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Antoni D, Mesny E, El Kabbaj O, Josset S, Noël G, Biau J, Feuvret L, Latorzeff I. Role of radiotherapy in the management of brain oligometastases. Cancer Radiother 2024; 28:103-110. [PMID: 37802747 DOI: 10.1016/j.canrad.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/27/2023] [Accepted: 03/29/2023] [Indexed: 10/08/2023]
Abstract
The management of patients with brain oligometastases is complex and relies on specific reasoning compared to extracranial oligometastases. The levels of evidence are still low because patients with brain oligometastases are frequently excluded from randomized clinical trials. Stereotactic radiotherapy should be preferred in this indication over whole brain irradiation, both for patients with metastases in place and for those who have undergone surgery. The decision of local treatment and its timing must be a multidisciplinary reflection taking into account the histological and molecular characteristics of the tumor as well as the intracranial efficacy of the prescribed systemic treatments. Great caution must be observed when using stereotactic radiotherapy and concomitant systemic treatments because interactions are still poorly documented. We present the recommendations of the French society of radiation oncology on the management of brain oligometastatic patients with radiotherapy.
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Affiliation(s)
- D Antoni
- Radiation Therapy Department, Institut de cancérologie Strasbourg Europe, 67033 Strasbourg, France.
| | - E Mesny
- Radiation Therapy Department, Hospices civils de Lyon, 69000 Lyon, France
| | - O El Kabbaj
- Radiation Therapy Department, hôpital privé Océane, 56000 Vannes, France
| | - S Josset
- Medical Physics, Institut de cancérologie de l'Ouest, 44800 Saint-Herblain, France
| | - G Noël
- Radiation Therapy Department, Institut de cancérologie Strasbourg Europe, 67033 Strasbourg, France
| | - J Biau
- Radiation Therapy Department, centre Jean-Perrin, 63011 Clermont-Ferrand, France
| | - L Feuvret
- Radiation Therapy Department, Hospices civils de Lyon, 69000 Lyon, France
| | - I Latorzeff
- Radiation Therapy Department, clinique Pasteur, 31300 Toulouse, France
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2
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Su M, Yang Y, Wang P. Efficacy and safety of the combined use of ipilimumab and nivolumab for melanoma patients with brain metastases: a systematic review and meta-analysis. Immunopharmacol Immunotoxicol 2023; 45:761-769. [PMID: 37228242 DOI: 10.1080/08923973.2023.2215403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/14/2023] [Indexed: 05/27/2023]
Abstract
CONTEXT Immune checkpoint inhibitors have advanced immunotherapy for melanoma patients.Objective: This study evaluates efficacy and safety of ipilimumab and nivolumab combination (IN) for melanoma brain metastases (MBM) patients. MATERIALS AND METHODS Literature search was conducted in electronic databases and studies were included if they reported efficacy and safety of IN in MBM patients or prognostic information related to brain metastases. Outcomes evaluated were objective response rate (ORR), complete remission/stable disease/progressive disease rates, progression-free survival (PFS), overall survival (OS), incidence rates of adverse events, and hazard ratios of disease progression or mortality between IN-treated patients with and without brain metastasis. RESULTS Intracranial ORR was higher in IN-treated MBM patients than with control therapies (nivolumab or ipilimumab plus fotemustine). IN treatment led to longer PFS and OS in than control treatments. Five-year OS of IN-treated MBM patients was up to 51% compared to 34% for nivolumab. Outcomes were better for treatment naïve and asymptomatic patients. Whereas many studies reported significantly higher mortality or progression risk with IN treatment in MBM patients compared to non-MBM melanoma patients, many others did not find this risk significant. Incidence of grade 3/4 adverse events in IN-treated MBM patients was: diarrhea or colitis (16%), hepatitis (15%), rash (8%), increased alanine transaminase (8%), increased aspartate aminotransferase (7%), increased lipase (6%), increased amylase (4%), fatigue (3%), hypophysitis (2%), pneumonitis (2%), headache (2%), nausea or vomiting (1%), and neutropenia (1%). CONCLUSION IN is an efficacious and safer treatment option for MBM patients, especially for asymptomatic and treatment naïve patients.
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Affiliation(s)
- Mengmeng Su
- Department of Radiotherapy, Peking University People's Hospital, Beijing, China
| | - Yuyan Yang
- Department of Radiotherapy, Peking University International Hospital, Beijing, China
| | - Peng Wang
- Department of Radiotherapy, Peking University International Hospital, Beijing, China
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3
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Aglietta M, Chiarion-Sileni V, Fava P, Guidoboni M, Depenni R, Minisini A, Consoli F, Ascierto PA, Rinaldi G, Banzi M, Marconcini R, Gueli R, Ferraresi V, Tucci M, Tonini G, Lo Re G, Guida M, Del Vecchio M, Marcon IG, Queirolo P. Outcomes in patients with BRAFV600-mutated melanoma and brain metastases at baseline treated with dabrafenib plus trametinib. TUMORI JOURNAL 2023; 109:537-545. [PMID: 37417313 DOI: 10.1177/03008916231179251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND Brain metastases (BM) and lactate dehydrogenase (LDH) levels above the upper limit of normal (ULN) are associated with poor prognosis in patients with melanoma. Although treatment with the BRAF inhibitor dabrafenib and the MEK inhibitor trametinib have demonstrated long-term clinical benefit in patients with melanoma, data on their efficacy in patients with BM are limited. METHODS DESCRIBE Italy is an observational, retrospective, real-world study evaluating dabrafenib plus trametinib in 499 patients with BRAFV600-mutant stage III unresectable or stage IV melanoma from various sites across Italy. Here, we analyzed the clinical outcomes for the subgroup of patients receiving first-line treatment and presenting with BM at diagnosis and assessed the impact of predictive factors such as LDH levels and the presence of other metastases on median progression-free survival (mPFS). RESULTS Overall, 325 evaluable patients were on first-line therapy and are the focus of this analysis; of these, 76 patients (23.4%) had BM at baseline. mPFS was lower for patients with BM at baseline compared with overall patients (8.7 months vs 9.3 months, respectively). Patients with BM at diagnosis and LDH >ULN had a considerably shorter mPFS compared with patients with LDH ⩽ULN (5.3 months vs 9.9 months, respectively). mPFS was noticeably longer for patients with cerebral metastases only compared with patients with cerebral and other metastases (15.0 months vs 8.7 months, respectively). CONCLUSIONS Dabrafenib plus trametinib showed effectiveness in a real-world population of patients with advanced BRAFV600-mutated melanoma and BM at baseline, supporting its use in this population with poor outcomes.
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Affiliation(s)
- Massimo Aglietta
- Department of Oncology, University of Torino, Torino, Italy
- Department of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | | | - Paolo Fava
- Dermatologic Clinic, Department of Medical Sciences, University of Turin, Turin, Piemonte, Italy
| | - Massimo Guidoboni
- Immunotherapy - Cell Therapy and Biobank, IRCCS-IRST, Meldola (FC), Italy
| | - Roberta Depenni
- Department of Oncology and Hematology, University Hospital of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Alessandro Minisini
- Department of Oncology, Azienda Sanitaria Universitaria del Friuli Centrale, Udine, Italy
| | - Francesca Consoli
- Department of Oncology, ASST Spedali Civili, Brescia, Lombardia, Italy
| | - Paolo Antonio Ascierto
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Naples, Italy
| | - Gaetana Rinaldi
- UOC Oncologia Medica Aoup Paolo Giaccone, Palermo, Sicilia, Italy
| | - Maria Banzi
- Oncology Unit, Presidio Ospedaliero Arcispedale Santa Maria Nuova AUSL di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Riccardo Marconcini
- Presidio Ospedaliero S. Chiara - Az. Ospedaliero Universitaria Pisana, Pisa, Toscana, Italy
| | - Rossana Gueli
- Medical Oncology, ASST Sette Laghi, Circolo Hospital and Macchi Foundation, Varese, Lombardia, Italy
| | - Virginia Ferraresi
- Sarcomas and Rare Tumors Unit, IRCCS - Regina Elena National Cancer Institute, Rome, Lazio, Italy
| | - Marco Tucci
- Department of Biomedical Sciences and Clinical Oncology, University of Bari, "Aldo Moro," Bari, Italy
| | - Giuseppe Tonini
- Department of Medical Oncology, University Campus Bio-Medico, Rome, Italy
| | - Giovanni Lo Re
- Medical Oncology and Immune-Related Tumors, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Michele Guida
- Rare Tumors and Melanoma Unit, IRCCS Istituto dei Tumori Giovanni Paolo II, Bari, Italy
| | - Michele Del Vecchio
- Unit of Melanoma Medical Oncology, Department of Medical Oncology and Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Lombardia, Italy
| | | | - Paola Queirolo
- Oncology Division, Policlinico San Martino IRCCS, Genova, Liguria, Italy
- Division of Medical Oncology for Melanoma, Sarcoma, and Rare Tumors, IEO, European Institute of Oncology IRCCS, Milan, Italy
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Pelizzari G, Bertoli E, Buriolla S, Vitale MG, Basile D, Palmero L, Zara D, Iacono D, Andrea F, Pascoletti G, Bolzonello S, Garutti M, Fasola G, Puglisi F, Minisini AM. Estimating survival in patients with melanoma brain metastases: prognostic value of lactate dehydrogenase. Melanoma Res 2023; 33:398-405. [PMID: 37402350 DOI: 10.1097/cmr.0000000000000907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Patients with melanoma brain metastases (MBM) have poor prognosis, albeit advances in locoregional and systemic treatments. The melanoma-specific Graded Prognostic Assessment (GPA) effectively stratifies survival for patients with MBM. Nevertheless, lactate dehydrogenase (LDH), a well known prognostic factor for patients with melanoma, is not represented in the GPA scores and might add prognostic information for patients with MBM. In this study, 150 consecutive patients with MBM were retrospectively analyzed with the aim of evaluating independent prognostic factors for MBM patients, including LDH. Furthermore, we implemented a disease-specific prognostic score and estimated survival according to treatment modalities. On the basis of multivariable Cox regression analyses, six prognostic factors (age, BRAF status, number of MBM, number of extracranial metastatic sites, performance status, and LDH level) resulted statistically significant in terms of survival and were combined in a prognostic score to stratify patients in distinct prognostic groups ( P < 0.0001). Among treatment modalities, a multimodal approach with stereotactic radiosurgery or neurosurgery associated with systemic therapy showed the best outcome (median overall survival: 12.32 months, 95% confidence interval, 7.92-25.30). This is the first study to demonstrate that LDH has independent prognostic value for patients with MBM and might be used to improve prognostic stratification, albeit external validation is mandatory. Survival of patients with MBM is affected by both disease-specific risk factors and treatment modalities, with locoregional treatments associated with better outcomes.
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Affiliation(s)
- Giacomo Pelizzari
- Department of Oncology, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Elisa Bertoli
- Department of Medicine (DAME), University of Udine, Udine
- Department of Medical Oncology, CRO Aviano National Cancer Institute IRCSS, Aviano
| | - Silvia Buriolla
- Department of Oncology, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
- Department of Medicine (DAME), University of Udine, Udine
| | - Maria Grazia Vitale
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli
| | - Debora Basile
- Department of Medical Oncology, San Giovanni di Dio Hospital, Crotone, Italy
| | - Lorenza Palmero
- Department of Medicine (DAME), University of Udine, Udine
- Department of Medical Oncology, CRO Aviano National Cancer Institute IRCSS, Aviano
| | - Diego Zara
- Department of Medicine (DAME), University of Udine, Udine
- Department of Medical Oncology, CRO Aviano National Cancer Institute IRCSS, Aviano
| | - Donatella Iacono
- Department of Oncology, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Freschi Andrea
- Department of Medical Oncology, CRO Aviano National Cancer Institute IRCSS, Aviano
| | - Gaetano Pascoletti
- Department of Oncology, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Silvia Bolzonello
- Department of Medical Oncology, CRO Aviano National Cancer Institute IRCSS, Aviano
| | - Mattia Garutti
- Department of Medical Oncology, CRO Aviano National Cancer Institute IRCSS, Aviano
| | - Gianpiero Fasola
- Department of Oncology, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC)
| | - Fabio Puglisi
- Department of Medicine (DAME), University of Udine, Udine
- Department of Medical Oncology, CRO Aviano National Cancer Institute IRCSS, Aviano
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The influence of metastatic patterns and tumor load on therapeutic efficacy of immunotherapy in patients with metastatic melanoma as determined by quantitative PET-parameters using [18F]-fluorodeoxyglucose PET/computed tomography. Melanoma Res 2023; 33:199-207. [PMID: 36866631 DOI: 10.1097/cmr.0000000000000883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
The introduction of immunotherapy was a revolution in the treatment of metastatic melanoma. Nevertheless, there are only few clinical parameters to predict response to immunotherapy. The purpose of this study was to identify metastatic patterns that can predict response by using noninvasive 18F-FDG PET/CT imaging. In 93 immunotherapy-treated patients, total metabolic tumor volume (MTV) was measured before and after treatment. The differences were compared to quantify therapy response. Patients were divided into seven subgroups regarding the affected organ systems. The results as well as clinical factors were evaluated in multivariate analyses. No subgroup of metastatic patterns had a significant difference in response rates, but with a trend towards poorer response regarding osseous and hepatic metastases. Osseous metastases presented with significant lower disease-specific survival (DSS) (P = 0.001). Sole lymph node metastases were the only subgroup with MTV reduction and with significant higher DSS (57.6 months; P = 0.033). Patients, who ever developed brain metastases, showed a high progression of MTV of 201 ml (P = 0.583) and poor DSS of 49.7 months (P = 0.077). Lower numbers of affected organs indicated significantly higher DSS (hazard ratio, 1.346; P = 0.006). Osseous metastases represented a negative predictive factor for response to immunotherapy and survival. Cerebral metastases, especially when nonresponsive to immunotherapy, predicted poor survival and high increase of MTV. A high number of affected organ systems was identified as a negative factor for response and survival. Patients with only lymph node metastases showed a better response and survival.
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6
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Radiation therapy for melanoma brain metastases: a systematic review. Radiol Oncol 2022; 56:267-284. [PMID: 35962952 PMCID: PMC9400437 DOI: 10.2478/raon-2022-0032] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 06/17/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Radiation therapy (RT) for melanoma brain metastases, delivered either as whole brain radiation therapy (WBRT) or as stereotactic radiosurgery (SRS), is an established component of treatment for this condition. However, evidence allowing comparison of the outcomes, advantages and disadvantages of the two RT modalities is scant, with very few randomised controlled trials having been conducted. This has led to considerable uncertainty and inconsistent guideline recommendations. The present systematic review identified 112 studies reporting outcomes for patients with melanoma brain metastases treated with RT. Three were randomised controlled trials but only one was of sufficient size to be considered informative. Most of the evidence was from non-randomised studies, either specific treatment series or disease cohorts. Criteria for determining treatment choice were reported in only 32 studies and the quality of these studies was variable. From the time of diagnosis of brain metastasis, the median survival after WBRT alone was 3.5 months (IQR 2.4-4.0 months) and for SRS alone it was 7.5 months (IQR 6.7-9.0 months). Overall patient survival increased over time (pre-1989 to 2015) but this was not apparent within specific treatment groups. CONCLUSIONS These survival estimates provide a baseline for determining the incremental benefits of recently introduced systemic treatments using targeted therapy or immunotherapy for melanoma brain metastases.
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Franklin C, Mohr P, Bluhm L, Grimmelmann I, Gutzmer R, Meier F, Garzarolli M, Weichenthal M, Pfoehler C, Herbst R, Terheyden P, Utikal J, Ulrich J, Debus D, Haferkamp S, Kaatz M, Forschner A, Leiter U, Nashan D, Kreuter A, Sachse M, Welzel J, Heinzerling L, Meiss F, Weishaupt C, Gambichler T, Weyandt G, Dippel E, Schatton K, Celik E, Trommer M, Helfrich I, Roesch A, Zimmer L, Livingstone E, Schadendorf D, Horn S, Ugurel S. Impact of radiotherapy and sequencing of systemic therapy on survival outcomes in melanoma patients with previously untreated brain metastasis: a multicenter DeCOG study on 450 patients from the prospective skin cancer registry ADOREG. J Immunother Cancer 2022; 10:jitc-2022-004509. [PMID: 35688555 PMCID: PMC9189852 DOI: 10.1136/jitc-2022-004509] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Despite of various therapeutic strategies, treatment of patients with melanoma brain metastasis (MBM) still is a major challenge. This study aimed at investigating the impact of type and sequence of immune checkpoint blockade (ICB) and targeted therapy (TT), radiotherapy, and surgery on the survival outcome of patients with MBM. METHOD We assessed data of 450 patients collected within the prospective multicenter real-world skin cancer registry ADOREG who were diagnosed with MBM before start of the first non-adjuvant systemic therapy. Study endpoints were progression-free survival (PFS) and overall survival (OS). RESULTS Of 450 MBM patients, 175 (38.9%) received CTLA-4+PD-1 ICB, 161 (35.8%) PD-1 ICB, and 114 (25.3%) BRAF+MEK TT as first-line treatment. Additional to systemic therapy, 67.3% of the patients received radiotherapy (stereotactic radiosurgery (SRS); conventional radiotherapy (CRT)) and 24.4% had surgery of MBM. 199 patients (42.2%) received a second-line systemic therapy. Multivariate Cox regression analysis revealed the application of radiotherapy (HR for SRS: 0.213, 95% CI 0.094 to 0.485, p<0.001; HR for CRT: 0.424, 95% CI 0.210 to 0.855, p=0.016), maximal size of brain metastases (HR for MBM >1 cm: 1.977, 95% CI 1.117 to 3.500, p=0.019), age (HR for age >65 years: 1.802, 95% CI 1.016 to 3.197, p=0.044), and ECOG performance status (HR for ECOG ≥2: HR: 2.615, 95% CI 1.024 to 6.676, p=0.044) as independent prognostic factors of OS on first-line therapy. The type of first-line therapy (ICB vs TT) was not independently prognostic. As second-line therapy BRAF+MEK showed the best survival outcome compared with ICB and other therapies (HR for CTLA-4+PD-1 compared with BRAF+MEK: 13.964, 95% CI 3.6 to 54.4, p<0.001; for PD-1 vs BRAF+MEK: 4.587 95% CI 1.3 to 16.8, p=0.022 for OS). Regarding therapy sequencing, patients treated with ICB as first-line therapy and BRAF+MEK as second-line therapy showed an improved OS (HR for CTLA-4+PD-1 followed by BRAF+MEK: 0.370, 95% CI 0.157 to 0.934, p=0.035; HR for PD-1 followed by BRAF+MEK: 0.290, 95% CI 0.092 to 0.918, p=0.035) compared with patients starting with BRAF+MEK in first-line therapy. There was no significant survival difference when comparing first-line therapy with CTLA-4+PD-1 ICB with PD-1 ICB. CONCLUSIONS In patients with MBM, the addition of radiotherapy resulted in a favorable OS on systemic therapy. In BRAF-mutated MBM patients, ICB as first-line therapy and BRAF+MEK as second-line therapy were associated with a significantly prolonged OS.
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Affiliation(s)
- Cindy Franklin
- Department of Dermatology and Venereology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Peter Mohr
- Department of Dermatology, Elbe Kliniken Buxtehude, Buxtehude, Germany
| | - Leonie Bluhm
- Department of Dermatology, Elbe Kliniken Buxtehude, Buxtehude, Germany
| | - Imke Grimmelmann
- Department of Dermatology, Hannover Medical School, Hannover, Germany
| | - Ralf Gutzmer
- Department of Dermatology, Muehlenkreiskliniken Minden and Ruhr University Bochum, Minden, Germany
| | - Friedegund Meier
- Skin Cancer Center at the University Cancer Centre Dresden and National Center for Tumor Diseases, Dresden, Germany; Department of Dermatology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Marlene Garzarolli
- Skin Cancer Center at the University Cancer Centre Dresden and National Center for Tumor Diseases, Dresden, Germany; Department of Dermatology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Michael Weichenthal
- Department of Dermatology, Skin Cancer Center, Schleswig-Holstein University Hospital, Campus Kiel, Kiel, Germany
| | - Claudia Pfoehler
- Department of Dermatology, Saarland University Medical School, Homburg/Saar, Germany
| | - Rudolf Herbst
- Department of Dermatology, HELIOS Klinikum Erfurt, Erfurt, Germany
| | | | - Jochen Utikal
- Skin Cancer Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Dermatology, Venereology and Allergology, University Medical Center Mannheim, Ruprecht-Karl University of Heidelberg, Heidelberg, Germany
| | - Jens Ulrich
- Department of Dermatology and Skin Cancer Center, Harzklinikum Dorothea Christiane Erxleben, Quedlinburg, Germany
| | - Dirk Debus
- Department of Dermatology, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Sebastian Haferkamp
- Department of Dermatology, University Hospital Regensburg, Regensburg, Germany
| | - Martin Kaatz
- Department of Dermatology, SRH Wald-Klinikum Gera, Gera, Germany
| | - Andrea Forschner
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Ulrike Leiter
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Dorothee Nashan
- Department of Dermatology, Hospital of Dortmund, Dortmund, Germany
| | - Alexander Kreuter
- Department of Dermatology, Venereology and Allergology, HELIOS St. Elisabeth Klinik Oberhausen, University Witten-Herdecke, Herdecke, Germany
| | - Michael Sachse
- Department of Dermatology, Klinikum Bremerhaven Reinkenheide, Bremerhaven, Germany
| | - Julia Welzel
- Department of Dermatology and Allergology, University Hospital Augsburg, Augsburg, Germany
| | - Lucie Heinzerling
- Department of Dermatology and Allergology, Ludwig-Maximilian University, München, Germany
| | - Frank Meiss
- Department of Dermatology and Venereology, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Carsten Weishaupt
- Department of Dermatology, University Hospital of Münster, Münster, Germany
| | - Thilo Gambichler
- Department of Dermatology, Ruhr University Bochum, Bochum, Germany
| | - Gerhard Weyandt
- Department of Dermatology and Allergology, Hospital Bayreuth, Bayreuth, Germany
| | - Edgar Dippel
- Department of Dermatology, Ludwigshafen Medical Center, Ludwigshafen, Germany
| | - Kerstin Schatton
- Department of Dermatology, Heinrich Heine University, Düsseldorf, Germany
| | - Eren Celik
- Department of Radiation Oncology and Cyberknife Center, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Maike Trommer
- Department of Radiation Oncology and Cyberknife Center, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Iris Helfrich
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany and German Cancer Consortium (DKTK) partner site Essen/Düsseldorf, Essen, Germany
| | - Alexander Roesch
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany and German Cancer Consortium (DKTK) partner site Essen/Düsseldorf, Essen, Germany
| | - Lisa Zimmer
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany and German Cancer Consortium (DKTK) partner site Essen/Düsseldorf, Essen, Germany
| | - Elisabeth Livingstone
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany and German Cancer Consortium (DKTK) partner site Essen/Düsseldorf, Essen, Germany
| | - Dirk Schadendorf
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany and German Cancer Consortium (DKTK) partner site Essen/Düsseldorf, Essen, Germany
| | - Susanne Horn
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany and German Cancer Consortium (DKTK) partner site Essen/Düsseldorf, Essen, Germany.,Rudolf-Schönheimer-Institute of Biochemistry, Medical Faculty of the University Leipzig, Leipzig, Germany
| | - Selma Ugurel
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany and German Cancer Consortium (DKTK) partner site Essen/Düsseldorf, Essen, Germany
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Melanoma Brain Metastases: An Update on the Use of Immune Checkpoint Inhibitors and Molecularly Targeted Agents. Am J Clin Dermatol 2022; 23:523-545. [PMID: 35534670 DOI: 10.1007/s40257-022-00678-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 11/01/2022]
Abstract
Brain metastases from melanoma are no longer uniformly associated with dismal outcomes. Impressive tumor tissue-based (craniotomy) translational research has consistently shown that distinct patient subgroups may have a favorable prognosis. This review provides a historical overview of the standard-of-care treatments until the early 2010s. It subsequently summarizes more recent advances in understanding the biology of melanoma brain metastases (MBMs) and treating patients with MBMs, mainly focusing upon prospective clinical trials of BRAF/MEK and PD-1/CTLA-4 inhibitors in patients with previously untreated MBMs. These additional systemic treatments have provided effective complementary treatment approaches and/or alternatives to radiation and craniotomy. The current role of radiation therapy, especially in conjunction with systemic therapies, is also discussed through the lens of various retrospective studies. The combined efficacy of systemic treatments with radiation has improved overall survival over the last 10 years and has sparked considerable research interest regarding optimal dosing and sequencing of radiation treatments with systemic treatments. Finally, the review describes ongoing clinical trials in patients with MBMs.
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Hao P, Chen L, Ge Y, You Y, Yan G, Jin ZW. Time taken for a primary tumor to metastasize to the brain and the overall survival of patients with brain metastasis: An analysis of outcomes and factors affecting survival. Technol Health Care 2022; 30:259-270. [PMID: 35124603 PMCID: PMC9028614 DOI: 10.3233/thc-228025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND: Brain metastasis (BM) is one of the main causes of high morbidity and mortality in cancer patients. OBJECTIVE: To evaluate the factors that influenced the survival time of patients with primary cancer and survival time after BM. METHODS: Ninety patients with BM diagnosed by magnetic resonance imaging (MRI) were included in the study. We retrospectively analyzed the time to brain metastasis (TTB), overall survival time (OS1) and survival time after BM (OS2). The Kaplan-Meier method and Cox regression analysis were used for survival analyses. RESULTS: The median TTB was 12.0 (95% CI: 9.2–14.8 months), the median OS1 was 31.0 (95% CI: 25.8–35.2 months) and the median OS2 was 14.0 (95% CI: 10.9–17.1 months). Surgical excision of the primary tumor was an independent factor for a prolonged TTB (p< 0.000) and prolonged OS1 (p< 0.000). A single intracranial metastatic lesion was an independent protective factor for prolonged OS1 (p= 0.011) and prolonged OS2 (p= 0.050). TTB, OS1 and OS2 were analyzed with Gender (p< 0.000, < 0.000, and = 0.017, respectively). CONCLUSIONS: It suggests that TTB can be prolonged by primary tumor resection. Furthermore, women with a prolonged TTB and single intracranial metastasis are associated with high OS. These were helpful for the clinical treatment of BM patients before brain metastasis.
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Affiliation(s)
- Peiyu Hao
- Department of Public Health and Preventive Medicine, Wuxi School of Medicine, Jiangnan University, Wuxi, Fujian, China
- Department of Public Health and Preventive Medicine, Wuxi School of Medicine, Jiangnan University, Wuxi, Fujian, China
| | - Limei Chen
- Department of Public Health and Preventive Medicine, Wuxi School of Medicine, Jiangnan University, Wuxi, Fujian, China
- Department of Public Health and Preventive Medicine, Wuxi School of Medicine, Jiangnan University, Wuxi, Fujian, China
| | - Yuxi Ge
- Department of Radiology, Affiliated Hospital of Jiangnan University, Wuxi, Fujian, China
| | - Yaqian You
- Department of Public Health and Preventive Medicine, Wuxi School of Medicine, Jiangnan University, Wuxi, Fujian, China
| | - Gen Yan
- Department of Radiology, Affiliated Hospital of Jiangnan University, Wuxi, Fujian, China
- Deparment of Radiology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, Fujian, China
| | - Zhe-Wu Jin
- Department of Anatomy, Wuxi School of Medicine, Jiangnan University, Wuxi, Fujian, China
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10
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Guddati AK, Picon H. Analysis of Demographics and Outcomes of Surgical Resection in the Central Nervous System of Patients With Metastatic Melanoma. World J Oncol 2022; 12:225-231. [PMID: 35059082 PMCID: PMC8734505 DOI: 10.14740/wjon1408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/30/2021] [Indexed: 11/11/2022] Open
Abstract
Background Patients with melanoma frequently develop central nervous system metastases. Oligometastatic disease is often treated either by surgical resection or by stereotactic radiotherapy. This study investigates the trends and clinical outcomes of patients with melanoma who have undergone surgical procedures on the central nervous system during their hospitalization. Methods A retrospective study was performed based on admissions of adult patients who underwent craniotomy for metastatic melanoma from 2000 to 2014 using the Nationwide Inpatient Sample database. The primary outcome measure was all-cause in-hospital mortality. Secondary outcomes included hospital length of stay (LOS) and discharge disposition (home/home with health care and skilled nursing facilities/long-term acute care (SNFs/LTAC)). Factors associated with in-hospital mortality were examined by multivariable logistic regression. We adjusted for patient and hospital characteristics, payer, and comorbid conditions. We also examined trends of mortality for the study years. Results There were an estimated 1,216 discharges of patients with melanoma undergoing craniotomy during the study period. Patients undergoing surgical interventions were typically males (69%) and whites (79%). Ninety-eight percent of procedures were performed at teaching hospitals. Unadjusted all-cause in-hospital mortality was 3.1%. There was no significant difference in mortality over 13 years. Age, gender, and race were not associated with increased in-hospital mortality. LOS was longer in elderly and those with higher Charlson Comorbidity Index. Of the survivors, 76% were discharged to home or with home healthcare while 24% were discharged to SNFs/LTAC. Patients with age > 65 (odds ratio (OR): 2.9; 95% confidence interval (CI): 2.2 - 3.9, P < 0.001) and those with higher Charlson Comorbidity Index (OR: 1.2; 95% CI: 1.1 - 1.3) had higher odds for being discharged to SNFs/LTAC. Conclusions Patients who undergo craniotomy for metastatic melanoma have a low in-hospital mortality rate. One quarter of patients were discharged to SNFs/LTAC.
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Affiliation(s)
- Achuta Kumar Guddati
- Division of Hematology/Oncology, Georgia Cancer Center, Augusta University, Augusta, GA 30912, USA
| | - Hector Picon
- Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
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11
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Janka EA, Várvölgyi T, Sipos Z, Soós A, Hegyi P, Kiss S, Dembrovszky F, Csupor D, Kéringer P, Pécsi D, Solymár M, Emri G. Predictive Performance of Serum S100B Versus LDH in Melanoma Patients: A Systematic Review and Meta-Analysis. Front Oncol 2021; 11:772165. [PMID: 34950582 PMCID: PMC8688362 DOI: 10.3389/fonc.2021.772165] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/11/2021] [Indexed: 12/19/2022] Open
Abstract
Background Currently, no consensus on the use of blood tests for monitoring disease recurrence in patients with resected melanoma exists. The only meta-analysis conducted in 2008 found that elevated serum S100B levels were associated with significantly worse survival in melanoma patients. Serum LDH is an established prognostic factor in patients with advanced melanoma. Objective To compare the discriminative and prognostic ability of serum S100B with that of serum LDH in patients with melanoma. Methods This systematic review and meta-analysis were reported in accordance with the PRISMA Statement. The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42019137138). Results A quantitative analysis of data from 6 eligible studies included 1,033 patients with cutaneous melanoma. The discriminative ability of serum S100B at identifying disease relapse [pooled Area Under the ROC (AUROC) 78.64 (95% CI 70.28; 87.01)] was significantly greater than the discriminative ability of serum LDH [AUROC 64.41 (95% CI 56.05; 7278)] (p=0.013). Ten eligible studies with 1,987 patients were included in the risk of death analysis. The prognostic performance of serum S100B [pooled estimate of adjusted hazard ratio (HR) 1.78 (95% CI 1.38; 2.29)] was independent but not superior to that of serum LDH [HR 1.60 (95% CI 1.36; 2.29)]. Limitations A relatively small number of articles were eligible and there was considerable heterogeneity across the included studies. Conclusions Serum biomarkers may provide relevant information on melanoma patient status and should be further researched. Serum S100B is a valid marker for diagnosis of melanoma recurrence. Systematic Review Registration The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42019137138).
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Affiliation(s)
- Eszter Anna Janka
- Department of Dermatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Tünde Várvölgyi
- Department of Dermatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Sipos
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Alexandra Soós
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Szabolcs Kiss
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Fanni Dembrovszky
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Dezső Csupor
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Department of Pharmacognosy, Faculty of Pharmacy, University of Szeged, Szeged, Hungary
| | - Patrik Kéringer
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Dániel Pécsi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Margit Solymár
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Gabriella Emri
- Department of Dermatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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12
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Development and Validation of Tumor Immunogenicity Based Gene Signature for Skin Cancer Risk Stratification. Int J Mol Sci 2021; 22:ijms222112025. [PMID: 34769455 PMCID: PMC8584987 DOI: 10.3390/ijms222112025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 12/13/2022] Open
Abstract
Melanoma is one of the most aggressive types of skin cancer, with significant heterogeneity in overall survival. Currently, tumor-node-metastasis (TNM) staging is insufficient to provide accurate survival prediction and appropriate treatment decision making for several types of tumors, such as those in melanoma patients. Therefore, the identification of more reliable prognosis biomarkers is urgently essential. Recent studies have shown that low immune cells infiltration is significantly associated with unfavorable clinical outcome in melanoma patients. Here we constructed a prognostic-related gene signature for melanoma risk stratification by quantifying the levels of several cancer hallmarks and identify the Wnt/β-catenin activation pathway as a primary risk factor for low tumor immunity. A series of bioinformatics and statistical methods were combined and applied to construct a Wnt-immune-related prognosis gene signature. With this gene signature, we computed risk scores for individual patients that can predict overall survival. To evaluate the robustness of the result, we validated the signature in multiple independent GEO datasets. Finally, an overall survival-related nomogram was established based on the gene signature and clinicopathological features. The Wnt-immune-related prognostic risk score could better predict overall survival compared with standard clinicopathological features. Our results provide a comprehensive map of the oncogene-immune-related gene signature that can serve as valuable biomarkers for better clinical decision making.
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13
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Wang L, Wu J, Dai Z, Ji S, Jiang R. Clinical characteristics and prognosis of acral lentiginous melanoma: a single-center series of 211 cases in China. Int J Dermatol 2021; 60:1504-1509. [PMID: 34145578 DOI: 10.1111/ijd.15642] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 02/19/2021] [Accepted: 04/09/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Acral lentiginous melanoma (ALM) is common in China with poor prognosis. However, there are only a few studies of ALM in the Asian population. We aimed to summarize and analyze the clinical characteristics, treatment strategy, treatment effect, and prognostic factors of ALM in a Chinese population. METHODS We included a total of 249 ALM patients (211 with follow-up data) from a single institution. Demographic, laboratory data, treatment strategy, and prognosis were analyzed. RESULTS The ratio of male and female was 1.3 ∶ 1.0. The median age was 58 years old. The majority of patients (70.3%) had lesions on the sole. Trauma history and irritation were associated with lesion size increase in some patients. The prognosis of patients in stage II-III undergoing standard operation was significantly better compared with those without surgical treatment. Patients who did not receive postoperative adjuvant treatment had shorter time to distant metastasis. In multivariable analysis, distant metastasis, duration of disease, LDH level, and Ki67 index were independently associated with survival. CONCLUSIONS Prognosis for ALM patients was poor in our study. Distant metastasis, duration of disease, LDH level, and Ki67 index were independently associated with prognosis.
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Affiliation(s)
- Lei Wang
- Department of Bone and Soft Tissue, Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, China
| | - Junshen Wu
- Department of Bone and Soft Tissue, Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, China
| | - Zhibing Dai
- Department of Bone and Soft Tissue, Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, China
| | - Suzhi Ji
- Department of Bone and Soft Tissue, Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, China
| | - Renbing Jiang
- Department of Bone and Soft Tissue, Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, China
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14
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Amaral T, Kiecker F, Schaefer S, Stege H, Kaehler K, Terheyden P, Gesierich A, Gutzmer R, Haferkamp S, Uttikal J, Berking C, Rafei-Shamsabadi D, Reinhardt L, Meier F, Karoglan A, Posch C, Gambichler T, Pfoehler C, Thoms K, Tietze J, Debus D, Herbst R, Emmert S, Loquai C, Hassel JC, Meiss F, Tueting T, Heinrich V, Eigentler T, Garbe C, Zimmer L. Combined immunotherapy with nivolumab and ipilimumab with and without local therapy in patients with melanoma brain metastasis: a DeCOG* study in 380 patients. J Immunother Cancer 2021; 8:jitc-2019-000333. [PMID: 32221017 PMCID: PMC7206917 DOI: 10.1136/jitc-2019-000333] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2020] [Indexed: 12/29/2022] Open
Abstract
Background Nivolumab combined with ipilimumab have shown activity in melanoma brain metastasis (MBM). However, in most of the clinical trials investigating immunotherapy in this subgroup, patients with symptomatic MBM and/or prior local brain radiotherapy were excluded. We studied the efficacy of nivolumab plus ipilimumab alone or in combination with local therapies regardless of treatment line in patients with asymptomatic and symptomatic MBM. Methods Patients with MBM treated with nivolumab plus ipilimumab in 23 German Skin Cancer Centers between April 2015 and October 2018 were investigated. Overall survival (OS) was evaluated by Kaplan-Meier estimator and univariate and multivariate Cox proportional hazard analyses were performed to determine prognostic factors associated with OS. Results Three hundred and eighty patients were included in this study and 31% had symptomatic MBM (60/193 with data available) at the time of start nivolumab plus ipilimumab. The median follow-up was 18 months and the 2 years and 3 years OS rates were 41% and 30%, respectively. We identified the following independently significant prognostic factors for OS: elevated serum lactate dehydrogenase and protein S100B levels, number of MBM and Eastern Cooperative Oncology Group performance status. In these patients treated with checkpoint inhibition first-line or later, in the subgroup of patients with BRAFV600-mutated melanoma we found no differences in terms of OS when receiving first-line either BRAF and MEK inhibitors or nivolumab plus ipilimumab (p=0.085). In BRAF wild-type patients treated with nivolumab plus ipilimumab in first-line or later there was also no difference in OS (p=0.996). Local therapy with stereotactic radiosurgery or surgery led to an improvement in OS compared with not receiving local therapy (p=0.009), regardless of the timepoint of the local therapy. Receiving combined immunotherapy for MBM in first-line or at a later time point made no difference in terms of OS in this study population (p=0.119). Conclusion Immunotherapy with nivolumab plus ipilimumab, particularly in combination with stereotactic radiosurgery or surgery improves OS in asymptomatic and symptomatic MBM.
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Affiliation(s)
- Teresa Amaral
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University of Tuebingen, Eberhard Karls University of Tuebingen, Tubingen, Germany
| | - Felix Kiecker
- Skin Cancer Center, Department of Dermatology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Sarah Schaefer
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Henner Stege
- Department of Dermatology, University Medical Center Mainz, Mainz, Germany
| | - Katharina Kaehler
- Skin Cancer Center, Department of Dermatology, University Hospital Kiel, Kiel, Germany
| | - Patrick Terheyden
- Skin Cancer Center, Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Anja Gesierich
- Department of Dermatology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ralf Gutzmer
- Skin Cancer Center Hannover, Department of Dermatology, Hannover Medical School, Hannover, Germany
| | | | - Jochen Uttikal
- Skin Cancer Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Dermatology, Venereology and Allergology, University Medical Center Mannheim, Ruprecht-Karl University of Heidelberg, Mannheim, Germany
| | - Carola Berking
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU), Erlangen-Nürnberg, Germany.,Department of Dermatology and Allergy, University Hospital Munich, Ludwig Maximilian University, Munich, Germany
| | - David Rafei-Shamsabadi
- Skin Cancer Center, Department of Dermatology and Venerology, Medical Centre University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lydia Reinhardt
- Skin Cancer Center at the University Cancer Center and National Center for Tumor Diseases Dresden, Department of Dermatology, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Friedegund Meier
- Skin Cancer Center at the University Cancer Center and National Center for Tumor Diseases Dresden, Department of Dermatology, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Ante Karoglan
- Department of Dermatology, University Hospital Magdeburg, Magdeburg, Germany
| | - Christian Posch
- Department of Dermatology and Allergy, Technical University of Munich, School of Medicine, Munich, Germany.,Sigmund Freud Universität Wien, Faculty of Medicine, Wien, Austria
| | - Thilo Gambichler
- Skin Cancer Center, Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
| | - Claudia Pfoehler
- Department of Dermatology, Saarland University Medical School, Homburg/Saar, Germany
| | - Kai Thoms
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen, Germany
| | - Julia Tietze
- Department of Dermatology and Allergology, Augsburg Medical Center, Augsburg, Germany
| | - Dirk Debus
- Skin Cancer Center, Department of Dermatology, Paracelsus Medical University, General Hospital Nuremberg, Nuremberg, Germany
| | | | - Steffen Emmert
- Clinic for Dermatology and Venereology, University Medical Center, Rostock, Germany
| | - Carmen Loquai
- Department of Dermatology, University Medical Center Mainz, Mainz, Germany
| | - Jessica C Hassel
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Frank Meiss
- Skin Cancer Center, Department of Dermatology and Venerology, Medical Centre University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Tueting
- Department of Dermatology, University Hospital Magdeburg, Magdeburg, Germany
| | - Vanessa Heinrich
- Clinic of Radiation Oncology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Thomas Eigentler
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University of Tuebingen, Eberhard Karls University of Tuebingen, Tubingen, Germany
| | - Claus Garbe
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University of Tuebingen, Eberhard Karls University of Tuebingen, Tubingen, Germany
| | - Lisa Zimmer
- Department of Dermatology, University Hospital Essen, Essen, Germany
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15
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Kessel KA, Deichl A, Gempt J, Meyer B, Posch C, Diehl C, Zimmer C, Combs SE. Outcomes after stereotactic radiosurgery of brain metastases in patients with malignant melanoma and validation of the melanoma molGPA. Clin Transl Oncol 2021; 23:2020-2029. [PMID: 33993415 PMCID: PMC8390419 DOI: 10.1007/s12094-021-02607-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/22/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Malignant melanoma is the third most common primary in the diagnosis of brain metastases. Stereotactic radiosurgery (SRS) is a well-established treatment option in limited brain disease. We analyzed outcomes of SRS with a particular focus on the graded prognostic assessment (GPA, melanoma molGPA), prognostic factors, and toxicity. METHODS We evaluated 173 brain metastases in 83 patients with malignant melanoma. All were treated with SRS median dose of 20 Gy prescribed to the 80 or 100% isodose line between 2002 and 2019. All patients were followed-up regularly, including contrast-enhanced brain imaging as well as clinical examination, initially 6 weeks after treatment, then in quarterly follow-up. RESULTS The median age was 61 years (range 27-80); 36 female and 47 male patients were treated. After a median follow-up of 5.7 months, median OS (overall survival) was 9.7 months 95%-KI 4.7-14.7). LC (local control) at 6 months, 12, 24 months was 89%, 86%, and 72%, respectively (median was not reached). Median DBC (distant brain control) was 8.2 months (95%-KI 4.7-11.7). For OS, a KPS ≥ 80%, a positive BRAF mutation status, a small PTV (planning target volume), the absence of extracranial metastases, as well as a GPA and melanoma molGPA > 2 were prognostic factors. In the MVA, a small PTV and a melanoma molGPA > 2 remained significant. CONCLUSION The present survival outcomes support the use of the disease-specific melanoma molGPA as reliable prognostic score. Favorable outcomes for SRS compared to other studies were observed. In the treatment of brain metastases of malignant melanoma patients, a multidisciplinary approach consisting of surgery, SRS, chemotherapy, and immunotherapy should be considered.
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Affiliation(s)
- K A Kessel
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany.,Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site Munich, Munich, Germany
| | - A Deichl
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany.
| | - J Gempt
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site Munich, Munich, Germany.,Department of Neurosurgery, Technical University of Munich (TUM), Munich, Germany
| | - B Meyer
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site Munich, Munich, Germany.,Department of Neurosurgery, Technical University of Munich (TUM), Munich, Germany
| | - C Posch
- Department of Dermatology and Allergy, Technical University of Munich (TUM), Munich, Germany.,Faculty of Medicine, Sigmund Freud University, Vienna, Austria
| | - C Diehl
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site Munich, Munich, Germany
| | - C Zimmer
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site Munich, Munich, Germany.,Department of Neuroradiology, Technical University of Munich (TUM), Munich, Germany
| | - S E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany.,Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site Munich, Munich, Germany
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16
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O'Halloran PJ, Cleary A, Cryan JB, Beausang A, Brett FM, Caird J. Melanoma brain metastases in Ireland: surgical and systemic considerations. Br J Neurosurg 2021; 36:236-240. [PMID: 33904364 DOI: 10.1080/02688697.2021.1918327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
BACKGROUND Cerebral metastases is a common complication in patients with melanoma. There is a paucity of information in the Republic of Ireland regarding the factors associated with melanoma brain metastases (MBM). METHODS Patients diagnosed with melanoma brain metastases in Ireland were retrospectively identified in Beaumont Hospital between 1999 and 2018. Patient demographics; age at diagnosis of primary melanoma, age at detection of MBM, year of detection of MBM, anatomical location of primary melanoma, BRAF mutation analysis and the number of metastases were investigated. Follow-up data were also derived, including overall survival. RESULTS There has being a 158% increase in the incidence of primary melanoma from 1999 compared to 2016. Over the same time period 128 patients with melanoma brain metastases were diagnosed. There was a significant male predominance (n = 77/128; 60%; p < 0.0001). BRAF mutation and leptomeningeal disease were independent prognostic factors in our cohort with a median survival 8 months and 0.5 months, respectively. CONCLUSIONS Male predominance, leptomeningeal disease and BRAF mutation represent important considerations in this population group. The results of this study add to our knowledge concerning outcomes in melanoma brain metastases and may be useful in clinical planning and future treatments.
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Affiliation(s)
- Philip J O'Halloran
- National Neurosurgery Center, Beaumont Hospital, Dublin, Ireland.,Physiology and Medical Physics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Anna Cleary
- Physiology and Medical Physics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Jane B Cryan
- Department of Neuropathology, Beaumont Hospital, Dublin, Ireland
| | - Alan Beausang
- Department of Neuropathology, Beaumont Hospital, Dublin, Ireland
| | | | - John Caird
- National Neurosurgery Center, Beaumont Hospital, Dublin, Ireland
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17
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Hu J, Zhou J, Dong F, Tan J, Wang S, Li Z, Zhang X, Zhang H, Ming J, Huang T. Combination of serum lactate dehydrogenase and sex is predictive of severe disease in patients with COVID-19. Medicine (Baltimore) 2020; 99:e22774. [PMID: 33080747 PMCID: PMC7571917 DOI: 10.1097/md.0000000000022774] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Elevated serum lactate dehydrogenase (LDH) was commonly reported in COVID-19 patients. However, the relationship between LDH and the incidence of severe cases has not been characterized in those patients.We retrospectively analyzed the characteristics of patients from a designated isolation medical center for COVID-19 patients diagnosed from February 6 to March 1. Variables accessed within 48 hours on admission were compared between patients with and without the severe disease. Logistic model analyses were performed to examine the prognostic value of LDH for predicting severe disease.52 (28.6%) patients later developed severe disease. Comparing to non-severe cases, severe cases had a higher level of serum LDH (321.85 ± 186.24 vs 647.35 ± 424.26, P < .001), neutrophils (5.42 ± 3.26 vs 9.19 ± 6.33, P < .001), and C-reactive protein (38.63 ± 43.14 vs 83.20 ± 51.01, P < .001). The patients with severe disease tended to be male (44.6% vs 80.8%, P < .001), lower level of serum albumin (31.41 ± 6.20 vs 27.18 ± 5.74, P < .001), and SpO2 (96.30 ± 2.75 vs 92.37 ± 8.29, P < .001). In the multivariate analysis model, LDH and sex remained independent risk factors for severe disease. The serum LDH predicted severe cases with an area under the curve (AUC) of 0.7999. A combination of serum LDH and sex predicted severe cases with an AUC of 0.849. A combination of serum LDH accessed on admission and sex had a better predictive performance than the serum LDH (P = .0238).Serum LDH on admission combined with sex is independently associated with severe disease in COVID-19.
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18
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Bhatia A, Birger M, Veeraraghavan H, Um H, Tixier F, McKenney AS, Cugliari M, Caviasco A, Bialczak A, Malani R, Flynn J, Zhang Z, Yang TJ, Santomasso BD, Shoushtari AN, Young RJ. MRI radiomic features are associated with survival in melanoma brain metastases treated with immune checkpoint inhibitors. Neuro Oncol 2020; 21:1578-1586. [PMID: 31621883 DOI: 10.1093/neuonc/noz141] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Melanoma brain metastases historically portend a dismal prognosis, but recent advances in immune checkpoint inhibitors (ICIs) have been associated with durable responses in some patients. There are no validated imaging biomarkers associated with outcomes in patients with melanoma brain metastases receiving ICIs. We hypothesized that radiomic analysis of magnetic resonance images (MRIs) could identify higher-order features associated with survival. METHODS Between 2010 and 2019, we retrospectively reviewed patients with melanoma brain metastases who received ICI. After volumes of interest were drawn, several texture and edge descriptors, including first-order, Haralick, Gabor, Sobel, and Laplacian of Gaussian (LoG) features were extracted. Progression was determined using Response Assessment in Neuro-Oncology Brain Metastases. Univariate Cox regression was performed for each radiomic feature with adjustment for multiple comparisons followed by Lasso regression and multivariate analysis. RESULTS Eighty-eight patients with 196 total brain metastases were identified. Median age was 63.5 years (range, 19-91 y). Ninety percent of patients had Eastern Cooperative Oncology Group performance status of 0 or 1 and 35% had elevated lactate dehydrogenase. Sixty-three patients (72%) received ipilimumab, 11 patients (13%) received programmed cell death protein 1 blockade, and 14 patients (16%) received nivolumab plus ipilimumab. Multiple features were associated with increased overall survival (OS), and LoG edge features best explained the variation in outcome (hazard ratio: 0.68, P = 0.001). In multivariate analysis, a similar trend with LoG was seen, but no longer significant with OS. Findings were confirmed in an independent cohort. CONCLUSION Higher-order MRI radiomic features in patients with melanoma brain metastases receiving ICI were associated with a trend toward improved OS.
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Affiliation(s)
- Ankush Bhatia
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maxwell Birger
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Harini Veeraraghavan
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hyemin Um
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Florent Tixier
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anna Sophia McKenney
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marina Cugliari
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annalise Caviasco
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Angelica Bialczak
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rachna Malani
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jessica Flynn
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - T Jonathan Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bianca D Santomasso
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Robert J Young
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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19
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Gutzmer R, Vordermark D, Hassel JC, Krex D, Wendl C, Schadendorf D, Sickmann T, Rieken S, Pukrop T, Höller C, Eigentler TK, Meier F. Melanoma brain metastases - Interdisciplinary management recommendations 2020. Cancer Treat Rev 2020; 89:102083. [PMID: 32736188 DOI: 10.1016/j.ctrv.2020.102083] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 12/12/2022]
Abstract
Melanoma brain metastases (MBM) are common and associated with a particularly poor prognosis; they directly cause death in 60-70% of melanoma patients. In the past, systemic treatments have shown response rates around 5%, whole brain radiation as standard of care has achieved a median overall survival of approximately three months. Recently, the combination of immune checkpoint inhibitors and combinations of MAP-kinase inhibitors both have shown very promising response rates of up to 55% and 58%, respectively, and improved survival. However, current clinical evidence is based on multi-cohort studies only, as prospectively randomized trials have been carried out rarely in MBM, independently whether investigating systemic therapy, radiotherapy or surgical techniques. Here, an interdisciplinary expert team reviewed the outcome of prospectively conducted clinical studies in MBM, identified evidence gaps and provided recommendations for the diagnosis, treatment, outcome evaluation and monitoring of MBM patients. The recommendations refer to four distinct scenarios: patients (i) with 'brain-only' disease, (ii) with oligometastatic asymptomatic intra- and extracranial disease, (iii) with multiple asymptomatic metastases, and (iv) with multiple symptomatic MBM or leptomeningeal disease. Changes in current management recommendations comprise the use of immunotherapy - preferably combined anti-CTLA-4/PD-1-immunotherapy - in asymptomatic MBM minus/plus stereotactic radiosurgery which remains the mainstay of local brain therapy being safe and effective. Adjuvant whole-brain radiotherapy provides no clinical benefit in oligometastatic MBM. Among the systemic therapies, combined MAPK-kinase inhibition provides, in BRAFV600-mutated patients with rapidly progressing or/and symptomatic MBM, an alternative to combined immunotherapy.
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Affiliation(s)
- Ralf Gutzmer
- Department of Dermatology and Allergy, Skin Cancer Center Hannover, Hannover Medical School, Germany.
| | - Dirk Vordermark
- Department for Radiation Oncology, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Jessica C Hassel
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Dietmar Krex
- Department of Neurosurgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Christina Wendl
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital Essen, Essen, Germany
| | | | - Stefan Rieken
- Policlinic for Radiation Therapy and Radiation Oncology, University Hospital Göttingen, Göttingen, Germany
| | - Tobias Pukrop
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Höller
- Department of Dermatology, Medical University Vienna, Vienna, Austria
| | - Thomas K Eigentler
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Friedegund Meier
- Skin Cancer Center at the University Cancer Centre and National Center for Tumor Diseases, Department of Dermatology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
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20
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Pedersen JG, Madsen AT, Gammelgaard KR, Aggerholm-Pedersen N, Sørensen BS, Øllegaard TH, Jakobsen MR. Inflammatory Cytokines and ctDNA Are Biomarkers for Progression in Advanced-Stage Melanoma Patients Receiving Checkpoint Inhibitors. Cancers (Basel) 2020; 12:E1414. [PMID: 32486146 PMCID: PMC7353055 DOI: 10.3390/cancers12061414] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Checkpoint inhibitors have significantly improved treatment of metastatic melanoma. However, 40-60% of patients do not respond to therapy, emphasizing the need for better predictive biomarkers for treatment response to immune checkpoint inhibitors. Prorammed death-ligand 1(PD-L1) expression in tumor cells is currently used as a predictive biomarker; however, it lacks specificity. Therefore, it is of utmost importance to identify other novel biomarkers that can predict treatment outcome. EXPERIMENTAL DESIGN We studied a small cohort of 16 patients with advanced-stage melanoma treated with first-line checkpoint inhibitors. Plasma samples were collected prior to treatment initiation and continuously during the first year of treatment. Circulating tumor DNA (ctDNA) level and the expression of ten inflammatory cytokines were analyzed. RESULTS We found that the ctDNA-level in a blood sample collected after 6-8 weeks of therapy is predictive for response to checkpoint inhibitors. Patients with undetectable ctDNA had significantly longer progression-free survival (PFS) compared with patients with detectable ctDNA (median 26.3 vs. 2.1 months, p = 0.006). In parallel, we identified that high levels of the cytokines monocyte chemoattractant protein 1 (MCP1) and tumor necrosis factor a(TNFa) in baseline blood samples were significantly associated with longer PFS compared to low level of these cytokines (median not reached vs. 8.2 months p = 0.0008). CONCLUSIONS These findings suggest that the levels of ctDNA, MCP1, and TNFa in baseline and early follow-up samples can predict disease progression in metastatic melanoma patients treated with checkpoint inhibitors. Potentially, these minimally invasive biomarkers may identify responders from non-responders.
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Affiliation(s)
- Jesper Geert Pedersen
- Department of Biomedicine, Faculty of Health, Aarhus University, 8000 Aarhus, Denmark; (J.G.P.); (K.R.G.)
| | - Anne Tranberg Madsen
- Department of Clinical Biochemistry, Aarhus University Hospital, 8000 Aarhus, Denmark; (A.T.M.); (B.S.S.)
| | - Kristine Raaby Gammelgaard
- Department of Biomedicine, Faculty of Health, Aarhus University, 8000 Aarhus, Denmark; (J.G.P.); (K.R.G.)
| | | | - Boe Sandahl Sørensen
- Department of Clinical Biochemistry, Aarhus University Hospital, 8000 Aarhus, Denmark; (A.T.M.); (B.S.S.)
| | | | - Martin Roelsgaard Jakobsen
- Department of Biomedicine, Faculty of Health, Aarhus University, 8000 Aarhus, Denmark; (J.G.P.); (K.R.G.)
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21
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Kayaalti S, Kayaalti O, Hakan Aksebzeci B. A decision support system for the prediction of mortality in patients with acute kidney injury admitted in intensive care unit. J Appl Biomed 2020; 18:26-32. [PMID: 34907705 DOI: 10.32725/jab.2020.004] [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: 11/06/2018] [Accepted: 02/19/2020] [Indexed: 11/05/2022] Open
Abstract
Intensive care unit (ICU) is a very special unit of a hospital, where healthcare professionals provide treatment and, later, close follow-up to the patients. It is crucial to estimate mortality in ICU patients from many viewpoints. The purpose of this study is to classify the status of patients with acute kidney injury (AKI) in ICU as early mortality, late mortality, and survival by the application of Classification and Regression Trees (CART) algorithm to the patients' attributes such as blood urea nitrogen, creatinine, serum and urine neutrophil gelatinase-associated lipocalin (NGAL), alkaline phosphatase, lactate dehydrogenase (LDH), gamma-glutamyl transferase, laboratory electrolytes, blood gas, mean arterial pressure, central venous pressure and demographic details of patients. This study was conducted 50 patients with AKI who were followed up in the ICU. The study also aims to determine the significance of relationship between the attributes used in the prediction of mortality in CART and patients' status by employing the Kruskal-Wallis H test. The classification accuracy, sensitivity, and specificity of CART for the tested attributes for the prediction of early mortality, late mortality, and survival of patients were 90.00%, 83.33%, and 91.67%, respectively. The values of both urine NGAL and LDH on day 7 showed a considerable difference according to the patients' status after being examined by the Kruskal-Wallis H test.
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Affiliation(s)
- Selda Kayaalti
- Develi Hatice-Muammer Kocaturk Public Hospital, Department of Anesthesiology and Reanimation, Develi, Kayseri, Turkey
| | - Omer Kayaalti
- Kayseri University, Develi Huseyin Sahin Vocational College, Department of Computer Technologies, Kayseri, Turkey
| | - Bekir Hakan Aksebzeci
- Abdullah Gul University, Faculty of Engineering, Department of Biomedical Engineering, Kayseri, Turkey
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22
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23
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Pires da Silva I, Glitza IC, Haydu LE, Johnpulle R, Banks PD, Grass GD, Goldinger SMA, Smith JL, Everett AS, Koelblinger P, Roberts-Thomson R, Millward M, Atkinson VG, Guminski A, Kapoor R, Conry RM, Carlino MS, Wang W, Shackleton MJ, Eroglu Z, Lo S, Hong AM, Long GV, Johnson DB, Menzies AM. Incidence, features and management of radionecrosis in melanoma patients treated with cerebral radiotherapy and anti-PD-1 antibodies. Pigment Cell Melanoma Res 2019; 32:553-563. [PMID: 30767428 PMCID: PMC8258671 DOI: 10.1111/pcmr.12775] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/09/2019] [Accepted: 01/27/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Brain radiotherapy is used in the management of melanoma brain metastases (MBM) and can result in radionecrosis. Anti-PD-1 is active in the brain and may increase the risk of radionecrosis when combined with radiotherapy. We studied the incidence, associated factors and management of radionecrosis in longer-term survivors with MBM treated with this combination. METHODS Patients with MBM treated with radiotherapy and anti-PD-1 who survived >1 year were identified to determine radionecrosis incidence (Cohort A, n = 135). Cohort A plus additional radionecrosis cases were examined for factors associated with radionecrosis and management (Cohort B, n = 148). RESULTS From Cohort A, 17% developed radionecrosis, with a cumulative incidence at 2 years of 18%. Using Cohort B, multivariable analysis confirmed an association between radionecrosis and elevated lactate dehydrogenase (p = 0.0496) and prior treatment with ipilimumab (p = 0.0319). Radionecrosis was diagnosed based on MRI (100%), symptoms (69%) and pathology (56%). Treatment included corticosteroids, bevacizumab and neurosurgery. CONCLUSIONS Radionecrosis is a significant toxicity in longer-term melanoma survivors with MBM treated with anti-PD-1 and radiotherapy. Identification of those at risk of radionecrosis who may avoid radiotherapy is required.
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Affiliation(s)
- Ines Pires da Silva
- Melanoma Institute Australia and The University of Sydney, Sydney, New South Wales, Australia
| | | | - Lauren E Haydu
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - George D Grass
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | | | - Jessica L Smith
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | | | | | | | - Michael Millward
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Department of Medical Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Victoria G Atkinson
- Princess Alexandra Hospital and Greenslopes Private Hospital, University of Queensland, Brisbane, Queensland, Australia
| | - Alexander Guminski
- Melanoma Institute Australia and The University of Sydney, Sydney, New South Wales, Australia.,Royal North Shore and Mater Hospitals, Sydney, New South Wales, Australia
| | - Rony Kapoor
- Melanoma Institute Australia and The University of Sydney, Sydney, New South Wales, Australia
| | - Robert M Conry
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Matteo S Carlino
- Melanoma Institute Australia and The University of Sydney, Sydney, New South Wales, Australia.,Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Wei Wang
- Melanoma Institute Australia and The University of Sydney, Sydney, New South Wales, Australia.,Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Mark J Shackleton
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Department of Oncology, Alfred Health, Melbourne, Victoria, Australia
| | - Zeynep Eroglu
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Serigne Lo
- Melanoma Institute Australia and The University of Sydney, Sydney, New South Wales, Australia
| | - Angela M Hong
- Melanoma Institute Australia and The University of Sydney, Sydney, New South Wales, Australia
| | - Georgina V Long
- Melanoma Institute Australia and The University of Sydney, Sydney, New South Wales, Australia.,Royal North Shore and Mater Hospitals, Sydney, New South Wales, Australia
| | | | - Alexander M Menzies
- Melanoma Institute Australia and The University of Sydney, Sydney, New South Wales, Australia.,Royal North Shore and Mater Hospitals, Sydney, New South Wales, Australia
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24
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Amaral T, Tampouri I, Eigentler T, Keim U, Klumpp B, Heinrich V, Zips D, Paulsen F, Gepfner-Tuma I, Skardelly M, Tatagiba M, Tabatabai G, Garbe C, Forschner A. Immunotherapy plus surgery/radiosurgery is associated with favorable survival in patients with melanoma brain metastasis. Immunotherapy 2019; 11:297-309. [PMID: 30606066 DOI: 10.2217/imt-2018-0149] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Melanoma brain metastases (MBM) are associated with a dismal prognosis. Few clinical trials evaluated the impact of immunotherapy (IT) and targeted therapy (TT) alone or in combination with surgery and radiotherapy in this population. PATIENTS & METHODS Retrospective analysis of data from 163 patients diagnosed with MBM between January 2014 and December 2016. Prognostic factors of overall survival were analyzed using Kaplan-Meier survival curves, classification and regression tree and multivariate Cox regression analysis. RESULTS The median follow-up was 25 months; median overall survival (mOS) for all patients was 7 months. For patients receiving IT, the mOS was 13 months and 7 months for patients receiving TT or chemotherapy (CT). The mOS for patients treated with surgery/radiosurgery in combination with IT, TT and CT was 25, 14 and 11 months, respectively. CONCLUSION New systemic therapies, especially IT, improve mOS in patients with MBM, particularly when combined with surgery/radiosurgery upfront.
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Affiliation(s)
- Teresa Amaral
- Center for Dermatooncology, Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany.,Portuguese Air Force Health Direction, Paço do Lumiar, 1649-020, Lisbon, Portugal
| | - Ioanna Tampouri
- Center for Dermatooncology, Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
| | - Thomas Eigentler
- Center for Dermatooncology, Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
| | - Ulrike Keim
- Center for Dermatooncology, Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
| | - Bernhard Klumpp
- Department of Radiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Vanessa Heinrich
- Department of Radiation Oncology, University Hospital Tuebingen, Tuebingen, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University Hospital Tuebingen, Tuebingen, Germany.,Centre for CNS Tumors at the Comprehensive Cancer Centre Tuebingen-Stuttgart, University Hospital Tuebingen, Tuebingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital Tuebingen, Tuebingen, Germany.,Centre for CNS Tumors at the Comprehensive Cancer Centre Tuebingen-Stuttgart, University Hospital Tuebingen, Tuebingen, Germany
| | - Irina Gepfner-Tuma
- Interdisciplinary Division of Neuro-Oncology, Hertie Institute for Clinical Brain Research, University Hospital Tuebingen, Tuebingen, Germany.,Centre for CNS Tumors at the Comprehensive Cancer Centre Tuebingen-Stuttgart, University Hospital Tuebingen, Tuebingen, Germany
| | - Marco Skardelly
- Interdisciplinary Division of Neuro-Oncology, Hertie Institute for Clinical Brain Research, University Hospital Tuebingen, Tuebingen, Germany.,Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany.,Centre for CNS Tumors at the Comprehensive Cancer Centre Tuebingen-Stuttgart, University Hospital Tuebingen, Tuebingen, Germany
| | - Marcos Tatagiba
- Interdisciplinary Division of Neuro-Oncology, Hertie Institute for Clinical Brain Research, University Hospital Tuebingen, Tuebingen, Germany.,Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany.,Centre for CNS Tumors at the Comprehensive Cancer Centre Tuebingen-Stuttgart, University Hospital Tuebingen, Tuebingen, Germany
| | - Ghazaleh Tabatabai
- Interdisciplinary Division of Neuro-Oncology, Hertie Institute for Clinical Brain Research, University Hospital Tuebingen, Tuebingen, Germany.,Centre for CNS Tumors at the Comprehensive Cancer Centre Tuebingen-Stuttgart, University Hospital Tuebingen, Tuebingen, Germany
| | - Claus Garbe
- Center for Dermatooncology, Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
| | - Andrea Forschner
- Center for Dermatooncology, Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
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25
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Kuske M, Rauschenberg R, Garzarolli M, Meredyth-Stewart M, Beissert S, Troost EGC, Glitza OIC, Meier F. Melanoma Brain Metastases: Local Therapies, Targeted Therapies, Immune Checkpoint Inhibitors and Their Combinations-Chances and Challenges. Am J Clin Dermatol 2018; 19:529-541. [PMID: 29417399 PMCID: PMC6061393 DOI: 10.1007/s40257-018-0346-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Recent phase II trials have shown that BRAF/MEK inhibitors and immune checkpoint inhibitors are active in patients with melanoma brain metastases (MBM), reporting intracranial disease control rates of 50-75%. Furthermore, retrospective analyses suggest that combining stereotactic radiosurgery with immune checkpoint inhibitors or BRAF/MEK inhibitors prolongs overall survival. These data stress the need for inter- and multidisciplinary cooperation that takes into account the individual prognostic factors in order to establish the best treatment for each patient. Although the management of MBM has dramatically improved, a substantial number of patients still progress and die from brain metastases. Therefore, there is an urgent need for prospective studies in patients with MBM that focus on treatment combinations and sequences, new treatment strategies, and biomarkers of treatment response. Moreover, further research is needed to decipher brain-specific mechanisms of therapy resistance.
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Affiliation(s)
- Marvin Kuske
- Department of Dermatology, Medical Faculty of Technische Universität Dresden, University Hospital Carl Gustav Carus, University of Dresden, Fetscherstr. 74, 01307, Dresden, Germany
- Skin Cancer Center at the University Cancer Centre Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
| | - Ricarda Rauschenberg
- Department of Dermatology, Medical Faculty of Technische Universität Dresden, University Hospital Carl Gustav Carus, University of Dresden, Fetscherstr. 74, 01307, Dresden, Germany
- Skin Cancer Center at the University Cancer Centre Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
| | - Marlene Garzarolli
- Department of Dermatology, Medical Faculty of Technische Universität Dresden, University Hospital Carl Gustav Carus, University of Dresden, Fetscherstr. 74, 01307, Dresden, Germany
- Skin Cancer Center at the University Cancer Centre Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
| | - Michelle Meredyth-Stewart
- Department of Internal Medicine, Medical Faculty of Technische Universität Dresden, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Stefan Beissert
- Department of Dermatology, Medical Faculty of Technische Universität Dresden, University Hospital Carl Gustav Carus, University of Dresden, Fetscherstr. 74, 01307, Dresden, Germany
- Skin Cancer Center at the University Cancer Centre Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
| | - Esther G C Troost
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
- Department of Radiation Oncology, Medical Faculty Carl Gustav Carus, University Hospital, Technische Universität Dresden, Dresden, Germany
- OncoRay-National Center for Radiation Research in Oncology, Dresden, Germany
- Dresden and German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
- Institute of Radiooncology, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | | | - Friedegund Meier
- Department of Dermatology, Medical Faculty of Technische Universität Dresden, University Hospital Carl Gustav Carus, University of Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
- Skin Cancer Center at the University Cancer Centre Dresden, Dresden, Germany.
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany.
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26
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Berghoff AS, Wolpert F, Holland-Letz T, Koller R, Widhalm G, Gatterbauer B, Dieckmann K, Birner P, Bartsch R, Zielinski CC, Weller M, Preusser M. Combining standard clinical blood values for improving survival prediction in patients with newly diagnosed brain metastases-development and validation of the LabBM score. Neuro Oncol 2018; 19:1255-1262. [PMID: 28096493 DOI: 10.1093/neuonc/now290] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background We aimed to investigate the potential of standard hematologic and serum biochemical parameters to provide an independent and substantial contribution to the prediction of survival in patients with newly diagnosed brain metastases (BM). Methods Hemoglobin, white blood cell count, platelet count, serum albumin, creatinine, lactate dehydrogenase (LDH), and C-reactive protein (CRP) were assessed at diagnosis of BM in a discovery cohort of 1200 cancer patients. A multivariable Cox regression model was used to derive the LabBM score. The LabBM score was externally validated in an independent cohort consisting of 366 patients. Results Hemoglobin below lower limit of normal (<LLN; hazard ratio [HR] 1.28; P = .001), platelet count <LLN (HR: 1.36; P = .013), albumin <LLN (HR: 1.19; P = .038), LDH above upper limit of normal (>ULN; HR: 1.51; P < .001), and CRP >ULN (HR: 1.52; P < .001) were associated with survival in a multivariable Cox regression model and were included in the calculation of the LabBM score. Multivariable analysis including the LabBM score and graded prognostic assessment class revealed an independent and significant association of the LabBM score with overall survival (OS) (HR: 1.42; 95% CI: 1.29-1.57; P < .001). The strong and independent association of LabBM score (HR: 1.93; 95% CI: 1.54-2.42) with OS prognosis was confirmed in the validation cohort. Conclusion Standard clinical blood parameters, combined in the easy-to-calculate LabBM score, provide strong and independent prognostic information in patients with BM. The LabBM score is an objective, inexpensive, and reproducible tool to plan clinical management strategies in BM patients and to improve patient selection and stratification for clinical trials.
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Affiliation(s)
- Anna S Berghoff
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland; Biostatistics Division, German Cancer Research Center, Heidelberg, Germany; Department of Neurosurgery, Medical University of Vienna, Vienna, Austria; Department of Radiotherapy, Medical University of Vienna, Vienna, Austria; Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Fabian Wolpert
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland; Biostatistics Division, German Cancer Research Center, Heidelberg, Germany; Department of Neurosurgery, Medical University of Vienna, Vienna, Austria; Department of Radiotherapy, Medical University of Vienna, Vienna, Austria; Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Tim Holland-Letz
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland; Biostatistics Division, German Cancer Research Center, Heidelberg, Germany; Department of Neurosurgery, Medical University of Vienna, Vienna, Austria; Department of Radiotherapy, Medical University of Vienna, Vienna, Austria; Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Romina Koller
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland; Biostatistics Division, German Cancer Research Center, Heidelberg, Germany; Department of Neurosurgery, Medical University of Vienna, Vienna, Austria; Department of Radiotherapy, Medical University of Vienna, Vienna, Austria; Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Georg Widhalm
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland; Biostatistics Division, German Cancer Research Center, Heidelberg, Germany; Department of Neurosurgery, Medical University of Vienna, Vienna, Austria; Department of Radiotherapy, Medical University of Vienna, Vienna, Austria; Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Brigitte Gatterbauer
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland; Biostatistics Division, German Cancer Research Center, Heidelberg, Germany; Department of Neurosurgery, Medical University of Vienna, Vienna, Austria; Department of Radiotherapy, Medical University of Vienna, Vienna, Austria; Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Karin Dieckmann
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland; Biostatistics Division, German Cancer Research Center, Heidelberg, Germany; Department of Neurosurgery, Medical University of Vienna, Vienna, Austria; Department of Radiotherapy, Medical University of Vienna, Vienna, Austria; Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Peter Birner
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland; Biostatistics Division, German Cancer Research Center, Heidelberg, Germany; Department of Neurosurgery, Medical University of Vienna, Vienna, Austria; Department of Radiotherapy, Medical University of Vienna, Vienna, Austria; Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Rupert Bartsch
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland; Biostatistics Division, German Cancer Research Center, Heidelberg, Germany; Department of Neurosurgery, Medical University of Vienna, Vienna, Austria; Department of Radiotherapy, Medical University of Vienna, Vienna, Austria; Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Christoph C Zielinski
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland; Biostatistics Division, German Cancer Research Center, Heidelberg, Germany; Department of Neurosurgery, Medical University of Vienna, Vienna, Austria; Department of Radiotherapy, Medical University of Vienna, Vienna, Austria; Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Michael Weller
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland; Biostatistics Division, German Cancer Research Center, Heidelberg, Germany; Department of Neurosurgery, Medical University of Vienna, Vienna, Austria; Department of Radiotherapy, Medical University of Vienna, Vienna, Austria; Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Matthias Preusser
- Department of Medicine I, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland; Biostatistics Division, German Cancer Research Center, Heidelberg, Germany; Department of Neurosurgery, Medical University of Vienna, Vienna, Austria; Department of Radiotherapy, Medical University of Vienna, Vienna, Austria; Department of Pathology, Medical University of Vienna, Vienna, Austria
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27
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Advanced Melanoma: Current Treatment Options, Biomarkers, and Future Perspectives. Am J Clin Dermatol 2018; 19:303-317. [PMID: 29164492 DOI: 10.1007/s40257-017-0325-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Malignant melanoma accounts for the highest number of deaths from skin cancer, and the prognosis of patients with stage IV disease has historically been poor. Novel insights into both mutations driving tumorigenesis and immune escape mechanisms of these tumors have led to effective treatment options that have revolutionized the treatment of this disease. Targeting the MAPK kinase pathway (with BRAF and MEK inhibitors), as well as targeting checkpoints, such as cytotoxic T-lymphocyte associated protein 4 (CTLA-4) or programmed death 1 (PD-1), have improved overall survival in patients with late-stage melanoma, and biomarker research for personalized therapy is ongoing for each of these treatment modalities. In this review, we will discuss current first-line treatment options, discuss biomarkers supporting treatment decisions, and give an outlook on (combination) therapies we expect to become relevant in the near future.
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Vosoughi E, Lee JM, Miller JR, Nosrati M, Minor DR, Abendroth R, Lee JW, Andrews BT, Leng LZ, Wu M, Leong SP, Kashani-Sabet M, Kim KB. Survival and clinical outcomes of patients with melanoma brain metastasis in the era of checkpoint inhibitors and targeted therapies. BMC Cancer 2018; 18:490. [PMID: 29703161 PMCID: PMC5924486 DOI: 10.1186/s12885-018-4374-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 04/16/2018] [Indexed: 12/29/2022] Open
Abstract
Background Melanoma brain metastasis is associated with an extremely poor prognosis, with a median overall survival of 4–5 months. Since 2011, the overall survival of patients with stage IV melanoma has been significantly improved with the advent of new targeted therapies and checkpoint inhibitors. We analyze the survival outcomes of patients diagnosed with brain metastasis after the introduction of these novel drugs. Methods We performed a retrospective analysis of our melanoma center database and identified 79 patients with brain metastasis between 2011 and 2015. Results The median time from primary melanoma diagnosis to brain metastasis was 3.2 years. The median overall survival duration from the time of initial brain metastasis was 12.8 months. Following a diagnosis of brain metastasis, 39 (49.4%), 28 (35.4%), and 24 (30.4%) patients were treated with anti-CTLA-4 antibody, anti-PD-1 antibody, or BRAF inhibitors (with or without a MEK inhibitor), with a median overall survival of 19.2 months, 37.9 months and 12.7 months, respectively. Factors associated with significantly reduced overall survival included male sex, cerebellar metastasis, higher number of brain lesions, and treatment with whole-brain radiation therapy. Factors associated with significantly longer overall survival included treatment with craniotomy, stereotactic radiosurgery, or with anti-PD-1 antibody after initial diagnosis of brain metastasis. Conclusions These results show a significant improvement in the overall survival of patients with melanoma brain metastasis in the era of novel therapies. In addition, they suggest the activity of anti-PD-1 therapy specifically in the setting of brain metastasis.
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Affiliation(s)
- Elham Vosoughi
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, 2100 Webster Street, Suite 326, San Francisco, CA, 94115, USA
| | - Jee Min Lee
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, 2100 Webster Street, Suite 326, San Francisco, CA, 94115, USA
| | - James R Miller
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, 2100 Webster Street, Suite 326, San Francisco, CA, 94115, USA
| | - Mehdi Nosrati
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, 2100 Webster Street, Suite 326, San Francisco, CA, 94115, USA
| | - David R Minor
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, 2100 Webster Street, Suite 326, San Francisco, CA, 94115, USA
| | - Roy Abendroth
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, 2100 Webster Street, Suite 326, San Francisco, CA, 94115, USA
| | - John W Lee
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, 2100 Webster Street, Suite 326, San Francisco, CA, 94115, USA
| | - Brian T Andrews
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, 2100 Webster Street, Suite 326, San Francisco, CA, 94115, USA
| | - Lewis Z Leng
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, 2100 Webster Street, Suite 326, San Francisco, CA, 94115, USA
| | - Max Wu
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, 2100 Webster Street, Suite 326, San Francisco, CA, 94115, USA
| | - Stanley P Leong
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, 2100 Webster Street, Suite 326, San Francisco, CA, 94115, USA
| | - Mohammed Kashani-Sabet
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, 2100 Webster Street, Suite 326, San Francisco, CA, 94115, USA
| | - Kevin B Kim
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, 2100 Webster Street, Suite 326, San Francisco, CA, 94115, USA.
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29
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Wollina U, Brzezinski P. The value of metastasectomy in stage IV cutaneous melanoma. Wien Med Wochenschr 2018; 169:331-338. [PMID: 29511905 DOI: 10.1007/s10354-018-0630-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 02/13/2018] [Indexed: 12/27/2022]
Abstract
Cutaneous melanoma is an aggressive neoplasia of melanocytes. Prognosis is dependent on tumor stage. Stage IV melanoma is characterized by the occurrence of distant metastases. Response of metastases to classical chemotherapy is limited and toxicity of treatment is high. In recent years, new developments in immunotherapy and targeted therapies improved prognosis of stage IV melanoma patients with better tolerability of treatment. There is no dispute about surgical treatment of primary melanoma. But what is the value of metastasectomy in the era of new systemic treatments? This review aims to discuss available data for surgical removal of distant metastases for several organs and tissues. The available evidence suggests that for selected patients with possible complete resection of all tumor metastases, metastasectomy remains an effective treatment option with a benefit in overall survival.
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Affiliation(s)
- Uwe Wollina
- Department of Dermatology and Allergology, Städtisches Klinikum Dresden, Academic Teaching Hospital, Friedrichstraße 41, 01067, Dresden, Germany.
| | - Piotr Brzezinski
- Faculty of Mathematics and Natural Sciences, Institute of Biology and Environmental Protection, Pomeranian Academy, 76-200, Slupsk, Poland.,Department of Dermatology, 6th Military Support Unit, os. Ledowo 1N, 76-270, Ustka, Poland
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30
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Khan M, Lin J, Liao G, Tian Y, Liang Y, Li R, Liu M, Yuan Y. SRS in Combination With Ipilimumab: A Promising New Dimension for Treating Melanoma Brain Metastases. Technol Cancer Res Treat 2018; 17:1533033818798792. [PMID: 30213236 PMCID: PMC6137552 DOI: 10.1177/1533033818798792] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 05/10/2018] [Accepted: 08/01/2018] [Indexed: 01/08/2023] Open
Abstract
Stereotactic radiosurgery provides effective local control, but high recurrence rate are observed while ipilimumab have shown promising improvements in survival in the treatment of melanoma brain metastases. This meta-analysis was done to review the clinical evidence regarding the combination of stereotactic radiosurgery and ipilimumab in the treatment of brain metastases from melanoma. Comprehensive research of the electronic databases (PubMed and Cochrane Library) was carried out in April 2017. Different combination of MESH headings and words were used. Review Manager was used to analyze the outcome data of interest. According to heterogeneity, fixed effects model or random effects model was adapted. Six retrospective studies comparing stereotactic radiosurgery plus ipilimumab with stereotactic radiosurgery alone were found. Total of 411 participants were included in this meta-analysis. Of that, 128 patients had received stereotactic radiosurgery + ipilimumab, while 283 patients had received stereotactic radiosurgery only. Stereotactic radiosurgery plus ipilimumab significantly improved survival when compared to stereotactic radiosurgery alone (hazard ratio: 0.74 [95% confidence interval: 0.56-0.99, P = .04]), with no significant increase in the incidence of adverse events (odds ratio 0.57 [95% confidence interval: 0.28-1.17, P = .12]). Stereotactic radiosurgery with ipilimumab is safe and effective treatment option and can be recommended for the treatment of brain metastases in patients with melanoma.
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Affiliation(s)
- Muhammad Khan
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute
of Guangzhou Medical University, Guangzhou, Guangdong Province, People’s Republic of
China
| | - Jie Lin
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute
of Guangzhou Medical University, Guangzhou, Guangdong Province, People’s Republic of
China
| | - Guixiang Liao
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute
of Guangzhou Medical University, Guangzhou, Guangdong Province, People’s Republic of
China
| | - Yunhong Tian
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute
of Guangzhou Medical University, Guangzhou, Guangdong Province, People’s Republic of
China
| | - Yingying Liang
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute
of Guangzhou Medical University, Guangzhou, Guangdong Province, People’s Republic of
China
| | - Rong Li
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute
of Guangzhou Medical University, Guangzhou, Guangdong Province, People’s Republic of
China
| | - Mengzhong Liu
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute
of Guangzhou Medical University, Guangzhou, Guangdong Province, People’s Republic of
China
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Sun
Yat-sen Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Yawei Yuan
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute
of Guangzhou Medical University, Guangzhou, Guangdong Province, People’s Republic of
China
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Sun
Yat-sen Medical University, Guangzhou, Guangdong Province, People’s Republic of China
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31
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McArthur GA, Maio M, Arance A, Nathan P, Blank C, Avril MF, Garbe C, Hauschild A, Schadendorf D, Hamid O, Fluck M, Thebeau M, Schachter J, Kefford R, Chamberlain M, Makrutzki M, Robson S, Gonzalez R, Margolin K. Vemurafenib in metastatic melanoma patients with brain metastases: an open-label, single-arm, phase 2, multicentre study. Ann Oncol 2017; 28:634-641. [PMID: 27993793 DOI: 10.1093/annonc/mdw641] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Vemurafenib has shown activity in patients with BRAFV600 mutated melanoma with brain metastases (BM). This phase 2 study evaluated vemurafenib in patients with/without prior treatment for BM. Methods Patients with BRAFV600 mutated melanoma with BM were enrolled into cohort 1 (previously untreated BM) and cohort 2 (previously treated BM) and received vemurafenib (960 mg BID) until disease progression (PD) or intolerance. Primary endpoint was best overall response rate (BORR) in the brain in cohort 1 that was evaluated using modified RECIST 1.1 criteria using lesions ≥0.5 cm to assess response. Results 146 patients were treated (cohort 1 n = 90; cohort 2 n = 56), 62% of whom were male. Median (range) time since diagnosis of BM: 1.0 (0-9) month in cohort 1 and 4.2 (1-68) months in cohort 2. Median duration of treatment was 4.1 months (range 0.3-34.5) in cohort 1 and 4.1 months (range 0.2-27.6) in cohort 2. Intracranial BORR in cohort 1 by an independent review committee (IRC) was 18% (2 CRs, 14 PRs). Extracranial BORR by IRC was 33% in cohort 1 and 23% in cohort 2. Median PFS (brain only, investigator-assessed) was 3.7 months (range 0.03-33.4; IQR 1.9-5.6) in cohort 1 and 4.0 months (range 0.3-27.4; IQR 2.2-7.4) in cohort 2. Median OS was 8.9 months (range 0.6-34.5; IQR 4.9-17.0) in cohort 1 and 9.6 months (range 0.7-34.3; IQR 4.5-18.4) in cohort 2. Adverse events (AEs) were similar in type, grade and frequency to other studies of single-agent vemurafenib. Grade 3/4 AEs occurred in 59 (66%) patients in cohort 1 and 36 (64%) in cohort 2. Overall, 84% of patients died during the study (86% in cohort 1 and 80% in cohort 2), mainly due to disease progression. Conclusions The study demonstrates clinically meaningful response rates of melanoma BM to vemurafenib, which was well tolerated and without significant CNS toxicity.
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Affiliation(s)
- G A McArthur
- Department of Medical Oncology, Peter MacCallum Cancer Centre, East Melbourne and University of Melbourne, Parkville, Australia
| | - M Maio
- AOU Senese Policlinico Santa Maria Alle Scotte, Siena, Italy
| | - A Arance
- Department of Medical Oncology, Hospital Clínic Barcelona, Spain
| | - P Nathan
- Mount Vernon Hospital, Centre for Cancer Treatment, Northwood, UK
| | - C Blank
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - M-F Avril
- University Paris Descartes, Hospital Cochin, APHP, Paris, France
| | - C Garbe
- Department of Dermatology, University Hospital Tuebingen, Tuebingen
| | - A Hauschild
- Department of Dermatology, University Hospital Schleswig-Holstein (UKSH), Campus Kiel, Kiel
| | - D Schadendorf
- Department of Dermatology, Comprehensive Cancer Center, University Hospital Essen, Essen, Germany
| | - O Hamid
- Angeles Clinic and Research Institute, Los Angeles, USA
| | - M Fluck
- Fachklinik Hornheide, Munster, Germany
| | | | - J Schachter
- Chaim Sheba Medical Centre, Oncology Institute, Ramat-Gan, Israel
| | - R Kefford
- Crown Princess Cancer Centre Westmead Hospital and Department of Clinical Medicine, Macquarie University, Sydney NSW, Australia
| | | | - M Makrutzki
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - S Robson
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - R Gonzalez
- University of Colorado Cancer Center, Aurora
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Eigentler TK, Mühlenbein C, Follmann M, Schadendorf D, Garbe C. S3-Leitlinie Diagnostik, Therapie und Nachsorge des Melanoms - Update 2015/2016, Kurzversion 2.0. J Dtsch Dermatol Ges 2017; 15:e1-e41. [DOI: 10.1111/ddg.13247] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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33
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Cui J, Xiong J, Zhang Y, Peng T, Huang M, Lin Y, Guo Y, Wu H, Wang C. Serum lactate dehydrogenase is predictive of persistent organ failure in acute pancreatitis. J Crit Care 2017; 41:161-165. [PMID: 28554094 DOI: 10.1016/j.jcrc.2017.05.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 04/27/2017] [Accepted: 05/03/2017] [Indexed: 02/08/2023]
Abstract
PURPOSE Elevated serum lactate dehydrogenase (LDH) has been reported in a serious of clinical diseases. However, the relationship between LDH and the incidence of persistent organ failure (POF) in acute pancreatitis (AP) has not been characterized. MATERIALS AND METHODS A total of 105 patients with AP who presented within 72h from symptom onset between 2014 and 2015 were included in this retrospective study. Demographic parameters and laboratory data on admission were compared between patients with and without POF. Multivariable logistic regression analyses were utilized to evaluate the prognostic value of LDH for predicting POF. RESULTS 21 patients were diagnosed with POF. Compared to non-POF, patients with POF showed a significantly higher value of serum LDH on admission (741.57±331.72 vs. 296.08±135.73U/L, P<0.001). After multivariate logistic analysis, LDH remained an independent risk factor for POF (Hazard ratio 4.38, 95%CI: 1.42-13.47; P=0.010). A LDH value of 647U/L predicted POF with an area under the curve (AUC) of 0.876, a sensitivity with 76.2% and specificity with 98.8%, respectively. CONCLUSIONS Our results indicate that serum LDH on admission is independently associated with POF in AP and may serve as a potential prognostic factor.
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Affiliation(s)
- Jing Cui
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - Jiongxin Xiong
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yushun Zhang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - Tao Peng
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Min Huang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yan Lin
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yao Guo
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Heshui Wu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Chunyou Wang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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Trino E, Mantovani C, Badellino S, Ricardi U, Filippi AR. Radiosurgery/stereotactic radiotherapy in combination with immunotherapy and targeted agents for melanoma brain metastases. Expert Rev Anticancer Ther 2017; 17:347-356. [PMID: 28277101 DOI: 10.1080/14737140.2017.1296764] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The clinical landscape of advanced melanoma drastically changed after the introduction of both targeted therapies and immunotherapy. This rapid development in systemic therapies led to a change in the management of patients with brain metastases, with the subsequent need to re-assess the role of local therapies, in particular stereotactic radiosurgery (SRS). Areas covered: In this non-systematic review, we report on the current knowledge on the use of SRS in combination with immunotherapy and BRAF/MEK inhibitors for patients with melanoma brain metastases, as well as ongoing trials in this field. Expert commentary: It is now more common to observe patients with melanoma brain metastases with better performance status and prolonged life expectancy. A combination of targeted therapy and immunotherapy, in different sequences, has been shown to be feasible and well tolerable, on the basis of retrospective reports. Additional data from ongoing prospective trials are however needed to confirm or not these findings and better explore the efficacy of the combination.
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Affiliation(s)
- Elisabetta Trino
- a Department of Oncology , University of Torino , Torino , Italy
| | - Cristina Mantovani
- b Radiation Oncology , Città della Salute e della Scienza University Hospital , Torino , Italy
| | - Serena Badellino
- b Radiation Oncology , Città della Salute e della Scienza University Hospital , Torino , Italy
| | - Umberto Ricardi
- a Department of Oncology , University of Torino , Torino , Italy
- b Radiation Oncology , Città della Salute e della Scienza University Hospital , Torino , Italy
| | - Andrea Riccardo Filippi
- a Department of Oncology , University of Torino , Torino , Italy
- c Radiation Oncology , San Luigi Gonzaga University Hospital , Orbassano , Italy
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35
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Long GV, Grob JJ, Nathan P, Ribas A, Robert C, Schadendorf D, Lane SR, Mak C, Legenne P, Flaherty KT, Davies MA. Factors predictive of response, disease progression, and overall survival after dabrafenib and trametinib combination treatment: a pooled analysis of individual patient data from randomised trials. Lancet Oncol 2016; 17:1743-1754. [PMID: 27864013 DOI: 10.1016/s1470-2045(16)30578-2] [Citation(s) in RCA: 236] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/30/2016] [Accepted: 10/04/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Dabrafenib plus trametinib treatment provides significant benefits over BRAF-inhibitor monotherapy in patients with BRAFV600E-mutant or BRAFV600K-mutant advanced melanoma; however, in many patients the disease progresses, leading to death. With many treatment options available, understanding clinical factors that predict long-term response and survival for treatments is important for optimisation of patient management. We aimed to identify clinical factors associated with long-term response and survival using pooled data from randomised trials of dabrafenib plus trametinib in patients with metastatic BRAF-mutant melanoma. METHODS We did a retrospective individual data analysis based on all published randomised trials that included treatment-naive patients with BRAFV600E-mutant or BRAFV600K-mutant metastatic melanoma who received the approved dose of dabrafenib 150 mg twice daily plus trametinib 2 mg once daily. Data were pooled from patients in the BRF113220 (part C; March 26, 2010, to Jan 15, 2015), COMBI-d (May 4, 2012, to Jan 12, 2015), and COMBI-v (June 4, 2012, to March 13, 2015) randomised trials. Patients with untreated brain metastases were not permitted to enrol in these trials. Baseline factors, identified a priori based on known melanoma clinical or prognostic characteristics, were analysed for association with progression-free survival and overall survival using univariate and multivariate analyses and assessed for hierarchical effect on outcomes using regression tree analyses. We also analysed factors identified after baseline, on treatment, and at progression, for associations with survival after progression. The trials included in this analysis are registered with ClinicalTrials.gov: BRF113220, number NCT01072175; COMBI-d, number NCT01584648; COMBI-v, number NCT01597908. FINDINGS 617 patients were included in this analysis with a median follow-up of 20·0 months (range 0-48·0, IQR 10·1-24·8); 396 patients had progression events (ie, disease progression or death) and 290 patients had died. Median progression-free survival (11·1 months [95% CI 9·7-12·9]), median overall survival (25·6 months [23·1-34·3]), 1-year progression-free survival (48% [44-52]) and overall survival (74% [71-78]), and 2-year progression-free survival (30% [26-34]) and overall survival (53% [49-57]) were consistent with those in the individual trials. Patients with normal lactate dehydrogenase (LDH) concentration and fewer than three organ sites containing metastases (n=237) had the longest 1-year progression-free survival (68% [95% CI 62-74]) and overall survival (90% [87-94]) and 2-year progression-free survival (46% [40-54]) and overall survival (75% [70-81]), whereas patients with LDH concentration at least two times the upper limit of normal (n=70) had the shortest 1-year progression-free survival (8% [3-19]) and overall survival (40% [29-55]) and 2-year progression-free survival (2% [0-13]) and overall survival (7% [3-19]). Of patients with disease progression (n=379), survival after progression was longest in those with progression in baseline or new non-CNS lesions (n=205; median 10·0 months [95% CI 7·9-12·0]) and shortest in those with new CNS lesions or concurrent progression in baseline and new lesions (n=171; median 4·0 months [3·5-4·9]). INTERPRETATION Several patient and clinical characteristics at and after baseline are associated with outcomes with dabrafenib plus trametinib, and durable benefit is possible with targeted treatment in defined patient subsets. FUNDING Novartis.
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Affiliation(s)
- Georgina V Long
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Royal North Shore and Mater Hospitals, Sydney, Australia.
| | - Jean-Jacques Grob
- Service de Dermatologie, Centre Hospitalo-Universitaire Timone, Aix Marseille Université, Marseille CEDEX 05, France
| | | | - Antoni Ribas
- Department of Medicine, Hematology/Oncology, UCLA Jonsson Comprehensive Cancer Center, Los Angeles, CA, USA
| | - Caroline Robert
- Gustave Roussy, Département de Médecine Oncologique, Service de Dermatologie et Université Paris-Sud, Faculté de Médecine, Villejuif, France
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital Essen, Essen, Germany; German Cancer Consortium, Heidelberg, Germany
| | - Stephen R Lane
- Biostatistics, Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Carmen Mak
- Biostatistics, Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Keith T Flaherty
- Developmental Therapeutics and Melanoma Programs, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Michael A Davies
- Melanoma Medical Oncology and Systems Biology, The University of Texas MDAnderson Cancer Center, Houston, TX, USA
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Gampa G, Vaidhyanathan S, Resman BW, Parrish KE, Markovic SN, Sarkaria JN, Elmquist WF. Challenges in the delivery of therapies to melanoma brain metastases. ACTA ACUST UNITED AC 2016; 2:309-325. [PMID: 28546917 DOI: 10.1007/s40495-016-0072-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Brain metastases are a major cause of morbidity and mortality in patients with advanced melanoma. Recent approval of several molecularly-targeted agents and biologics has brought hope to patients with this previously untreatable disease. However, patients with symptomatic melanoma brain metastases have often been excluded from pivotal clinical trials. This may be in part attributed to the fact that several of the approved small molecule molecularly-targeted agents are substrates for active efflux at the blood-brain barrier, limiting their effective delivery to brain metastases. We believe that successful treatment of melanoma brain metastases will depend on the ability of these agents to traverse the blood-brain barrier and reach micrometastases that are often not clinically detectable. Moreover, overcoming the emergence of a unique pattern of resistance, possibly through adequate delivery of combination targeted therapies in brain metastases will be important in achieving a durable response. These concepts, and the current challenges in the delivery of new treatments to melanoma brain metastases, are discussed in this review.
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Affiliation(s)
- Gautham Gampa
- Brain Barriers Research Center, Department of Pharmaceutics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shruthi Vaidhyanathan
- Brain Barriers Research Center, Department of Pharmaceutics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Brynna-Wilken Resman
- Brain Barriers Research Center, Department of Pharmaceutics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Karen E Parrish
- Brain Barriers Research Center, Department of Pharmaceutics, University of Minnesota, Minneapolis, Minnesota, USA
| | | | | | - William F Elmquist
- Brain Barriers Research Center, Department of Pharmaceutics, University of Minnesota, Minneapolis, Minnesota, USA
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Melanoma brain metastases: correlation of imaging features with genomic markers and patient survival. J Neurooncol 2016; 131:341-348. [PMID: 27822597 DOI: 10.1007/s11060-016-2305-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 10/17/2016] [Indexed: 12/28/2022]
Abstract
Purpose To identify MR imaging features of melanoma brain metastases (MBM) that correlate with genetic profile of melanoma and patient survival. Materials and methods Patients with newly diagnosed melanoma metastases were identified from institutional database A retrospective review of brain MRI was performed focusing on lesion number, size, T1-, T2- and diffusion-weighted signal characteristics, hemorrhage, necrosis, enhancement pattern and edema. Genomic (BRAF status), treatment and survival data was collected. Results 98 patients were included in final analysis. A strong correlation was found between size of the largest lesion and the percent of lesions with T1-weighted hyperintense signal (R = 0.49), percent of lesions with size >1 cm (0.55), and the lesions that are clearly hemorrhagic (0.43). The analyzed imaging parameters were found to be independent of BRAF mutation status. The median survival of subjects with single lesion (9.1 months) was significantly higher than the median survival of subjects with more than 1 lesion (4.9 months) (p = 0.002). Patients with 2-18 lesions had significantly longer survival (5.6 months) than with >18 lesions (2 months) (p < 0.001). Other imaging parameters such as lesion size, T1-weighted hyperintensity, number of lesions with edema and hemorrhage were not found to be significantly related to survival. BRAF inhibitor treatment was found to be the most significant prognostic factor (p = 0.002) among patients with multiple lesions. Conclusion There is a statistically significant correlation between number of brain metastases and survival. In patients with multiple lesions, BRAF inhibitor treatment was the most significant prognostic factor.
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Dagogo-Jack I, Gill CM, Cahill DP, Santagata S, Brastianos PK. Treatment of brain metastases in the modern genomic era. Pharmacol Ther 2016; 170:64-72. [PMID: 27773784 DOI: 10.1016/j.pharmthera.2016.10.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Development of brain metastasis (BM) portends a dismal prognosis for patients with cancer. Melanomas and carcinomas of the lung, breast, and kidney are the most common malignancies to metastasize to the brain. Recent advances in molecular genetics have enabled the identification of actionable, clinically relevant genetic alterations within primary tumors and their corresponding metastases. Adoption of genotype-guided treatment strategies for the management of systemic malignancy has resulted in dramatic and durable responses. Unfortunately, despite these therapeutic advances, central nervous system (CNS) relapses are not uncommon. Although these relapses have historically been attributed to limited blood brain barrier penetration of anti-neoplastic agents, recent work has demonstrated genetic heterogeneity such that metastatic sites, including BM, harbor relevant genetic alterations that are not present in primary tumor biopsies. This improved insight into molecular mechanisms underlying site specific recurrences can inform strategies for targeting these oncogenic drivers. Thus, development of rational, genomically guided CNS-penetrant therapies is crucial for ongoing therapeutic success.
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Affiliation(s)
- Ibiayi Dagogo-Jack
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Corey M Gill
- Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Daniel P Cahill
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Sandro Santagata
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Priscilla K Brastianos
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.
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Rauschenberg R, Tabatabai G, Troost EGC, Garzarolli M, Beissert S, Meier F. Hirnmetastasen des malignen Melanoms. Hautarzt 2016; 67:536-43. [DOI: 10.1007/s00105-016-3797-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Nowak-Sadzikowska J, Walasek T, Jakubowicz J, Blecharz P, Reinfuss M. Current treatment options of brain metastases and outcomes in patients with malignant melanoma. Rep Pract Oncol Radiother 2015; 21:271-7. [PMID: 27601961 DOI: 10.1016/j.rpor.2015.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/31/2015] [Accepted: 12/01/2015] [Indexed: 10/22/2022] Open
Abstract
The prognosis for patients with melanoma who have brain metastases is poor, a median survival does not exceed 4-6 months. There are no uniform standards of treatment for patients with melanoma brain metastases (MBMs). The most preferred treatment approaches include local therapy - surgical resection and/or stereotactic radiosurgery (SRS). The role of whole brain radiotherapy (WBRT) as an adjuvant to local therapy is controversial. WBRT remains a palliative approach for those patients who have multiple MBMs with contraindications for surgery or SRS, or/and poor performance status, or/and very widespread extracranial metastases. Corticosteroids have been used in palliative treatment of MBMs as relief from symptoms related to intracranial pressure and edema. In recent years, the development of new systemic therapeutic strategies has been observed. Various modalities of systemic treatment include chemotherapy, immunotherapy and targeted therapy. Also, multimodality management in different combinations is a common strategy. Decisions regarding the use of specific treatment modalities are dependent on patient's performance status, and the extent of both intracranial and extracranial disease. This review summarizes current treatment options, indications and outcomes in patients with brain metastases from melanoma.
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Affiliation(s)
- Jadwiga Nowak-Sadzikowska
- Oncology Clinic, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Kraków, Poland
| | - Tomasz Walasek
- Radiotherapy Department, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Kraków, Poland
| | - Jerzy Jakubowicz
- Oncology Clinic, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Kraków, Poland
| | - Paweł Blecharz
- Gynecologic Oncology Clinic, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Kraków, Poland
| | - Marian Reinfuss
- Radiotherapy Department, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Kraków, Poland
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Wilkins A, Furness A, W Corbett R, Bloomfield A, Porta N, Morris S, Ali Z, Larkin J, Harrington K. The melanoma-specific graded prognostic assessment does not adequately discriminate prognosis in a modern population with brain metastases from malignant melanoma. Br J Cancer 2015; 113:1275-81. [PMID: 26484413 PMCID: PMC4815790 DOI: 10.1038/bjc.2015.357] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 08/13/2015] [Accepted: 09/10/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The melanoma-specific graded prognostic assessment (msGPA) assigns patients with brain metastases from malignant melanoma to 1 of 4 prognostic groups. It was largely derived using clinical data from patients treated in the era that preceded the development of newer therapies such as BRAF, MEK and immune checkpoint inhibitors. Therefore, its current relevance to patients diagnosed with brain metastases from malignant melanoma is unclear. This study is an external validation of the msGPA in two temporally distinct British populations. METHODS Performance of the msGPA was assessed in Cohort I (1997-2008, n=231) and Cohort II (2008-2013, n=162) using Kaplan-Meier methods and Harrell's c-index of concordance. Cox regression was used to explore additional factors that may have prognostic relevance. RESULTS The msGPA does not perform well as a prognostic score outside of the derivation cohort, with suboptimal statistical calibration and discrimination, particularly in those patients with an intermediate prognosis. Extra-cerebral metastases, leptomeningeal disease, age and potential use of novel targeted agents after brain metastases are diagnosed, should be incorporated into future prognostic models. CONCLUSIONS An improved prognostic score is required to underpin high-quality randomised controlled trials in an area with a wide disparity in clinical care.
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Affiliation(s)
- Anna Wilkins
- Melanoma Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
- The Institute of Cancer Research, Division of Radiotherapy and Imaging, 123 Old Brompton Road, London SW7 3RP, UK
- The Institute of Cancer Research, Division of Clinical Studies, 123 Old Brompton Road, London SW7 3RP, UK
| | - Andrew Furness
- Melanoma Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
- The Institute of Cancer Research, Division of Radiotherapy and Imaging, 123 Old Brompton Road, London SW7 3RP, UK
| | - Richard W Corbett
- Department of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Adam Bloomfield
- Melanoma Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
| | - Nuria Porta
- The Institute of Cancer Research, Division of Clinical Studies, 123 Old Brompton Road, London SW7 3RP, UK
| | - Stephen Morris
- Department of Clinical Oncology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK
| | - Zohra Ali
- Melanoma Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
- The Institute of Cancer Research, Division of Radiotherapy and Imaging, 123 Old Brompton Road, London SW7 3RP, UK
| | - James Larkin
- Melanoma Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
- The Institute of Cancer Research, Division of Clinical Studies, 123 Old Brompton Road, London SW7 3RP, UK
| | - Kevin Harrington
- Melanoma Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
- The Institute of Cancer Research, Division of Radiotherapy and Imaging, 123 Old Brompton Road, London SW7 3RP, UK
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Development and External Validation of Nomograms for Predicting Survival in Nasopharyngeal Carcinoma Patients after Definitive Radiotherapy. Sci Rep 2015; 5:15638. [PMID: 26497224 PMCID: PMC4620487 DOI: 10.1038/srep15638] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 09/28/2015] [Indexed: 11/08/2022] Open
Abstract
The distant metastasis free survival (DMFS) and overall survival (OS) differ significantly among individuals even within the same clinical stages. The purpose of this retrospective study was to build nomograms incorporating plasma EBV DNA for predicting DMFS and OS of nasopharyngeal carcinoma (NPC) patients after definitive radiotherapy. A total of 1168 non-metastatic NPC patients from two institutions were included to develop the nomograms. Seven and six independent prognostic factors were identified to build the nomograms for OS and DMFS, respectively. The models were externally validated by a separate cohort of 756 NPC patients from the third institutions. For predicting OS, the c-index of the nomogram was significantly better than that of the TNM staging system (Training cohort, P = 0.005; validation cohort, P = 0.03). The c-index of nomogram for DMFS in the training and validation set were both higher than that of TNM classification with marginal significance (P = 0.048 and P = 0.057, respectively). The probability of 1-, 3-, and 5-year OS and DMFS showed optimal agreement between nomogram prediction and actual observation. The proposed stratification of risk groups based on the nomograms allowed significant distinction between Kaplan-Meier curves for survival outcomes. The prognostic nomograms could better stratify patients into different risk groups.
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Saria M, Piccioni D, Carter J, Orosco H, Turpin T, Kesari S. Current Perspectives in the Management of Brain Metastases. Clin J Oncol Nurs 2015. [DOI: 10.1188/15.cjon.475-478] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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KPS/LDH index: a simple tool for identifying patients with metastatic melanoma who are unlikely to benefit from palliative whole brain radiotherapy. Support Care Cancer 2015; 24:523-528. [DOI: 10.1007/s00520-015-2793-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 06/01/2015] [Indexed: 11/25/2022]
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Patel KR, Lawson DH, Kudchadkar RR, Carthon BC, Oliver DE, Okwan-Duodu D, Ahmed R, Khan MK. Two heads better than one? Ipilimumab immunotherapy and radiation therapy for melanoma brain metastases. Neuro Oncol 2015; 17:1312-21. [PMID: 26014049 DOI: 10.1093/neuonc/nov093] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 05/03/2015] [Indexed: 12/15/2022] Open
Abstract
Melanoma is an aggressive malignancy with a deplorable penchant for spreading to the brain. While focal therapies such as surgery and stereotactic radiosurgery can help provide local control, the majority of patients still develop intracranial progression. Novel therapeutic combinations to improve outcomes for melanoma brain metastases (MBM) are clearly needed. Ipilimumab, the anticytotoxic T-lymphocyte-associated antigen 4 monoclonal antibody, has been shown to improve survival in patients with metastatic melanoma, but many of these trials either excluded or had very few patients with MBM. This article will review the efficacy and limitations of ipilimumab therapy for MBM, describe the current evidence for combining ipilimumab with radiation therapy, illustrate potential mechanisms for synergy, and discuss emerging clinical trials specifically investigating this combination in MBM.
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Affiliation(s)
- Kirtesh R Patel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia (K.R.P., D.O.-D., M.K.K.); Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia (D.H.L., R.R.K., B.C.C.); School of Medicine, Emory University, Atlanta, Georgia (D.E.O.); Emory Vaccine Center and Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, Georgia (R.A.)
| | - David H Lawson
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia (K.R.P., D.O.-D., M.K.K.); Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia (D.H.L., R.R.K., B.C.C.); School of Medicine, Emory University, Atlanta, Georgia (D.E.O.); Emory Vaccine Center and Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, Georgia (R.A.)
| | - Ragini R Kudchadkar
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia (K.R.P., D.O.-D., M.K.K.); Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia (D.H.L., R.R.K., B.C.C.); School of Medicine, Emory University, Atlanta, Georgia (D.E.O.); Emory Vaccine Center and Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, Georgia (R.A.)
| | - Bradley C Carthon
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia (K.R.P., D.O.-D., M.K.K.); Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia (D.H.L., R.R.K., B.C.C.); School of Medicine, Emory University, Atlanta, Georgia (D.E.O.); Emory Vaccine Center and Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, Georgia (R.A.)
| | - Daniel E Oliver
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia (K.R.P., D.O.-D., M.K.K.); Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia (D.H.L., R.R.K., B.C.C.); School of Medicine, Emory University, Atlanta, Georgia (D.E.O.); Emory Vaccine Center and Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, Georgia (R.A.)
| | - Derick Okwan-Duodu
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia (K.R.P., D.O.-D., M.K.K.); Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia (D.H.L., R.R.K., B.C.C.); School of Medicine, Emory University, Atlanta, Georgia (D.E.O.); Emory Vaccine Center and Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, Georgia (R.A.)
| | - Rafi Ahmed
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia (K.R.P., D.O.-D., M.K.K.); Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia (D.H.L., R.R.K., B.C.C.); School of Medicine, Emory University, Atlanta, Georgia (D.E.O.); Emory Vaccine Center and Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, Georgia (R.A.)
| | - Mohammad K Khan
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia (K.R.P., D.O.-D., M.K.K.); Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia (D.H.L., R.R.K., B.C.C.); School of Medicine, Emory University, Atlanta, Georgia (D.E.O.); Emory Vaccine Center and Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, Georgia (R.A.)
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Gibney GT, Gauthier G, Ayas C, Galebach P, Wu EQ, Abhyankar S, Reyes C, Guérin A, Yim YM. Treatment patterns and outcomes in BRAF V600E-mutant melanoma patients with brain metastases receiving vemurafenib in the real-world setting. Cancer Med 2015; 4:1205-13. [PMID: 25991583 PMCID: PMC4559032 DOI: 10.1002/cam4.475] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 04/15/2015] [Accepted: 04/21/2015] [Indexed: 01/22/2023] Open
Abstract
Brain metastases are a common and serious complication among patients with metastatic melanoma. The selective BRAF inhibitor vemurafenib has demonstrated clinical efficacy in patients with BRAF V600E-mutant melanoma brain metastases (MBM). We examined the real-world application and clinical outcomes of vemurafenib in this patient population. Demographic, treatment patterns, response, and survival data were collected from medical charts. Clinical data on 283 patients with active BRAF V600E-mutant MBM treated with vemurafenib were provided by 70 US oncologists. Mean age was 57.2 years, 60.8% were male, 67.5% had ECOG performance status of 0–1, and 43.1% used corticosteroids at vemurafenib initiation. Median follow-up was 5.7 months. Following vemurafenib initiation, 48.1% of patients experienced intracranial response and 45.6% experienced extracranial response. The Kaplan–Meier estimate for overall survival was 59% at 12 months. Multivariate analyses showed associations between intracranial response and both corticosteroid use and vemurafenib as initial therapy after MBM diagnosis. Larger size (5–10 mm vs. <5 mm) and number of brain metastases (≥5 vs. <2) and progressive extracranial disease at treatment initiation were associated with decreased intracranial response and increased risk of disease progression. Multiple extracranial sites (2 vs. <2) and the absence of local treatments were also associated with increased risk of progression. Increased risk of death was associated with ≥2 extracranial disease sites, progressive extracranial disease, and ≥5 brain metastases. Subgroups of MBM patients may derive more benefit with vemurafenib, warranting prospective investigation.
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Affiliation(s)
| | | | | | | | - Eric Q Wu
- Analysis Group Inc., Boston, Massachusetts
| | | | | | | | - Yeun Mi Yim
- Genentech Inc., South San Francisco, California
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Harding JJ, Catalanotti F, Munhoz RR, Cheng DT, Yaqubie A, Kelly N, McDermott GC, Kersellius R, Merghoub T, Lacouture ME, Carvajal RD, Panageas KS, Berger MF, Rosen N, Solit DB, Chapman PB. A Retrospective Evaluation of Vemurafenib as Treatment for BRAF-Mutant Melanoma Brain Metastases. Oncologist 2015; 20:789-97. [PMID: 25956405 DOI: 10.1634/theoncologist.2014-0012] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 02/04/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND RAF inhibitors are an effective therapy for patients with BRAF-mutant melanoma and brain metastasis. Efficacy data are derived from clinical studies enriched with physiologically fit patients; therefore, it is of interest to assess the real-world experience of vemurafenib in this population. Tumor-specific genetic variants that influence sensitivity to RAF kinase inhibitors also require investigation. METHODS Records of patients with BRAF-mutant melanoma and brain metastases who were treated with vemurafenib were reviewed. Clinical data were extracted to determine extracranial and intracranial objective response rates, progression-free survival (PFS), overall survival (OS), and safety. A bait-capture, next-generation sequencing assay was used to identify mutations in pretreatment tumors that could explain primary resistance to vemurafenib. RESULTS Among patients with intracranial disease treated with vemurafenib, 27 were included in survival analyses and 22 patients were assessable for response. The extracranial and intracranial objective response rates were 71% and 50%, respectively. Discordant responses were observed between extracranial and intracranial metastatic sites in 4 of 19 evaluable patients. Median PFS was 4.1 months (95% confidence interval [CI]: 2.6-7.9); median intracranial PFS was 4.6 months (95% CI: 2.7-7.9), median OS was 7.5 months (95% CI: 4.3-not reached), with a 30.4% 1-year OS rate. Outcomes were influenced by performance status. Vemurafenib was tolerable, although radiation-induced dermatitis occurred in some patients who received whole-brain radiotherapy. Adequate samples for next-generation sequencing analysis were available for seven patients. Melanomas categorized as "poorly sensitive" (≥20% tumor growth, new lesions, or ≤50% shrinkage for <4 months) harbored co-occurring mutations in genes predicted to activate the phosphatidylinositol 3-kinase-AKT (PI3K-AKT) pathway. CONCLUSION Vemurafenib is highly active in BRAF-mutant melanoma brain metastases but has limited activity in patients with poor performance status. The safety and efficacy of concurrent radiotherapy and RAF inhibition requires careful clinical evaluation. Combination strategies blocking the MAPK and PI3K-AKT pathway may be warranted in a subset of patients. IMPLICATIONS FOR PRACTICE Vemurafenib is active for BRAF-mutant intracranial melanoma metastases in an unselected patient population typical of routine oncologic practice. Patients with poor performance status appear to have poor outcomes despite vemurafenib therapy. Preliminary data indicate that co-occurring or secondary alterations in the phosphatidylinositol 3-kinase-AKT (PI3K-AKT) pathway are involved in resistance to RAF inhibition, thus providing a rationale for dual MAPK and PI3K-AKT pathway inhibition in this patient population.
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Affiliation(s)
- James J Harding
- Departments of Medicine and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Human Oncology and Pathogenesis Program, Memorial Hospital Research Laboratories, New York, New York, USA; Immunology and Molecular and Pharmacology and Chemistry Programs, Sloan Kettering Institute, New York, New York, USA
| | - Federica Catalanotti
- Departments of Medicine and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Human Oncology and Pathogenesis Program, Memorial Hospital Research Laboratories, New York, New York, USA; Immunology and Molecular and Pharmacology and Chemistry Programs, Sloan Kettering Institute, New York, New York, USA
| | - Rodrigo R Munhoz
- Departments of Medicine and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Human Oncology and Pathogenesis Program, Memorial Hospital Research Laboratories, New York, New York, USA; Immunology and Molecular and Pharmacology and Chemistry Programs, Sloan Kettering Institute, New York, New York, USA
| | - Donavan T Cheng
- Departments of Medicine and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Human Oncology and Pathogenesis Program, Memorial Hospital Research Laboratories, New York, New York, USA; Immunology and Molecular and Pharmacology and Chemistry Programs, Sloan Kettering Institute, New York, New York, USA
| | - Amin Yaqubie
- Departments of Medicine and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Human Oncology and Pathogenesis Program, Memorial Hospital Research Laboratories, New York, New York, USA; Immunology and Molecular and Pharmacology and Chemistry Programs, Sloan Kettering Institute, New York, New York, USA
| | - Nicole Kelly
- Departments of Medicine and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Human Oncology and Pathogenesis Program, Memorial Hospital Research Laboratories, New York, New York, USA; Immunology and Molecular and Pharmacology and Chemistry Programs, Sloan Kettering Institute, New York, New York, USA
| | - Gregory C McDermott
- Departments of Medicine and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Human Oncology and Pathogenesis Program, Memorial Hospital Research Laboratories, New York, New York, USA; Immunology and Molecular and Pharmacology and Chemistry Programs, Sloan Kettering Institute, New York, New York, USA
| | - Romona Kersellius
- Departments of Medicine and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Human Oncology and Pathogenesis Program, Memorial Hospital Research Laboratories, New York, New York, USA; Immunology and Molecular and Pharmacology and Chemistry Programs, Sloan Kettering Institute, New York, New York, USA
| | - Taha Merghoub
- Departments of Medicine and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Human Oncology and Pathogenesis Program, Memorial Hospital Research Laboratories, New York, New York, USA; Immunology and Molecular and Pharmacology and Chemistry Programs, Sloan Kettering Institute, New York, New York, USA
| | - Mario E Lacouture
- Departments of Medicine and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Human Oncology and Pathogenesis Program, Memorial Hospital Research Laboratories, New York, New York, USA; Immunology and Molecular and Pharmacology and Chemistry Programs, Sloan Kettering Institute, New York, New York, USA
| | - Richard D Carvajal
- Departments of Medicine and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Human Oncology and Pathogenesis Program, Memorial Hospital Research Laboratories, New York, New York, USA; Immunology and Molecular and Pharmacology and Chemistry Programs, Sloan Kettering Institute, New York, New York, USA
| | - Katherine S Panageas
- Departments of Medicine and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Human Oncology and Pathogenesis Program, Memorial Hospital Research Laboratories, New York, New York, USA; Immunology and Molecular and Pharmacology and Chemistry Programs, Sloan Kettering Institute, New York, New York, USA
| | - Michael F Berger
- Departments of Medicine and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Human Oncology and Pathogenesis Program, Memorial Hospital Research Laboratories, New York, New York, USA; Immunology and Molecular and Pharmacology and Chemistry Programs, Sloan Kettering Institute, New York, New York, USA
| | - Neal Rosen
- Departments of Medicine and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Human Oncology and Pathogenesis Program, Memorial Hospital Research Laboratories, New York, New York, USA; Immunology and Molecular and Pharmacology and Chemistry Programs, Sloan Kettering Institute, New York, New York, USA
| | - David B Solit
- Departments of Medicine and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Human Oncology and Pathogenesis Program, Memorial Hospital Research Laboratories, New York, New York, USA; Immunology and Molecular and Pharmacology and Chemistry Programs, Sloan Kettering Institute, New York, New York, USA
| | - Paul B Chapman
- Departments of Medicine and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA; Human Oncology and Pathogenesis Program, Memorial Hospital Research Laboratories, New York, New York, USA; Immunology and Molecular and Pharmacology and Chemistry Programs, Sloan Kettering Institute, New York, New York, USA
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48
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OSTHEIMER CHRISTIAN, BORMANN CAROLINE, FIEDLER ECKHARD, MARSCH WOLFGANG, VORDERMARK DIRK. Malignant melanoma brain metastases: Treatment results and prognostic factors - a single-center retrospective study. Int J Oncol 2015; 46:2439-48. [DOI: 10.3892/ijo.2015.2970] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 03/27/2015] [Indexed: 11/06/2022] Open
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Wattson DA, Sullivan RJ, Niemierko A, Merritt RM, Lawrence DP, Oh KS, Flaherty KT, Shih HA. Survival patterns following brain metastases for patients with melanoma in the MAP-kinase inhibitor era. J Neurooncol 2015; 123:75-84. [PMID: 25864098 DOI: 10.1007/s11060-015-1761-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 03/28/2015] [Indexed: 01/18/2023]
Abstract
Survival with BRAF-mutant metastatic melanoma is prolonged with MAP-kinase pathway inhibitors (MAPKi). Among patients with brain metastases (BM), however, the clinical course of MAPKi-treated patients is not well described. We therefore explored these patients' survival patterns compared to contemporary patients not treated with MAPKi. We analyzed 106 patients who developed melanoma BM between 2007 and 2013. Of these, 37 (35%) received de novo MAPKi for BRAF-mutant disease, which preceded BM in 49%. Immunotherapy was given to 54% of MAPKi-treated patients and 94% of those who did not receive MAPKi. We evaluated the potential influence of patient characteristics, systemic therapies, and BM-directed treatments on time to appearance of new BM and overall survival. With a median follow-up of 8.0 months after initial BM, MAPKi use was an independent predictor of prolonged survival after BM diagnosis (median 14.1 vs 7.0 months, P = 0.03, adjusted hazard ratio 0.39). This survival advantage was driven by the 16.6-month median survival of patients who initiated MAPKi after BM were diagnosed, versus 5.6 months if initiated prior to BM development (P = 0.03). Median survival from the onset of any systemic metastases was 22 months regardless of the timing of MAPKi relative to BM appearance. Time to in-brain progression was longer among patients whose MAPKi course was started after BM diagnosis, but MAPKi initiation prior to BM diagnosis was associated with longer time to intracranial involvement. These findings are consistent with potential MAPKi activity in intracranial melanoma.
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Affiliation(s)
- Daniel A Wattson
- Harvard Radiation Oncology Program, 75 Francis Street, ASB1, L2, Boston, MA, 02115, USA
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50
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Hu EC, He JG, Liu ZH, Ni XH, Zheng YG, Gu Q, Zhao ZH, Xiong CM. High levels of serum lactate dehydrogenase correlate with the severity and mortality of idiopathic pulmonary arterial hypertension. Exp Ther Med 2015; 9:2109-2113. [PMID: 26136943 DOI: 10.3892/etm.2015.2376] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 02/16/2015] [Indexed: 11/05/2022] Open
Abstract
Liver dysfunction reflects the status of heart failure, and previous studies have demonstrated that serum lactate dehydrogenase (S-LDH) levels are increased in patients exhibiting heart failure and liver dysfunction. Right heart failure is a main characteristic of idiopathic pulmonary arterial hypertension (IPAH). The aim of the present study was to assess the prognostic significance of S-LDH levels in patients with IPAH. S-LDH levels were determined in 173 patients with IPAH, and these patients were subclassified into two groups according to a defined upper reference limit of S-LDH (250 IU/l). Right heart catheterization was performed in all patients. A total of 53 patients were found to have elevated S-LDH to ≥250 IU/l. In a mean follow-up period of 31.2±17.9 months, 57 patients succumbed. In the group with lower S-LDH levels (S-LDH <250 IU/l), 16.7% of the patients succumbed, compared with 69.8% of patients in the group with higher S-LDH levels (S-LDH ≥250 IU/l). The Kaplan-Meier survival curves demonstrated that patients with higher S-LDH levels had a significantly lower survival rate than did those with lower S-LDH levels (log-rank test, P<0.001). Cox proportional hazard analyses identified reduced body mass index, reduced cardiac index, elevated World Health Organization functional class, higher S-LDH and an absence of PAH-targeted therapy as significant predictors of adverse outcomes. In conclusion, elevated S-LDH is a risk factor for mortality in patients with IPAH.
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Affiliation(s)
- En-Ci Hu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, P.R. China
| | - Jian-Guo He
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, P.R. China
| | - Zhi-Hong Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, P.R. China
| | - Xin-Hai Ni
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, P.R. China
| | - Ya-Guo Zheng
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, P.R. China
| | - Qing Gu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, P.R. China
| | - Zhi-Hui Zhao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, P.R. China
| | - Chang-Ming Xiong
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, P.R. China
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