Improved survival of patients with melanoma brain metastases in the era of targeted BRAF and immune checkpoint therapies

BACKGROUND

The development of brain metastases is common for systemic treatment failure in patients with melanoma and has been associated with a poor prognosis. Recent advances with BRAF and immune checkpoint therapies have led to improved patient survival. Herein, the authors evaluated the risk of de novo brain metastases and survival among patients with melanoma brain metastases (MBM) since the introduction of more effective therapies.

METHODS

Patients with unresectable AJCC stage III/IV melanoma who received first-line systemic therapy at Moffitt Cancer Center between 2000 and 2012 were identified. Data were collected regarding patient characteristics, stage of disease, systemic therapies, MBM status/management, and overall survival (OS). The risk of de novo MBM was calculated using a generalized estimating equation model and survival comparisons were performed using Kaplan-Meier and Cox proportional analyses.

RESULTS

A total of 610 patients were included, 243 of whom were diagnosed with MBM (40%). Patients with MBM were younger, with a lower frequency of regional metastasis. No significant differences were noted with regard to sex, BRAF status, or therapeutic class. The risk of de novo MBM was found to be similar among patients treated with chemotherapy, biochemotherapy, BRAF-targeted therapy, ipilimumab, and anti-programmed cell death protein 1/programmed death-ligand 1 regimens. The median OS of patients with MBM was significantly shorter when determined from the time of first regional/distant metastasis but not when determined from the time of first systemic therapy. The median OS from the time of MBM diagnosis was 7.5 months, 8.5 months, and 22.7 months, respectively, for patients diagnosed from 2000 to 2008, 2009 to 2010, and 2011 to the time of last follow-up (P = .002).

CONCLUSIONS

Brain metastases remain a common source of systemic treatment failure. The OS for patients with MBM has improved significantly. Further research into MBM prevention is needed. Cancer 2018;124:297-305. © 2017 American Cancer Society.

Developments in Intralesional Therapy for Metastatic Melanoma

BACKGROUND

Locoregional advanced melanoma poses a complex clinical challenge that requires a multidisciplinary, patient-centered approach. Numerous agents have been studied for their suitability as intralesional therapy in the past decades, but few have successfully completed phase 3 clinical trial testing.

METHODS

The relevant medical literature was searched for articles regarding use of intralesional therapies in metastatic melanoma. Therapies with data from phase 2 or higher studies were selected for review. This review also summarizes the mechanisms of action, adverse-event profiles, and clinical data for these agents.

RESULTS

Intralesional therapies demonstrate promising effects in select patients with advanced melanoma. The optimal approach should be individually tailored and consist of a combination of intralesional therapies, regional perfusions, systemic immunotherapies, targeted therapies, and surgery, if necessary.

CONCLUSIONS

Due to its relatively good local response rates and tolerable adverse-event profile, intralesional therapy may be a treatment option for select patients with unresectable, locally advanced or metastatic melanoma.

Challenging the knowledge base and skillset for providing surgical consent by orthopedic and plastic surgeons in the Netherlands: an identified area of improvement in patient safety

Background

Successfully completing a surgical informed consent process is an important element of the preoperative consult. A previous study of Dutch general surgeons demonstrated that the implementation of SIC did not meet acceptable standards. However, the quality of the SIC process in the orthopedic surgical or plastic surgical arena is unknown.

Methods

Following ethical approval, an online survey investigating specifics of surgical informed consent was performed among members of the Dutch Scientific Association of Orthopedic Surgeons and the Dutch Society for Plastic Surgery.

Results

A total of 335 responses from a majority of departments of orthopedic (86 %) and plastic surgery (78 %) were eligible for analysis. Scores on knowledge were poor as only 50 % recognized the three basic elements of surgical informed consent (competence, exchange of information and consent). The orthopedic group used more tools in the surgical informed consent process, such as instruction movies and websites or specialized nursing staff, compared to plastic surgery (orthopedic: 31-50 % vs. plastic: 6-30 %, p = 0.05- < 0.001). In contrast, surgical informed consent forms were used more frequently by the plastic surgical group (orthopedic 21 % vs. plastic:42 % p < 0.001). Control of the efficacy of the surgical informed consent process was low, 36 % in both groups. One in every seven orthopedic or plastic surgeons was faced with an official surgical informed consent-related complaint in the previous five years.

Conclusions

Similar to general surgeons, Dutch orthopedic and plastic surgeons demonstrate poor knowledge and skills regarding surgical informed consent. Increased awareness, better training and use of modern tools including standard forms and online software programs will improve the SIC process and will optimize patient care.

Electronic supplementary material

The online version of this article (doi:10.1186/s13037-016-0110-0) contains supplementary material, which is available to authorized users.

Tumor mitotic rate added to the equation: melanoma prognostic factors changed? : a single-institution database study on the prognostic value of tumor mitotic rate for sentinel lymph node status and survival of cutaneous melanoma patients

BACKGROUND

This study aimed to investigate the predictive value of the tumor mitotic rate per mm(2) (TMR) for sentinel lymph node (SLN) status and survival in intermediate and thick cutaneous melanoma.

METHODS

Patients treated for stage I and II melanoma with wide local excision and SLN biopsy between May 1995 and May 2013 were analyzed. In case of insufficient data regarding TMR, pathology slides were reanalyzed. Prognostic factors for SLN status and survival were analyzed with the emphasis on TMR, which was analyzed as a continuous variable, dichotomized (median value) and categorized by two methods.

RESULTS

The study analyzed 453 patients with complete TMR data. The median Breslow thickness was 2.20 mm, and 31.8 % of patients had tumor-positive sentinel lymph node biopsies (SLNBs). In the univariate analysis, TMR was associated with tumor-positive SLNB. This association was not significant in the multivariate analysis. Breslow thickness, primary tumor location on trunk and legs, and younger age were associated with tumor-positive SNLB. At a median follow-up of 47 months, 119 patients (26.3 %) had recurrent disease, and 92 (20.3 %) had died of melanoma. In the univariate analysis, TMR could be established as a significant prognostic factor for disease-free and disease-specific survival, but not in the multivariate analyses. Breslow thickness, ulcerated melanoma, and tumor-positive SLNB were significant prognostic factors for survival.

CONCLUSION

The study was unable to establish TMR as an independent prognostic factor associated with the presence of SLN metastasis. Regarding survival, increasing TMR showed a strong association with decreased survival in the univariate analysis, but this association was rendered nonsignificant by the importance of Breslow thickness and ulceration status in the multivariate model.

Ligand-independent EPHA2 signaling drives the adoption of a targeted therapy-mediated metastatic melanoma phenotype

Many patients with BRAF inhibitor resistance can develop disease at new sites, suggesting that drug-induced selection pressure drives metastasis. Here, we used mass spectrometry-based phosphoproteomic screening to uncover ligand-independent EPHA2 signaling as an adaptation to BRAF inhibitor therapy that led to the adoption of a metastatic phenotype. The EPHA2-mediated invasion was AKT-dependent and readily reversible upon removal of the drug as well as through PI3K and AKT inhibition. In xenograft models, BRAF inhibition led to the development of EPHA2-positive metastases. A retrospective analysis of patients with melanoma on BRAF inhibitor therapy showed that 68% of those failing therapy develop metastases at new disease sites, compared with 35% of patients on dacarbazine. Further IHC staining of melanoma specimens taken from patients on BRAF inhibitor therapy as well as metastatic samples taken from patients failing therapy showed increased EPHA2 staining. We suggest that inhibition of ligand-independent EPHA2 signaling may limit metastases associated with BRAF inhibitor therapy.

SIGNIFICANCE

This study provides evidence that BRAF inhibition promotes the adoption of a reversible, therapy-driven metastatic phenotype in melanoma. The cotargeting of ligand-independent EPHA2 signaling and BRAF may be one strategy to prevent the development of therapy-mediated disease at new sites.

Intralesional therapy for metastatic melanoma

INTRODUCTION

Intralesional therapy for metastatic melanoma has some advantages over systemic therapy. Local drug administration allows for delivery of an increased concentration of the agent and reduced systemic exposure, thereby increasing local efficacy and limiting toxicity. Moreover, since in vivo tumor nodules contain the tumor antigens, this tumor tissue may serve as an autologous vaccine to induce systemic immunity. This so-called 'bystander effect', where uninjected distant lesions exhibit a response, has been reported in select intralesional therapy trials.

AREAS COVERED

This review will give an overview of the working mechanisms, clinical evidence and side effects for available intralesional and topical therapies and summarize the most recent developments in this field.

EXPERT OPINION

The ideal treatment approach for locoregionally advanced melanoma should be multidisciplinary and tailored to the patient, taking into consideration patient-related, tumor-related factors (such as location, tumor burden, mutation status) and previous treatments received. It will likely not be a single therapy, but rather a combination of injectable treatments, regional perfusions and systemic therapies.

Abstract 1610: MAPK inhibitor resistance leads to ligand-independent Ephrin A2 receptor signaling and the formation of new melanoma metastases

Melanoma is the deadliest form of skin cancer with the worst prognosis in patients with metastasis to distant sites such as brain, liver and bone. Studies have shown that MAPK reactivation is a key signaling event leading to BRAF inhibitor resistance. As such, clinical investigations are now underway to evaluate the efficacy of combining frontline BRAF plus MEK inhibitors. Though this approach appears to have meaningful clinical benefit, there are a number of patients who do not respond to therapy, or who through unknown mechanisms, succumb to refractory disease. In order to identify the dynamic changes that drive MAPK inhibitor resistance, we have developed a systems level approach combining mass spectrometry based phosphoproteomic and bioinformatics methodologies. Based on significant changes in tyrosine, threonine and serine phosphorylation events between naive and vemurafenib resistant melanoma cell lines, we have mapped a resistance interactome of ∼550 nodes. This resistance network was significantly enriched for pathways associated with metastatic disease where changes in network connectivity resulted in the appearance of new signaling hubs such as EGFR, EphA2, EphB4, STAT3, FAK1 and HDAC1. The clinical relevance of these findings was demonstrated in a retrospective study showing that 65% of BRAFV600E patients on vemurafenib therapy developed metastases at new sites, with 25% of these new metastases involving the brain. Consistent with our bioinformatics prediction, resistant lines had greater metastatic potential as seen by increased migration and invasion across matrigel and endothelial cell barriers. Extending our findings to a panel of BRAF and BRAF plus MEK inhibitor resistant cell lines, we found compelling evidence that EphA2 is essential for maintaining a resistance phenotype. This phenotype was associated with AKT activation and uncoupled Eph-ephrin signaling resulting in S897 phosphorylation and overexpression of EphA2. In vivo analysis of matched primary and metastatic tumors from vemurafenib resistant xenografts showed that EphA2 expression is increased in metastatic but not primary lesions. Importantly, analysis of clinical specimens from melanoma patients undergoing or failing vemurafenib therapy confirmed that EphA2 receptor expression is significantly upregulated in metastatic but not primary tumors. Functionally, EphA2 S897 phosphorylation was increased at the tumor leading edge of metastatic lesions while absent in primary lesions. Our results show that MAPK resistant melanomas can adaptively rewire their signaling leading to a more malignant phenotype and that through proteomics based approaches we can reliably identify resistance pathways that will translate into rational therapeutic strategies for disseminated disease.

Citation Format: Kim H. T. Paraiso, Meghna Das Thakur, Jobin K. John, Bin Fang, John M. Koomen, Inna V. Fedorenko, Hensin Tsao, Keith T. Flaherty, Jane L. Messina, Elena M. Pasquale, Alejandro Villagra, John M. Kirkwood, Friedegund Meier, Sarah Sloot, Geoffrey T. Gibney, Darrin Stuart, Hussein Tawbi, Keiran S.M. Smalley. MAPK inhibitor resistance leads to ligand-independent Ephrin A2 receptor signaling and the formation of new melanoma metastases. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 1610. doi:10.1158/1538-7445.AM2014-1610

Side effects of analgesia may significantly reduce quality of life in symptomatic multiple myeloma: a cross-sectional prevalence study

Background

Pain is a common symptom in patients with multiple myeloma (MM). Many patients are dependent on analgesics and in particular opioids, but there is limited information on the impact of these drugs and their side effects on health-related quality of life (HRQoL).

Method

In a cross-sectional study, semi-structured interviews were performed in 21 patients attending the hospital with symptomatic MM on pain medications. HRQoL was measured using items 29 and 30 of the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30.

Results

Patients were able to recall a median of two (range 0–4) analgesics. They spontaneously identified a median of two (range 1–5) side effects attributable to their analgesic medications. Patients’ assessment of HRQoL based on the EORTC QLQ-C30 questions 29/30 was mean 48.3 (95 % CI; 38.7–57.9) out of 100. Patients’ assessment of their HRQoL in the hypothetical situation, in which they would not experience any side effects from analgesics, was significantly higher: 62.6 (53.5–71.7) (t test, p = 0.001).

Conclusion

This study provides, for the first time, evidence that side effects of analgesics are common in symptomatic MM and may result in a statistically and clinically significant reduction of self-reported HRQoL.

Bilateral catheter-directed thrombolysis in a patient with deep venous thrombosis caused by a hypoplastic inferior vena cava

Introduction

Deep venous thrombosis treatment using catheter-directed thrombolysis is advocated over systemic thrombolysis because it reduces bleeding complications. With the development of a catheter that combines ultrasound vibrations and the local delivering of thrombolytics, new and safer treatments appear that are suitable for more complex problems.

Report

An adolescent male presented with bilateral iliofemoral thrombosis based on a hypoplastic inferior vena cava that had existed for more than two weeks. He was succesfully treated by bilateral ultrasound-accelerated catheter-directed thrombolysis using EkoSonic® (Small Vessel) Endovascular System (EKOS) and stenting of the inferior vena cava. After eight months of follow-up, the inferior vena cava is still patent.

Conclusion

EKOS thrombolysis of longer existing bilateral deep venous thrombosis in the central venous system is a succesful treatment modality in congenital inferior vena cava anomalies.

[Preoperative medical record-keeping can be improved: new informed consent form assists both physicians and patients]

Adequate record-keeping is an important part of the surgical informed consent (IC) process. Standardization can enhance the quality of this process but is incomplete and qualitatively insufficiently implemented in current surgical practice. The introduction of well-designed tools would improve daily practice. We inventoried preoperative reporting at all 91 Dutch departments of General Surgery. Thirty-nine of the 73 departments that provided information on their IC process used a standard form. Twenty-nine of these forms were sent for analysis using a checklist based on legislation, recent case law and specialist literature. The mean number of items per form was 37, but not a single form was complete. Based on these results in combination with relevant legislation, guidelines and expert opinions, an adequate, user-friendly and straightforward preoperative IC form was designed. This IC form can serve as a checklist and report for the physician and as an information leaflet for the patient.

Body mass index as a prognostic marker for biochemical recurrence in Dutch men treated with radical prostatectomy

OBJECTIVE

To investigate whether body mass index (BMI) is a prognostic factor for biochemical recurrence (BCR) in Dutch men after radical prostatectomy (RP), as although epidemiological studies of obesity in relation to prostate cancer have provided conflicting results, recent studies from the USA suggest that a higher BMI is a risk factor for progression of prostate cancer.

PATIENTS AND METHODS

Of the 1417 patients with prostate cancer who had RP at two University hospitals, 1302 were included in the present study. BMI (kg/m(2)) classes were defined as normal (<25), overweight (25-30) and obese (> or =30). The median follow-up was 59 months and clinical data were obtained retrospectively from charts. BCR was defined as two consecutive prostate-specific antigen (PSA) levels of >0.1 ng/mL.

RESULTS

In all, 600 patients were classified as having normal weight (43.9%), 665 as overweight (48.6%) and 103 as obese (7.5%). Overall, 297 patients developed BCR after RP; the 10-year risk (95% confidence interval) of BCR was 31.9 (26.6-37.2)%, 30.5 (25.8-35.2)% and 23.9 (14.9-32.9)% for patients in the three categories, respectively (P = 0.836). Multivariable proportional hazard regression analyses of BMI and established prognostic factors for BCR did not change these results.

CONCLUSION

BMI appeared to have no prognostic value for BCR in Dutch patients with clinically localized prostate cancer and treated with RP.