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Abstract
Melanoma is considered one of the immunogenic - if not the most immunogenic - malignancies. This is based on several observations.1.Spontaneous remissions occur occasionally.2.In about 5% of melanomas no primary tumour is found. The genetic aberrations of these tumours closely resemble those of cutaneous melanomas, and therefore are suggestive of spontaneous regressions of the primary tumours.3.Both primary tumours and metastases often have brisk lymphocytic infiltrates, a phenomenon that is correlated with better outcome.4.Studies of isolates of these tumour-infiltrating T lymphocytes have revealed that a proportion of these cells recognise melanoma antigens.5.Melanomas respond to immunotherapy. These observations have led to over 30 years of research on immunotherapy for melanoma; many of these efforts have failed, with only a few exceptions: interleukin-2 (IL-2) and to a lesser degree interferon-a (IFN-〈). Recently, new developments in immunotherapy have revolutionised this treatment modality. Anti-CTLA4 has received approval from the Food and Drugs Administration (FDA) and the European Medicines Agency (EMA) for the treatment of stage IV melanomas based on the improvement in overall survival in phase III trials, and more recently blockade of PD1/PDL1 interactions has shown objective clinical responses in a stage IV melanoma in early-phase clinical trials. In addition, several independent single-institution phase I/II trials using adoptive cell therapy have shown a consistently high response rate, including durable complete remissions in a substantial percentage of treated patients. Now, for the first time, immunotherapy has moved beyond the treatment of melanoma as both CTLA4 and PD1 blockade have been shown to induce objective responses in other tumour types as well. This chapter will discuss the mechanism of action, clinical efficacy and side effects of IL-2, the novel treatments consisting of the immune checkpoint blockade drugs anti-CTLA4 and anti-PD1 and adoptive cell therapy.
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Marzuka A, Huang L, Theodosakis N, Bosenberg M. Melanoma Treatments: Advances and Mechanisms. J Cell Physiol 2015; 230:2626-33. [DOI: 10.1002/jcp.25019] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 04/14/2015] [Indexed: 02/03/2023]
Affiliation(s)
- Alexander Marzuka
- Department of Dermatology; Yale-New Haven Hospital; Yale School of Medicine; New Haven Connecticut
- Department of Internal Medicine; Yale-New Haven Hospital; Yale School of Medicine; New Haven Connecticut
| | - Laura Huang
- Department of Dermatology; Yale-New Haven Hospital; Yale School of Medicine; New Haven Connecticut
- Department of Internal Medicine; Yale-New Haven Hospital; Yale School of Medicine; New Haven Connecticut
| | - Nicholas Theodosakis
- Department of Pathology; Yale-New Haven Hospital; Yale School of Medicine; New Haven Connecticut
| | - Marcus Bosenberg
- Department of Dermatology; Yale-New Haven Hospital; Yale School of Medicine; New Haven Connecticut
- Department of Pathology; Yale-New Haven Hospital; Yale School of Medicine; New Haven Connecticut
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Yu LJ, Wall BA, Chen S. The current management of brain metastasis in melanoma: a focus on riluzole. Expert Rev Neurother 2015; 15:779-92. [PMID: 26092602 DOI: 10.1586/14737175.2015.1055321] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Brain metastasis is a common endpoint in human malignant melanoma, and the prognosis for patients remains poor despite advancements in therapy. Current treatment for melanoma metastatic to the brain is grouped into those providing symptomatic relief such as corticosteroids and antiepileptic agents, to those that are disease modifying. Related to the latter group, recent studies have demonstrated that aberrant glutamate signaling plays a role in the transformation and maintenance of various cancer types, including melanoma. Glutamate secretion from these and surrounding cells have been found to stimulate regulatory pathways that control tumor growth, proliferation and survival in vitro and in vivo. The antiglutamatergic actions of an inhibitor of glutamate release, riluzole, have been detected by its ability to clear glutamate from the synapse, and it has been shown to inhibit glutamate release rather than directly inhibiting glutamate receptors. Preclinical studies have demonstrated the ability of riluzole to act as a radiosensitizing agent in melanoma. The effect of riluzole on downstream glutamatergic signaling has pointed to cross talk between the metabotropic G-protein-coupled glutamate receptors implicated in a subset of human melanomas with other signaling pathways, including apoptotic, angiogenic, ROS and cell invasion mechanisms, thus establishing its potential to be further explored in combination therapy regimens for both primary human melanoma and melanoma metastatic to the brain.
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Affiliation(s)
- Lumeng J Yu
- Susan Lehman Cullman Laboratory for Cancer Research, Ernest Mario School of Pharmacy, Rutgers, the State University, Piscataway, NJ, 08854, USA
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Ito A, Kondo S, Tada K, Kitano S. Clinical Development of Immune Checkpoint Inhibitors. BIOMED RESEARCH INTERNATIONAL 2015; 2015:605478. [PMID: 26161407 PMCID: PMC4486755 DOI: 10.1155/2015/605478] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 12/07/2014] [Indexed: 01/21/2023]
Abstract
Recent progress in cancer immunotherapy has been remarkable. Most striking are the clinical development and approval of immunomodulators, also known as immune checkpoint inhibitors. These monoclonal antibodies (mAb) are directed to immune checkpoint molecules, which are expressed on immune cells and mediate signals to attenuate excessive immune reactions. Although mAbs targeting tumor associated antigens, such as anti-CD20 mAb and anti-Her2 mAb, directly recognize tumor cells and induce cell death, immune checkpoint inhibitors restore and augment the antitumor immune activities of cytotoxic T cells by blocking immune checkpoint molecules on T cells or their ligands on antigen presenting and tumor cells. Based on preclinical data, many clinical trials have demonstrated the acceptable safety profiles and efficacies of immune checkpoint inhibitors in a variety of cancers. The first in class approved immune checkpoint inhibitor is ipilimumab, an anti-CTLA-4 (cytotoxic T lymphocyte antigen-4) mAb. Two pivotal phase III randomized controlled trials demonstrated a survival benefit in patients with metastatic melanoma. In 2011, the US Food and Drug Administration (FDA) approved ipilimumab for metastatic melanoma. Several clinical trials have since investigated new agents, alone and in combination, for various cancers. In this review, we discuss the current development status of and future challenges in utilizing immune checkpoint inhibitors.
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Affiliation(s)
- Ayumu Ito
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Shunsuke Kondo
- Department of Experimental Therapeutics, Exploratory Oncology Research and Clinical Trial Center (EPOC), National Cancer Center, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Kohei Tada
- Division of Cancer Immunotherapy, Exploratory Oncology Research and Clinical Trial Center (EPOC), National Cancer Center, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Shigehisa Kitano
- Department of Experimental Therapeutics, Exploratory Oncology Research and Clinical Trial Center (EPOC), National Cancer Center, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
- Division of Cancer Immunotherapy, Exploratory Oncology Research and Clinical Trial Center (EPOC), National Cancer Center, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
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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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Barbee MS, Ogunniyi A, Horvat TZ, Dang TO. Current status and future directions of the immune checkpoint inhibitors ipilimumab, pembrolizumab, and nivolumab in oncology. Ann Pharmacother 2015; 49:907-37. [PMID: 25991832 DOI: 10.1177/1060028015586218] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To provide the clinician with an update and the current status and future direction of approved immune checkpoint inhibitors (ICIs) in oncology. DATA SOURCES A PubMed search from January 1, 1966 to March 13, 2015 was performed using the key terms ipilimumab, pembrolizumab, lambrolizumab, nivolumab, immune checkpoint inhibitor, MDX-010, MDX-101, BMS-734016, MK-3475, SCH 900475, MDX-1106, BMS-936558, ONO-4538, CTLA-4, PD-1, or PD-L1 and cancer, oncology, or neoplasm. Additional references were identified from the investigators(') personal files, recent oncology meetings, review articles, clinical guidelines, and package inserts. STUDY SELECTION AND DATA EXTRACTION All English-language clinical trials assessing the safety and efficacy of ipilimumab, nivolumab, and pembrolizumab in cancer were considered. The PubMed search resulted in 215 trials; 33 met inclusion criteria. A further 28 trials were identified from the above sources; 61 trials from 2005 to 2015 were included. We consolidated and clarified treatment recommendations for the management of immune-related adverse events (irAEs), assessed response criteria, and calculated the clinical utility of leading tumor profiling options. DATA SYNTHESIS Ipilimumab and nivolumab, but not pembrolizumab, have an overall survival (OS) advantage over chemotherapy first line in unresectable/metastatic melanoma. Nivolumab has an OS advantage versus chemotherapy in second-line squamous non-small-cell lung cancer. Data in other settings are promising. Nivolumab and pembrolizumab are better tolerated than ipilimumab. Further validation of response criteria is needed. Tumor profiling to predict clinical benefit is premature but promising. CONCLUSIONS The treatment landscape in oncology is quickly evolving with the advent of ICIs.
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Affiliation(s)
| | | | - Troy Z Horvat
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Thu-Oanh Dang
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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257
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Johnson DB, Peng C, Abramson RG, Ye F, Zhao S, Wolchok JD, Sosman JA, Carvajal RD, Ariyan CE. Clinical Activity of Ipilimumab in Acral Melanoma: A Retrospective Review. Oncologist 2015; 20:648-52. [PMID: 25964307 DOI: 10.1634/theoncologist.2014-0468] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 03/10/2015] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Ipilimumab improves overall survival (OS) in advanced melanoma. Acral melanoma is an uncommon clinical subtype of this disease associated with poor prognosis. The clinical activity of ipilimumab has not been well-defined in advanced acral melanoma. METHODS We retrospectively reviewed the demographics, treatment history, and clinical outcomes for all patients with acral melanoma treated with ipilimumab from two academic centers between February 2006 and June 2013. Using Cox proportional hazards models, we assessed for factors that correlated with OS. RESULTS A total of 35 patients with acral melanoma received ipilimumab. Melanomas arose on volar surfaces (n = 28) and subungual sites (n = 7); stage M1c disease was present in 54%, and 45% had elevated serum lactate dehydrogenase (LDH). Best response by RECIST 1.1 criteria was complete response in 1 patient, partial response in 3, and stable disease (SD) in 4 for an objective response rate (ORR) of 11.4% and a clinical benefit rate (ORR + SD) at 24 weeks of 22.9%. Median progression-free survival was 2.5 months (95% confidence interval [CI]: 2.3-2.7 months); median OS was 16.7 months (95% CI: 10.9-22.5 months). Normal LDH and absolute lymphocyte count ≥1,000 at 7 weeks predicted longer OS. Immune-related adverse events (irAEs) were noted in 16 patients including 7 with grade 3/4 irAEs (20%). CONCLUSION Ipilimumab is clinically active in acral melanoma with similar ORR and OS compared with unselected melanoma populations. Ipilimumab remains a viable therapeutic option for patients with advanced acral melanoma. IMPLICATIONS FOR PRACTICE Ipilimumab is a commonly used immune therapy that improves survival in metastatic melanoma. The clinical activity of ipilimumab in certain rare melanoma subtypes, such as uveal or mucosal melanomas, is suboptimal. Acral melanoma is another unusual subtype of this disease that arises on the palms, soles, and nailbeds. In this study of 35 patients with acral melanoma from 2 centers, ipilimumab was found to have activity that appears equivalent to unselected melanoma (response rate of 11.4%, median overall survival of 16.7 months). Ipilimumab remains a viable treatment option for this melanoma subpopulation.
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Affiliation(s)
- Douglas B Johnson
- Department of Medicine, School of Medicine, Department of Radiology, Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Departments of Medicine and Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Chengwei Peng
- Department of Medicine, School of Medicine, Department of Radiology, Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Departments of Medicine and Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Richard G Abramson
- Department of Medicine, School of Medicine, Department of Radiology, Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Departments of Medicine and Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Fei Ye
- Department of Medicine, School of Medicine, Department of Radiology, Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Departments of Medicine and Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Shilin Zhao
- Department of Medicine, School of Medicine, Department of Radiology, Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Departments of Medicine and Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Jedd D Wolchok
- Department of Medicine, School of Medicine, Department of Radiology, Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Departments of Medicine and Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Jeffrey A Sosman
- Department of Medicine, School of Medicine, Department of Radiology, Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Departments of Medicine and Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Richard D Carvajal
- Department of Medicine, School of Medicine, Department of Radiology, Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Departments of Medicine and Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Charlotte E Ariyan
- Department of Medicine, School of Medicine, Department of Radiology, Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Departments of Medicine and Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Columbia University Medical Center, New York, New York, USA
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Kotecki N, Penel N, Awada A. Metabolic disorders associated with the use of targeted cancer therapies. Curr Opin Oncol 2015; 27:258-66. [PMID: 25730544 DOI: 10.1097/cco.0000000000000176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW The everyday use of targeted therapies, whose mechanisms of action differ from the conventional cytotoxic agents, also causes the emergence of new toxicities as metabolic disorders about which little is known. We propose a systematic literature review of the incidence and physiopathology of targeted therapies-induced metabolic disorders and provide some management guidance. RECENT FINDINGS In recent decades, significant breakthroughs in molecular oncology and immunology have been made. The administration of targeted therapies and immunotherapy has been associated with metabolic toxicities such as endocrine disorders, dyslipidemia, induced diabetes, and electrolytic disorders. Current data show that metabolic disorders are becoming increasingly common, but rarely life threatening and often reversible with prompt therapeutic intervention. SUMMARY In the era of targeted therapies, medical oncologists should know the symptoms, carefully monitor patients for potential metabolic disorders, and manage these emerging side-effects with the help of endocrinologists and other medical specialists.
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Affiliation(s)
- Nuria Kotecki
- aDepartment of General Oncology, Center Oscar Lambret, Lille, France bMedical Oncology Clinic, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
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Rastogi P, Sultan M, Charabaty AJ, Atkins MB, Mattar MC. Ipilimumab associated colitis: An IpiColitis case series at MedStar Georgetown University Hospital. World J Gastroenterol 2015; 21:4373-4378. [PMID: 25892889 PMCID: PMC4394100 DOI: 10.3748/wjg.v21.i14.4373] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 10/22/2014] [Accepted: 12/16/2014] [Indexed: 02/06/2023] Open
Abstract
Although ipilimumab has been shown to improve survival in patients with metastatic melanoma and cause regression of metastatic renal cell carcinoma, the associated immune-related toxicities are of concern. The resultant T cell activation by this monoclonal antibody causes an increased immune response, which has been associated with many immune-regulated adverse effects. One of the most concerning effects is the development of colitis. Upwards to 8% of patients have been reported to develop colitis, with 5% being severe (Grades 3-4). While initial treatment of such adverse effects is generally comprised of supportive and symptomatic treatment, more severe cases warrant the use of high dose steroids. Furthermore, use of anti-TNF agents is usually reserved for those cases that prove to be refractory to steroids. We describe a systematic case review of seven patients who developed gastrointestinal symptoms following initiation of ipilimumab immunotherapy, and present the steps in their evaluation, treatment and outcomes at our institution.
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260
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Guibert N, Delaunay M, Mazières J. Targeting the immune system to treat lung cancer: rationale and clinical experience. Ther Adv Respir Dis 2015; 9:105-20. [PMID: 25827132 DOI: 10.1177/1753465815578349] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The use of immunotherapy that harnesses and enhances the innate powers of the immune system to fight cancer cells represents the most promising new cancer treatment approach since the development of the first chemotherapies and, more recently, targeted therapies. Unexpectedly, lung cancer has recently emerged as an exciting new target for immune-based therapies. Several approaches to immunotherapy for lung cancer have shown promise in early clinical trials and in late-phase development. The most advanced strategies can be split into two main categories: therapeutic vaccines and checkpoint inhibitors. At this time of great expectations, this review provides the reader with an update on the immunotherapies used to treat lung cancer with a focus on the rationale of targeting the immune system. It reports the results from recent major clinical trials, describes new toxicity profiles associated with such drugs, and particularly the role of the pulmonologists in their management. This review provides an overview of the main perspectives within this field.
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Affiliation(s)
- Nicolas Guibert
- Hôpital Larrey, Centre Hospitalier Universitaire, Université Paul Sabatier, Toulouse, France
| | - Myriam Delaunay
- Hôpital Larrey, Centre Hospitalier Universitaire, Université Paul Sabatier, Toulouse, France
| | - Julien Mazières
- Thoracic Oncology Unit, Respiratory Disease Department, Hôpital Larrey, CHU Toulouse, Chemin de Pouvourville, 31059 Toulouse Cedex, France
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261
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Late onset ipilimumab-induced pericarditis and pericardial effusion: a rare but life threatening complication. Case Rep Oncol Med 2015; 2015:794842. [PMID: 25918658 PMCID: PMC4396732 DOI: 10.1155/2015/794842] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 03/23/2015] [Indexed: 01/16/2023] Open
Abstract
Metastatic cutaneous melanoma has poor prognosis with 2-year survival rate of 10–20%. Melanoma cells express various antigens including gp100, melanoma antigen recognized by T cells 1 (MART-1), and tyrosinase, which can induce immune-mediated anticancer response via T cell activation. Cytotoxic T-lymphocyte associated antigen-4 (CTLA-4) is an immune check point molecule that negatively regulates T cell activation and proliferation. Accordingly, recent phase III clinical trials demonstrated significant survival benefit with ipilimumab, a human monoclonal antibody (IgG1) that blocks the interaction of CTLA-4 with its ligands. Since the efficacy of ipilimumab depends on T cell activation, it is associated with substantial risk of immune mediated adverse reactions such as colitis, hepatitis, thyroiditis, and hypophysitis. We report the first case of late onset pericarditis and cardiac tamponade associated with ipilimumab treatment in patient with metastatic cutaneous melanoma.
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262
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Cancer immunotherapy and immune-related response assessment: The role of radiologists in the new arena of cancer treatment. Eur J Radiol 2015; 84:1259-68. [PMID: 25937524 DOI: 10.1016/j.ejrad.2015.03.017] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 03/12/2015] [Accepted: 03/14/2015] [Indexed: 01/01/2023]
Abstract
The recent advances in the clinical application of anti-cancer immunotherapeutic agents have opened a new arena for the treatment of advanced cancers. Cancer immunotherapy is associated with a variety of important radiographic features in the assessments of tumor response and immune-related adverse events, which calls for radiologists' awareness and in-depth knowledge on the topic. This article will provide the state-of-the art review and perspectives of cancer immunotherapy, including its molecular mechanisms, the strategies for immune-related response assessment on imaging and their pitfalls, and the emerging knowledge of radiologic manifestations of immune-related adverse events. The cutting edge clinical and radiologic investigations are presented to provide future directions.
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Geng D, Kaczanowska S, Tsai A, Younger K, Ochoa A, Rapoport AP, Ostrand-Rosenberg S, Davila E. TLR5 Ligand-Secreting T Cells Reshape the Tumor Microenvironment and Enhance Antitumor Activity. Cancer Res 2015; 75:1959-1971. [PMID: 25795705 DOI: 10.1158/0008-5472.can-14-2467] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 02/16/2015] [Indexed: 12/21/2022]
Abstract
The tumor microenvironment counters antitumor T-cell responses, in part, by blunting their activation and infiltration. Ligands that engage Toll-like receptors (TLR) on T cells and antigen-presenting cells can act as potent immune adjuvants. In this study, we show how tumor-reactive T cells engineered to secrete bacterial flagellin, a TLR5 ligand (TLR5L), can engender a costimulatory signal that augments antitumor activity. Human T cells engineered to express TLR5L along with DMF5, a T-cell receptor that recognizes the melanoma antigen MART-127-35 (DMF5(TLR5L) T cells), displayed increased proliferation, cytokine production, and cytolytic activity against melanoma cells. In a xenogenetic model, adoptive transfer of DMF5(TLR5L) T cells reduced tumor growth kinetics and prolonged mouse survival. In a syngeneic model, similarly engineered melanoma-reactive T cells (pmel(TLR5L)) displayed a relative increase in antitumor activity against established tumors, compared with unmodified T cells. In this model, we documented increased T-cell infiltration associated with increased levels of CCR1 and CXCR3 levels on T cells, a reduction in PD-1(+)Lag3(+) T cells and CD11(+)Gr1(+) myeloid-derived suppressor cells, and changes in the chemokine/cytokine profile of tumors. Our findings show how T cell-mediated delivery of a TLR agonist to the tumor site can contribute to antitumor efficacy, in the context of adoptive T-cell immunotherapy.
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Affiliation(s)
- Degui Geng
- Marlene and Stewart Greenebaum Cancer Center, University of Maryland, Baltimore, Maryland, 21201
| | - Sabina Kaczanowska
- Marlene and Stewart Greenebaum Cancer Center, University of Maryland, Baltimore, Maryland, 21201
| | - Alexander Tsai
- Marlene and Stewart Greenebaum Cancer Center, University of Maryland, Baltimore, Maryland, 21201
| | - Kenisha Younger
- Marlene and Stewart Greenebaum Cancer Center, University of Maryland, Baltimore, Maryland, 21201
| | - Augusto Ochoa
- Louisiana State University Health Sciences Center, New Orleans, Louisiana, 70112
| | - Aaron P Rapoport
- Marlene and Stewart Greenebaum Cancer Center, University of Maryland, Baltimore, Maryland, 21201
| | - Sue Ostrand-Rosenberg
- Department of Biological Sciences, University of Maryland Baltimore County, Baltimore, MD 21250
| | - Eduardo Davila
- Marlene and Stewart Greenebaum Cancer Center, University of Maryland, Baltimore, Maryland, 21201.,Department of Microbiology and Immunology, University of Maryland, Baltimore, Maryland, 21201
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Johnson DB, Peng C, Sosman JA. Nivolumab in melanoma: latest evidence and clinical potential. Ther Adv Med Oncol 2015; 7:97-106. [PMID: 25755682 DOI: 10.1177/1758834014567469] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Melanoma has historically been considered a refractory disease with few if any options in the advanced/metastatic setting. Advances in both immune and genetically targeted treatment approaches have revolutionized the spectrum of treatment options for melanoma patients over the last several years. Recently, checkpoint inhibition has become a major focus in the immune-based therapy of cancer, especially melanoma. This concept involves inhibition of regulatory cell surface molecules which act normally to dampen or modulate T-cell activation. Cancer, including melanoma, takes advantage of this physiologic mechanism to turn off T-cell activation and prevent effective T-cell antitumor responses. Checkpoint inhibitors such as anti cytotoxic T-lymphocyte antigen 4 (anti-CTLA-4) and anti programmed death-1 (PD-1) can reverse this immune suppression and release T-cell activation. Nivolumab, a monoclonal antibody to the PD-1 receptor, promotes antitumor immunity by removing this key negative regulator of T-cell activation. In phase I/II studies, promising activity and safety have been observed and ongoing phase III trials are comparing nivolumab with other standard of care therapies (chemotherapy, ipilimumab). Efficacy may be even further increased when used in combination with ipilimumab (albeit with increased toxicity). In contrast to typical short-lived responses with cancer therapy in metastatic solid tumors, many responses induced by nivolumab appear durable. In this review, we discuss the evolution of immune therapy in melanoma leading to the development of nivolumab, the clinical experience with this agent, and its future development and clinical potential.
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Affiliation(s)
- Douglas B Johnson
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 777 Preston Research Building, 2220 Pierce Avenue, Nashville, TN 37232, USA
| | - Chengwei Peng
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey A Sosman
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
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265
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Cytotoxic T-lymphocyte antigen-4 blockade in melanoma. Clin Ther 2015; 37:755-63. [PMID: 25746738 DOI: 10.1016/j.clinthera.2015.02.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 02/03/2015] [Accepted: 02/03/2015] [Indexed: 02/05/2023]
Abstract
PURPOSE Melanoma is an aggressive malignancy that has a complex relationship with the host immune system. Immunotherapies have long been a mainstay of melanoma therapy, and advanced therapies continue to be effective in treating this disease. Immune checkpoint blockade has proven to be a novel target in melanoma, with the approval of cytotoxic T-lymphocyte antigen-4 (CTLA-4)-targeted therapy. This review evaluates the role of CTLA-4-targeted therapies in the treatment of metastatic melanoma, with a focus on mechanisms, efficacy, toxicity, and future directions of this therapy. METHODS A search was performed in PubMed to identify relevant clinical studies that explored the clinical experience with CTLA-4-targeted therapy in melanoma. FINDINGS Signaling through CTLA-4 causes deactivation of T cells after the initial stimulatory signals. Therapies that block CTLA-4 lead to increased T-cell function and an antitumor response in patients with metastatic melanoma. The adverse event profile of these agents is different from that seen with more traditional cancer therapies and consists of dermatitis, colitis, and other autoimmune toxicities. In addition, the pattern of response is different from that seen with traditional cytotoxic therapies, with some patients experiencing initial progression followed by response and some patients having long-term durable responses. IMPLICATIONS Extensive clinical evidence supports the use of CTLA-4-targeted agents in the treatment of metastatic melanoma. The durability of response seen in patients receiving these agents has changed the landscape for patients with melanoma. Combination therapies and other agents with similar mechanisms warrant further exploration for the treatment of metastatic melanoma.
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266
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Curti BD, Urba WJ. Clinical deployment of antibodies for treatment of melanoma. Mol Immunol 2015; 67:18-27. [PMID: 25746916 DOI: 10.1016/j.molimm.2015.01.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 01/23/2015] [Accepted: 01/26/2015] [Indexed: 01/15/2023]
Abstract
The concept of using immunotherapy to treat melanoma has existed for decades. The rationale comes from the knowledge that many patients with melanoma have endogenous immune responses against their tumor cells and clinically meaningful tumor regression can be achieved in a minority of patients using cytokines such as interleukin-2 and adoptive cellular therapy. In the last 5 years there has been a revolution in the clinical management of melanoma in large measure based on the development of antibodies that influence T cell regulatory pathways by overcoming checkpoint inhibition and providing co-stimulation, either of which results in significantly more effective immune-mediated tumor destruction. This review will describe the pre-clinical and clinical application of antagonistic antibodies targeting the T-cell checkpoints cytotoxic T-lymphocyte antigen 4 (CTLA-4) and programmed death 1 (PD-1), and agonistic antibodies targeting the costimulatory pathways OX40 and 4-1BB. Recent progress and opportunities for future investigation of combination antibody therapy will be described.
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Affiliation(s)
- Brendan D Curti
- Earle A. Chiles Research Institute, Providence Cancer Center, 4805 NE Glisan St. 2N35, Portland, OR 97213, United States.
| | - Walter J Urba
- Earle A. Chiles Research Institute, Providence Cancer Center, 4805 NE Glisan St. 2N35, Portland, OR 97213, United States.
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267
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Teulings HE, Limpens J, Jansen SN, Zwinderman AH, Reitsma JB, Spuls PI, Luiten RM. Vitiligo-like depigmentation in patients with stage III-IV melanoma receiving immunotherapy and its association with survival: a systematic review and meta-analysis. J Clin Oncol 2015; 33:773-81. [PMID: 25605840 DOI: 10.1200/jco.2014.57.4756] [Citation(s) in RCA: 436] [Impact Index Per Article: 48.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Vitiligo-like depigmentation in patients with melanoma may be associated with more favorable clinical outcome. We conducted a systematic review of patients with stage III to IV melanoma treated with immunotherapy to determine the cumulative incidence of vitiligo-like depigmentation and the prognostic value of vitiligo development on survival. METHODS We systemically searched and selected all studies on melanoma immunotherapy that reported on autoimmune toxicity and/or vitiligo between 1995 and 2013. Methodologic quality of each study was appraised using adapted criteria for systematic reviews in prognostic studies. Random-effect models were used to calculate summary estimates of the cumulative incidence of vitiligo-like depigmentation across studies. The prognostic value of vitiligo-like depigmentation on survival outcome was assessed using random-effects Cox regression survival analyses. RESULTS One hundred thirty-seven studies were identified comprising 139 treatment arms (11 general immune stimulation, 84 vaccine, 28 antibody-based, and 16 adoptive transfer) including a total of 5,737 patients. The overall cumulative incidence of vitiligo was 3.4% (95% CI, 2.5% to 4.5%). In 27 studies reporting individual patient data, vitiligo development was significantly associated with both progression-free-survival (hazard ratio [HR], 0.51; 95% CI, 0.32 to 0.82; P < .005) and overall survival (HR, 0.25; 95% CI, 0.10 to 0.61; P < .003), indicating that these patients have two to four times less risk of disease progression and death, respectively, compared with patients without vitiligo development. CONCLUSION Although vitiligo occurs only in a low percentage of patients with melanoma treated with immunotherapy, our findings suggest clear survival benefit in these patients. Awareness of vitiligo induction in patients with melanoma is important as an indicator of robust antimelanoma immunity and associated improved survival.
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Affiliation(s)
- Hansje-Eva Teulings
- Hansje-Eva Teulings, Jacqueline Limpens, Sophia N. Jansen, Aeilko H. Zwinderman, Johannes B. Reitsma, Phyllis I. Spuls, and Rosalie M. Luiten, Academic Medical Centre, University of Amsterdam, Amsterdam; Johannes B. Reitsma, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Jacqueline Limpens
- Hansje-Eva Teulings, Jacqueline Limpens, Sophia N. Jansen, Aeilko H. Zwinderman, Johannes B. Reitsma, Phyllis I. Spuls, and Rosalie M. Luiten, Academic Medical Centre, University of Amsterdam, Amsterdam; Johannes B. Reitsma, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Sophia N Jansen
- Hansje-Eva Teulings, Jacqueline Limpens, Sophia N. Jansen, Aeilko H. Zwinderman, Johannes B. Reitsma, Phyllis I. Spuls, and Rosalie M. Luiten, Academic Medical Centre, University of Amsterdam, Amsterdam; Johannes B. Reitsma, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Aeilko H Zwinderman
- Hansje-Eva Teulings, Jacqueline Limpens, Sophia N. Jansen, Aeilko H. Zwinderman, Johannes B. Reitsma, Phyllis I. Spuls, and Rosalie M. Luiten, Academic Medical Centre, University of Amsterdam, Amsterdam; Johannes B. Reitsma, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Johannes B Reitsma
- Hansje-Eva Teulings, Jacqueline Limpens, Sophia N. Jansen, Aeilko H. Zwinderman, Johannes B. Reitsma, Phyllis I. Spuls, and Rosalie M. Luiten, Academic Medical Centre, University of Amsterdam, Amsterdam; Johannes B. Reitsma, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Phyllis I Spuls
- Hansje-Eva Teulings, Jacqueline Limpens, Sophia N. Jansen, Aeilko H. Zwinderman, Johannes B. Reitsma, Phyllis I. Spuls, and Rosalie M. Luiten, Academic Medical Centre, University of Amsterdam, Amsterdam; Johannes B. Reitsma, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Rosalie M Luiten
- Hansje-Eva Teulings, Jacqueline Limpens, Sophia N. Jansen, Aeilko H. Zwinderman, Johannes B. Reitsma, Phyllis I. Spuls, and Rosalie M. Luiten, Academic Medical Centre, University of Amsterdam, Amsterdam; Johannes B. Reitsma, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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268
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Woźniak S, Mackiewicz-Wysocka M, Krokowicz Ł, Kwinta Ł, Mackiewicz J. Febrile neutropenia in a metastatic melanoma patient treated with ipilimumab - case report. Oncol Res Treat 2015; 38:105-8. [PMID: 25792081 DOI: 10.1159/000377650] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 09/17/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ipilimumab is a fully human monoclonal antibody (mAb) targeting cytotoxic T-lymphocyte antigen-4 (CTLA-4). Ipilimumab is currently approved in the U.S. and Europe for the treatment of metastatic melanoma in the first- and second-line treatment. Treatment with ipilimumab is linked to immune-related adverse events (irAEs) occurring in the majority of patients. These specific AEs include dermatitis, gastrointestinal disorders (diarrhea, colitis), hepatitis, hypophysitis, hypothyroidism, neuropathy, and iritis/inflammation of the ciliary body. CASE REPORT We report a case of febrile neutropenia with agranulocytosis in the blood smear of a 35-year-old metastatic melanoma patient treated with ipilimumab 3 mg/kg. CONCLUSION This AE was probably caused by antineutrophil antibodies associated with ipilimumab treatment. To our knowledge this is the first case report of febrile neutropenia in a metastatic melanoma patient treated with ipilimumab 3 mg/kg.
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Affiliation(s)
- Sebastian Woźniak
- Department of Chemotherapy, Greater Poland Cancer Centre, Poznan, Poland
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269
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Abstract
The anti-cytotoxic T-lymphocyte antigen-4 (anti-CTLA-4) antibody ipilimumab is the first treatment that significantly improved the survival rates of metastatic melanoma patients, marking a new era in the treatment of melanoma. During its development, a hallmark of ipilimumab therapy was the extended duration of response, achieved in 20% of patients. The follow-up of patients included in phase II and phase III trials and in expanded access programs revealed that the survival rates remained stable after 3 years. These results demonstrated that ipilimumab induces an effective anti-tumor immune response persisting after the completion of treatment, and suggested a potential remission in a subset of patients. In this article we review the development of ipilimumab and highlight the long-term results. This approach emphasizes the need to optimize the use of ipilimumab in the future, by identifying the patients most likely to achieve long term survival after ipilimumab therapy, and by developing combined therapeutic approaches involving cytotoxic agents, targeted therapies or other immunotherapies to achieve durable control in a larger proportion of patients.
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Affiliation(s)
- Julie Delyon
- AP-HP, Hôpital Saint-Louis, Département de Dermatologie, Paris, France; INSERM U976, Paris 7 University, Paris, France
| | - Michele Maio
- Medical Oncology and Immunotherapy, University Hospital of Siena, Istituto Toscano Tumori, Siena, Italy
| | - Celeste Lebbé
- AP-HP, Hôpital Saint-Louis, Département de Dermatologie, Paris, France; INSERM U976, Paris 7 University, Paris, France; Université Paris-Diderot, Sorbonne Paris Cité, Paris, France.
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270
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Optimal management of immune-related toxicities associated with checkpoint inhibitors in lung cancer. Lung Cancer 2015; 88:117-23. [PMID: 25776466 DOI: 10.1016/j.lungcan.2015.02.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 02/08/2015] [Indexed: 12/29/2022]
Abstract
Antibodies against immune checkpoints including CTLA-4, PD-1 and PD-L1 are increasingly being used in lung cancer. They are associated with novel, immune related toxicities not previously encountered with established treatments for lung cancer including colitis, hepatitis, rashes, neuropathies and other rarer immune mediated toxicities. Although generally these are low grade, there is a potential to be life threatening if not managed promptly. Early recognition of toxicity and institution of management algorithms are key to ensuring patient safety. We review the common toxicities and provide recommendations on their management.
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271
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Schadendorf D, Hodi FS, Robert C, Weber JS, Margolin K, Hamid O, Patt D, Chen TT, Berman DM, Wolchok JD. Pooled Analysis of Long-Term Survival Data From Phase II and Phase III Trials of Ipilimumab in Unresectable or Metastatic Melanoma. J Clin Oncol 2015; 33:1889-94. [PMID: 25667295 DOI: 10.1200/jco.2014.56.2736] [Citation(s) in RCA: 1561] [Impact Index Per Article: 173.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To provide a more precise estimate of long-term survival observed for ipilimumab-treated patients with advanced melanoma, we performed a pooled analysis of overall survival (OS) data from multiple studies. METHODS The primary analysis pooled OS data for 1,861 patients from 10 prospective and two retrospective studies of ipilimumab, including two phase III trials. Patients were previously treated (n = 1,257) or treatment naive (n = 604), and the majority of patients received ipilimumab 3 mg/kg (n = 965) or 10 mg/kg (n = 706). We also conducted a secondary analysis of OS data (n = 4,846) with an additional 2,985 patients from an expanded access program. OS rates were estimated using the Kaplan-Meier method. RESULTS Among 1,861 patients, median OS was 11.4 months (95% CI, 10.7 to 12.1 months), which included 254 patients with at least 3 years of survival follow-up. The survival curve began to plateau around year 3, with follow-up of up to 10 years. Three-year survival rates were 22%, 26%, and 20% for all patients, treatment-naive patients, and previously treated patients, respectively. Including data from the expanded access program, median OS was 9.5 months (95% CI, 9.0 to 10.0 months), with a plateau at 21% in the survival curve beginning around year 3. CONCLUSION To our knowledge, this is the largest analysis of OS to date for ipilimumab-treated patients with advanced melanoma. We observed a plateau in the survival curve, beginning at approximately 3 years, which was independent of prior therapy or ipilimumab dose. These data add to the evidence supporting the durability of long-term survival in ipilimumab-treated patients with advanced melanoma.
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Affiliation(s)
- Dirk Schadendorf
- Dirk Schadendorf, University Hospital Essen, Essen, Germany; F. Stephen Hodi, Dana-Farber Cancer Institute, Boston, MA; Caroline Robert, Institute Gustave Roussy, Villejuif, France; Jeffrey S. Weber, Moffitt Cancer Center, Tampa, FL; Kim Margolin, University of Washington, Seattle, WA; Omid Hamid, The Angeles Clinic and Research Institute, Los Angeles, CA; Debra Patt, The US Oncology Network, McKesson Specialty Health, Houston, TX; Tai-Tsang Chen, Bristol-Myers Squibb, Wallingford, CT; David M. Berman, Bristol-Myers Squibb, Lawrenceville, NJ; and Jedd D. Wolchok, Memorial Sloan Kettering Cancer Center, New York, NY.
| | - F Stephen Hodi
- Dirk Schadendorf, University Hospital Essen, Essen, Germany; F. Stephen Hodi, Dana-Farber Cancer Institute, Boston, MA; Caroline Robert, Institute Gustave Roussy, Villejuif, France; Jeffrey S. Weber, Moffitt Cancer Center, Tampa, FL; Kim Margolin, University of Washington, Seattle, WA; Omid Hamid, The Angeles Clinic and Research Institute, Los Angeles, CA; Debra Patt, The US Oncology Network, McKesson Specialty Health, Houston, TX; Tai-Tsang Chen, Bristol-Myers Squibb, Wallingford, CT; David M. Berman, Bristol-Myers Squibb, Lawrenceville, NJ; and Jedd D. Wolchok, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Caroline Robert
- Dirk Schadendorf, University Hospital Essen, Essen, Germany; F. Stephen Hodi, Dana-Farber Cancer Institute, Boston, MA; Caroline Robert, Institute Gustave Roussy, Villejuif, France; Jeffrey S. Weber, Moffitt Cancer Center, Tampa, FL; Kim Margolin, University of Washington, Seattle, WA; Omid Hamid, The Angeles Clinic and Research Institute, Los Angeles, CA; Debra Patt, The US Oncology Network, McKesson Specialty Health, Houston, TX; Tai-Tsang Chen, Bristol-Myers Squibb, Wallingford, CT; David M. Berman, Bristol-Myers Squibb, Lawrenceville, NJ; and Jedd D. Wolchok, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeffrey S Weber
- Dirk Schadendorf, University Hospital Essen, Essen, Germany; F. Stephen Hodi, Dana-Farber Cancer Institute, Boston, MA; Caroline Robert, Institute Gustave Roussy, Villejuif, France; Jeffrey S. Weber, Moffitt Cancer Center, Tampa, FL; Kim Margolin, University of Washington, Seattle, WA; Omid Hamid, The Angeles Clinic and Research Institute, Los Angeles, CA; Debra Patt, The US Oncology Network, McKesson Specialty Health, Houston, TX; Tai-Tsang Chen, Bristol-Myers Squibb, Wallingford, CT; David M. Berman, Bristol-Myers Squibb, Lawrenceville, NJ; and Jedd D. Wolchok, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kim Margolin
- Dirk Schadendorf, University Hospital Essen, Essen, Germany; F. Stephen Hodi, Dana-Farber Cancer Institute, Boston, MA; Caroline Robert, Institute Gustave Roussy, Villejuif, France; Jeffrey S. Weber, Moffitt Cancer Center, Tampa, FL; Kim Margolin, University of Washington, Seattle, WA; Omid Hamid, The Angeles Clinic and Research Institute, Los Angeles, CA; Debra Patt, The US Oncology Network, McKesson Specialty Health, Houston, TX; Tai-Tsang Chen, Bristol-Myers Squibb, Wallingford, CT; David M. Berman, Bristol-Myers Squibb, Lawrenceville, NJ; and Jedd D. Wolchok, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Omid Hamid
- Dirk Schadendorf, University Hospital Essen, Essen, Germany; F. Stephen Hodi, Dana-Farber Cancer Institute, Boston, MA; Caroline Robert, Institute Gustave Roussy, Villejuif, France; Jeffrey S. Weber, Moffitt Cancer Center, Tampa, FL; Kim Margolin, University of Washington, Seattle, WA; Omid Hamid, The Angeles Clinic and Research Institute, Los Angeles, CA; Debra Patt, The US Oncology Network, McKesson Specialty Health, Houston, TX; Tai-Tsang Chen, Bristol-Myers Squibb, Wallingford, CT; David M. Berman, Bristol-Myers Squibb, Lawrenceville, NJ; and Jedd D. Wolchok, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Debra Patt
- Dirk Schadendorf, University Hospital Essen, Essen, Germany; F. Stephen Hodi, Dana-Farber Cancer Institute, Boston, MA; Caroline Robert, Institute Gustave Roussy, Villejuif, France; Jeffrey S. Weber, Moffitt Cancer Center, Tampa, FL; Kim Margolin, University of Washington, Seattle, WA; Omid Hamid, The Angeles Clinic and Research Institute, Los Angeles, CA; Debra Patt, The US Oncology Network, McKesson Specialty Health, Houston, TX; Tai-Tsang Chen, Bristol-Myers Squibb, Wallingford, CT; David M. Berman, Bristol-Myers Squibb, Lawrenceville, NJ; and Jedd D. Wolchok, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Tai-Tsang Chen
- Dirk Schadendorf, University Hospital Essen, Essen, Germany; F. Stephen Hodi, Dana-Farber Cancer Institute, Boston, MA; Caroline Robert, Institute Gustave Roussy, Villejuif, France; Jeffrey S. Weber, Moffitt Cancer Center, Tampa, FL; Kim Margolin, University of Washington, Seattle, WA; Omid Hamid, The Angeles Clinic and Research Institute, Los Angeles, CA; Debra Patt, The US Oncology Network, McKesson Specialty Health, Houston, TX; Tai-Tsang Chen, Bristol-Myers Squibb, Wallingford, CT; David M. Berman, Bristol-Myers Squibb, Lawrenceville, NJ; and Jedd D. Wolchok, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David M Berman
- Dirk Schadendorf, University Hospital Essen, Essen, Germany; F. Stephen Hodi, Dana-Farber Cancer Institute, Boston, MA; Caroline Robert, Institute Gustave Roussy, Villejuif, France; Jeffrey S. Weber, Moffitt Cancer Center, Tampa, FL; Kim Margolin, University of Washington, Seattle, WA; Omid Hamid, The Angeles Clinic and Research Institute, Los Angeles, CA; Debra Patt, The US Oncology Network, McKesson Specialty Health, Houston, TX; Tai-Tsang Chen, Bristol-Myers Squibb, Wallingford, CT; David M. Berman, Bristol-Myers Squibb, Lawrenceville, NJ; and Jedd D. Wolchok, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jedd D Wolchok
- Dirk Schadendorf, University Hospital Essen, Essen, Germany; F. Stephen Hodi, Dana-Farber Cancer Institute, Boston, MA; Caroline Robert, Institute Gustave Roussy, Villejuif, France; Jeffrey S. Weber, Moffitt Cancer Center, Tampa, FL; Kim Margolin, University of Washington, Seattle, WA; Omid Hamid, The Angeles Clinic and Research Institute, Los Angeles, CA; Debra Patt, The US Oncology Network, McKesson Specialty Health, Houston, TX; Tai-Tsang Chen, Bristol-Myers Squibb, Wallingford, CT; David M. Berman, Bristol-Myers Squibb, Lawrenceville, NJ; and Jedd D. Wolchok, Memorial Sloan Kettering Cancer Center, New York, NY
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272
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Yu C, Chopra IJ, Ha E. A novel melanoma therapy stirs up a storm: ipilimumab-induced thyrotoxicosis. Endocrinol Diabetes Metab Case Rep 2015; 2015:140092. [PMID: 25759760 PMCID: PMC4330494 DOI: 10.1530/edm-14-0092] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 01/26/2015] [Indexed: 11/23/2022] Open
Abstract
Ipilimumab, a novel therapy for metastatic melanoma, inhibits cytotoxic T-lymphocyte apoptosis, causing both antitumor activity and significant autoimmunity, including autoimmune thyroiditis. Steroids are frequently used in treatment of immune-related adverse events; however, a concern regarding the property of steroids to reduce therapeutic antitumor response exists. This study describes the first reported case of ipilimumab-associated thyroid storm and implicates iopanoic acid as an alternative therapy for immune-mediated adverse effects. An 88-year-old woman with metastatic melanoma presented with fatigue, anorexia, decreased functional status, and intermittent diarrhea for several months, shortly after initiation of ipilimumab – a recombinant human monoclonal antibody to the cytotoxic T-lymphocyte-associated antigen 4 (CTLA4). On arrival, she was febrile, tachycardic, and hypertensive with a wide pulse pressure, yet non-toxic appearing. She had diffuse, non-tender thyromegaly. An electrocardiogram (EKG) revealed supraventricular tachycardia. Blood, urine, and stool cultures were collected, and empiric antibiotics were started. A computed tomography (CT) angiogram of the chest was negative for pulmonary embolism or pneumonia, but confirmed a diffusely enlarged thyroid gland, which prompted thyroid function testing. TSH was decreased at 0.16 μIU/ml (normal 0.3–4.7); free tri-iodothyronine (T3) was markedly elevated at 1031 pg/dl (normal 249–405), as was free thyroxine (T4) at 5.6 ng/dl (normal 0.8–1.6). With iopanoic acid and methimazole therapy, she markedly improved within 48 h, which could be attributed to lowering of serum T3 with iopanoic acid rather than to any effect of the methimazole. Ipilimumab is a cause of overt thyrotoxicosis and its immune-mediated adverse effects can be treated with iopanoic acid, a potent inhibitor of T4-to-T3 conversion.
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Affiliation(s)
- Christine Yu
- Department of Medicine, University of California , Los Angeles, Los Angeles, California, 90095 , USA
| | - Inder J Chopra
- Division of Endocrinology, Department of Medicine, University of California , 757 Westwood Plaza Blvd, Suite 7501, Los Angeles, CA, 90095 , USA
| | - Edward Ha
- Department of Medicine, University of California , Los Angeles, Los Angeles, California, 90095 , USA
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273
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Abstract
Side effects in the therapy of malignant melanoma are primarily of importance for radiologists in advanced tumor stages. The available treatment options and their respective side effect profiles have undergone a profound change in recent years after the introduction of modern oncological therapies (e.g. immunotherapy and targeted therapy) with an increasing focus on individual tumor biology and differ significantly from those of classical chemotherapy. The immunotherapeutic agents, in particular ipilimumab, take on a special position because of their specific immune-mediated mechanisms of action and the associated side effects, so-called immune-related adverse events (irAE). The majority of the treatment effects are manifested on the skin (> 50 %) and are generally not detectable by diagnostic radiology. Only a comparatively small proportion of treatment side effects is detectable with diagnostic imaging (15-20 %) but as in the example of therapy-induced colitis with ipilimumab, may be rapidly fatal. In addition to colitis (10-20 %) further therapy side effects apparent in diagnostic imaging are hypophysitis (1.8-17 %), thyroiditis (0.8 %), myositis (1.7 %), fasciitis and sarcoid-like lymph node alterations (6.8 %). To detect radiologically detectable side effects early on and to delineate them especially from tumor progression and (opportunistic) infections, detailed knowledge of the therapeutic methods for melanoma, the mechanisms of action and in particular the sometimes very specific side effects is imperative for radiologists.
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Affiliation(s)
- T Stahl
- Zentralinstitut für diagnostische und interventionelle Radiologie, Klinikum der Stadt Ludwigshafen gGmbH, Bremserstr. 79, 67063, Ludwigshafen, Deutschland,
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274
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Camacho LH. CTLA-4 blockade with ipilimumab: biology, safety, efficacy, and future considerations. Cancer Med 2015; 4:661-72. [PMID: 25619164 PMCID: PMC4430259 DOI: 10.1002/cam4.371] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 09/26/2014] [Accepted: 09/29/2014] [Indexed: 01/22/2023] Open
Abstract
Melanoma remains a critical public health problem worldwide. Patients with stage IV disease have very poor prognosis and their 1-year survival rate is only 25%. Until recently, systemic treatments with a positive impact on overall survival (OS) had remained elusive. In recent years, the United States Food and Drug Administration (FDA) – approved several novel agents targeting the RAS/RAF/MEK/ERK pathway (vemurafenib, dabrafenib, and trametinib) – critical in cell division and proliferation of melanoma, and an immune checkpoint inhibitor (ipilimumab) directed against the cytotoxic T lymphocyte Antigen - (CTLA-4). Moreover, recent reports of clinical trials studying other immune checkpoint modulating agents will most likely result in their FDA approval within the next months. This review focuses on ipilimumab, its safety and efficacy, and future considerations. Ipilimumab has demonstrated a positive OS impact after a several-year follow-up. It is also recognized that due to its mechanism of action, the response patterns to ipilimumab can differ from those observed in patients following treatment with conventional cytotoxic agents and even the most recently approved BRAF inhibitors. Most patients (84.8%) experience drug-related adverse events (AEs) of any grade; most of these are mild to moderate and immune mediated. However, a minority of patients may also experience severe and life-threatening AEs. In clinical studies, AEs were managed according to guidelines that emphasized close clinical monitoring and early use of corticosteroids when appropriate. Preliminary results have taught us the potential greater toxicity when in combination with vemurafenib, and the greater antitumor efficacy when combined with nivolumab, a monoclonal antibody directed against programmed death receptor-1 (PD-1), another immune checkpoint inhibitor. Future challenges include the optimization of dosing and toxicities when used as a single agent, and studying the safety and efficacy of combinations with targeted small molecules and other monoclonal antibodies to treat patients with melanoma and other malignancies.
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275
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Abstract
Diarrhoea induced by chemotherapy in cancer patients is common, causes notable morbidity and mortality, and is managed inconsistently. Previous management guidelines were based on poor evidence and neglect physiological causes of chemotherapy-induced diarrhoea. In the absence of level 1 evidence from randomised controlled trials, we developed practical guidance for clinicians based on a literature review by a multidisciplinary team of clinical oncologists, dietitians, gastroenterologists, medical oncologists, nurses, pharmacist, and a surgeon. Education of patients and their carers about the risks associated with, and management of, chemotherapy-induced diarrhoea is the foundation for optimum treatment of toxic effects. Adequate--and, if necessary, repeated--assessment, appropriate use of loperamide, and knowledge of fluid resuscitation requirements of affected patients is the second crucial step. Use of octreotide and seeking specialist advice early for patients who do not respond to treatment will reduce morbidity and mortality. In view of the burden of chemotherapy-induced diarrhoea, appropriate multidisciplinary research to assess meaningful endpoints is urgently required.
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276
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Rahbar R, Lin A, Ghazarian M, Yau HL, Paramathas S, Lang PA, Schildknecht A, Elford AR, Garcia-Batres C, Martin B, Berman HK, Leong WL, McCready DR, Reedijk M, Done SJ, Miller N, Youngson B, Suh WK, Mak TW, Ohashi PS. B7-H4 expression by nonhematopoietic cells in the tumor microenvironment promotes antitumor immunity. Cancer Immunol Res 2014; 3:184-95. [PMID: 25527357 DOI: 10.1158/2326-6066.cir-14-0113] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The B7 family plays a critical role in both positive and negative regulation of immune responses by engaging a variety of receptors on lymphocytes. Importantly, blocking coinhibitory molecules using antibodies specific for CTLA-4 and PD-1 enhances tumor immunity in a subset of patients. Therefore, it is critical to understand the role of different B7 family members since they may be suitable therapeutic targets. B7-H4 is another member that inhibits T-cell function, and it is also upregulated on a variety of tumors and has been proposed to promote tumor growth. Here, we investigate the role of B7-H4 in tumor development and show that B7-H4 expression inhibits tumor growth in two mouse models. Furthermore, we show that B7-H4 expression is required for antitumor immune responses in a mouse model of mammary tumorigenesis. We found that the expression levels of B7-H4 correlate with MHC class I expression in both mouse and human samples. We show that IFNγ upregulates B7-H4 expression on mouse embryo fibroblasts and that the upregulation of B7-H4 on tumors is dependent on T cells. Notably, patients with breast cancer with increased B7-H4 expression show a prolonged time to recurrence. These studies demonstrate a positive role for B7-H4 in promoting antitumor immunity.
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Affiliation(s)
- Ramtin Rahbar
- Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, Toronto, Ontario, Canada. Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Albert Lin
- Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, Toronto, Ontario, Canada. Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Magar Ghazarian
- Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, Toronto, Ontario, Canada. Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Helen-Loo Yau
- Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, Toronto, Ontario, Canada. Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Sangeetha Paramathas
- Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, Toronto, Ontario, Canada. Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Philipp A Lang
- Department of Molecular Medicine II, Heinrich Heine University Dösseldorf, Dösseldorf, Germany
| | - Anita Schildknecht
- Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Alisha R Elford
- Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Carlos Garcia-Batres
- Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Bernard Martin
- Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Hal K Berman
- Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, Toronto, Ontario, Canada. Laboratory Medicine Program, University Health Network (UHN), Toronto, Ontario, Canada. Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Wey L Leong
- Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - David R McCready
- Department of Surgical Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Michael Reedijk
- Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Susan J Done
- Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, Toronto, Ontario, Canada. Laboratory Medicine Program, University Health Network (UHN), Toronto, Ontario, Canada. Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada. Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Miller
- Laboratory Medicine Program, University Health Network (UHN), Toronto, Ontario, Canada. Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Bruce Youngson
- Laboratory Medicine Program, University Health Network (UHN), Toronto, Ontario, Canada. Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Woong-Kyung Suh
- Immune Regulation Laboratory, Institut de Recherches Cliniques de Montreal (IRCM), Montreal, Quebec, Canada
| | - Tak W Mak
- Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, Toronto, Ontario, Canada. Department of Immunology, University of Toronto, Toronto, Ontario, Canada. Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Pamela S Ohashi
- Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, Toronto, Ontario, Canada. Department of Immunology, University of Toronto, Toronto, Ontario, Canada. Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.
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Ritprajak P, Azuma M. Intrinsic and extrinsic control of expression of the immunoregulatory molecule PD-L1 in epithelial cells and squamous cell carcinoma. Oral Oncol 2014; 51:221-8. [PMID: 25500094 DOI: 10.1016/j.oraloncology.2014.11.014] [Citation(s) in RCA: 252] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 11/13/2014] [Accepted: 11/20/2014] [Indexed: 01/01/2023]
Abstract
Recent clinical results for PD-1 blockade therapy have demonstrated durable tumor control with minimal immune-related adverse effects. PD-L1 is induced in non-lymphoid tissue cells and tumor cells, in addition to tissue-recruiting immune cells, under inflammatory conditions triggered by several cytokines, especially IFN-γ, and exogenous stimuli delivered by pathogen-associated molecular patterns. Receptor-mediated signaling molecules that affect the cell cycle, proliferation, apoptosis, and survival (including NF-κB, MAPK, PI3K, mTOR, and JAK/STAT) are involved in PD-L1 induction. PD-L1 expression in tumor cells is also triggered by the signals described above, but in some instances, intrinsic cell alteration associated with carcinogenesis contributes to PD-L1 induction. The tumor suppressor genes PTEN and Lkb1 and epithelial-mesenchymal transition-related molecules are also involved in the regulation of PD-L1 expression. Notably, squamous cell carcinoma of the head and neck (SCCHN) often exhibits both host immunosuppression and cytogenetic alternations of tumor cells. Precise understanding of how PD-L1 expression is controlled will allow the development of effective approaches to PD-1 blockade therapy for patients with SCCHN.
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Affiliation(s)
- Patcharee Ritprajak
- Department of Microbiology and Immunology and DRU of Oral Microbiology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Miyuki Azuma
- Department of Molecular Immunology, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan.
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278
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Drakes ML, Stiff PJ. Harnessing immunosurveillance: current developments and future directions in cancer immunotherapy. Immunotargets Ther 2014; 3:151-65. [PMID: 27471706 PMCID: PMC4918242 DOI: 10.2147/itt.s37790] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Despite improved methods of cancer detection and disease management over the last few decades, cancer remains a major public health problem in many societies. Conventional therapies, such as chemotherapy, radiation, and surgery, are not usually sufficient to prevent disease recurrence. Therefore, efforts have been focused on developing novel therapies to manage metastatic disease and to prolong disease-free and overall survival, by modulating the immune system to alleviate immunosuppression, and to enhance antitumor immunity. This review discusses protumor mechanisms in patients that circumvent host immunosurveillance, and addresses current immunotherapy modalities designed to target these mechanisms. Given the complexity of cancer immunosuppressive mechanisms, we propose that identification of novel disease biomarkers will drive the development of more targeted immunotherapy. Finally, administration of different classes of immunotherapy in combination regimens, will be the ultimate route to impact low survival rates in advanced cancer patients.
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Affiliation(s)
- Maureen L Drakes
- Department of Medicine, Division of Hematology and Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Patrick J Stiff
- Department of Medicine, Division of Hematology and Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
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279
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Berman D, Korman A, Peck R, Feltquate D, Lonberg N, Canetta R. The development of immunomodulatory monoclonal antibodies as a new therapeutic modality for cancer: the Bristol-Myers Squibb experience. Pharmacol Ther 2014; 148:132-53. [PMID: 25476108 DOI: 10.1016/j.pharmthera.2014.11.017] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 11/24/2014] [Indexed: 12/19/2022]
Abstract
The discovery and increased understanding of the complex interactions regulating the immune system have contributed to the pharmacologic activation of antitumor immunity. The activity of effector cells, such as T and NK cells, is regulated by an array of activating and attenuating receptors and ligands. Agents that target these molecules can modulate immune responses by exerting antagonistic or agonistic effects. Several T- or NK-cell modulators have entered clinical trials, and two have been approved for use. Ipilimumab (Yervoy®, Bristol-Myers Squibb) and nivolumab (OPDIVO, Ono Pharmaceutical Co., Ltd./Bristol-Myers Squibb) were approved for the treatment of metastatic melanoma, in March 2011 in the United States, and in July 2014 in Japan, respectively. The clinical activity of these two antibodies has not been limited to tumor types considered sensitive to immunotherapy, and promising activity has been reported in other solid and hematologic tumors. Clinical development of ipilimumab and nivolumab has presented unique challenges in terms of safety and efficacy, requiring the establishment of new evaluation criteria for adverse events and antitumor effects. Guidelines intended to help oncologists properly manage treatment in view of these non-traditional features have been implemented. The introduction of this new modality of cancer treatment, which is meant to integrate with or replace the current standards of care, requires additional efforts in terms of optimization of treatment administration, identification of biomarkers and application of new clinical trial designs. The availability of immune modulators with different mechanisms of action offers the opportunity to establish immunological combinations as new standards of care.
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Affiliation(s)
- David Berman
- Bristol-Myers Squibb, Research and Development Division, United States
| | - Alan Korman
- Bristol-Myers Squibb, Research and Development Division, United States
| | - Ronald Peck
- Bristol-Myers Squibb, Research and Development Division, United States
| | - David Feltquate
- Bristol-Myers Squibb, Research and Development Division, United States
| | - Nils Lonberg
- Bristol-Myers Squibb, Research and Development Division, United States
| | - Renzo Canetta
- Bristol-Myers Squibb, Research and Development Division, United States.
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280
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Schneider SL, Ross AL, Grichnik JM. Do inflammatory pathways drive melanomagenesis? Exp Dermatol 2014; 24:86-90. [PMID: 25041143 DOI: 10.1111/exd.12502] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2014] [Indexed: 12/12/2022]
Abstract
Inflammatory pathways serve to protect the host and promote tissue healing/repair; however, over-activation or dysregulation can be pathological with unintended consequences including malignant progression. A correlation between inflammation and cancer has been well established, and anti-inflammatory medications have been shown to be chemopreventive in certain malignancies. Data are now becoming available that outline an inflammatory pathway that may have a critical role in melanomagenesis. ATP-regulated membrane channels/receptors P2X7 and PANX1 have been directly implicated in melanoma tumor growth. Among other potential effects, opening of the P2X7/PANX1 channel results in activation of the NALP3 inflammasome, which in turn leads to caspase-1 activation and increased levels of activated IL-1β. Elevated levels of caspase-1 and IL-1β have been correlated with melanoma progression, and inhibitors of the inflammasome, caspase and IL-1β activity have all been shown to inhibit melanoma growth. Among many other potential actions, IL-1β increases cyclooxygenase-2 expression leading to local increases in inflammatory mediators such as prostaglandin E2 (PGE2). Anti-inflammatory medications targeting the end of this pathway have had positive results for certain cancers but overall remain mixed for melanoma. A better understanding of the pathways and appropriate intervention points may help direct future therapies. In this viewpoint, we will review data and attempt to model an inflammatory pathway that may be critical for melanomagenesis and propose future directions for exploration.
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Affiliation(s)
- Samantha L Schneider
- Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA; Albert Einstein College of Medicine, Bronx, NY, USA
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281
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Ipilimumab-associated Sweet syndrome in a melanoma patient. J Am Acad Dermatol 2014; 71:e211-3. [DOI: 10.1016/j.jaad.2014.06.042] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 06/24/2014] [Indexed: 11/23/2022]
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282
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O'Kane GM, Lyons TG, Colleran GC, Ahmad MW, Alken S, Kavanagh EC, Fitzpatrick D, Murray B, Kelly CM. Late-Onset Paraplegia after Complete Response to Two Cycles of Ipilimumab for Metastatic Melanoma. Oncol Res Treat 2014; 37:757-60. [DOI: 10.1159/000368316] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 08/18/2014] [Indexed: 11/19/2022]
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283
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Expression of cancer testis antigens CT10 (MAGE-C2) and GAGE in gastrointestinal stromal tumors. Eur J Surg Oncol 2014; 40:1307-12. [DOI: 10.1016/j.ejso.2014.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 02/25/2014] [Accepted: 03/13/2014] [Indexed: 02/03/2023] Open
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284
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Santegoets SJ, Stam AG, Lougheed SM, Gall H, Jooss K, Sacks N, Hege K, Lowy I, Scheper RJ, Gerritsen WR, van den Eertwegh AJ, de Gruijl TD. Myeloid derived suppressor and dendritic cell subsets are related to clinical outcome in prostate cancer patients treated with prostate GVAX and ipilimumab. J Immunother Cancer 2014. [PMID: 26196012 PMCID: PMC4507359 DOI: 10.1186/s40425-014-0031-3] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Cancer-related disturbances in myeloid lineage development, marked by high levels of myeloid-derived suppressor cells (MDSC) and impaired dendritic cell (DC) development, are associated with poor clinical outcome due to immune escape and therapy resistance. Redressing this balance may therefore be of clinical benefit. Here we investigated the effects of combined Prostate GVAX/ipilimumab immunotherapy on myeloid subsets in peripheral blood of castration-resistant prostate cancer (CRPC) patients as well as the putative predictive value of baseline and on-treatment myeloid parameters on clinical outcome. Methods Patients with CRPC (n = 28) received thirteen intradermal administrations of Prostate GVAX, consisting of two allogeneic GM-CSF-transduced and irradiated prostate cancer cell lines (LN-CaP and PC3) and six infusions of escalating doses of anti-CTLA4/ipilimumab. Frequencies and activation status of peripheral blood DC (PBDC) and MDSC were determined before, during and after treatment by flowcytometric analysis and related to clinical benefit. Results Significant treatment-induced activation of conventional and plasmacytoid DC subsets (cDC and pDC) was observed, which in the case of BDCA1/CD1c+ cDC1 and MDC8+/6-sulfoLacNAc+ inflammatory cDC3 was associated with significantly prolonged overall survival (OS), but also with the development of autoimmune-related adverse events. High pre-treatment levels of CD14+HLA-DR−monocytic MDSC (mMDSC) were associated with reduced OS. Unsupervised clustering of these myeloid biomarkers revealed particular survival advantage in a group of patients with high treatment-induced PBDC activation and low pretreatment frequencies of suppressive mMDSC in conjunction with our previously identified lymphoid biomarker of high pretreatment CD4+CTLA4+ T cell frequencies. Conclusions Our data demonstrate that DC and MDSC subsets are affected by prostate GVAX/ipilimumab therapy and that myeloid profiling may contribute to the identification of patients with possible clinical benefit of Prostate GVAX/ipilimumab treatment. Electronic supplementary material The online version of this article (doi:10.1186/s40425-014-0031-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Saskia Jam Santegoets
- Department of Medical Oncology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Anita Gm Stam
- Department of Medical Oncology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands ; Department of Pathology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Sinéad M Lougheed
- Department of Medical Oncology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Helen Gall
- Department of Medical Oncology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Karin Jooss
- Cell Genesys Inc, South San Francisco, CA USA
| | | | | | - Israel Lowy
- Medarex, Bloomsbury, NJ/Bristol-Myers Squibb Company, Wallingford, CT USA
| | - Rik J Scheper
- Department of Pathology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Winald R Gerritsen
- Department of Medical Oncology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Alfons Jm van den Eertwegh
- Department of Medical Oncology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Tanja D de Gruijl
- Department of Medical Oncology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
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285
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McElnea E, Ní Mhéalóid A, Moran S, Kelly R, Fulcher T. Thyroid-like ophthalmopathy in a euthyroid patient receiving Ipilimumab. Orbit 2014; 33:424-7. [PMID: 25207976 DOI: 10.3109/01676830.2014.949792] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A 68-year-old lady with metastatic malignant melanoma was treated with Ipilimumab. She presented to Eye Casualty unable to move her eyes. Physical examination confirmed ophthalmoplegia and identified proptosis bilaterally. Radiological imaging showed bilateral enlargement of all the extra-ocular muscles suggestive of thyroid eye disease. Laboratory investigations found this patient to be euthyroid. A diagnosis of thyroid-like orbitopathy secondary to Ipilimumab therapy was made. Thyroid function tests should be performed for all patients prior to their commencement of Ipilimumab. Thyroid-like eye disease may develop in patients treated with Ipilimumab even if they remain euthyroid.
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Affiliation(s)
- Elizabeth McElnea
- Department of Ophthalmology, Mater Misericordiae University Hospital , Dublin , Ireland
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286
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Lebbé C, Weber JS, Maio M, Neyns B, Harmankaya K, Hamid O, O'Day SJ, Konto C, Cykowski L, McHenry MB, Wolchok JD. Survival follow-up and ipilimumab retreatment of patients with advanced melanoma who received ipilimumab in prior phase II studies. Ann Oncol 2014; 25:2277-2284. [PMID: 25210016 DOI: 10.1093/annonc/mdu441] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This report provides a survival update at a follow-up of >5 years (5.5-6 years) for patients with advanced melanoma who previously received ipilimumab in phase II clinical trials. Safety and efficacy data following ipilimumab retreatment are also reported. PATIENTS AND METHODS Patients who previously received ipilimumab 0.3, 3, or 10 mg/kg in one of six phase II trials (CA184-004, CA184-007, CA184-008, CA184-022, MDX010-08, and MDX010-15) were eligible to enroll in the companion study, CA184-025. Upon enrollment, patients initially received ipilimumab retreatment, extended maintenance therapy, or were followed for survival only. Overall survival (OS) rates were evaluated in patients from studies CA184-004, CA184-007, CA184-008, and CA184-022. Safety and best overall response during ipilimumab retreatment at 10 mg/kg were assessed in study CA184-025. RESULTS Five-year OS rates for previously treated patients who received ipilimumab induction at 0.3, 3, or 10 mg/kg were 12.3%, 12.3%-16.5%, and 15.5%-28.4%, respectively. Five-year OS rates for treatment-naive patients who received ipilimumab induction at 3 or 10 mg/kg were 26.8% and 21.4%-49.5%, respectively. Little to no change in OS was observed from year 5 up to year 6. The objective response rate among retreated patients was 23%. Grade 3/4 immune-related adverse events occurred in 25%, 5.9%, and 13.2% of retreated patients who initially received ipilimumab 0.3, 3, and 10 mg/kg, with the most common being observed in the skin (4.2%, 2.9%, 3.8%) and gastrointestinal tract (12.5%, 2.9%, 3.8%), respectively. CONCLUSIONS At a follow-up of 5-6 years, ipilimumab continues to demonstrate durable, long-term survival in a proportion of patients with advanced melanoma. In some patients, ipilimumab retreatment can re-establish disease control with a safety profile that is comparable with that observed during ipilimumab induction. Further studies are needed to determine the contribution of ipilimumab retreatment to OS. CLINICALTRIALSGOV NCT00162123.
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Affiliation(s)
- C Lebbé
- Department of Dermatology, APHP, CIC, U976 Hôpital Saint-Louis University Paris Diderot, Paris, France.
| | - J S Weber
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - M Maio
- Medical Oncology and Immunotherapy, Department of Oncology, University Hospital of Siena, Istituto Toscano Tumori, Siena, Italy
| | - B Neyns
- Department of Medical Oncology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - K Harmankaya
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - O Hamid
- Melanoma Therapeutics, Translational Research and Immunotherapy, The Angeles Clinic and Research Institute, Los Angeles
| | - S J O'Day
- Los Angeles Skin Cancer Institute at Beverly Hills Cancer Center, Beverly Hills
| | | | | | - M B McHenry
- Global Biometric Sciences, Bristol-Myers Squibb Company, Wallingford
| | - J D Wolchok
- Ludwig Center for Cancer Immunotherapy, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
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287
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Trefzer U, Gutzmer R, Wilhelm T, Schenck F, Kähler KC, Jacobi V, Witthohn K, Lentzen H, Mohr P. Treatment of unresectable stage IV metastatic melanoma with aviscumine after anti-neoplastic treatment failure: a phase II, multi-centre study. J Immunother Cancer 2014; 2:27. [PMID: 25324973 PMCID: PMC4198912 DOI: 10.1186/s40425-014-0027-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 07/16/2014] [Indexed: 11/10/2022] Open
Abstract
Background Aviscumine, a recombinant plant protein, is an immune modulator that induces ribotoxic stress at the 28S ribosomal RNA subunit. In this way cytokine release and T-cell responses are enhanced. This phase II trial was conducted to test the efficacy and safety of aviscumine in patients with systemically pre-treated metastatic melanoma stage IV. Methods A total of 32 patients with progressive stage IV melanoma after failure of standard therapy were enrolled onto a single-arm, multi-centre, open-label, phase II trial. All patients had an ECOG performance status of 0 or 1. Patients received 350 ng aviscumine twice weekly by subcutaneous injection until progression. The primary end points were progression-free survival (PFS) and overall survival (OS). Safety was assessed as adverse events (AEs). Tumor response was assessed every eight weeks and survival of patients was followed up to one year after the end of therapy. Thirty one patients (intent-to-treat population (ITT)) were assessed for efficacy; safety was assessed in the whole population. Results One patient achieved a partial response (PR) and 10 patients showed stable disease/no change (SD). The median progression-free survival (mPFS) was 63 days (95% CI 57–85) and median overall survival (mOS) was 335 days (95% CI 210–604). In total 210 treatment-emergent adverse events were recorded. Grade 1 or 2 AEs occurred in 72% of patients and were mostly application-site effects such as pruritus Grade 3–4 treatment-emergent drug-related adverse events occurred in 9% of patients. Conclusion These results suggest that aviscumine may have a clinical impact in patients with previously treated metastatic melanoma and provide rationale for further clinical evaluation of this agent. In the light of effective new immune checkpoint blockers it might be a candidate for combinations with these agents. Trial registration ClinicalTrials.gov: NCT00658437
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Affiliation(s)
| | - Ralf Gutzmer
- Klinik für Dermatologie, Allergologie und Venerologie, Hauttumorzentrum Hannover (HTZH), Hannover, Germany
| | - Tabea Wilhelm
- Charité- Universitätsmedizin Berlin, Hauttumorcentrum Charité (HTCC), Klinik für Dermatologie, Venerologie und Allergologie, Berlin, Germany
| | | | - Katharina C Kähler
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein -Campus Kiel-, Kiel, Germany
| | - Volkmar Jacobi
- Institut für Diagnostische Radiologie, Klinikum der Johann-Wolfgang-Goethe-Universität, Frankfurt/Main, Germany
| | | | | | - Peter Mohr
- Elbe-Klinikum Buxtehude, Dermatologisches Zentrum, Buxtehude, Germany
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288
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Li XD, Ji M, Zheng X, Ning ZH, Wu J, Lu B, Wu CP, Jiang JT. Evaluation of tumor response to cytokine-induced killer cells therapy in malignant solid tumors. J Transl Med 2014; 12:215. [PMID: 25113800 PMCID: PMC4256683 DOI: 10.1186/s12967-014-0215-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 07/21/2014] [Indexed: 12/01/2022] Open
Abstract
CIK cells therapy has been evaluated as an adoptive cell immunotherapy for cancer patients, but there still have not been any standardized systems for evaluating the antitumor efficacy yet. The WHO and RECIST criteria have already been established for a few years but not sufficient to fully characterize the activity of immunotherapy. Based on these two criteria, the irRC was proposed for evaluating the efficacy of immunotherapy. A variety of bioassays for immune monitoring including the specific and non-specific methods, have been established. We recommend detect levels of various immunocytes, immune molecules and soluble molecules to find the correlations among them and clinicopathological characteristics to establish criteria for immunological classification. We also recommend a paradigm shift for the oncologists in the evaluation of immune therapies to ensure assessment of activity based on clinically relevant criteria and time points.
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289
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Baker JJ, Stitzenberg KB, Collichio FA, Meyers MO, Ollila DW. Systematic Review: Surgery for Patients with Metastatic Melanoma during Active Treatment with Ipilimumab. Am Surg 2014. [DOI: 10.1177/000313481408000833] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Studies of ipilimumab have shown improved overall survival in patients with metastatic cutaneous melanoma. As a result, use of ipilimumab in patients with Stage IV melanoma is rapidly increasing. Patients with Stage IV melanoma often require urgent operations for complications from metastases, but little is known about the safety of surgical intervention for patients receiving ipilimumab. We performed a systematic review of the literature using PubMed. Our search terms were melanoma and ipilimumab. We excluded foreign language articles, review articles, and those not addressing cutaneous melanoma. We identified 194 publications matching the search criteria. Only six of those met the inclusion criteria. In these six publications, seven patients who had undergone surgical intervention during treatment with ipilimumab were described. There were no documented surgical complications. We reviewed our institutional experience and identified an additional three patients. No postoperative complications could be attributed directly to ipilimumab. There are limited data on the safety of surgical intervention during treatment with ipilimumab. Preliminary reports suggest there is no reason to withhold or delay surgery for patients receiving ipilimumab therapy.
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Affiliation(s)
- Justin J. Baker
- Division of Surgical Oncology, Department of Surgery, Maine Medical Center, Portland, Maine
| | | | | | - Michael O. Meyers
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery
| | - David W. Ollila
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery
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290
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Abstract
Targeting CTLA-4 represents a new type of immunotherapeutic approach, namely immune checkpoint inhibition. Blockade of CTLA-4 by ipilimumab was the first strategy to achieve a significant clinical benefit for late-stage melanoma patients in two phase 3 trials. These results fueled the notion of immunotherapy being the breakthrough strategy for oncology in 2013. Subsequently, many trials have been set up to test various immune checkpoint modulators in malignancies, not only in melanoma. In this review, recent new ideas about the mechanism of action of CTLA-4 blockade, its current and future therapeutic use, and the intensive search for biomarkers for response will be discussed. Immune checkpoint blockade, targeting CTLA-4 and/or PD-1/PD-L1, is currently the most promising systemic therapeutic approach to achieve long-lasting responses or even cure in many types of cancer, not just in patients with melanoma.
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Affiliation(s)
- Christian U Blank
- Department of Medical Oncology and Division of Immunology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066CX Amsterdam, The Netherlands
| | - Alexander Enk
- Department of Dermatology, The University of Heidelberg, Im Neunheimer Feld 440, 69115 Heidelberg, Germany
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291
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Luke JJ, Ott PA. New developments in the treatment of metastatic melanoma - role of dabrafenib-trametinib combination therapy. DRUG HEALTHCARE AND PATIENT SAFETY 2014; 6:77-88. [PMID: 25018652 PMCID: PMC4075957 DOI: 10.2147/dhps.s39568] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Development of selective inhibitors of BRAF has improved the survival of patients with BRAF-mutant melanoma. The progression-free survival after treatment with a BRAF inhibitor is modest, however, and BRAF inhibitors induce cutaneous toxicity, likely due to paradoxical activation of the mitogen-activated protein kinase pathway. Combining selective BRAF and MEK inhibition, such as the BRAF inhibitor dabrafenib and the MEK inhibitor trametinib, has been shown to improve the response rate and progression-free survival in patients with advanced melanoma while significantly alleviating the paradoxical activation of mitogen-activated protein kinase. This combination treatment results in a reduction in skin toxicity relative to that seen with a BRAF inhibitor alone; however, addition of the MEK inhibitor adds other toxicities, such as pyrexia and gastrointestinal or ocular toxicity. While combined BRAF–MEK inhibition appears primed to become a standard molecular approach for BRAF-mutant melanoma, the utility of the combination has to be considered in the rapidly changing landscape of immunotherapeutics, such as immune checkpoint blockade using anti-cytotoxic T lymphocyte antigen-4 and anti-programmed death-1/programmed death-L1 antibodies. Here we review the development of the dabrafenib plus trametinib combination, the characteristics of each drug and the combination, and the role of this combination in the management of patients with BRAF-mutant melanoma.
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Affiliation(s)
- Jason J Luke
- Melanoma Disease Center, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Patrick A Ott
- Melanoma Disease Center, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
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292
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Nishino M, Gargano M, Suda M, Ramaiya NH, Hodi FS. Optimizing immune-related tumor response assessment: does reducing the number of lesions impact response assessment in melanoma patients treated with ipilimumab? J Immunother Cancer 2014; 2:17. [PMID: 24991412 PMCID: PMC4077549 DOI: 10.1186/2051-1426-2-17] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 04/16/2014] [Indexed: 11/16/2022] Open
Abstract
Background Investigate the impact of the reduction of the number of target lesions on immune-related response assessment in advanced melanoma patients treated with ipilimumab. Method Ninety patients (53 males, 37 females; age range: 25–87) with advanced melanoma treated with ipilimumab in two clinical trials were studied. Tumor measurements during trial allowing up to 5 lesions per organ and 10 lesions in total were retrospectively reviewed. A second set of tumor measurements allowing up to 2 lesions per organ and 5 lesions in total was generated. Immune-related response assessments by two measurements were compared. Results The number of target lesions was significantly reduced when up to 2 per organ and 5 in total lesions were allowed (Wilcoxon P < 0.0001). The immune-related response assessment using reduced number of lesions was highly concordant with assessment using the original number of lesions (Spearman r for the percent change on 1st-3rd follow-up: 0.860-0.970; κw for best immune-related response: 0.908). Median time-to-progression was 26.9 months (95%CI: 9.1-∞) by both assessments. Interobserver agreement of measurements was high for both assessments, with the concordance correlation coefficient above 0.98. Conclusion Reduction of the number of target lesions did not significantly affect immune-related response assessment or the measurement variability in advanced melanoma patients treated with ipilimumab. Using up to 2 per organ and 5 in total target lesions is proposed to assess immune-related response, while it is important to keep other novel features of immune-related response criteria such as confirmation of progression and inclusion of new lesion measurements.
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Affiliation(s)
- Mizuki Nishino
- Department of Radiology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, USA
| | - Maria Gargano
- Department of Medical Oncology and Department of Medicine, Dana-Farber Cancer Institute and Brigham and Women's Hospital, 450 Brookline Ave, Boston, MA 02215, USA
| | - Margaret Suda
- Department of Medical Oncology and Department of Medicine, Dana-Farber Cancer Institute and Brigham and Women's Hospital, 450 Brookline Ave, Boston, MA 02215, USA
| | - Nikhil H Ramaiya
- Department of Radiology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, USA
| | - F Stephen Hodi
- Department of Medical Oncology and Department of Medicine, Dana-Farber Cancer Institute and Brigham and Women's Hospital, 450 Brookline Ave, Boston, MA 02215, USA
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293
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De Remigis A, de Gruijl TD, Uram JN, Tzou SC, Iwama S, Talor MV, Armstrong TD, Santegoets SJAM, Slovin SF, Zheng L, Laheru DA, Jaffee EM, Gerritsen WR, van den Eertwegh AJM, Le DT, Caturegli P. Development of thyroglobulin antibodies after GVAX immunotherapy is associated with prolonged survival. Int J Cancer 2014; 136:127-37. [PMID: 24832153 DOI: 10.1002/ijc.28973] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 04/30/2014] [Indexed: 12/26/2022]
Abstract
Cancer immunotherapy induces a variety of autoinflammatory responses, including those against the thyroid gland, which can be exploited to predict clinical outcomes. Considering the paucity of information about thyroid autoimmunity in patients receiving cancer vaccines, we designed our study to assess the development of thyroglobulin antibodies (TgAbs) in patients treated with GVAX (vaccine made of a tumor cell type transfected with GM-CSF) and/or ipilimumab and correlated seroconversion with survival. Using both in house and commercial ELISA assays, we measured TgAbs in patients with pancreatic (No. = 53), prostate (No. = 35) or colon (No. = 8) cancer, before and after treatment with GVAX only (No. = 34), GVAX plus ipilimumab (No. = 42) or ipilimumab (No. = 20), and correlated their levels with patient's survival, disease status and T-cell surface markers. Antibodies to thyroperoxidase, myeloperoxidase, proteinase 3, insulin and actin were also measured. TgAbs specifically developed after GVAX, independent of the underlying cancer (81% in prostate, 75% colon cancer and 76% pancreatic cancer) and co-administration of ipilimumab (75% in GVAX only and 78% in GVAX plus ipilimumab). This TgAbs seroconversion could be detected mainly by the in house assay, suggesting that the thyroglobulin epitopes recognized by the antibodies induced by GVAX are different from the epitopes seen in the classic form of Hashimoto thyroiditis. Notably, TgAbs seroconversion was associated with significantly prolonged survival (p = 0.01 for pancreas and p = 0.005 for prostate cancer). In conclusion, GVAX immunotherapy induces the appearance of TgAbs that recognize a unique antigenic repertoire and associate with prolonged survival.
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294
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Ott PA, Hodi FS, Robert C. CTLA-4 and PD-1/PD-L1 blockade: new immunotherapeutic modalities with durable clinical benefit in melanoma patients. Clin Cancer Res 2014; 19:5300-9. [PMID: 24089443 DOI: 10.1158/1078-0432.ccr-13-0143] [Citation(s) in RCA: 514] [Impact Index Per Article: 51.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Immune checkpoint blockade with monoclonal antibodies directed at the inhibitory immune receptors CTLA-4, PD-1, and PD-L1 has emerged as a successful treatment approach for patients with advanced melanoma. Ipilimumab is the first agent associated with a documented improved overall survival benefit in this patient population. A striking attribute of CTLA-4 blockade is the durability of objective responses, leading to speculation of a possible cure for some patients. Many tumor responses achieved with PD-1 and PD-L1 inhibition were durable in the phase I trials and were seen in a higher proportion of patients with melanoma than typically observed with ipilimumab. Biomarker development to identify the subset of patients with melanoma who will achieve durable clinical benefit with checkpoint blockade is critical; tumor PD-L1 expression has been promising in early studies. The contrast between unprecedented response rates but limited durability of responses achieved with BRAF and MEK inhibition in BRAF(V600)-mutated melanoma and the impressive durability but relatively low rate of response achieved with immune checkpoint blockade is striking. Preclinical data on potential synergies between CTLA-4/PD-1/PD-L1 inhibition and MAPK-targeted therapy is emerging, and combined immune checkpoint blockade and MAPK inhibition are being explored in clinical trials. Other promising approaches to increase the number of patients with melanoma who benefit from durable responses with immune checkpoint blockade include concurrent or sequenced CTLA-4 and PD-1/PD-L1 inhibition and combination with other immunotherapeutic strategies. Clin Cancer Res; 19(19); 5300-9. ©2013 AACR.
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Affiliation(s)
- Patrick A Ott
- Authors' Affiliations: Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts; and Institut Gustave Roussy, Villejuif-Paris Sud, Paris, France
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295
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Queirolo P, Spagnolo F, Ascierto PA, Simeone E, Marchetti P, Scoppola A, Del Vecchio M, Di Guardo L, Maio M, Di Giacomo AM, Antonuzzo A, Cognetti F, Ferraresi V, Ridolfi L, Guidoboni M, Guida M, Pigozzo J, Chiarion Sileni V. Efficacy and safety of ipilimumab in patients with advanced melanoma and brain metastases. J Neurooncol 2014; 118:109-16. [PMID: 24532241 PMCID: PMC4023079 DOI: 10.1007/s11060-014-1400-y] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 01/31/2014] [Indexed: 11/28/2022]
Abstract
Patients with melanoma brain metastases have a poor prognosis and historically have been excluded from clinical trials. The Expanded Access Program (EAP) provided an opportunity to evaluate the feasibility of ipilimumab (3 mg/kg every 3 weeks for four doses) in patients with stage 3 (unresectable) or 4 melanoma and asymptomatic brain metastases, who had failed or did not tolerate previous treatments and had no other therapeutic option available. Tumor assessments were conducted at baseline and week 12 using immune-related response criteria and patients were monitored for adverse events (AEs). Of 855 patients participating in the EAP in Italy, 146 had asymptomatic brain metastases. With a median follow-up of 4 months, the global disease control rate was 27%, including 4 patients with a complete response and 13 with a partial response. Median progression-free survival and overall survival were 2.8 and 4.3 months, respectively and approximately one-fifth of patients were alive 1 year after starting ipilimumab. In total, 29% of patients reported a treatment-related AE of any grade, which were grade 3/4 in 6% of patients. AEs were generally reversible with treatment as per protocol-specific guidelines. Ipilimumab shows durable benefits in some patients with advanced melanoma metastatic to the brain, with safety results consistent with those previously reported in clinical trials.
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Affiliation(s)
- Paola Queirolo
- Medical Oncology, IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Largo Rosanna Benzi, 10, 16132, Genova, Italy,
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296
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Rijavec E, Genova C, Barletta G, Burrafato G, Biello F, Dal Bello MG, Coco S, Truini A, Alama A, Boccardo F, Grossi F. Ipilimumab in non-small cell lung cancer and small-cell lung cancer: new knowledge on a new therapeutic strategy. Expert Opin Biol Ther 2014; 14:1007-17. [PMID: 24702205 DOI: 10.1517/14712598.2014.907786] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Despite recent advances with new chemotherapeutic agents and target therapies, the prognosis of NSCLC remains poor. Recent results from clinical trials of immunotherapeutic agents, especially with immune checkpoint inhibitors, make this approach very exciting in NSCLC. Ipilimumab is a monoclonal antibody directed against cytotoxic T-lymphocyte antigen 4 that is able to stimulate the antitumour immune response by promoting T-cell activation. AREAS COVERED We have reviewed the literature and have described the most important results obtained with ipilimumab in NSCLC in recent trials with a specific focus on its peculiar toxicity profile and pattern of response. Trials ongoing with ipilimumab are also reported. EXPERT OPINION The results from clinical trials with ipilimumab are promising. Some important issues in the near future will be to identify prognostic and predictive biomarkers to select patients who could benefit from this drug. Further studies are warranted to understand how to combine ipilimumab with other anticancer strategies.
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Affiliation(s)
- Erika Rijavec
- UOS Tumori Polmonari, IRCCS San Martino - IST Istituto Nazionale per la Ricerca sul Cancro , L.go Benzi 10, Genova , Italy
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297
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Shah DJ, Dronca RS. Latest advances in chemotherapeutic, targeted, and immune approaches in the treatment of metastatic melanoma. Mayo Clin Proc 2014; 89:504-19. [PMID: 24684873 PMCID: PMC4034544 DOI: 10.1016/j.mayocp.2014.02.002] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 02/03/2014] [Accepted: 02/05/2014] [Indexed: 12/28/2022]
Abstract
Melanoma is the most dangerous form of skin cancer owing to its metastatic potential and is an important public health concern. The melanoma incidence has been increasing worldwide. Although potentially curable when diagnosed early, metastatic melanoma carries a poor prognosis. Until recently, systemic therapy for metastatic melanoma was ineffective, but the recent successes in the development of new therapies for metastatic melanoma, such as mitogen-activated protein kinase (MAPK) pathway inhibitors, anti-cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4), and programmed cell death protein 1 (PD-1)/programmed cell death ligand 1 (PD-L1) pathway blocking antibodies, as well as combination strategies of cytotoxic chemotherapy and inhibitors of angiogenesis, have all yielded promising results, changing the continually evolving landscape of therapeutic options for patients with this disease. The aim of this review was to summarize the evolution of and recent advances in the treatment of metastatic melanoma. Therefore, we conducted a comprehensive PubMed search between January 1, 1960, and February 1, 2014, using the search term melanoma or metastatic melanoma combined with terms such as chemotherapy, immunotherapy, CTLA-4, PD-1, PD-L1, adoptive T cell, targeted therapy, MAPK, molecular biology, and survival.
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Affiliation(s)
- Darshil J Shah
- Department of Internal Medicine, Oakland University William Beaumont School of Medicine, Beaumont Health System, Royal Oak, MI.
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298
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Roddie C, Peggs KS. Emerging options for the treatment of melanoma - focus on ipilimumab. Immunotargets Ther 2014; 3:67-78. [PMID: 27482517 PMCID: PMC4918235 DOI: 10.2147/itt.s43522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Ipilimumab is a fully human immunoglobulin subclass G1 anticytotoxic-T-lymphocyte-antigen-4 monoclonal antibody. It has been approved by the US Food and Drug Administration (FDA) and the European Medicines Agency for use in advanced melanoma following clear evidence of survival benefit in randomized Phase III studies. It is also under investigation as a treatment for other solid tumors such as renal cell, lung, and prostate cancers. The purported mechanism of antitumor activity of ipilimumab is through T-cell activation, and the side effect profile reflects this. Immune-related adverse events (irAEs) affect 60% of treated patients and 15% are defined as severe. Fortunately, most irAEs are reversible with early diagnosis and correct management. FDA approval of ipilimumab is dependent on the careful execution of a risk evaluation and mitigation strategy, with the aim of increasing awareness amongst patients and clinicians of the immunological risks of treatment, and providing algorithms for management of irAEs as they develop. Ipilimumab is one of the first immunotherapies to become widely available in the setting of solid tumors, and ongoing research aims to elucidate optimal dosing, optimal scheduling, and expanded access to ipilimumab as an adjuvant or maintenance therapy where appropriate. The identification of clinical correlates or biomarkers to identify those likely to benefit from this high-cost therapy is a top priority.
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Affiliation(s)
- Claire Roddie
- UCL Cancer Institute, Department of Hematology, London, UK
| | - Karl S Peggs
- UCL Cancer Institute, Department of Hematology, London, UK
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299
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McCutcheon JL, McClain CM, Puzanov I, Smith TA. Infectious Colitis Associated With Ipilimumab Therapy. Gastroenterology Res 2014; 7:28-31. [PMID: 27785266 PMCID: PMC5051139 DOI: 10.14740/gr594e] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2014] [Indexed: 01/12/2023] Open
Abstract
Ipilimumab is a monoclonal antibody against cytotoxic T lymphocyte-associated molecule-4 and is thought to promote anti-tumor activity by enhancing cell mediated immunity. It is one of the few therapies shown to improve overall survival in metastatic melanoma. Given its mechanism of action, the drug is associated with significant immune-related adverse events with the gastrointestinal system being commonly involved. Our patient is a 22-year-old female with stage IVA melanoma on ipilimumab therapy who presented with fever, diarrhea and abdominal pain. She gave a history of recent travel to a wedding where several other guests in attendance had also developed diarrheal illnesses. Her colonoscopy and pathology were consistent with ipilimumab-induced colitis. Her stool culture returned positive for Salmonella enteritides. She was treated with prednisone and ciprofloxacin with resolution of her symptoms. In our case, we describe ipilimumab-induced colitis where an infectious pathogen was identified with temporal relationship to symptoms and could be suggestive of a causal relationship.
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Affiliation(s)
- Jessica L McCutcheon
- Vanderbilt University Hospital, Department of Medicine, 1161 21st Ave South, D3100 Medical Center North, Nashville, TN 37232, USA
| | - Colt M McClain
- Vanderbilt University Hospital, Department of Pathology, Microbiology, and Immunology, 1161 21st Avenue South, CC 3322 Medical Center North, Nashville TN 37232, USA
| | - Igor Puzanov
- Vanderbilt University Hospital, Hematology/Oncology Division, 777 Preston Research building Nashville, TN 32232, USA
| | - Terrence A Smith
- Vanderbilt University Hospital, Division of Gastroenterology, Hepatology, and Nutrition, 1301 Medical Center Drive, 1160 The Vanderbilt Clinic, Nashville, TN 37232, USA
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300
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Chiarion-Sileni V, Pigozzo J, Ascierto PA, Simeone E, Maio M, Calabrò L, Marchetti P, De Galitiis F, Testori A, Ferrucci PF, Queirolo P, Spagnolo F, Quaglino P, Carnevale Schianca F, Mandalà M, Di Guardo L, Del Vecchio M. Ipilimumab retreatment in patients with pretreated advanced melanoma: the expanded access programme in Italy. Br J Cancer 2014; 110:1721-6. [PMID: 24619072 PMCID: PMC3974075 DOI: 10.1038/bjc.2014.126] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 02/14/2014] [Accepted: 02/17/2014] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Retreatment with ipilimumab has been shown to re-establish disease control in some patients with disease progression. Here, we report the efficacy and safety of retreatment with ipilimumab 3 mg kg(-1) among patients participating in an expanded access programme in Italy. METHODS Patients who achieved disease control during induction therapy were retreated with ipilimumab upon progression (3 mg kg(-1) every 3 weeks for up to four doses), providing they had not experienced toxicity that precluded further dosing. Tumour assessments were conducted after retreatment, and patients were monitored throughout for adverse events. RESULTS Of 855 patients treated with ipilimumab, 51 were retreated upon disease progression. Of these, 28 (55%) regained disease control upon retreatment and 42% were alive 2 years after the first induction dose of ipilimumab; median overall survival was 21 months. Eleven patients (22%) had a treatment-related adverse event of any grade during retreatment. These were generally mild-to-moderate and resolved within a median of 4 days. No new types of toxicity were reported. CONCLUSIONS For patients who meet predefined criteria, retreatment with ipilimumab is generally well tolerated and can translate into clinical benefit. This strategy should be compared with other therapeutic options in randomised controlled trials.
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Affiliation(s)
- V Chiarion-Sileni
- Melanoma Cancer Unit, Veneto Institute of Oncology IOV-IRCCS, Via Gattamelata, 64, 35128 Padua, Italy
| | - J Pigozzo
- Melanoma Cancer Unit, Veneto Institute of Oncology IOV-IRCCS, Via Gattamelata, 64, 35128 Padua, Italy
| | - P A Ascierto
- Melanoma, Cancer Immunotherapy and Innovative Therapy Unit, Istituto Nazionale Tumori Fondazione 'G Pascale', Via Cappella dei Cangiani, 1, 80131 Naples, Italy
| | - E Simeone
- Melanoma, Cancer Immunotherapy and Innovative Therapy Unit, Istituto Nazionale Tumori Fondazione 'G Pascale', Via Cappella dei Cangiani, 1, 80131 Naples, Italy
| | - M Maio
- Medical Oncology and Immunotherapy Unit, University Hospital of Siena, Istituto Toscano Tumori, Strada delle Scotte, 14, 53100 Siena, Italy
| | - L Calabrò
- Medical Oncology and Immunotherapy Unit, University Hospital of Siena, Istituto Toscano Tumori, Strada delle Scotte, 14, 53100 Siena, Italy
| | - P Marchetti
- 1] Medical Oncology, Dermopathic Institute of the Immaculate IDI-IRCCS, Via dei Monti di Creta, 104, 00167 Rome, Italy [2] Medical Oncology, Sant'Andrea Hospital, Sapienza University of Rome, Via di Grottarossa, 1035-39, 00189 Rome, Italy
| | - F De Galitiis
- Medical Oncology, Dermopathic Institute of the Immaculate IDI-IRCCS, Via dei Monti di Creta, 104, 00167 Rome, Italy
| | - A Testori
- Divisione Melanoma, Istituto Europeo di Oncologia, Via Ripamonti, 435, 20141 Milan, Italy
| | - P F Ferrucci
- Oncology of Melanoma Unit, Istituto Europeo di Oncologia, Via Ripamonti, 435, 20141 Milan, Italy
| | - P Queirolo
- Department of Medical Oncology A, San Martino Hospital, National Institute for Cancer Research, L.go R. Benzi, 10, 16132 Genoa, Italy
| | - F Spagnolo
- Department of Medical Oncology A, San Martino Hospital, National Institute for Cancer Research, L.go R. Benzi, 10, 16132 Genoa, Italy
| | - P Quaglino
- Dermatologic Clinic, Department of Medical Sciences, University of Torino, San Giovanni Battista di Torino, Via Cherasco, 23, 10126 Turin, Italy
| | - F Carnevale Schianca
- Division of Medical Oncology, Institute for Cancer Research and Treatment, IRCC, Piedmont Oncology Foundation, Strada Provinciale, 142, 10060 Candiolo, Italy
| | - M Mandalà
- Unit of Medical Oncology, Papa Giovanni XXIII Hospital, Piazza OMS-Organizzazione Mondiale della Sanità, 1, 24127 Bergamo, Italy
| | - L Di Guardo
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian, 1, 20133 Milan, Italy
| | - M Del Vecchio
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian, 1, 20133 Milan, Italy
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