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Bar-Hai N, Ben-Betzalel G, Stoff R, Grynberg S, Schachter J, Shapira-Frommer R, Asher N. Better Late Than Never: The Impact of Steroidal Treatment on the Outcome of Melanoma Patients Treated with Immunotherapy. Cancers (Basel) 2023; 15:cancers15113041. [PMID: 37297003 DOI: 10.3390/cancers15113041] [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: 03/26/2023] [Revised: 05/29/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Successful treatment with Immune Checkpoint Inhibitors (ICI) requires the balanced activation of the immune system. Over-activation may result in immune-related adverse events (irAEs), which often require steroidal treatment. This study examined the possible impact of steroids on treatment efficacy in melanoma patients concerning initiation timing and dosage. METHODS A retrospective, single-center analysis of patients with advanced melanoma who underwent first-line ICI therapy during 2014-2020 was conducted. RESULTS Among the 415 patients, two-hundred patients (48.3%) were exposed to steroids during the first line, most of them due to irAEs (n = 169, 84.5%). Nearly a quarter of them were exposed to steroids within the first four weeks of treatment. Surprisingly, steroidal exposure was associated with better progression-free survival (PFS; HR = 0.74, p = 0.015); however, early exposure (within four weeks of treatment) resulted in a significantly shorter PFS compared to late exposure (adjusted HR 3.2, p < 0.001). CONCLUSIONS Early exposure to corticosteroids during the priming phase of ICI therapy could impede the establishment of an effective immune response. These results suggest that caution should be exercised when considering the use of steroids for the management of early-onset irAEs.
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Affiliation(s)
- Neta Bar-Hai
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Guy Ben-Betzalel
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Ronen Stoff
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Shirly Grynberg
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Jacob Schachter
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan 52621, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Ronnie Shapira-Frommer
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Nethanel Asher
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan 52621, Israel
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Asher N, Ben-Betzalel G, Lev-Ari S, Shapira-Frommer R, Steinberg-Silman Y, Gochman N, Schachter J, Meirson T, Markel G. Real World Outcomes of Ipilimumab and Nivolumab in Patients with Metastatic Melanoma. Cancers (Basel) 2020; 12:cancers12082329. [PMID: 32824780 PMCID: PMC7464656 DOI: 10.3390/cancers12082329] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/06/2020] [Accepted: 08/14/2020] [Indexed: 12/17/2022] Open
Abstract
Background: Immunotherapy has drastically changed the outlook for melanoma patients over the past decade. Specifically, the dual blockade of immune checkpoints using ipilimumab and nivolumab has shown unprecedented response rates and survival outcomes. This immense achievement, though, is at the cost of toxicity, with 60% of the patients experiencing high-grade adverse events (AEs). Our study aims to report the efficacy and toxicity outcomes of an out-of-trial, real-life population. Methods: Data on metastatic melanoma patients treated with ipilimumab and nivolumab were retrieved from our melanoma database—a single-center prospectively updated, medical-records based oncologic registry. Data included demographics, clinical and pathological information, as well as tumor responses and survival. Associations between patient or treatment characteristics and outcomes were also evaluated. Results: We identified 172 metastatic melanoma patients, of whom 64% were treatment-naïve. The median follow-up was 12 months. The response rates for treatment-naïve and previously-treated patients were 61% and 25%, respectively; median progression-free survival (PFS) were 12.2 and 2.6 months, and median overall survival (OS) were not-reached (NR) and 6.1 months, respectively. The estimated three-year OS for treatment-naïve patients was 58% (95% CI 42–65). At data cutoff, 22% were still on-treatment. Grade 3–4 adverse events (AEs) were reported in 60% of the patients, almost all of whom were exposed to steroid treatments (59%); AEs were fatal in 4 patients, and led to permanent treatment discontinuation in 31%. Factors significantly associated with outcome were cutaneous histology, low lactate dehydrogenase (LDH), low number of metastatic sites, performance status, first line of treatment and number of combinations administered during the induction phase. Conclusions: Despite the profoundly different baseline patient characteristics, the combination of ipilimumab and nivolumab is as effective in the real-world population as it was in clinical trials, including long-term outcomes. In addition to confirming the significance of baseline prognostic factors, our study reveals that the number of combinations effectively administered may also be correlated with good outcome.
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Affiliation(s)
- Nethanel Asher
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan 52621, Israel; (G.B.-B.); (S.L.-A.); (R.S.-F.); (Y.S.-S.); (N.G.); (J.S.); (T.M.)
- Correspondence: (N.A.); (G.M.); Tel.: +972-526669283 (N.A.); Fax: +972-35304934 (N.A.)
| | - Guy Ben-Betzalel
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan 52621, Israel; (G.B.-B.); (S.L.-A.); (R.S.-F.); (Y.S.-S.); (N.G.); (J.S.); (T.M.)
| | - Shaked Lev-Ari
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan 52621, Israel; (G.B.-B.); (S.L.-A.); (R.S.-F.); (Y.S.-S.); (N.G.); (J.S.); (T.M.)
| | - Ronnie Shapira-Frommer
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan 52621, Israel; (G.B.-B.); (S.L.-A.); (R.S.-F.); (Y.S.-S.); (N.G.); (J.S.); (T.M.)
| | - Yael Steinberg-Silman
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan 52621, Israel; (G.B.-B.); (S.L.-A.); (R.S.-F.); (Y.S.-S.); (N.G.); (J.S.); (T.M.)
| | - Neta Gochman
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan 52621, Israel; (G.B.-B.); (S.L.-A.); (R.S.-F.); (Y.S.-S.); (N.G.); (J.S.); (T.M.)
| | - Jacob Schachter
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan 52621, Israel; (G.B.-B.); (S.L.-A.); (R.S.-F.); (Y.S.-S.); (N.G.); (J.S.); (T.M.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Tomer Meirson
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan 52621, Israel; (G.B.-B.); (S.L.-A.); (R.S.-F.); (Y.S.-S.); (N.G.); (J.S.); (T.M.)
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1589, Israel
| | - Gal Markel
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan 52621, Israel; (G.B.-B.); (S.L.-A.); (R.S.-F.); (Y.S.-S.); (N.G.); (J.S.); (T.M.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- The Department of Clinical Microbiology and Immunology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Correspondence: (N.A.); (G.M.); Tel.: +972-526669283 (N.A.); Fax: +972-35304934 (N.A.)
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3
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Kimbara S, Fujiwara Y, Iwama S, Ohashi K, Kuchiba A, Arima H, Yamazaki N, Kitano S, Yamamoto N, Ohe Y. Association of antithyroglobulin antibodies with the development of thyroid dysfunction induced by nivolumab. Cancer Sci 2018; 109:3583-3590. [PMID: 30230649 PMCID: PMC6215874 DOI: 10.1111/cas.13800] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/05/2018] [Accepted: 09/07/2018] [Indexed: 02/07/2023] Open
Abstract
Thyroid dysfunction (TD) induced by immune checkpoint inhibitors is not sufficiently understood. The purpose of this retrospective observational study was to identify risk factors and the clinical course of TD induced by nivolumab. Patients with advanced solid tumors who were treated with nivolumab from March 2009 through to March 2016 at the National Cancer Center Hospital (Tokyo, Japan) were included. Thyroid function and antithyroid Abs from serum samples among all patients were evaluated at baseline and during nivolumab treatment. Overt hypothyroidism was defined as low serum‐free T4 together with elevated thyroid‐stimulating hormone (TSH) >10 μIU/mL. Thyrotoxicosis was defined as low TSH with elevated free T4 and/or free T3. We defined thyroid autoimmunity as the presence of antithyroid Abs at baseline, including antithyroid peroxidase Abs and antithyroglobulin Abs (TgAb). Twenty‐three (14%) of a total of 168 patients developed TD, including 17 cases of hypothyroidism and 20 of thyrotoxicosis. Thyrotoxicosis followed by hypothyroidism occurred in 14 cases. Fourteen of 35 patients (40%) with thyroid autoimmunity developed TD vs 9 of 133 (7%) without (odds ratio 9.19; 95% confidence interval [CI], 3.53‐23.9). In multivariate analysis, elevated TSH and TgAb at baseline were significantly associated with the development of TD, with odds ratio of 7.36 (95% CI, 1.66‐32.7) and 26.5 (95% CI, 8.18‐85.8), respectively. Association between TD and elevated antithyroid peroxidase Abs at baseline was not significant. These results suggest that patients with pre‐existing TgAb and elevated TSH at baseline are at high risk of TD.
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Affiliation(s)
- Shiro Kimbara
- Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo, Japan.,Department of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Japan
| | - Yutaka Fujiwara
- Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo, Japan.,Department of Experimental Therapeutics, National Cancer Center Hospital, Tokyo, Japan
| | - Shintaro Iwama
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ken Ohashi
- Department of General Internal Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Aya Kuchiba
- Biostatistics Division, Center for Research Administration and Support, National Cancer Center, Tokyo, Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoya Yamazaki
- Department of Dermatologic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Shigehisa Kitano
- Department of Experimental Therapeutics, National Cancer Center Hospital, Tokyo, Japan
| | - Noboru Yamamoto
- Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo, Japan.,Department of Experimental Therapeutics, National Cancer Center Hospital, Tokyo, Japan
| | - Yuichiro Ohe
- Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo, Japan
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Ascierto PA, Puzanov I, Agarwala SS, Bifulco C, Botti G, Caracò C, Ciliberto G, Davies MA, Dummer R, Ferrone S, Gajewski TF, Garbe C, Luke JJ, Marincola FM, Masucci G, Mehnert JM, Mozzillo N, Palmieri G, Postow MA, Schoenberger SP, Wang E, Thurin M. Perspectives in melanoma: Meeting report from the Melanoma Bridge (30 November-2 December, 2017, Naples, Italy). J Transl Med 2018; 16:207. [PMID: 30031393 PMCID: PMC6054754 DOI: 10.1186/s12967-018-1568-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/03/2018] [Indexed: 12/22/2022] Open
Abstract
Metastatic melanoma represents a challenging clinical situation and, until relatively recently, there was an absence of effective treatment options. However, in 2011, the advanced melanoma treatment landscape was revolutionised with the approval of the anti-cytotoxic T-lymphocyte-associated protein-4 checkpoint inhibitor ipilimumab and the selective BRAF kinase inhibitor vemurafenib, both of which significantly improved overall survival. Since then, availability of new immunotherapies, especially the anti-programmed death-1 checkpoint inhibitors, as well as other targeted therapies, have further improved outcomes for patients with advanced melanoma. Seven years on from the first approval of these novel therapies, evidence for the use of various immune-based and targeted approaches is continuing to increase at a rapid rate. Improved understanding of the tumour microenvironment and tumour immuno-evasion strategies has resulted in different approaches to target and harness the immune response. These new immune-based approaches offer the opportunity for various approaches with distinct modes of action being used in combination with one another, as well as combined with other treatment modalities such as targeted therapy, electrochemotherapy and surgery. The increasing number of treatment options that are now available has resulted in a growing need to identify which patients will derive most benefit from which treatments. Much research is now focused on the identification of biomarkers that can be utilised to help select patients for treatment. These and other recent advances in the management of melanoma were the focus of discussions at the third Melanoma Bridge meeting (30 November-2 December, 2017, Naples, Italy), which is summarised in this report.
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Affiliation(s)
- Paolo A. Ascierto
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori-IRCCS Fondazione “G. Pascale”, Via Mariano Semmola snc, 80131 Naples, NA Italy
| | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY USA
| | - Sanjiv S. Agarwala
- Medical Oncology and Hematology, St. Luke’s University Hospital and Temple University, Bethlehem, PA USA
| | - Carlo Bifulco
- Earle A. Chiles Research Institute, Robert W. Franz Cancer Research Center, Providence Portland Medical Center, Portland, OR USA
| | - Gerardo Botti
- Istituto Nazionale Tumori-Fondazione “G. Pascale”, Naples, Italy
| | - Corrado Caracò
- Division of Surgery of Melanoma and Skin Cancer, Istituto Nazionale Tumori–Fondazione “G.Pascale”, Naples, Italy
| | | | - Michael A. Davies
- Department of Melanoma Medical Oncology, Department of Systems Biology, University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Reinhard Dummer
- Department of Dermatology, University of Zurich Hospital, Zurich, Switzerland
| | | | - Thomas F. Gajewski
- Department of Pathology and Department of Medicine, Section of Hematology/Oncology, The University of Chicago Medicine, Chicago, IL USA
| | - Claus Garbe
- Division of Dermatologic Oncology, Department of Dermatology, Eberhard Karls University, Tuebingen, Germany
| | | | | | - Giuseppe Masucci
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Janice M. Mehnert
- Developmental Therapeutics Program, Cancer Institute of New Jersey, New Brunswick, NJ USA
| | - Nicola Mozzillo
- Istituto Nazionale Tumori Fondazione G. Pascale, Naples, Italy
| | - Giuseppe Palmieri
- Unit of Cancer Genetics, Institute of Biomolecular Chemistry, National Research Council, Sassari, Italy
| | - Michael A. Postow
- Memorial Sloan Kettering Cancer Center, New York, NY USA
- Weill Cornell Medical College, New York, NY USA
| | | | - Ena Wang
- Immune Oncology Discovery and System Biology, AbbVie, Redwood City, CA USA
| | - Magdalena Thurin
- Cancer Diagnosis Program, Division of Cancer Treatment and Diagnosis, NCI, NIH, Rockville, MD USA
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5
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Ascierto PA, Agarwala SS, Ciliberto G, Demaria S, Dummer R, Duong CPM, Ferrone S, Formenti SC, Garbe C, Halaban R, Khleif S, Luke JJ, Mir LM, Overwijk WW, Postow M, Puzanov I, Sondel P, Taube JM, Thor Straten P, Stroncek DF, Wargo JA, Zarour H, Thurin M. Future perspectives in melanoma research "Melanoma Bridge", Napoli, November 30th-3rd December 2016. J Transl Med 2017; 15:236. [PMID: 29145885 PMCID: PMC5691855 DOI: 10.1186/s12967-017-1341-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 11/07/2017] [Indexed: 02/07/2023] Open
Abstract
Major advances have been made in the treatment of cancer with targeted therapy and immunotherapy; several FDA-approved agents with associated improvement of 1-year survival rates became available for stage IV melanoma patients. Before 2010, the 1-year survival were quite low, at 30%; in 2011, the rise to nearly 50% in the setting of treatment with Ipilimumab, and rise to 70% with BRAF inhibitor monotherapy in 2013 was observed. Even more impressive are 1-year survival rates considering combination strategies with both targeted therapy and immunotherapy, now exceeding 80%. Can we improve response rates even further, and bring these therapies to more patients? In fact, despite these advances, responses are heterogeneous and are not always durable. There is a critical need to better understand who will benefit from therapy, as well as proper timing, sequence and combination of different therapeutic agents. How can we better understand responses to therapy and optimize treatment regimens? The key to better understanding therapy and to optimizing responses is with insights gained from responses to targeted therapy and immunotherapy through translational research in human samples. Combination therapies including chemotherapy, radiotherapy, targeted therapy, electrochemotherapy with immunotherapy agents such as Immune Checkpoint Blockers are under investigation but there is much room for improvement. Adoptive T cell therapy including tumor infiltrating lymphocytes and chimeric antigen receptor modified T cells therapy is also efficacious in metastatic melanoma and outcome enhancement seem likely by improved homing capacity of chemokine receptor transduced T cells. Tumor infiltrating lymphocytes therapy is also efficacious in metastatic melanoma and outcome enhancement seem likely by improved homing capacity of chemokine receptor transduced T cells. Understanding the mechanisms behind the development of acquired resistance and tests for biomarkers for treatment decisions are also under study and will offer new opportunities for more efficient combination therapies. Knowledge of immunologic features of the tumor microenvironment associated with response and resistance will improve the identification of patients who will derive the most benefit from monotherapy and might reveal additional immunologic determinants that could be targeted in combination with checkpoint blockade. The future of advanced melanoma needs to involve education and trials, biobanks with a focus on primary tumors, bioinformatics and empowerment of patients and clinicians.
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Affiliation(s)
- Paolo A. Ascierto
- Unit of Melanoma, Cancer Immunotherapy and Innovative Therapy, IRCCS Istituto Nazionale Tumori “Fondazione G. Pascale”, Naples, Italy
- Istituto Nazionale Tumori di Napoli Fondazione “G. Pascale”, Via Mariano Semmola, 80131 Naples, Italy
| | - Sanjiv S. Agarwala
- Oncology & Hematology, St. Luke’s University Hospital and Temple University, Bethlehem, PA USA
| | | | - Sandra Demaria
- Radiation Oncology and Pathology, Weill Cornell Medical College, New York City, NY USA
| | - Reinhard Dummer
- Department of Dermatology, University of Zurich Hospital, Zurich, Switzerland
| | - Connie P. M. Duong
- INSERM (National Institute of Health and Medical Research), Institut Gustave Roussy, Villejuif, France
| | | | - Silvia C. Formenti
- Department of Radiation Oncology, Weill Cornell Medical College, New York City, NY USA
| | - Claus Garbe
- Division of Dermatologic Oncology, Department of Dermatology, Eberhard Karls University, Tübingen, Germany
| | - Ruth Halaban
- Department of Dermatology, Yale University School of Medicine, New Haven, CT USA
| | - Samir Khleif
- Georgia Cancer Center, Augusta University, Augusta, GA USA
| | - Jason J. Luke
- Department of Hematology/Oncology, University of Chicago Comprehensive Cancer Center, Chicago, IL USA
| | - Lluis M. Mir
- CNRS (National Center for Scientific Research, France), University Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Willem W. Overwijk
- Division of Cancer Medicine, Department of Melanoma Medical Oncology-Research, University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Michael Postow
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, NY USA
- Weill Cornell Medical College, New York, NY USA
| | - Igor Puzanov
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY USA
| | - Paul Sondel
- Pediatrics, Human Oncology and Genetics, University of Wisconsin, Madison, WI USA
- UW Carbone Cancer Center, Madison, WI USA
| | - Janis M. Taube
- Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Per Thor Straten
- Center for Cancer Immune Therapy (CCIT), Department of Hematology, University Hospital Herlev, Herlev, Denmark
- Department of Immunology and Microbiology, University of Copenhagen, Herlev, Denmark
| | | | - Jennifer A. Wargo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Hassane Zarour
- Medicine, Immunology and Dermatology Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Magdalena Thurin
- Cancer Diagnosis Program, Division of Cancer Treatment and Diagnosis, NCI, NIH, Rockville, MD USA
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Mandalà M, Tondini C, Merelli B, Massi D. Rationale for New Checkpoint Inhibitor Combinations in Melanoma Therapy. Am J Clin Dermatol 2017; 18:597-611. [PMID: 28432648 DOI: 10.1007/s40257-017-0282-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The use of monoclonal antibodies that block immunologic checkpoints, which mediate adaptive immune resistance, has revolutionized the treatment of metastatic melanoma patients. Specifically, targeting single immune suppressive molecules such as cytotoxic T lymphocyte-associated protein 4 (CTLA-4), or programmed cell death protein 1 (PD-1) expressed on T cells or its primary ligand, programmed cell death ligand 1 (PD-L1), resulted in pronounced clinical benefit for a subset of melanoma patients. Although single-agent immune checkpoint inhibitor therapy has demonstrated promising clinical activity in metastatic melanoma patients, there is still a significant proportion of patients who show primary resistance to these therapies. Increased clinical efficacy was reported in phase II and III randomized studies by co-targeting CTLA-4 and PD-1 in the treatment of advanced melanoma, indicating the existence of multiple non-redundant immunosuppressive pathways in the tumor microenvironment. Nevertheless, only 50% of patients responded to combined anti-CTLA-4 and anti-PD-1 treatment. Additionally, the combination regimen was associated with severe toxicity in >50-60% of patients. In this review we summarize the rationale for new checkpoint inhibitor combinations in melanoma therapy and discuss how biologic-driven stratification enables the design of optimal combination therapies tailored to target different tumor microenvironments.
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Balar AV, Weber JS. PD-1 and PD-L1 antibodies in cancer: current status and future directions. Cancer Immunol Immunother 2017; 66:551-564. [PMID: 28213726 PMCID: PMC11028560 DOI: 10.1007/s00262-017-1954-6] [Citation(s) in RCA: 220] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 01/06/2017] [Indexed: 12/20/2022]
Abstract
Immunotherapy has moved to the center stage of cancer treatment with the recent success of trials in solid tumors with PD-1/PD-L1 axis blockade. Programmed death-1 or PD-1 is a checkpoint molecule on T cells that plays a vital role in limiting adaptive immune responses and preventing autoimmune and auto-inflammatory reactivity in the normal host. In cancer patients, PD-1 expression is very high on T cells in the tumor microenvironment, and PD-L1, its primary ligand, is variably expressed on tumor cells and antigen-presenting cells within tumors, providing a potent inhibitory influence within the tumor microenvironment. While PD-L1 expression on tumors is often regarded as a negative prognostic factor, it is clearly associated with a positive outcome for treatment with PD-1/PD-L1 blocking antibodies, and has been used to select patients for this therapy. Responses of long duration, a minority of patients with atypical responses in which progression may precede tumor shrinkage, and a pattern of autoimmune side effects often seen with this class of drugs characterize therapy with PD-1/PD-L1 blocking drugs. While excellent efficacy has been seen with a limited number of tumor types, most epithelial cancers do not show responses of long duration with these agents. In the current review, we will briefly summarize the scientific background data supporting the development of PD-1/PD-L1 blockade, and then describe the track record of these antibodies in multiple different histologies ranging from melanoma and lung cancer to less common tumor types as well as discuss biomarkers that may assist in patient selection.
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Affiliation(s)
- Arjun Vasant Balar
- Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, 522 First Avenue, 1310 Smilow Research Building, New York, NY, 10016, USA
| | - Jeffrey S Weber
- Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, 522 First Avenue, 1310 Smilow Research Building, New York, NY, 10016, USA.
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Bourke JM, O'Sullivan M, Khattak MA. Management of adverse events related to new cancer immunotherapy (immune checkpoint inhibitors). Med J Aust 2017; 205:418-424. [PMID: 27809739 DOI: 10.5694/mja16.00586] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 07/20/2016] [Indexed: 12/19/2022]
Abstract
New immunotherapies have significantly improved survival in certain advanced cancers in recent years, particularly metastatic melanoma and lung cancer. The most effective of these therapies are the immune checkpoint inhibitors (ICIs) such as ipilimumab, nivolumab and pembrolizumab. The use of ICIs will continue to increase in the coming years as evidence of their benefit in a range of other cancers builds. ICIs are associated with novel immune-related adverse events (irAEs), which can involve a wide range of organs. The most common irAEs involve the skin (rash, pruritus), gastrointestinal tract (diarrhoea, colitis) and endocrine system (thyroid, pituitary). While severity is generally mild, life-threatening complications can occur if not recognised and treated promptly. Due to the diverse manifestations of irAEs, patients may present to doctors who are not familiar with these drugs, which creates the potential for delays in management. Management of irAEs depends on severity and the organ affected. Systemic steroids are often required and ICI therapy may be withheld or discontinued. Additional immunosuppressive medications may be necessary in steroid-refractory cases. This review provides an overview of the potential toxicities and their management for general clinicians. Broader awareness of these issues among medical professionals will hopefully reduce unnecessary delays in diagnosis and treatment. Patient and carer education regarding irAEs is extremely important; patients and carers should be advised to seek urgent medical attention if required.
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Salama AKS, Moschos SJ. Next steps in immuno-oncology: enhancing antitumor effects through appropriate patient selection and rationally designed combination strategies. Ann Oncol 2017; 28:57-74. [PMID: 28177433 PMCID: PMC6887913 DOI: 10.1093/annonc/mdw534] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Cancers escape immune surveillance via distinct mechanisms that involve central (negative selection within the thymus) or peripheral (lack of costimulation, receipt of death/anergic signals by tumor, immunoregulatory cell populations) immune tolerance. During the 1990s, moderate clinical benefit was seen using several cytokine therapies for a limited number of cancers. Over the past 20 years, extensive research has been performed to understand the role of various components of peripheral immune tolerance, with the co-inhibitory immune checkpoint molecules cytotoxic T-lymphocyte antigen 4 (CTLA-4), programmed death 1 (PD-1), and its ligand (PD-L1) being the most well-characterized at preclinical and clinical levels. Patients and methods We used PubMed and Google Scholar searches to identify key articles published reporting preclinical and clinical studies investigating CTLA-4 and PD-1/PD-L1, frequently cited review articles, and clinical studies of CTLA-4 and PD-1/PD-L1 pathway inhibitors, including combination therapy strategies. We also searched recent oncology congress presentations and clinicaltrials.gov to cover the most up-to-date clinical trial data and ongoing clinical trials of immune checkpoint inhibitor (ICI) combinations. Results Inhibiting CTLA-4 and PD-1 using monoclonal antibody therapies administered as single agents has been associated with clinical benefit in distinct patient subgroups across several malignancies. Concurrent blockade of CTLA-4 and components of the PD-1/PD-L1 system using various schedules has shown synergy and even higher incidence of durable antitumor responses at the expense of increased rates of immune-mediated adverse events, which can be life-threatening, but are rarely fatal and are reversible in most cases using established treatment guidelines. Conclusions Dual immune checkpoint blockade has demonstrated promising clinical benefit in numerous solid tumor types. This example of concurrent modulation of multiple components of the immune system is currently being investigated in other cancers using various immunomodulatory strategies.
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Affiliation(s)
- A. K. S. Salama
- Division of Medical Oncology, Duke University Medical Center, Durham
| | - S. J. Moschos
- Division of Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, USA
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O'Donnell JS, Long GV, Scolyer RA, Teng MWL, Smyth MJ. Resistance to PD1/PDL1 checkpoint inhibition. Cancer Treat Rev 2016; 52:71-81. [PMID: 27951441 DOI: 10.1016/j.ctrv.2016.11.007] [Citation(s) in RCA: 389] [Impact Index Per Article: 48.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 11/19/2016] [Indexed: 12/16/2022]
Abstract
For the first time in decades, patients with difficult-to-treat cancers such as advanced stage metastatic melanoma are being offered a glimpse of hope in the form of immunotherapies. By targeting factors that foster the development and maintenance of an immunosuppressive microenvironment within tumors, these therapies release the brakes on the host's own immune system; allowing cure of disease. Indeed, phase III clinical trials have revealed that therapies such as ipilimumab and pembrolizumab which target the CTLA4 and PD-1 immune checkpoints, respectively, have raised the three-year survival of patients with melanoma to ∼70%, and overall survival (>5years) to ∼30%. Despite this unprecedented efficacy, many patients fail to respond, and more concerning, some patients who demonstrate encouraging initial responses to immunotherapy, can acquire resistance over time. There is now an urgent need to identify mechanisms of resistance, to predict outcome and to identify targets for combination therapy. Here, with the aim of guiding future combination trials that target specific resistance mechanisms to immunotherapies, we have summarised and discussed the current understanding of mechanisms promoting resistance to anti-PD1/PDL1 therapies, and how combination strategies which target these pathways might yield better outcomes for patients.
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Affiliation(s)
- Jake S O'Donnell
- Immunology in Cancer and Infection Laboratory, QIMR Berghofer Medical Research Institute, Herston 4006, Queensland, Australia; School of Medicine, The University of Queensland, Herston 4006, Queensland, Australia; Cancer Immunoregulation and Immunotherapy Laboratory, QIMR Berghofer Medical Research Institute, Herston 4006, Queensland, Australia
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, and Royal North Shore and Mater Hospitals, Sydney, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, and Royal Prince Alfred Hospital, Australia
| | - Michele W L Teng
- Cancer Immunoregulation and Immunotherapy Laboratory, QIMR Berghofer Medical Research Institute, Herston 4006, Queensland, Australia
| | - Mark J Smyth
- Immunology in Cancer and Infection Laboratory, QIMR Berghofer Medical Research Institute, Herston 4006, Queensland, Australia; School of Medicine, The University of Queensland, Herston 4006, Queensland, Australia.
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