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Hadley CE, Matsui JK, Blakaj DM, Beyer S, Grecula JC, Chakravarti A, Thomas E, Raval RR, Elder JB, Wu K, Kendra K, Giglio P, Palmer JD. Delayed and Concurrent Stereotactic Radiosurgery in Immunotherapy-Naïve Melanoma Brain Metastases. Cancers (Basel) 2024; 16:3733. [PMID: 39594689 PMCID: PMC11591981 DOI: 10.3390/cancers16223733] [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: 09/20/2024] [Revised: 10/31/2024] [Accepted: 10/31/2024] [Indexed: 11/28/2024] Open
Abstract
Melanoma remains a formidable challenge in oncology, causing the majority of skin cancer deaths in the United States, with brain metastases contributing substantially to this mortality. This paper reviews the current therapeutic strategies for melanoma brain metastases, with a focus on delayed and concurrent stereotactic radiosurgery (SRS). While surgery and traditional chemotherapy offer limited efficacy, recent advances in immunotherapy, particularly immune checkpoint inhibitors (ICIs), have played a major role in the advancement and improved efficacy of the treatment of cancers, including brain metastases. Recent studies indicate that monotherapy with ICIs may lead to a higher median overall survival compared to historical benchmarks, potentially allowing patients to delay radiosurgery. Other studies have found that combining SRS with ICIs demonstrates promise, with results indicating improved intracranial control. Ongoing clinical trials explore novel combinations of immunotherapies and radiotherapies, aiming to optimize treatment outcomes while minimizing adverse effects. As treatment options expand, future studies will be necessary to understand the interplay between therapies and their optimal sequencing to improve patient outcomes.
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Affiliation(s)
| | | | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Sasha Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - John C. Grecula
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Arnab Chakravarti
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Evan Thomas
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Raju R. Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - James B. Elder
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Kyle Wu
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Kari Kendra
- Division of Neuro-Oncology, Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Pierre Giglio
- Division of Neuro-Oncology, Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Joshua D. Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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Ho C, Samlowski W. Outcome of an Accelerated Treatment Algorithm for Patients Developing Diarrhea as a Complication of Ipilimumab-Based Cancer Immunotherapy in a Community Practice. Curr Oncol 2024; 31:3529-3545. [PMID: 38920743 PMCID: PMC11202529 DOI: 10.3390/curroncol31060260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 06/12/2024] [Accepted: 06/14/2024] [Indexed: 06/27/2024] Open
Abstract
Immune-mediated diarrhea represents a serious complication of checkpoint inhibitor therapy, especially following ipilimumab-based treatment. Efficient diagnosis and control of diarrhea remains an ongoing challenge. We developed an accelerated management paradigm for patients with ipilimumab-induced diarrhea. Patients who developed significant diarrhea (>five loose stools/day) were presumed to be developing immune colitis. Therapy was interrupted and patients were treated with a methylprednisolone dose pack. If diarrhea was not completely resolved, high-dose steroids and infliximab were promptly added. Only non-responding patients underwent further evaluation for infection or other causes of diarrhea. A total of 242 patients were treated with ipilimumab-based regimens. Forty-six developed significant diarrhea (19%) and thirty-four (74.4%) had a rapid resolution of diarrhea following glucocorticosteroid and infliximab treatment. The median time to resolution of diarrhea was only 8.5 ± 16.4 days. Accelerated treatment for presumed immune-mediated diarrhea resulted in the rapid control of symptoms in the majority of patients. There were no intestinal complications or deaths. Immunosuppressive therapy for diarrhea did not appear to decrease the remission rate or survival. After the control of diarrhea, most patients were able to continue their planned immunotherapy. Further testing in 11/46 patients with unresponsive diarrhea revealed additional diagnoses, allowing their treatment to be adjusted.
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Affiliation(s)
- Clarice Ho
- School of Medicine, University of Nevada, Reno, NV 89557, USA;
| | - Wolfram Samlowski
- School of Medicine, University of Nevada, Reno, NV 89557, USA;
- Comprehensive Cancer Centers of Nevada, Las Vegas, NV 89148, USA
- Kerkorian School of Medicine, University of Nevada Las Vegas (UNLV), Las Vegas, NV 89106, USA
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Samlowski W. The Effect of Non-Overlapping Somatic Mutations in BRAF, NRAS, NF1, or CKIT on the Incidence and Outcome of Brain Metastases during Immune Checkpoint Inhibitor Therapy of Metastatic Melanoma. Cancers (Basel) 2024; 16:594. [PMID: 38339344 PMCID: PMC10854687 DOI: 10.3390/cancers16030594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/24/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
Previous studies suggested that somatic BRAF and NRAS mutations in metastatic melanoma increase the risk for brain metastases. The risk related to other non-overlapping "driver" mutations is unknown. We performed a retrospective evaluation of the incidence, timing, and outcome of brain metastases in a population of melanoma patients that underwent uniform next-gen sequencing. All patients were treated with initial checkpoint inhibitor therapy. Seventeen of 88 patients (20.0%) developed brain metastases. Eleven patients had brain metastases at diagnosis (12.9%). These were all patients with BRAF V600 or NF1 mutations. Only six patients with NRAS, NF1, KIT, or BRAF mutations (including fusions/internal rearrangements experienced delayed CNS progression following immunotherapy (7.1%)). No "quadruple negative" patient developed brain metastases. Patients with brain metastases at diagnosis had a better outcome than those with delayed intracranial progression. Current predictive markers, (LDH, tumor mutation burden, and PDL1) were poorly correlated with the development of brain metastases. Treatment with immunotherapy appears to reduce the incidence of brain metastases. Next-gen molecular sequencing of tumors in metastatic melanoma patients was useful in identifying genetic subpopulations with an increased or reduced risk of brain metastases. This may allow eventual personalization of screening strategies.
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Affiliation(s)
- Wolfram Samlowski
- Comprehensive Cancer Centers of Nevada, Las Vegas, NV 89148, USA; ; Tel.: +1-702-321-3930
- Kirk Kerkorian School of Medicine, University of Nevada Las Vegas (UNLV), Las Vegas, NV 89106, USA
- School of Medicine, University of Nevada (Reno), Reno, NV 89557, USA
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Pradhan AK, Modi J, Maji S, Kumar A, Bhoopathi P, Mannangatti P, Guo C, Afosah DK, Mochel MC, Mukhopadhyay ND, Kirkwood JM, Wang XY, Desai UR, Sarkar D, Emdad L, Das SK, Fisher PB. Dual Targeting of the PDZ1 and PDZ2 Domains of MDA-9/Syntenin Inhibits Melanoma Metastasis. Mol Cancer Ther 2023; 22:1115-1127. [PMID: 37721536 DOI: 10.1158/1535-7163.mct-22-0653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 04/14/2023] [Accepted: 06/27/2023] [Indexed: 09/19/2023]
Abstract
Genome-wide gene expression analysis and animal modeling indicate that melanoma differentiation associated gene-9 (mda-9, Syntenin, Syndecan binding protein, referred to as MDA-9/Syntenin) positively regulates melanoma metastasis. The MDA-9/Syntenin protein contains two tandem PDZ domains serving as a nexus for interactions with multiple proteins that initiate transcription of metastasis-associated genes. Although targeting either PDZ domain abrogates signaling and prometastatic phenotypes, the integrity of both domains is critical for full biological function. Fragment-based drug discovery and NMR identified PDZ1i, an inhibitor of the PDZ1 domain that effectively blocks cancer invasion in vitro and in vivo in multiple experimental animal models. To maximize disruption of MDA-9/Syntenin signaling, an inhibitor has now been developed that simultaneously binds and blocks activity of both PDZ domains. PDZ1i was joined to the second PDZ binding peptide (TNYYFV) with a PEG linker, resulting in PDZ1i/2i (IVMT-Rx-3) that engages both PDZ domains of MDA-9/Syntenin. IVMT-Rx-3 blocks MDA-9/Syntenin interaction with Src, reduces NF-κB activation, and inhibits MMP-2/MMP-9 expression, culminating in repression of melanoma metastasis. The in vivo antimetastatic properties of IVMT-Rx-3 are enhanced when combined with an immune-checkpoint inhibitor. Collectively, our results support the feasibility of engineering MDA-9 dual-PDZ inhibitors with enhanced antimetastatic activities and applications of IVMT-Rx-3 for developing novel therapeutic strategies effectively targeting melanoma and in principle, a broad spectrum of human cancers that also overexpress MDA-9/Syntenin.
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Affiliation(s)
- Anjan K Pradhan
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
- VCU Institute of Molecular Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
| | - Jinkal Modi
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
| | - Santanu Maji
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
| | - Amit Kumar
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
| | - Praveen Bhoopathi
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
- VCU Institute of Molecular Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
| | - Padmanabhan Mannangatti
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
- VCU Institute of Molecular Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
| | - Chunqing Guo
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
- VCU Institute of Molecular Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
- VCU Institute of Molecular Medicine, Massey Comprehensive Cancer Center, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
| | - Daniel K Afosah
- Department of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Mark C Mochel
- Department of Pathology, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
| | - Nitai D Mukhopadhyay
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - John M Kirkwood
- Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Xiang-Yang Wang
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
- VCU Institute of Molecular Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
- VCU Institute of Molecular Medicine, Massey Comprehensive Cancer Center, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
| | - Umesh R Desai
- Department of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Devanand Sarkar
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
- VCU Institute of Molecular Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
- VCU Institute of Molecular Medicine, Massey Comprehensive Cancer Center, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
| | - Luni Emdad
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
- VCU Institute of Molecular Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
- VCU Institute of Molecular Medicine, Massey Comprehensive Cancer Center, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
| | - Swadesh K Das
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
- VCU Institute of Molecular Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
- VCU Institute of Molecular Medicine, Massey Comprehensive Cancer Center, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
| | - Paul B Fisher
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
- VCU Institute of Molecular Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
- VCU Institute of Molecular Medicine, Massey Comprehensive Cancer Center, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
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Panning A, Samlowski W, Allred G. Lack of Influence of Non-Overlapping Mutations in BRAF, NRAS, or NF1 on 12-Month Best Objective Response and Long-Term Survival after Checkpoint Inhibitor-Based Treatment for Metastatic Melanoma. Cancers (Basel) 2023; 15:3527. [PMID: 37444637 DOI: 10.3390/cancers15133527] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 07/01/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Non-overlapping somatic mutations in BRAF, NRAS, or NF1 genes occur in 85% of metastatic melanoma patients. It is not known whether these mutations affect immunotherapy outcome. MATERIALS AND METHODS Next-Gen sequencing of 324 oncogenes was performed in 73 metastatic melanoma patients. A retrospective review of immunotherapy outcome was performed. RESULTS BRAF fusions/internal rearrangements, BRAF V600E, NRAS, NF1 mutations, and triple-negative genotypes occurred in 6.9%, 30.1%, 17.8%, 32.9%, and 12.3% of patients, respectively. Median potential follow-up was 41.0 months. Patients with BRAF fusion/rearrangement had decreased progression-free and overall survival (p = 0.015). The other genotypes each had similar progression-free and overall survival. Patients who achieved a complete best objective response at 12 months (n = 36, 49.3%) were found to have significantly improved survival compared those who failed to achieve remissions (n = 37, 50.7%, p < 0.001). CONCLUSIONS The most important determinant of long-term survival was achievement of a complete response by 12 months following immunotherapy. PR and SD were not a stable type of response and generally resulted in progression and death from melanoma. Rare patients with BRAF fusions or rearrangements had decreased progression-free and overall survival following initial immunotherapy. Other BRAF, NRAS, or NF1 mutations were not associated with significant differences in outcome.
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Affiliation(s)
- Alyssa Panning
- Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV 89106, USA
| | - Wolfram Samlowski
- Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV 89106, USA
- Comprehensive Cancer Centers of Nevada, Las Vegas, NV 89148, USA
- School of Medicine, University of Nevada, Reno, NV 89557, USA
| | - Gabriel Allred
- Gables Statistical Consulting, Bella Vista, AR 72714, USA
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Perez L, Samlowski W, Lopez-Flores R. Outcome of Elective Checkpoint Inhibitor Discontinuation in Patients with Metastatic Melanoma Who Achieved a Complete Remission: Real-World Data. Biomedicines 2022; 10:biomedicines10051144. [PMID: 35625881 PMCID: PMC9138966 DOI: 10.3390/biomedicines10051144] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/02/2022] [Accepted: 05/12/2022] [Indexed: 12/18/2022] Open
Abstract
Checkpoint inhibitor therapy for metastatic melanoma has dramatically improved outcomes. Currently, 20 to 40% of treated patients achieve lengthy remissions. It is not clear whether patients in remission require ongoing therapy or if treatment can be safely discontinued. A retrospective chart review was performed of patients who underwent elective treatment discontinuation after two negative scans three months apart. Of 132 checkpoint inhibitor-treated patients, 46 achieved a complete response (34.8%) and electively discontinued therapy. The progression-free survival was 97.5% at 1 year and 94.7% at 3 years following treatment discontinuation. The median duration of follow-up was 26 months. In total, 4 of 46 individuals (8.7%) eventually relapsed (median time to relapse: 27 months). The median disease-specific survival of the entire cohort was not reached and was 100% at 4 years from the start of therapy. Two patients eventually died, one from melanoma and the other from an unrelated illness. We have identified an elective treatment discontinuation strategy that is generalizable to a variety of checkpoint inhibitor ± targeted therapy regimens. We found that most complete remissions remained durable after elective treatment discontinuation. We hypothesize that this approach could decrease potential drug toxicities, reduce the treatment-related financial burden, and improve patients’ quality of life.
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Affiliation(s)
- Leanne Perez
- University of Nevada School of Medicine, Reno, NV 89557, USA; (L.P.); (R.L.-F.)
| | - Wolfram Samlowski
- University of Nevada School of Medicine, Reno, NV 89557, USA; (L.P.); (R.L.-F.)
- Comprehensive Cancer Centers of Nevada, Las Vegas, NV 89148, USA
- Department of Internal Medicine, Las Vegas Kerkorian School of Medicine, University of Nevada, Las Vegas, NV 89102, USA
- Correspondence: ; Tel.: +1-702-321-3930
| | - Ruby Lopez-Flores
- University of Nevada School of Medicine, Reno, NV 89557, USA; (L.P.); (R.L.-F.)
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