment with dabrafenib and trametinib increases OS (HR 0.28, 95% CI 0.03 to 2.25; 1 study, 21 participants; very low-certainty evidence) or TTR (HR 0.02, 95% CI 0.00 to 0.22; 1 study, 21 participants; very low-certainty evidence) when compared to surgery. The study did not report comparative rates of AEs and overall response, and did not measure QOL. We are very uncertain if neoadjuvant immunotherapy with talimogene laherparepvec increases OS when compared to no neoadjuvant treatment (HR 0.49, 95% CI 0.15 to 1.64; 1 study, 150 participants, very low-certainty evidence). It may have a higher rate of AEs, but the evidence is very uncertain (16.5% versus 5.8%, RR 2.84, 95% CI 0.96 to 8.37; 1 study, 142 participants; very low-certainty evidence). We are very uncertain if it increases TTR (HR 0.75, 95% CI 0.31 to 1.79; 1 study, 150 participants; very low-certainty evidence). The study did not report comparative ORRs or measure QOL. OS was not reported for neoadjuvant immunotherapy (combined ipilimumab and nivolumab) when compared to the combination of ipilimumab and nivolumab as adjuvant treatment. There may be little or no difference in the rate of AEs between these treatments (9%, RR 1.0, 95% CI 0.75 to 1.34; 1 study, 20 participants; low-certainty evidence). The study did not report comparative ORRs or measure TTR and QOL. Neoadjuvant immunotherapy (combined ipilimumab and nivolumab) likely results in little to no difference in OS when compared to neoadjuvant nivolumab monotherapy (P = 0.18; 1 study, 23 participants; moderate-certainty evidence). It may increase the rate of AEs, but the certainty of this evidence is very low (72.8% versus 8.3%, RR 8.73, 95% CI 1.29 to 59; 1 study, 23 participants); this trial was halted early due to observation of disease progression preventing surgical resection in the monotherapy arm and the high rate of treatment-related AEs in the combination arm. Neoadjuvant combination treatment may lead to higher ORR, but the evidence is very uncertain (72.8% versus 25%, RR 2.91, 95% CI 1.02 to 8.27; 1 study, 23 participants; very low-certainty evidence). It likely results in little to no difference in TTR (P = 0.19; 1 study, 23 participants; low-certainty evidence). The study did not measure QOL. OS was not reported for neoadjuvant immunotherapy (combined ipilimumab and nivolumab) when compared to neoadjuvant sequential immunotherapy (ipilimumab then nivolumab). Only Grade 3 to 4 immune-related AEs were reported; fewer were reported with combination treatment, and the sequential treatment arm closed early due to a high incidence of severe AEs. The neoadjuvant combination likely results in a higher ORR compared to sequential neoadjuvant treatment (60.1% versus 42.3%, RR 1.42, 95% CI 0.87 to 2.32; 1 study, 86 participants; low-certainty evidence). The study did not measure TTR and QOL. No data were reported on OS, AEs, TTR, or QOL for the comparison of neoadjuvant interferon (HDI) plus chemotherapy versus neoadjuvant chemotherapy. Neoadjuvant HDI plus chemotherapy may have little to no effect on ORR, but the evidence is very uncertain (33% versus 22%, RR 1.75, 95% CI 0.62 to 4.95; 1 study, 36 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS We are uncertain if neoadjuvant treatment increases OS or TTR compared with no neoadjuvant treatment, and it may be associated with a slightly higher rate of AEs. There is insufficient evidence to support the use of neoadjuvant treatment in clinical practice. Priorities for research include the development of a core outcome set for neoadjuvant trials that are adequately powered, with validation of pathological and radiological responses as intermediate endpoints, to investigate the relative benefits of neoadjuvant treatment compared with adjuvant treatment with immunotherapies or targeted therapies.
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Affiliation(s)
- Claire Gorry
- National Centre for Pharmacoeconomics, St James's Hospital, Dublin, Ireland
| | - Laura McCullagh
- National Centre for Pharmacoeconomics, St James's Hospital, Dublin, Ireland
- Department of Pharmacology and Therapeutics, Trinity College Dublin, Dublin, Ireland
| | - Helen O'Donnell
- Department of Pharmacology and Therapeutics, Trinity College Dublin, Dublin, Ireland
| | - Sarah Barrett
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity St James's Cancer Institute, Trinity College Dublin, Dublin, Ireland
| | - Susanne Schmitz
- Department of Pharmacology and Therapeutics, Trinity College Dublin, Dublin, Ireland
| | - Michael Barry
- Department of Pharmacology and Therapeutics, Trinity College Dublin, Dublin, Ireland
| | - Kay Curtin
- Melanoma Support Ireland, Dublin, Ireland
| | - Eamon Beausang
- Plastic and Reconstructive Surgery, St James's Hospital, Dublin, Ireland
| | - Rupert Barry
- Department of Dermatology, St James's Hospital, Dublin, Ireland
| | - Imelda Coyne
- School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland
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Witt RG, Erstad DJ, Wargo JA. Neoadjuvant therapy for melanoma: rationale for neoadjuvant therapy and pivotal clinical trials. Ther Adv Med Oncol 2022; 14:17588359221083052. [PMID: 35251322 PMCID: PMC8894940 DOI: 10.1177/17588359221083052] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/03/2022] [Indexed: 12/26/2022] Open
Abstract
The treatment of malignant melanoma has drastically changed over the past decade with the advent of immune checkpoint blockade, targeted therapy with BRAF/MEK inhibition, and other novel therapies such as oncolytic virus intralesional therapy. Despite improvements in patient response rates and survival with these new treatments, there exists a large portion of patients with surgically resectable disease that are high risk for relapse. Patients with high-risk resectable melanoma account for up to 20% of newly diagnosed cases. For this high-risk group of patients, neoadjuvant therapy has many purposed advantages over adjuvant therapy, including a more robust immune response due to abundant tumor antigens at treatment initiation, the ability to assess pathologic response to therapy, tumor downstaging leading to increased disease resectability, and a potential decreased need for extensive lymphadenectomies. These findings have been backed by preclinical models and multiple neoadjuvant trials are underway. In this review, we will discuss the trials that have set the foundation for the current treatment standards and discuss the role and rationale for neoadjuvant therapy for high-risk malignant melanomas.
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Affiliation(s)
- Russell G. Witt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Derek J. Erstad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer A. Wargo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1484, Houston, TX 77030-4009, USA
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Gingrich AA, Kirane AR. Novel Targets in Melanoma: Intralesional and Combination Therapy to Manipulate the Immune Response. Surg Oncol Clin N Am 2021; 29:467-483. [PMID: 32482321 DOI: 10.1016/j.soc.2020.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Clinical outcomes for metastatic melanoma have been dramatically altered by recent developments in immunotherapy and targeted strategies, but response to these therapies is not uniform, the majority of patients do not respond, and clinical response can be self-limited. Current directions in melanoma treatment aim to leverage a combination of therapies for tumors refractory to monoimmunotherapy, to include tumor-directed strategies, such as intralesional therapy and inhibitors designed for novel targets, which may augment current systemic agents when used in combination. Here, we summarize new classes of agents and emerging multimodal combination strategies that demonstrate significant promise in future melanoma management.
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Affiliation(s)
- Alicia A Gingrich
- Department of Surgery, University of California Davis, 4501 X Street, Suite 3010, Sacramento, CA 95817, USA
| | - Amanda R Kirane
- Department of Surgery, University of California Davis, 4501 X Street, Suite 3010, Sacramento, CA 95817, USA.
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Troiani T, De Falco V, Napolitano S, Trojaniello C, Ascierto PA. How we treat locoregional melanoma. ESMO Open 2021; 6:100136. [PMID: 33930656 PMCID: PMC8100625 DOI: 10.1016/j.esmoop.2021.100136] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/02/2021] [Indexed: 12/19/2022] Open
Abstract
Cutaneous melanoma is the most lethal form of skin cancer and its incidence has been increasing in the past 30 years. Although this is completely resectable in most cases, thicker melanoma and those with regional lymph-node involvement are at a high risk of relapse. In recent years, the management of locoregional disease has drastically changed. In particular, in the 8th Edition of the American Joint Committee on Cancer (AJCC), subgroup classification of TNM (tumor–node–metastasis) has been modified, with the addition of the IIID stage. Furthermore, in recent randomized trials, completion lymph node dissection in case of sentinel lymph node biopsy positivity has not been shown to offer any improvement in overall survival versus observation. Consequently, radical dissection has been recommended as the standard treatment, but only in patients with palpable nodal metastases. However, the major novelty in the treatment of locally advanced melanoma has been the introduction of drugs, already used for metastatic disease, that have also shown clinical efficacy in the adjuvant setting. In fact, immunotherapies and, in the case of BRAF V600E/K-mutated melanoma, combination treatment of BRAF and MEK inhibitors have improved recurrence-free survival in these patients. In this paper, we will describe the current management of a patient with radically resectable melanoma and discuss the key points in light of the latest scientific evidence. Melanoma is the deadliest of skin cancers, although most cases are resectable at diagnosis. Use of targeted therapies and immunotherapies as adjuvant treatment revolutionized the scenario in stage III melanoma. In this review, we summarize all current evidence about locoregional melanoma, including open issues and future directions.
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Affiliation(s)
- T Troiani
- Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania 'Luigi Vanvitelli', Napoli, Italy.
| | - V De Falco
- Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania 'Luigi Vanvitelli', Napoli, Italy
| | - S Napolitano
- Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania 'Luigi Vanvitelli', Napoli, Italy
| | - C Trojaniello
- Melanoma, Cancer Immunotherapy and Innovative Therapy Unit, Istituto Nazionale dei Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - P A Ascierto
- Melanoma, Cancer Immunotherapy and Innovative Therapy Unit, Istituto Nazionale dei Tumori IRCCS Fondazione Pascale, Napoli, Italy.
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5
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Boulva K, Apte S, Yu A, Tran A, Shorr R, Song X, Ong M, Nessim C. Contemporary Neoadjuvant Therapies for High-Risk Melanoma: A Systematic Review. Cancers (Basel) 2021; 13:1905. [PMID: 33920967 PMCID: PMC8071293 DOI: 10.3390/cancers13081905] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/10/2021] [Accepted: 04/13/2021] [Indexed: 11/16/2022] Open
Abstract
Despite advances in adjuvant immuno- and targeted therapies, the risk of relapse for stage III melanoma remains high. With 43 active entries on clinicaltrials.gov (8 July 2020), there is a surge of interest in the role of contemporary therapies in the neoadjuvant setting. We conducted a systematic review of trials performed in the last decade evaluating neoadjuvant targeted, immuno- or intralesional therapy for resectable stage III or IV melanoma. Database searches of Medline, Embase, and the Cochrane Central Register of Controlled Trials were conducted from inception to 13 February 2020. Two reviewers assessed titles, abstracts, and full texts. Trials investigating contemporary neoadjuvant therapies in high-risk melanoma were included. Eight phase II trials (4 randomized and 4 single-arm) involving 450 patients reported on neoadjuvant anti-BRAF/MEK targeted therapy (3), anti-PD-1/CTLA-4 immunotherapy (3), and intralesional therapy (2). The safest and most efficacious regimens were dabrafenib/trametinib and combination ipilimumab (1 mg/kg) + nivolumab (3 mg/kg). Pathologic complete response (pCR) and adverse events were comparable. Ipilimumab + nivolumab exhibited longer RFS. Contemporary neoadjuvant therapies are not only safe, but also demonstrate remarkable pCR and RFS-outcomes which are regarded as meaningful surrogates for long-term survival. Studies defining predictors of pCR, its correlation with oncologic outcomes, and phase III trials comparing neoadjuvant therapy to standard of care will be crucial.
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Affiliation(s)
- Kerianne Boulva
- Division of General Surgery, The Ottawa Hospital, Ottawa, ON K1H 8L6, Canada; (K.B.); (S.A.); (A.T.)
| | - Sameer Apte
- Division of General Surgery, The Ottawa Hospital, Ottawa, ON K1H 8L6, Canada; (K.B.); (S.A.); (A.T.)
- The Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (R.S.); (X.S.); (M.O.)
| | - Ashley Yu
- Department of Family Medicine, McMaster University, Hamilton, ON L8P 1H6, Canada;
| | - Alexandre Tran
- Division of General Surgery, The Ottawa Hospital, Ottawa, ON K1H 8L6, Canada; (K.B.); (S.A.); (A.T.)
- The Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (R.S.); (X.S.); (M.O.)
| | - Risa Shorr
- The Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (R.S.); (X.S.); (M.O.)
| | - Xinni Song
- The Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (R.S.); (X.S.); (M.O.)
- Division of Medical Oncology, The Ottawa Hospital, Ottawa, ON K1H 8L6, Canada
| | - Michael Ong
- The Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (R.S.); (X.S.); (M.O.)
- Division of Medical Oncology, The Ottawa Hospital, Ottawa, ON K1H 8L6, Canada
| | - Carolyn Nessim
- Division of General Surgery, The Ottawa Hospital, Ottawa, ON K1H 8L6, Canada; (K.B.); (S.A.); (A.T.)
- The Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (R.S.); (X.S.); (M.O.)
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Ascierto PA, Agarwala SS, Eggermont A, Gershenwald JE, Grob JJ, Hamid O, Michielin O, Postow M, Puzanov I, Zarour HM, Caracò C, Testori A. The Great Debate at "Melanoma Bridge", Naples, December 7th, 2019. J Transl Med 2020; 18:171. [PMID: 32299446 PMCID: PMC7164218 DOI: 10.1186/s12967-020-02340-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/09/2020] [Indexed: 12/21/2022] Open
Abstract
The Great Debate session at the 2019 Melanoma Bridge congress (December 5-7, Naples, Italy) featured counterpoint views from experts on five topical issues in melanoma. These were whether to choose local intratumoral treatment or systemic treatment, whether patients with stage IIIA melanoma require adjuvant therapy or not, whether treatment is better changed at disease progression or during stable disease, whether adoptive cell transfer (ACT) therapy is more appropriate used before or in combination with checkpoint inhibition therapy, and whether treatment can be stopped while the patient is still on response. As was the case for previous meetings, the debates were assigned by meeting Chairs. As such, positions taken by each of the melanoma experts during the debates may not have reflected their respective personal approach.
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Affiliation(s)
- Paolo A Ascierto
- Unit of Melanoma, Cancer Immunotherapy and Innovative Therapy, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Via Mariano Semmola, 80131, Naples, Italy.
| | | | - Alexander Eggermont
- Princess Máxima Center Research Directorate, CS, 3584 CS, Utrecht, The Netherlands
| | - Jeffrey E Gershenwald
- Department of Surgical Oncology and Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Omid Hamid
- Angeles Clinic & Research Institute, Santa Monica, CA, USA
| | - Olivier Michielin
- Oncology Service, Precision Oncology Center, Oncology Department, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Michael Postow
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY, USA
| | - Igor Puzanov
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Hassane M Zarour
- Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Corrado Caracò
- Department Melanoma, Soft Tissue, Muscle-Skeletal and Head-Neck, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
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