1
|
Steindl A, Brastianos PK, Preusser M, Berghoff AS. Precision medicine biomarkers in brain metastases: applications, discordances, and obstacles. Neurooncol Adv 2021; 3:v35-v42. [PMID: 34859231 PMCID: PMC8633753 DOI: 10.1093/noajnl/vdab105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Brain metastases (BM) present a common cause of mortality and morbidity in several metastatic cancer entities. New therapeutic developments during the last decades, including targeted and immune-related therapies, have shown considerable extra- and intracranial response rates in specific subgroups of BM patients. However, differences in the molecular alteration in the BM tumor tissue compared to extracranial tumors leads to heterogeneous therapeutic responses. Therefore, an accurate molecular analyzation of BM tissue, if possible, has become an essential part in therapeutic decision making in BM patients. The concordance of predictive molecular biomarkers between multiple sites including extracranial and intracranial tumor tissue have been analyzed for some but not all biomarkers routinely applied in modern precision medicine approaches. In the present review, we summarize the current evidence of predictive biomarkers for personalized therapy approaches in the treatment of parenchymal BM.
Collapse
Affiliation(s)
- Ariane Steindl
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Priscilla K Brastianos
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Anna S Berghoff
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
2
|
Zhang L, Yao J, Wei Y, Zhou Z, Li P, Qu J, Badu-Nkansah A, Yuan X, Huang YW, Fukumura K, Mao X, Chang WC, Saunus J, Lakhani S, Huse JT, Hung MC, Yu D. Blocking immunosuppressive neutrophils deters pY696-EZH2-driven brain metastases. Sci Transl Med 2021; 12:12/545/eaaz5387. [PMID: 32461334 DOI: 10.1126/scitranslmed.aaz5387] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 04/15/2020] [Indexed: 12/12/2022]
Abstract
The functions of immune cells in brain metastases are unclear because the brain has traditionally been considered "immune privileged." However, we found that a subgroup of immunosuppressive neutrophils is recruited into the brain, enabling brain metastasis development. In brain metastatic cells, enhancer of zeste homolog 2 (EZH2) is highly expressed and phosphorylated at tyrosine-696 (pY696)-EZH2 by nuclear-localized Src tyrosine kinase. Phosphorylation of EZH2 at Y696 changes its binding preference from histone H3 to RNA polymerase II, which consequently switches EZH2's function from a methyltransferase to a transcription factor that increases c-JUN expression. c-Jun up-regulates protumorigenic inflammatory cytokines, including granulocyte colony-stimulating factor (G-CSF), which recruits Arg1+- and PD-L1+ immunosuppressive neutrophils into the brain to drive metastasis outgrowth. G-CSF-blocking antibodies or immune checkpoint blockade therapies combined with Src inhibitors impeded brain metastasis in multiple mouse models. These findings indicate that pY696-EZH2 can function as a methyltransferase-independent transcription factor to facilitate the brain infiltration of immunosuppressive neutrophils, which could be clinically targeted for brain metastasis treatment.
Collapse
Affiliation(s)
- Lin Zhang
- Department of Molecular and Cellular Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.,MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX 77030, USA
| | - Jun Yao
- Department of Molecular and Cellular Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Yongkun Wei
- Department of Molecular and Cellular Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Zhifen Zhou
- Department of Molecular and Cellular Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ping Li
- Department of Molecular and Cellular Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jingkun Qu
- Department of Molecular and Cellular Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Akosua Badu-Nkansah
- Department of Molecular and Cellular Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Xiangliang Yuan
- Department of Molecular and Cellular Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Yu-Wen Huang
- Department of Molecular and Cellular Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.,Center for Molecular Medicine, China Medical University, Taichung 40402, Taiwan
| | - Kazutaka Fukumura
- Department of Pathology and Translational Molecular Pathology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Xizeng Mao
- Department of Genomic Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Wei-Chao Chang
- Center for Molecular Medicine, China Medical University, Taichung 40402, Taiwan
| | - Jodi Saunus
- Faculty of Medicine, University of Queensland, St Lucia, QLD 4072, Australia
| | - Sunil Lakhani
- Faculty of Medicine, University of Queensland, St Lucia, QLD 4072, Australia.,Pathology Queensland, The Royal Brisbane & Women's Hospital, Herston, QLD 4029, Australia
| | - Jason T Huse
- Department of Pathology and Translational Molecular Pathology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Mien-Chie Hung
- Center for Molecular Medicine, China Medical University, Taichung 40402, Taiwan
| | - Dihua Yu
- Department of Molecular and Cellular Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA. .,MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX 77030, USA.,Center for Molecular Medicine, China Medical University, Taichung 40402, Taiwan
| |
Collapse
|
3
|
Váraljai R, Horn S, Sucker A, Piercianek D, Schmitt V, Carpinteiro A, Becker KA, Reifenberger J, Roesch A, Felsberg J, Reifenberger G, Sure U, Schadendorf D, Helfrich I. Integrative Genomic Analyses of Patient-Matched Intracranial and Extracranial Metastases Reveal a Novel Brain-Specific Landscape of Genetic Variants in Driver Genes of Malignant Melanoma. Cancers (Basel) 2021; 13:cancers13040731. [PMID: 33578810 PMCID: PMC7916600 DOI: 10.3390/cancers13040731] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/28/2021] [Accepted: 02/08/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Development of brain metastases in advanced melanoma patients is a frequent event that limits patients' quality of life and survival. Despite recent insights into melanoma genetics, systematic analyses of genetic alterations in melanoma brain metastasis formation are lacking. Moreover, whether brain metastases harbor distinct genetic alterations beyond those observed at different anatomic sites of the same patient remains unknown. EXPERIMENTAL DESIGN AND RESULTS In our study, 54 intracranial and 18 corresponding extracranial melanoma metastases were analyzed for mutations using targeted next generation sequencing of 29 recurrently mutated driver genes in melanoma. In 11 of 16 paired samples, we detected nucleotide modifications in brain metastases that were absent in matched metastases at extracranial sites. Moreover, we identified novel genetic variants in ARID1A, ARID2, SMARCA4 and BAP1, genes that have not been linked to brain metastases before; albeit most frequent mutations were found in ARID1A, ARID2 and BRAF. Conclusion: Our data provide new insights into the genetic landscape of intracranial melanoma metastases supporting a branched evolution model of metastasis formation.
Collapse
Affiliation(s)
- Renáta Váraljai
- Skin Cancer Unit of the Dermatology Department, Medical Faculty, West German Cancer Center, University Duisburg-Essen, 45147 Essen, Germany; (R.V.); (S.H.); (A.S.); (A.R.); (D.S.)
- German Cancer Consortium (DKTK), partner site Essen/Düsseldorf, 45147 Essen, Germany; (D.P.); (G.R.); (U.S.)
| | - Susanne Horn
- Skin Cancer Unit of the Dermatology Department, Medical Faculty, West German Cancer Center, University Duisburg-Essen, 45147 Essen, Germany; (R.V.); (S.H.); (A.S.); (A.R.); (D.S.)
- German Cancer Consortium (DKTK), partner site Essen/Düsseldorf, 45147 Essen, Germany; (D.P.); (G.R.); (U.S.)
- Faculty Rudolf-Schönheimer-Institute for Biochemistry, University of Leipzig, 04103 Leipzig, Germany
| | - Antje Sucker
- Skin Cancer Unit of the Dermatology Department, Medical Faculty, West German Cancer Center, University Duisburg-Essen, 45147 Essen, Germany; (R.V.); (S.H.); (A.S.); (A.R.); (D.S.)
- German Cancer Consortium (DKTK), partner site Essen/Düsseldorf, 45147 Essen, Germany; (D.P.); (G.R.); (U.S.)
| | - Daniela Piercianek
- German Cancer Consortium (DKTK), partner site Essen/Düsseldorf, 45147 Essen, Germany; (D.P.); (G.R.); (U.S.)
- Department of Neurosurgery, Medical Faculty, West German Cancer Center, University Duisburg-Essen, 45147 Essen, Germany
| | - Verena Schmitt
- Institute of Anatomy, Medical Faculty, University Duisburg-Essen, 45147 Essen, Germany;
| | - Alexander Carpinteiro
- Department of Molecular Biology, Medical Faculty, University Duisburg-Essen, 45147 Essen, Germany; (A.C.); (K.A.B.)
| | - Katrin Anne Becker
- Department of Molecular Biology, Medical Faculty, University Duisburg-Essen, 45147 Essen, Germany; (A.C.); (K.A.B.)
| | - Julia Reifenberger
- Department of Dermatology, Medical Faculty, Heinrich Heine University, 40225 Düsseldorf, Germany;
| | - Alexander Roesch
- Skin Cancer Unit of the Dermatology Department, Medical Faculty, West German Cancer Center, University Duisburg-Essen, 45147 Essen, Germany; (R.V.); (S.H.); (A.S.); (A.R.); (D.S.)
- German Cancer Consortium (DKTK), partner site Essen/Düsseldorf, 45147 Essen, Germany; (D.P.); (G.R.); (U.S.)
| | - Jörg Felsberg
- Institute of Neuropathology, Heinrich Heine University, 40225 Düsseldorf, Germany;
| | - Guido Reifenberger
- German Cancer Consortium (DKTK), partner site Essen/Düsseldorf, 45147 Essen, Germany; (D.P.); (G.R.); (U.S.)
- Institute of Neuropathology, Heinrich Heine University, 40225 Düsseldorf, Germany;
| | - Ulrich Sure
- German Cancer Consortium (DKTK), partner site Essen/Düsseldorf, 45147 Essen, Germany; (D.P.); (G.R.); (U.S.)
- Department of Neurosurgery, Medical Faculty, West German Cancer Center, University Duisburg-Essen, 45147 Essen, Germany
| | - Dirk Schadendorf
- Skin Cancer Unit of the Dermatology Department, Medical Faculty, West German Cancer Center, University Duisburg-Essen, 45147 Essen, Germany; (R.V.); (S.H.); (A.S.); (A.R.); (D.S.)
- German Cancer Consortium (DKTK), partner site Essen/Düsseldorf, 45147 Essen, Germany; (D.P.); (G.R.); (U.S.)
| | - Iris Helfrich
- Skin Cancer Unit of the Dermatology Department, Medical Faculty, West German Cancer Center, University Duisburg-Essen, 45147 Essen, Germany; (R.V.); (S.H.); (A.S.); (A.R.); (D.S.)
- German Cancer Consortium (DKTK), partner site Essen/Düsseldorf, 45147 Essen, Germany; (D.P.); (G.R.); (U.S.)
- Correspondence: ; Tel.: +49-201-723-1648; Fax: +49-201-723-5525
| |
Collapse
|
4
|
Cheok SK, Narayan A, Arnal-Estape A, Gettinger S, Goldberg SB, Kluger HM, Nguyen D, Patel A, Chiang V. Tumor DNA Mutations From Intraparenchymal Brain Metastases Are Detectable in CSF. JCO Precis Oncol 2021; 5:PO.20.00292. [PMID: 34250381 DOI: 10.1200/po.20.00292] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/29/2020] [Accepted: 12/07/2020] [Indexed: 11/20/2022] Open
Abstract
Discordant responses between brain metastases and extracranial tumors can arise from branched tumor evolution, underscoring the importance of profiling mutations to optimize therapy. However, the morbidity of brain biopsies limits their use. We investigated whether cell-free DNA (cfDNA) in CSF could serve as an effective surrogate marker for genomic profiling of intraparenchymal (IP) brain metastases. METHODS CSF and blood were collected simultaneously from patients with progressive brain metastases undergoing a craniotomy or lumbar puncture. Mutations in both biofluids were measured using an error-suppressed deep sequencing method previously published by our group. Forty-three regions of 24 cancer-associated genes were assayed. RESULTS This study enrolled 14 patients with either IP brain metastases (n = 12) or cytology-positive leptomeningeal disease (LMD, n = 2) and two controls with normal pressure hydrocephalus. Primary cancer types were lung, melanoma, renal cell, and colorectal. cfDNA was measurable in all sixteen samples of CSF. Cancer-associated mutations were found in the CSF of ten patients (eight with IP [67%] and two with LMD [100%]) and plasma of five patients (five with IP [42%] and none with LMD). All patients with plasma cfDNA had extracranial tumors. Among the five patients in the cohort who also had mutation data from time-matched brain metastasis tissue, four patients (80%) had matching mutations detected in CSF and brain, whereas only one patient (20%) had matching mutations detected in plasma and brain. CONCLUSION The detection of mutational DNA in CSF is not restricted to LMD and was found in two thirds of patients with IP brain metastases in our cohort. Analysis of CSF can be a viable alternative to biopsy for detection of somatic mutations in brain metastases.
Collapse
Affiliation(s)
| | - Azeet Narayan
- Department of Therapeutic Radiology, Yale University, New Haven, CT
| | - Anna Arnal-Estape
- Department of Pathology, Yale University, New Haven, CT.,Yale Cancer Center, New Haven, CT
| | - Scott Gettinger
- Yale Cancer Center, New Haven, CT.,Department of Medicine (Medical Oncology), Yale University, New Haven, CT
| | - Sarah B Goldberg
- Yale Cancer Center, New Haven, CT.,Department of Medicine (Medical Oncology), Yale University, New Haven, CT
| | - Harriet M Kluger
- Yale Cancer Center, New Haven, CT.,Department of Medicine (Medical Oncology), Yale University, New Haven, CT
| | - Don Nguyen
- Department of Pathology, Yale University, New Haven, CT.,Yale Cancer Center, New Haven, CT.,Department of Medicine (Medical Oncology), Yale University, New Haven, CT
| | - Abhijit Patel
- Department of Therapeutic Radiology, Yale University, New Haven, CT.,Yale Cancer Center, New Haven, CT
| | - Veronica Chiang
- Department of Neurosurgery, Yale University, New Haven, CT.,Yale Cancer Center, New Haven, CT
| |
Collapse
|
5
|
Steindl A, Berghoff AS. Brain metastases in metastatic cancer: a review of recent advances in systemic therapies. Expert Rev Anticancer Ther 2020; 21:325-339. [PMID: 33196341 DOI: 10.1080/14737140.2021.1851200] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: Brain metastases (BM) are a frequent complication of metastatic cancer. Due to the wider availability and application of screening procedures, an increasing fraction of patients are diagnosed at the asymptomatic stage. The introduction of immune checkpoint inhibitors and targeted therapies has revolutionized treatment in several frequently BM-causing entities like metastatic lung cancer, melanoma and breast cancer. However, registered trials of new targeted and immunotherapy mostly excluded patients with BM resulting in limited knowledge of the intracranial efficacy of new systemic agents.Areas covered: The present review highlights recent advances in systemic therapies for the treatment and prophylaxis of the three leading BM causing tumors: NSCLC, melanoma and breast cancer.Expert opinion: High intracranial efficacy was observed for several next-generation tyrosine kinase inhibitors as well as immune checkpoint inhibitors, especially in patients with asymptomatic disease. Ongoing discussions addressed the need for local therapies in patients with asymptomatic BM and the availability of systemic therapy with high intracranial efficacy. Further BM-specific studies as well as BM-specific endpoints in registered trials are needed to define the role of systemic monotherapies in patients with BM.
Collapse
Affiliation(s)
- Ariane Steindl
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Anna S Berghoff
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
6
|
Forschner A, Weißgraeber S, Hadaschik D, Schulze M, Kopp M, Kelkenberg S, Sinnberg T, Garbe C, Biskup S, Battke F. Circulating Tumor DNA Correlates with Outcome in Metastatic Melanoma Treated by BRAF and MEK Inhibitors - Results of a Prospective Biomarker Study. Onco Targets Ther 2020; 13:5017-5032. [PMID: 32581559 PMCID: PMC7280255 DOI: 10.2147/ott.s248237] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/09/2020] [Indexed: 12/14/2022] Open
Abstract
Purpose BRAF and MEK inhibitors significantly improved the prognosis of metastatic melanoma. Nevertheless, initial treatment response may be only temporary. Liquid biopsies (LB) offer a possibility to monitor patients by measuring circulating tumor DNA (ctDNA). We sought to find out whether ctDNA can be used to reliably determine progressive disease under targeted therapy. In addition, we wanted to check whether ctDNA may represent a possible prognostic marker for survival. Patients and Methods We included 19 melanoma patients with BRAF and MEK inhibitor therapy. For each patient, a 710 gene panel was analyzed on the latest available tumor tissue before the start of therapy. Repetitive LB were collected in which BRAF V600E/K mutations were monitored using digital droplet PCR (ddPCR). We correlated radiological staging results and overall survival with ctDNA results. Results In 13 patients, ctDNA was detectable when starting targeted therapy, whereas in six patients, ddPCR was always negative, which we confirmed with ultra-deep sequencing. All patients with initially detectable ctDNA had ctDNA values declining to zero during follow-up, increasing again at the time of extracerebral progression or even slightly before detection by imaging. Survival was significantly worse for patients with elevated LDH (p=0.034) or detectable ctDNA (p=0.008) at the start of targeted therapy. Conclusion Therapy monitoring by ctDNA seems to be a reliable method for detecting extracranial progression, even more sensitive and specific than LDH or S100B. However, due to the small number of cases in our study, further studies are necessary.
Collapse
Affiliation(s)
- Andrea Forschner
- Center for Dermatooncology, Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
| | | | - Dirk Hadaschik
- Center for Genomics and Transcriptomics (CeGaT) GmbH, Tuebingen, Germany
| | | | - Maria Kopp
- Center for Genomics and Transcriptomics (CeGaT) GmbH, Tuebingen, Germany
| | - Sabine Kelkenberg
- Center for Genomics and Transcriptomics (CeGaT) GmbH, Tuebingen, Germany
| | - Tobias Sinnberg
- Center for Dermatooncology, Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
| | - Claus Garbe
- Center for Dermatooncology, Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
| | - Saskia Biskup
- Center for Genomics and Transcriptomics (CeGaT) GmbH, Tuebingen, Germany.,Practice for Human Genetics, Tuebingen, Germany
| | - Florian Battke
- Center for Genomics and Transcriptomics (CeGaT) GmbH, Tuebingen, Germany
| |
Collapse
|
7
|
Armocida D, Marzetti F, Pesce A, Caporlingua A, D'Angelo L, Santoro A. Purely Meningeal Intracranial Relapse of Melanoma Brain Metastases After Surgical Resection and Immunotherapy as a Unique Disease Progression Pattern: Our Experience and Review of the Literature. World Neurosurg 2020; 134:150-154. [PMID: 31751613 DOI: 10.1016/j.wneu.2019.10.101] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 10/15/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND We present a case of 72-year-old man with a history of metastatic melanoma diagnosed in 2015 presenting a stable disease in treatment with dabrafenib. CASE DESCRIPTION The patient had been surgically treated for a presumed intracranial parietooccipital metastasis. He presented 1 month later with a meningeal lesion associated with a subdural hematoma. A second surgical treatment confirmed the diagnosis of meningeal recurrence of metastatic melanoma. CONCLUSIONS The most recent literature lacks studies defining the clinical phenomena of an early recurrence of intracranial melanoma with de novo involvement of dural compartment in patients in treatment with a target immunotherapy. The aim of this present study is to report a case of early recurrence of intracranial melanoma metastases with evidence of fast immunohistochemical and macroscopical mutation of pathologic elements, with an analysis of literature that shows the lack of well-described occurrences.
Collapse
Affiliation(s)
- Daniele Armocida
- Azienda Ospedaliero-Universitaria "Policlinico Umberto I", Neurosurgery Division, Human Neurosciences Department, Sapienza University, Rome, Italy.
| | - Francesco Marzetti
- Azienda Ospedaliero-Universitaria "Policlinico Umberto I", Neurosurgery Division, Human Neurosciences Department, Sapienza University, Rome, Italy
| | - Alessandro Pesce
- A. O. "Sant'Andrea"-Neurosurgery Division, Sapienza University, Rome NESMOS Department, Rome, Italy
| | - Alessandro Caporlingua
- Azienda Ospedaliero-Universitaria "Policlinico Umberto I", Neurosurgery Division, Human Neurosciences Department, Sapienza University, Rome, Italy
| | - Luca D'Angelo
- Azienda Ospedaliero-Universitaria "Policlinico Umberto I", Neurosurgery Division, Human Neurosciences Department, Sapienza University, Rome, Italy
| | - Antonio Santoro
- Azienda Ospedaliero-Universitaria "Policlinico Umberto I", Neurosurgery Division, Human Neurosciences Department, Sapienza University, Rome, Italy
| |
Collapse
|
8
|
Weaver BD, Goodman JR, Jensen R. Concurrent Radiosurgery and Systemic Therapies for Melanoma Brain Metastases: A Systematic Review. Cureus 2019; 11:e6147. [PMID: 31886081 PMCID: PMC6907724 DOI: 10.7759/cureus.6147] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Intracranial metastatic melanoma is a major challenge for neuro-oncological teams. Historically, treatment has focused on surgical or radiosurgical treatment of appropriate lesions, mostly for palliative purposes. Immunotherapies and other targeted therapies (BRAF/mitogen-activated protein kinase kinase inhibitors (BRAFi/MEKi)) are mainstays of advanced melanoma therapy, yet the optimal timing and synergistic properties of concurrent combinations of these systemic therapies and stereotactic radiosurgery (SRS) are poorly understood. We performed a systematic review of the MEDLINE and Scopus databases focused on outcomes after therapy using SRS and either immunotherapies or targeted therapies in an effort to define the optimal timing. We defined concurrent therapy as SRS within three months of treatment with any systemic therapy. End points included local control, distant control, overall survival, and toxicities. We identified five retrospective cohort studies from the literature. These studies found that concurrent SRS plus immunotherapy or BRAFi/MEKi is well tolerated by most patients and generally improved local control, distant control, and overall survival. Importantly, no significant increases in toxicities were noted with concurrent therapy. Combining concurrent SRS with immunotherapy or BRAFi/MEKi may offer important advances for patients with intracranial metastatic melanoma. To address interstudy heterogeneity, we propose reporting two major time intervals defining “concurrent treatment”: concurrent-SRS (≤4 weeks) and peri-SRS (≤3 months). Future large-scale, prospective trials considering truly concurrent SRS therapies with systemic therapies are desperately needed.
Collapse
Affiliation(s)
| | - James R Goodman
- Anesthesiology, Oregon Health & Science University, Portland, USA
| | - Randy Jensen
- Neurosurgery, University of Utah, Salt Lake City, USA
| |
Collapse
|
9
|
Erickson AW, Das S. The Impact of Targeted Therapy on Intracranial Metastatic Disease Incidence and Survival. Front Oncol 2019; 9:797. [PMID: 31508362 PMCID: PMC6716495 DOI: 10.3389/fonc.2019.00797] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 08/06/2019] [Indexed: 11/13/2022] Open
Abstract
Intracranial metastatic disease (IMD) is a common and severe complication of primary cancers. Current treatment options for IMD include surgical resection and radiation therapy, although there has been recent interest in targeted therapy in the management of IMD. As of yet, insufficient data exist to support the recommendation of targeted therapies in the treatment of IMD. Paradoxically, targeted therapy has been hypothesized to play a role in the development of IMD in patients with primary cancers. This is based on the observations that patients who receive targeted therapy for primary cancer experience prolonged survival, and that prolonged survival has been associated with increased incidence of IMD. Few data exist to clarify if treatment of primary cancers with targeted therapies influences IMD incidence. Here, we discuss the role of targeted therapy in IMD management, review the current literature on IMD incidence and targeted therapy use in primary cancer, and propose the need for future studies to inform physicians in choosing treatment options and counseling patients.
Collapse
Affiliation(s)
- Anders W Erickson
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sunit Das
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| |
Collapse
|
10
|
Schvartsman G, Ma J, Bassett RL, Haydu LE, Amaria RN, Hwu P, Wong MK, Hwu WJ, Diab A, Patel SP, Davies MA, Hamerschlak N, Tawbi HAH, Glitza Oliva IC. Incidence, patterns of progression, and outcomes of preexisting and newly discovered brain metastases during treatment with anti-PD-1 in patients with metastatic melanoma. Cancer 2019; 125:4193-4202. [PMID: 31398264 DOI: 10.1002/cncr.32454] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 06/06/2019] [Accepted: 07/12/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Melanoma brain metastases (MBM) occur in up to 50% of patients with metastatic melanoma (MM) and represent a frequent site of systemic treatment failure for targeted therapies. However, to the authors' knowledge, little is known regarding the incidence, patterns of disease progression, and outcomes of MBM in patients treated with anti-PD-1 immunotherapy. METHODS A total of 320 patients with MM who were treated with anti-PD-1 at The University of Texas MD Anderson Cancer Center in Houston were reviewed. Analyses were performed to identify factors associated with brain metastasis-free survival and overall survival (OS) using Cox regression models. RESULTS The median age of the patients was 63.3 years. OS from the initiation of anti-PD-1 therapy was not significantly different between patients without MBM prior to anti-PD-1 compared with patients with prior MBM (P = .359). Among patients without prior MBM, 21 patients (8.6%) developed MBM during anti-PD-1 therapy, 12 of whom (4.9%) presented with disease progression in the central nervous system (CNS) only. Developing MBM during or after therapy with anti-PD-1 (hazard ratio, 4.70; 95% CI, 3.18-6.93) was associated with shorter OS. Among patients with MBM prior to anti-PD-1 treatment, 15 (20.0%) progressed in the CNS only and 19 (25.3%) progressed both intracranially and extracranially; at the time of the last data cutoff, 27 patients (36.0%) had not developed disease progression. Radiation necrosis occurred in 11.3% of patients (7 of 62 patients) in the group with a prior MBM who received stereotactic radiosurgery. CONCLUSIONS Anti-PD-1 therapy may change the natural history of patients with preexisting MBM. However, CNS failure during treatment with anti-PD-1 is predictive of a worse prognosis compared with extracranial progression. The results of the current study support the activity of anti-PD-1 in patients with MBM, although routine CNS imaging during therapy is warranted.
Collapse
Affiliation(s)
- Gustavo Schvartsman
- Department of Hematology/Oncology, Albert Einstein Israeli Hospital, Sao Paulo, Brazil
| | - Junsheng Ma
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Roland L Bassett
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lauren E Haydu
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rodabe Navroze Amaria
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Patrick Hwu
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael K Wong
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Wen-Jen Hwu
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adi Diab
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sapna Pradyuman Patel
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael A Davies
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nelson Hamerschlak
- Department of Hematology/Oncology, Albert Einstein Israeli Hospital, Sao Paulo, Brazil
| | - Hussein Abdul-Hassan Tawbi
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Isabella C Glitza Oliva
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
11
|
Rauschenberg R, Bruns J, Brütting J, Daubner D, Lohaus F, Zimmer L, Forschner A, Zips D, Hassel JC, Berking C, Kaehler KC, Utikal J, Gutzmer R, Terheyden P, Meiss F, Rafei-Shamsabadi D, Kiecker F, Debus D, Dabrowski E, Arnold A, Garzarolli M, Kuske M, Beissert S, Löck S, Linn J, Troost EGC, Meier F. Impact of radiation, systemic therapy and treatment sequencing on survival of patients with melanoma brain metastases. Eur J Cancer 2019; 110:11-20. [PMID: 30739835 DOI: 10.1016/j.ejca.2018.12.023] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 12/01/2018] [Accepted: 12/22/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Combining stereotactic radiosurgery (SRS) and active systemic therapies (STs) achieved favourable survival outcomes in patients with melanoma brain metastases (MBMs) in retrospective analyses. However, several aspects of this treatment strategy remain poorly understood. We report on the overall survival (OS) of patients with MBM treated with a combination of radiotherapy (RT) and ST as well as the impact of the v-Raf murine sarcoma viral oncogene homolog B (BRAF)-V600 mutation (BRAFmut) status, types of RT and ST and their sequence. PATIENTS AND METHODS Data of 208 patients treated with SRS or whole brain radiation therapy (WBRT) and either immunotherapy (IT) or targeted therapy (TT) within a 6-week interval to RT were analysed retrospectively. OS was calculated from RT to death or last follow-up. Univariate and multivariate Cox proportional hazard analyses were performed to determine prognostic features associated with OS. RESULTS The median follow-up was 7.3 months. 139 patients received IT, 67 received TT and 2 received IT and TT within 6 weeks to RT (WBRT 45%; SRS 55%). One-year Kaplan-Meier OS rates were 69%, 65%, 33% and 18% (P < .001) for SRS with IT, SRS with TT, WBRT with IT and WBRT with TT, respectively. Patients with a BRAFmut receiving IT combined with RT experienced higher OS rates (88%, 65%, 50% and 18%). TT following RT or started before and continued thereafter was associated with improved median OS compared with TT solely before RT (12.2 [95% confidence interval {CI} 9.3-15.1]; 9.8 [95% CI 6.9-12.6] versus 5.1 [95% CI 2.7-7.5]; P = .03). CONCLUSION SRS and IT achieved the highest OS rates. A BRAFmut appears to be a favourable prognostic factor for OS. For the combination of RT and TT, the sequence appears to be crucial. Combinations of WBRT and ST achieved unprecedentedly high OS rates and warrant further studies.
Collapse
Affiliation(s)
- Ricarda Rauschenberg
- Skin Cancer Center at the University Cancer Centre, Department of Dermatology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; National Center for Tumor Diseases (NCT), Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Johannes Bruns
- Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Julia Brütting
- Skin Cancer Center at the University Cancer Centre, Department of Dermatology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Dirk Daubner
- Institute of Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Fabian Lohaus
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
| | - Lisa Zimmer
- Department of Dermatology, University Hospital, University Duisburg-Essen, Germany & German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Andrea Forschner
- Skin Cancer Center, Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Daniel Zips
- Department of Radiation Oncology, Skin Cancer Center, CCC Tübingen-Stuttgart, University of Tübingen, Germany
| | - Jessica C Hassel
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Carola Berking
- Skin Cancer Center, Department of Dermatology and Allergy, University Hospital Munich, Munich, Germany
| | - Katharina C Kaehler
- Skin Cancer Center, Department of Dermatology, University Hospital Kiel, Kiel, Germany
| | - Jochen Utikal
- Skin Cancer Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany and Department of Dermatology, Venereology and Allergology, University Medical Center Mannheim, Ruprecht-Karl University of Heidelberg, Mannheim, Germany
| | - Ralf Gutzmer
- Skin Cancer Center Hannover, Department of Dermatology and Allergy, Hannover Medical School, Hannover, Germany
| | - Patrik Terheyden
- Skin Cancer Center, Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Frank Meiss
- Skin Cancer Center, Department of Dermatology and Venereology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - David Rafei-Shamsabadi
- Skin Cancer Center, Department of Dermatology and Venereology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Felix Kiecker
- Skin Cancer Center, Department of Dermatology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Dirk Debus
- Skin Cancer Center, Department of Dermatology, Paracelsus Medical University, General Hospital Nuremberg, Germany
| | - Evelyn Dabrowski
- Skin Cancer Center, Department of Dermatology, Ludwigshafen Medical Center, Ludwigshafen, Germany
| | - Andreas Arnold
- Skin Cancer Center, Department of Dermatology, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Marlene Garzarolli
- Skin Cancer Center at the University Cancer Centre, Department of Dermatology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; National Center for Tumor Diseases (NCT), Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Marvin Kuske
- Skin Cancer Center at the University Cancer Centre, Department of Dermatology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; National Center for Tumor Diseases (NCT), Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stefan Beissert
- Skin Cancer Center at the University Cancer Centre, Department of Dermatology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; National Center for Tumor Diseases (NCT), Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Steffen Löck
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
| | - Jennifer Linn
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Esther G C Troost
- National Center for Tumor Diseases (NCT), Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany; Institute of Radiooncology - OncoRay, Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Friedegund Meier
- Skin Cancer Center at the University Cancer Centre, Department of Dermatology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; National Center for Tumor Diseases (NCT), Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.
| |
Collapse
|
12
|
Kakadia S, Yarlagadda N, Awad R, Kundranda M, Niu J, Naraev B, Mina L, Dragovich T, Gimbel M, Mahmoud F. Mechanisms of resistance to BRAF and MEK inhibitors and clinical update of US Food and Drug Administration-approved targeted therapy in advanced melanoma. Onco Targets Ther 2018; 11:7095-7107. [PMID: 30410366 PMCID: PMC6200076 DOI: 10.2147/ott.s182721] [Citation(s) in RCA: 170] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Approximately 50% of melanomas harbor an activating BRAF mutation. Combined BRAF and MEK inhibitors such as dabrafenib and trametinib, vemurafenib and cobimetinib, and encorafenib and binimetinib are US Food and Drug Administration (FDA)-approved to treat patients with BRAFV600-mutated advanced melanoma. Both genetic and epigenetic alterations play a major role in resistance to BRAF inhibitors by reactivation of the MAPK and/or the PI3K–Akt pathways. The role of BRAF inhibitors in modulating the immunomicroenvironment and perhaps enhancing the efficacy of checkpoint inhibitors is gaining interest. This article provides a comprehensive review of mechanisms of resistance to BRAF and MEK inhibitors in melanoma and summarizes landmark trials that led to the FDA approval of BRAF and MEK inhibitors in metastatic melanoma.
Collapse
Affiliation(s)
- Sunilkumar Kakadia
- Department of Internal Medicine, Division of Hematology and Oncology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Naveen Yarlagadda
- Department of Internal Medicine, Division of Hematology and Oncology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ramez Awad
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Madappa Kundranda
- TW Lewis Melanoma Center of Excellence, Banner MD Anderson Cancer Center, Gilbert, AZ, USA,
| | - Jiaxin Niu
- TW Lewis Melanoma Center of Excellence, Banner MD Anderson Cancer Center, Gilbert, AZ, USA,
| | - Boris Naraev
- TW Lewis Melanoma Center of Excellence, Banner MD Anderson Cancer Center, Gilbert, AZ, USA,
| | - Lida Mina
- TW Lewis Melanoma Center of Excellence, Banner MD Anderson Cancer Center, Gilbert, AZ, USA,
| | - Tomislav Dragovich
- TW Lewis Melanoma Center of Excellence, Banner MD Anderson Cancer Center, Gilbert, AZ, USA,
| | - Mark Gimbel
- TW Lewis Melanoma Center of Excellence, Banner MD Anderson Cancer Center, Gilbert, AZ, USA,
| | - Fade Mahmoud
- TW Lewis Melanoma Center of Excellence, Banner MD Anderson Cancer Center, Gilbert, AZ, USA,
| |
Collapse
|
13
|
Kuske M, Rauschenberg R, Garzarolli M, Meredyth-Stewart M, Beissert S, Troost EGC, Glitza OIC, Meier F. Melanoma Brain Metastases: Local Therapies, Targeted Therapies, Immune Checkpoint Inhibitors and Their Combinations-Chances and Challenges. Am J Clin Dermatol 2018; 19:529-541. [PMID: 29417399 PMCID: PMC6061393 DOI: 10.1007/s40257-018-0346-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Recent phase II trials have shown that BRAF/MEK inhibitors and immune checkpoint inhibitors are active in patients with melanoma brain metastases (MBM), reporting intracranial disease control rates of 50-75%. Furthermore, retrospective analyses suggest that combining stereotactic radiosurgery with immune checkpoint inhibitors or BRAF/MEK inhibitors prolongs overall survival. These data stress the need for inter- and multidisciplinary cooperation that takes into account the individual prognostic factors in order to establish the best treatment for each patient. Although the management of MBM has dramatically improved, a substantial number of patients still progress and die from brain metastases. Therefore, there is an urgent need for prospective studies in patients with MBM that focus on treatment combinations and sequences, new treatment strategies, and biomarkers of treatment response. Moreover, further research is needed to decipher brain-specific mechanisms of therapy resistance.
Collapse
Affiliation(s)
- Marvin Kuske
- Department of Dermatology, Medical Faculty of Technische Universität Dresden, University Hospital Carl Gustav Carus, University of Dresden, Fetscherstr. 74, 01307, Dresden, Germany
- Skin Cancer Center at the University Cancer Centre Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
| | - Ricarda Rauschenberg
- Department of Dermatology, Medical Faculty of Technische Universität Dresden, University Hospital Carl Gustav Carus, University of Dresden, Fetscherstr. 74, 01307, Dresden, Germany
- Skin Cancer Center at the University Cancer Centre Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
| | - Marlene Garzarolli
- Department of Dermatology, Medical Faculty of Technische Universität Dresden, University Hospital Carl Gustav Carus, University of Dresden, Fetscherstr. 74, 01307, Dresden, Germany
- Skin Cancer Center at the University Cancer Centre Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
| | - Michelle Meredyth-Stewart
- Department of Internal Medicine, Medical Faculty of Technische Universität Dresden, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Stefan Beissert
- Department of Dermatology, Medical Faculty of Technische Universität Dresden, University Hospital Carl Gustav Carus, University of Dresden, Fetscherstr. 74, 01307, Dresden, Germany
- Skin Cancer Center at the University Cancer Centre Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
| | - Esther G C Troost
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
- Department of Radiation Oncology, Medical Faculty Carl Gustav Carus, University Hospital, Technische Universität Dresden, Dresden, Germany
- OncoRay-National Center for Radiation Research in Oncology, Dresden, Germany
- Dresden and German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
- Institute of Radiooncology, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | | | - Friedegund Meier
- Department of Dermatology, Medical Faculty of Technische Universität Dresden, University Hospital Carl Gustav Carus, University of Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
- Skin Cancer Center at the University Cancer Centre Dresden, Dresden, Germany.
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany.
| |
Collapse
|
14
|
Deutsch GB, Tyrell R, Yost S, Deutsch MB, Barkhoudarian G, Kelly DF, Faries MB. Predicting the incidence and timing of central nervous system disease in metastatic melanoma: Implications for surveillance and preventative therapy. J Am Acad Dermatol 2018; 78:419-421. [PMID: 29332716 DOI: 10.1016/j.jaad.2017.07.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 07/06/2017] [Accepted: 07/23/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Gary B Deutsch
- Hofstra-Northwell School of Medicine Uniondale, New York, New York.
| | - Richard Tyrell
- Hofstra-Northwell School of Medicine Uniondale, New York, New York
| | | | - Mariel B Deutsch
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Mark B Faries
- Donald L. Morton, MD, Melanoma Research Program, New York, New York
| |
Collapse
|
15
|
Sloot S, Chen YA, Zhao X, Weber J, Benedict JJ, Mulé JJ, Smalley KS, Weber JS, Zager JS, Forsyth P, Sondak VK, Gibney GT. Improved survival of patients with melanoma brain metastases in the era of targeted BRAF and immune checkpoint therapies. Cancer 2018; 124:297-305. [PMID: 29023643 PMCID: PMC7771556 DOI: 10.1002/cncr.30946] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 07/07/2017] [Accepted: 07/14/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND The development of brain metastases is common for systemic treatment failure in patients with melanoma and has been associated with a poor prognosis. Recent advances with BRAF and immune checkpoint therapies have led to improved patient survival. Herein, the authors evaluated the risk of de novo brain metastases and survival among patients with melanoma brain metastases (MBM) since the introduction of more effective therapies. METHODS Patients with unresectable AJCC stage III/IV melanoma who received first-line systemic therapy at Moffitt Cancer Center between 2000 and 2012 were identified. Data were collected regarding patient characteristics, stage of disease, systemic therapies, MBM status/management, and overall survival (OS). The risk of de novo MBM was calculated using a generalized estimating equation model and survival comparisons were performed using Kaplan-Meier and Cox proportional analyses. RESULTS A total of 610 patients were included, 243 of whom were diagnosed with MBM (40%). Patients with MBM were younger, with a lower frequency of regional metastasis. No significant differences were noted with regard to sex, BRAF status, or therapeutic class. The risk of de novo MBM was found to be similar among patients treated with chemotherapy, biochemotherapy, BRAF-targeted therapy, ipilimumab, and anti-programmed cell death protein 1/programmed death-ligand 1 regimens. The median OS of patients with MBM was significantly shorter when determined from the time of first regional/distant metastasis but not when determined from the time of first systemic therapy. The median OS from the time of MBM diagnosis was 7.5 months, 8.5 months, and 22.7 months, respectively, for patients diagnosed from 2000 to 2008, 2009 to 2010, and 2011 to the time of last follow-up (P = .002). CONCLUSIONS Brain metastases remain a common source of systemic treatment failure. The OS for patients with MBM has improved significantly. Further research into MBM prevention is needed. Cancer 2018;124:297-305. © 2017 American Cancer Society.
Collapse
Affiliation(s)
- Sarah Sloot
- Department of General Surgery, Groningen University Medical Center, Groningen, The Netherlands
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Yian A. Chen
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida
| | - Xiuhua Zhao
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida
| | - Jamie Weber
- University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Jacob J. Benedict
- University of South Florida Morsani College of Medicine, Tampa, Florida
| | - James J. Mulé
- Department of Immunology, Moffitt Cancer Center, Tampa, Florida
| | - Keiran S. Smalley
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida
- Department of Tumor Biology, Moffitt Cancer Center, Tampa, Florida
| | - Jeffrey S. Weber
- Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York, New York
| | - Jonathan S. Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida
- Departments of Oncologic Sciences and Surgery, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Peter Forsyth
- Department of Neurooncology, Moffitt Cancer Center, Tampa, Florida
- Department of Neurooncology, Southern Alberta Cancer Research Institute, Calgary, Canada
| | - Vernon K. Sondak
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida
- Departments of Oncologic Sciences and Surgery, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Geoffrey T. Gibney
- Georgetown Lombardi Comprehensive Cancer Center, Medstar Georgetown University Hospital, Washington, District of Columbia
| |
Collapse
|
16
|
A Retrospective Analysis of the Efficacy of Pembrolizumab in Melanoma Patients With Brain Metastasis. J Immunother 2018; 40:108-113. [PMID: 28221189 DOI: 10.1097/cji.0000000000000159] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A total of 50% of patients with melanoma will develop brain metastasis (BM). Pembrolizumab was approved for treatment of metastatic melanoma on the basis of significant systemic antitumor activity. Because of low enrollment of patients with BM in pembrolizumab trials, efficacy against melanoma BM remains unknown. We reviewed records of 89 consecutive patients with melanoma treated with pembrolizumab at our institution between May 1, 2014 and October 31, 2015 to determine the time to progression. Thirty-six (40%) patients had BM before pembrolizumab. Twenty-six (72%) patients with BM had received prior treatment for BM. With median follow-up of 17.2 months, 54 patients (61%) developed progressive disease on pembrolizumab. Intracranial progression occurred in 19 patients (21%), 3 of whom did not have BM before treatment. Median time to progression at any site was 6 months for those without BM (n=53), 5 months for those with treated BM (n=26), and 1.2 months for patients with untreated BM (n=10). Using a Cox regression model adjusted for baseline factors, there was a statistically significant (Wald χ P=0.003) reduction in the hazard of progression for patients without BM [hazard ratio, 0.19; 90% confidence interval, 0.08-0.42) and patients with treated BM (hazard ratio, 0.27; 90% confidence interval, 0.12-0.64) compared with those with untreated BM. In conclusion, melanoma patients with pretreated BM can have durable systemic responses to pembrolizumab. Large, prospective studies are needed to evaluate the intracranial antitumor activity of pembrolizumab in melanoma patients with untreated BM.
Collapse
|
17
|
Nolan C, Deangelis LM. Overview of metastatic disease of the central nervous system. HANDBOOK OF CLINICAL NEUROLOGY 2018; 149:3-23. [PMID: 29307359 DOI: 10.1016/b978-0-12-811161-1.00001-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
In 2016, the American Society of Clinical Oncology reported that 1.7 million Americans were diagnosed with cancer; this number will rise to 2.3 million in the United States and 22 million worldwide in 2030. This rising need is being met by an explosion of new cancer therapies, including: immune checkpoint inhibitors, T-cell therapies, tumor vaccines, antiangiogenic therapies, and various targeted therapies. This armamentarium of targeted therapies has led to better systemic control of disease and longer patient overall survival (OS). The incidence of metastatic disease to the central nervous system (CNS) is rising as patients are living longer with these more effective systemic therapies. Prolonged OS allows increased time to develop CNS metastases. The CNS is also a sanctuary for metastatic tumor cells that are protected from full exposure to therapeutic concentrations of most anticancer agents by the blood-brain barrier, the tumor microenvironment, and immune system. In addition, CNS metastases often develop late in the course of the disease, so patients are frequently heavily pretreated, resulting in drug resistance. Although genomic profiling has led to more effective therapies for systemic disease, the same therapy may not be effective in treating CNS disease, not only due to failure of blood-brain barrier penetration, but from discordance between the molecular profile in systemic and CNS tumor.
Collapse
Affiliation(s)
- Craig Nolan
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
| | - Lisa M Deangelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| |
Collapse
|
18
|
Di Lorenzo R, Ahluwalia MS. Targeted therapy of brain metastases: latest evidence and clinical implications. Ther Adv Med Oncol 2017; 9:781-796. [PMID: 29449898 PMCID: PMC5808839 DOI: 10.1177/1758834017736252] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 09/18/2017] [Indexed: 12/16/2022] Open
Abstract
Brain metastases (BM) occur in 20-40% of patients with cancer and 60-75% of patients with BM become symptomatic. Due to an aging population and advances in the treatment of primary cancers, patients are living longer and are more likely to experience complications from BM. The diagnosis of BM drastically worsens long-term survival rates, with multiple metastases being a poor prognostic factor. Until recently, the mainstay of treatment consisted of stereotactic radiosurgery (SRS), surgical resection, whole brain radiation therapy (WBRT), or a combination of these modalities. Systemic chemotherapy has been felt largely ineffective in the treatment of BM due to the presence of the blood-brain barrier (BBB), which includes efflux pumps on brain capillaries. Over the past decade however, researchers have identified therapeutic agents that are able to cross the BBB. These findings could make a multimodality treatment approach possible, consisting of surgery, radiation, immunotherapy, and targeted therapy, which could lead to better disease control in this patient population and prolong survival. In this review, we discuss present evidence on available targeted therapies and their role in the treatment of BM from primary tumors with the highest prevalence of central nervous system (CNS) involvement, specifically non-small cell lung cancer (NSCLC), breast cancer melanoma, and renal cell carcinoma.
Collapse
Affiliation(s)
- Rodica Di Lorenzo
- Brain Tumor and Neuro-Oncology Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Manmeet S Ahluwalia
- Brain Tumor and Neuro-Oncology Center, Cleveland Clinic Foundation, 9500 Euclid Avenue, CA-51, Cleveland, OH 44195, USA
| |
Collapse
|
19
|
Bohn JP, Pall G, Stockhammer G, Steurer M. Targeted Therapies for the Treatment of Brain Metastases in Solid Tumors. Target Oncol 2017; 11:263-75. [PMID: 26822319 DOI: 10.1007/s11523-015-0414-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Brain metastases are a major cause of morbidity and mortality in cancer patients. While the mainstay treatment comprises surgery and radiation therapy, the role of systemic agents remains controversial. In general, it has been presumed that poor blood-brain barrier (BBB) penetration and inherently more resistant metastatic brain disease preclude a favorable systemic treatment approach. However, a better understanding of tumor biology and the subsequent development of targeted drugs have reawakened interest in systemic therapy. Despite still limited brain distribution, a variety of targeted drugs have demonstrated activity in brain metastases in early clinical trials. Nevertheless, disease progression commonly occurs, and it remains to be elucidated whether limited CNS drug distribution or the acquisition of resistant metastatic clones must be held responsible for this prognosis. Moreover, micrometastatic brain disease beyond an intact BBB-and ultimately prevention of brain metastasis formation-may generally remain inaccessible for first-generation targeted agents with poor CNS penetration. To overcome limited brain distribution and possibly emerging acquired resistance, highly potent next-generation targeted drugs with enhanced CNS distribution have been developed. In view of this emerging but yet undefined role of targeted therapies in the treatment of brain metastases from solid tumors, this review aims to summarize the current knowledge from clinical trials and discusses clinically relevant obstacles to overcome.
Collapse
Affiliation(s)
- Jan-Paul Bohn
- Department of Internal Medicine V, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria.
| | - Georg Pall
- Department of Internal Medicine V, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Guenther Stockhammer
- Department of Neurology and Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Steurer
- Department of Internal Medicine V, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| |
Collapse
|
20
|
Westphal D, Glitza Oliva IC, Niessner H. Molecular insights into melanoma brain metastases. Cancer 2017; 123:2163-2175. [PMID: 28543697 DOI: 10.1002/cncr.30594] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 12/19/2016] [Accepted: 12/28/2016] [Indexed: 01/26/2023]
Abstract
Substantial proportions of patients with metastatic melanoma develop brain metastases during the course of their disease, often resulting in significant morbidity and death. Despite recent advances with BRAF/MEK and immune-checkpoint inhibitors in the treatment of patients who have melanoma with extracerebral metastases, patients who have melanoma brain metastases still have poor overall survival, highlighting the need for further therapy options. A deeper understanding of the molecular pathways involved in the development of melanoma brain metastases is required to develop more brain-specific therapies. Here, the authors summarize the currently known preclinical data and describe steps involved in the development of melanoma brain metastases. Only by knowing the molecular background is it possible to design new therapeutic agents that can be used to improve the outcome of patients with melanoma brain metastases. Cancer 2017;123:2163-75. © 2017 American Cancer Society.
Collapse
Affiliation(s)
- Dana Westphal
- Department of Dermatology, Carl Gustav Carus Medical Center, Technical University of Dresden, Dresden, Germany.,Center for Regenerative Therapies, Technical University of Dresden, Dresden, Germany
| | - Isabella C Glitza Oliva
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Heike Niessner
- Department of Dermatology, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| |
Collapse
|
21
|
Young GJ, Bi WL, Wu WW, Johanns TM, Dunn GP, Dunn IF. Management of intracranial melanomas in the era of precision medicine. Oncotarget 2017; 8:89326-89347. [PMID: 29179523 PMCID: PMC5687693 DOI: 10.18632/oncotarget.19223] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 04/24/2017] [Indexed: 01/08/2023] Open
Abstract
Melanoma is the most lethal of skin cancers, in part because of its proclivity for rapid and distant metastasis. It is also potentially the most neurotropic cancer in terms of probability of CNS metastasis from the primary lesion. Despite surgical resection and radiotherapy, prognosis remains guarded for patients with brain metastases. Over the past five years, a new domain of personalized therapy has emerged for advanced melanoma patients with the introduction of BRAF and other MAP kinase pathway inhibitors, immunotherapy, and combinatory therapeutic strategies. By targeting critical cellular signaling pathways and unleashing the adaptive immune response against tumor antigens, a subset of melanoma patients have demonstrated remarkable responses to these treatments. Over time, acquired resistance to these modalities inexorably develops, providing new challenges to overcome. We review the rapidly evolving terrain for intracranial melanoma treatment, address likely and potential mechanisms of resistance, as well as evaluate promising future therapeutic approaches currently under clinical investigation.
Collapse
Affiliation(s)
- Grace J Young
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Cancer Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Winona W Wu
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tanner M Johanns
- Division of Medical Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA.,Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
| | - Gavin P Dunn
- Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA.,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ian F Dunn
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
22
|
|
23
|
Wang S, Wang A, Lin J, Xie Y, Wu L, Huang H, Bian J, Yang X, Wan X, Zhao H, Huang J. Brain metastases from hepatocellular carcinoma: recent advances and future avenues. Oncotarget 2017; 8:25814-25829. [PMID: 28445959 PMCID: PMC5421971 DOI: 10.18632/oncotarget.15730] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 02/07/2017] [Indexed: 12/25/2022] Open
Abstract
The incidence of brain metastases from hepatocellular carcinoma (BMHCC) is becoming more frequent than that of the past as a result of prolonged survival of patients with HCC. Compared with brain metastases from other types of cancer, BMHCC tends to exhibit a high incidence of intracerebral hemorrhage (ICH) and poor liver function. Unfortunately, the prognosis is extremely poor for patients with BMHCC owing to the limited treatment selection. Currently, optimal treatment requires multidisciplinary approaches including surgery, whole-brain radiation therapy and stereotactic radiosurgery. Besides these traditional approaches, novel treatments such as target therapy and immunotherapy provide an opportunity to improve the survival of these patients. This review provides an overview of the incidence, characteristics, prognosis, and current and potential future management strategies for BMHCC.
Collapse
Affiliation(s)
- Shanshan Wang
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Anqiang Wang
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianzhen Lin
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Xie
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liangcai Wu
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hanchun Huang
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jin Bian
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaobo Yang
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xueshuai Wan
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haitao Zhao
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Center of Translational Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiefu Huang
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
24
|
Abstract
Brain metastases are a major clinical challenge occurring in up to 60% of patients suffering from metastatic melanoma. They cause significant clinical symptoms and impair the overall survival prognosis. The introduction of targeted therapies including BRAF and MEK inhibitors as well as CTLA-4 and PD-1 axis targeting immune checkpoint inhibitors have dramatically improved the treatment and prognosis of patients with extracranial metastatic melanoma. Although, similar response rates for extra- and intracranial metastases have been reported, only few data from brain metastasis specific trails are available so far. The following review will provide an overview on the currently available data on targeted therapies, remaining questions and the most important side effects in the special clinical situation of melanoma brain metastases.
Collapse
Affiliation(s)
- Anna S Berghoff
- Department of Medicine I and Comprehensive Cancer Center CNS Unit (CCC-CNS), Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Matthias Preusser
- Department of Medicine I and Comprehensive Cancer Center CNS Unit (CCC-CNS), Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| |
Collapse
|
25
|
Applications for quantitative measurement of BRAF V600 mutant cell-free tumor DNA in the plasma of patients with metastatic melanoma. Melanoma Res 2017; 26:157-63. [PMID: 26636909 DOI: 10.1097/cmr.0000000000000224] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Small fragments of cell-free DNA that are shed by normal and tumor cells can be detected in the plasma of patients with advanced melanoma. Quantitative measurement of BRAF V600 mutant DNA within the cell-free DNA holds promise as a tumor-specific biomarker for diagnosis and therapeutic monitoring in patients with BRAF V600 mutant melanoma. Allele-specific quantitative PCR analysis for BRAF V600 E/E2/D/K/R/M mutations on DNA extracted from 1 ml of plasma is currently under evaluation in a number of ongoing prospective clinical studies. We report five patient cases that indicate the potential applications and utility of quantitative measurements of BRAF V600 mutant cell-free tumor DNA as a diagnostic test and as a therapeutic monitoring tool in stage IV melanoma patients treated with BRAF-targeted therapy or immunotherapy. Finally, we offer novel insights into the dynamics of cell-free tumor DNA in melanoma.
Collapse
|
26
|
Chamberlain MC, Baik CS, Gadi VK, Bhatia S, Chow LQM. Systemic therapy of brain metastases: non-small cell lung cancer, breast cancer, and melanoma. Neuro Oncol 2017; 19:i1-i24. [PMID: 28031389 PMCID: PMC5193029 DOI: 10.1093/neuonc/now197] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Brain metastases (BM) occur frequently in many cancers, particularly non-small cell lung cancer (NSCLC), breast cancer, and melanoma. The development of BM is associated with poor prognosis and has an adverse impact on survival and quality of life. Commonly used therapies for BM such as surgery or radiotherapy are associated with only modest benefits. However, recent advances in systemic therapy of many cancers have generated considerable interest in exploration of those therapies for treatment of intracranial metastases.This review discusses the epidemiology of BM from the aforementioned primary tumors and the challenges of using systemic therapies for metastatic disease located within the central nervous system. Cumulative data from several retrospective and small prospective studies suggest that molecularly targeted systemic therapies may be an effective option for the treatment of BM from NSCLC, breast cancer, and melanoma, either as monotherapy or in conjunction with other therapies. Larger prospective studies are warranted to further characterize the efficacy and safety profiles of these targeted agents for the treatment of BM.
Collapse
Affiliation(s)
- Marc C Chamberlain
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
| | - Christina S Baik
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
| | - Vijayakrishna K Gadi
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
| | - Shailender Bhatia
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
| | - Laura Q M Chow
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
| |
Collapse
|
27
|
Gampa G, Vaidhyanathan S, Resman BW, Parrish KE, Markovic SN, Sarkaria JN, Elmquist WF. Challenges in the delivery of therapies to melanoma brain metastases. ACTA ACUST UNITED AC 2016; 2:309-325. [PMID: 28546917 DOI: 10.1007/s40495-016-0072-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Brain metastases are a major cause of morbidity and mortality in patients with advanced melanoma. Recent approval of several molecularly-targeted agents and biologics has brought hope to patients with this previously untreatable disease. However, patients with symptomatic melanoma brain metastases have often been excluded from pivotal clinical trials. This may be in part attributed to the fact that several of the approved small molecule molecularly-targeted agents are substrates for active efflux at the blood-brain barrier, limiting their effective delivery to brain metastases. We believe that successful treatment of melanoma brain metastases will depend on the ability of these agents to traverse the blood-brain barrier and reach micrometastases that are often not clinically detectable. Moreover, overcoming the emergence of a unique pattern of resistance, possibly through adequate delivery of combination targeted therapies in brain metastases will be important in achieving a durable response. These concepts, and the current challenges in the delivery of new treatments to melanoma brain metastases, are discussed in this review.
Collapse
Affiliation(s)
- Gautham Gampa
- Brain Barriers Research Center, Department of Pharmaceutics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shruthi Vaidhyanathan
- Brain Barriers Research Center, Department of Pharmaceutics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Brynna-Wilken Resman
- Brain Barriers Research Center, Department of Pharmaceutics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Karen E Parrish
- Brain Barriers Research Center, Department of Pharmaceutics, University of Minnesota, Minneapolis, Minnesota, USA
| | | | | | - William F Elmquist
- Brain Barriers Research Center, Department of Pharmaceutics, University of Minnesota, Minneapolis, Minnesota, USA
| |
Collapse
|
28
|
Dagogo-Jack I, Gill CM, Cahill DP, Santagata S, Brastianos PK. Treatment of brain metastases in the modern genomic era. Pharmacol Ther 2016; 170:64-72. [PMID: 27773784 DOI: 10.1016/j.pharmthera.2016.10.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Development of brain metastasis (BM) portends a dismal prognosis for patients with cancer. Melanomas and carcinomas of the lung, breast, and kidney are the most common malignancies to metastasize to the brain. Recent advances in molecular genetics have enabled the identification of actionable, clinically relevant genetic alterations within primary tumors and their corresponding metastases. Adoption of genotype-guided treatment strategies for the management of systemic malignancy has resulted in dramatic and durable responses. Unfortunately, despite these therapeutic advances, central nervous system (CNS) relapses are not uncommon. Although these relapses have historically been attributed to limited blood brain barrier penetration of anti-neoplastic agents, recent work has demonstrated genetic heterogeneity such that metastatic sites, including BM, harbor relevant genetic alterations that are not present in primary tumor biopsies. This improved insight into molecular mechanisms underlying site specific recurrences can inform strategies for targeting these oncogenic drivers. Thus, development of rational, genomically guided CNS-penetrant therapies is crucial for ongoing therapeutic success.
Collapse
Affiliation(s)
- Ibiayi Dagogo-Jack
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Corey M Gill
- Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Daniel P Cahill
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Sandro Santagata
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Priscilla K Brastianos
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.
| |
Collapse
|
29
|
Niessner H, Schmitz J, Tabatabai G, Schmid AM, Calaminus C, Sinnberg T, Weide B, Eigentler TK, Garbe C, Schittek B, Quintanilla-Fend L, Bender B, Mai M, Praetorius C, Beissert S, Schackert G, Muders MH, Meinhardt M, Baretton GB, Dummer R, Flaherty K, Pichler BJ, Kulms D, Westphal D, Meier F. PI3K Pathway Inhibition Achieves Potent Antitumor Activity in Melanoma Brain Metastases In Vitro and In Vivo. Clin Cancer Res 2016; 22:5818-5828. [PMID: 27307593 DOI: 10.1158/1078-0432.ccr-16-0064] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 05/03/2016] [Accepted: 05/25/2016] [Indexed: 11/16/2022]
Abstract
PURPOSE Great advances have recently been made in treating patients with metastatic melanoma. However, existing therapies are less effective on cerebral than extracerebral metastases. This highlights the potential role of the brain environment on tumor progression and drug resistance and underlines the need for "brain-specific" therapies. We previously showed that the PI3K-AKT survival pathway is hyperactivated in brain but not extracerebral melanoma metastases and that astrocyte-conditioned medium activates AKT in melanoma cells in vitro We therefore tested the PI3K inhibitor buparlisib as an antitumor agent for melanoma brain metastases. EXPERIMENTAL DESIGN AND RESULTS Buparlisib inhibited AKT activity, decreased proliferation, and induced apoptosis in metastatic melanoma cell lines and short-term brain melanoma cells, irrespective of their BRAF and NRAS mutation status. In addition, buparlisib inhibited hyperactivated AKT and induced apoptosis in melanoma cells that were stimulated with astrocyte-conditioned medium. The growth of tumors induced by injecting human BRAF- and NRAS-mutant metastatic melanoma cells into the brain of mice was significantly inhibited by buparlisib. CONCLUSIONS These results emphasize the value of targeting the PI3K pathway as a strategy to develop drugs for melanoma brain metastases. Clin Cancer Res; 22(23); 5818-28. ©2016 AACR.
Collapse
Affiliation(s)
- Heike Niessner
- Department of Dermatology, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Jennifer Schmitz
- Werner Siemens Imaging Center, Department of Preclinical Imaging and Radiopharmacy, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Ghazaleh Tabatabai
- Interdisciplinary Division of Neuro-Oncology, Departments of Vascular Neurology & Neurosurgery, Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Eberhard Karls University, Tübingen Germany.,Neuro-Oncology Center Tübingen, Comprehensive Cancer Center Tübingen-Stuttgart, Germany.,Center for Personalized Medicine, Eberhard Karls University, Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site, Tübingen, Germany
| | - Andreas M Schmid
- Werner Siemens Imaging Center, Department of Preclinical Imaging and Radiopharmacy, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Carsten Calaminus
- Werner Siemens Imaging Center, Department of Preclinical Imaging and Radiopharmacy, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Tobias Sinnberg
- Department of Dermatology, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Benjamin Weide
- Department of Dermatology, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Thomas K Eigentler
- Department of Dermatology, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Claus Garbe
- Department of Dermatology, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Birgit Schittek
- Department of Dermatology, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Leticia Quintanilla-Fend
- Department of Pathology, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Benjamin Bender
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Marion Mai
- Department of Dermatology, Medical Faculty and University Hospital Carl Gustav Carus, TU Dresden, Germany.,Center for Regenerative Therapies Dresden, DFG Research Center and Cluster of Excellence, TU Dresden, Germany
| | - Christian Praetorius
- Department of Dermatology, Medical Faculty and University Hospital Carl Gustav Carus, TU Dresden, Germany.,Center for Regenerative Therapies Dresden, DFG Research Center and Cluster of Excellence, TU Dresden, Germany
| | - Stefan Beissert
- Department of Dermatology, Medical Faculty and University Hospital Carl Gustav Carus, TU Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany
| | - Gabriele Schackert
- Department of Neurosurgery, Medical Faculty and University Hospital Carl Gustav Carus, TU Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany
| | - Michael H Muders
- Department of Pathology, Medical Faculty and University Hospital Carl Gustav Carus, TU Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany
| | - Matthias Meinhardt
- Department of Pathology, Medical Faculty and University Hospital Carl Gustav Carus, TU Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany
| | - Gustavo B Baretton
- Department of Pathology, Medical Faculty and University Hospital Carl Gustav Carus, TU Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany
| | - Reinhard Dummer
- Department of Dermatology, University Hospital Zürich, Zürich, Switzerland
| | - Keith Flaherty
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Bernd J Pichler
- Werner Siemens Imaging Center, Department of Preclinical Imaging and Radiopharmacy, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Dagmar Kulms
- Department of Dermatology, Medical Faculty and University Hospital Carl Gustav Carus, TU Dresden, Germany.,Center for Regenerative Therapies Dresden, DFG Research Center and Cluster of Excellence, TU Dresden, Germany
| | - Dana Westphal
- Department of Dermatology, Medical Faculty and University Hospital Carl Gustav Carus, TU Dresden, Germany.,Center for Regenerative Therapies Dresden, DFG Research Center and Cluster of Excellence, TU Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany
| | - Friedegund Meier
- Department of Dermatology, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany. .,Department of Dermatology, Medical Faculty and University Hospital Carl Gustav Carus, TU Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany
| |
Collapse
|
30
|
Geukes Foppen M, Brandsma D, Blank C, van Thienen J, Haanen J, Boogerd W. Targeted treatment and immunotherapy in leptomeningeal metastases from melanoma. Ann Oncol 2016; 27:1138-1142. [DOI: 10.1093/annonc/mdw134] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 03/03/2016] [Indexed: 11/13/2022] Open
|
31
|
Vemurafenib in leptomeningeal carcinomatosis from melanoma: a case report of near-complete response and prolonged survival. Melanoma Res 2016; 26:312-5. [DOI: 10.1097/cmr.0000000000000257] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
32
|
Rauschenberg R, Tabatabai G, Troost EGC, Garzarolli M, Beissert S, Meier F. Hirnmetastasen des malignen Melanoms. Hautarzt 2016; 67:536-43. [DOI: 10.1007/s00105-016-3797-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
33
|
Schreuer M, Meersseman G, Van Den Herrewegen S, Jansen Y, Chevolet I, Bott A, Wilgenhof S, Seremet T, Jacobs B, Buyl R, Maertens G, Neyns B. Quantitative assessment of BRAF V600 mutant circulating cell-free tumor DNA as a tool for therapeutic monitoring in metastatic melanoma patients treated with BRAF/MEK inhibitors. J Transl Med 2016; 14:95. [PMID: 27095081 PMCID: PMC4837559 DOI: 10.1186/s12967-016-0852-6] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 04/06/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND BRAF V600 mutant circulating cell-free tumor DNA (BRAF V600mut ctDNA) could serve as a specific biomarker in patients with BRAF V600 mutant melanoma. We analyzed the value of BRAF V600mut ctDNA from plasma as a monitoring tool for advanced melanoma patients treated with BRAF/MEK inhibitors. METHODS Allele-specific quantitative PCR analysis for BRAF V600 E/E2/D/K/R/M mutations was performed on DNA extracted from plasma of patients with known BRAF V600 mutant melanoma who were treated with dabrafenib and trametinib. RESULTS 245 plasma samples from 36 patients were analyzed. In 16 patients the first plasma sample was obtained before the first dosing of dabrafenib/trametinib. At baseline, BRAF V600mut ctDNA was detected in 75 % of patients (n = 12/16). BRAF V600mut ctDNA decreased rapidly upon initiation of targeted therapy (p < 0.001) and became undetectable in 60 % of patients (n = 7/12) after 6 weeks of treatment. During treatment, disease progression (PD) was diagnosed in 27 of 36 patients. An increase of the BRAF V600mut ctDNA copy number and fraction, identified PD with a sensitivity of 70 % (n = 19/27) and a specificity of 100 %. An increase in the BRAF V600mut ctDNA fraction was detected prior to clinical PD in 44 % of cases (n = 12/27) and simultaneously with PD in 26 % of patients (n = 7/27). CONCLUSIONS Quantitative analysis of BRAF V600mut ctDNA in plasma has unique features as a monitoring tool during treatment with BRAF/MEK inhibitors. Its potential as an early predictor of acquired resistance deserves further evaluation.
Collapse
Affiliation(s)
- Max Schreuer
- />Department of Medical Oncology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Geert Meersseman
- />Biocartis, Generaal De Wittelaan 11 B3, 2800 Mechelen, Belgium
| | | | - Yanina Jansen
- />Department of Medical Oncology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Ines Chevolet
- />Department of Dermatology, Universitair ziekenhuis Gent (UZ Gent), Universiteit Gent (UGent), De Pintelaan 185, 9000 Ghent, Belgium
| | - Ambre Bott
- />Department of Medical Oncology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Sofie Wilgenhof
- />Department of Medical Oncology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Teofila Seremet
- />Department of Medical Oncology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Bart Jacobs
- />Biocartis, Generaal De Wittelaan 11 B3, 2800 Mechelen, Belgium
| | - Ronald Buyl
- />Department of Biostatistics and Medical Informatics, Vrije Universiteit Brussel (VUB), Laarbeeklaan, 103, 1090 Brussels, Belgium
| | - Geert Maertens
- />Biocartis, Generaal De Wittelaan 11 B3, 2800 Mechelen, Belgium
| | - Bart Neyns
- />Department of Medical Oncology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| |
Collapse
|
34
|
Parrish KE, Pokorny J, Mittapalli RK, Bakken K, Sarkaria JN, Elmquist WF. Efflux transporters at the blood-brain barrier limit delivery and efficacy of cyclin-dependent kinase 4/6 inhibitor palbociclib (PD-0332991) in an orthotopic brain tumor model. J Pharmacol Exp Ther 2015; 355:264-71. [PMID: 26354993 PMCID: PMC4613960 DOI: 10.1124/jpet.115.228213] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 09/08/2015] [Indexed: 02/01/2023] Open
Abstract
6-Acetyl-8-cyclopentyl-5-methyl-2-([5-(piperazin-1-yl)pyridin-2-yl]amino)pyrido(2,3-d)pyrimidin-7(8H)-one [palbociclib (PD-0332991)] is a cyclin-dependent kinase 4/6 inhibitor approved for the treatment of metastatic breast cancer and is currently undergoing clinical trials for many solid tumors. Glioblastoma (GBM) is the most common primary brain tumor in adults and has limited treatment options. The cyclin-dependent kinase 4/6 pathway is commonly dysregulated in GBM and is a promising target in treating this devastating disease. The blood-brain barrier (BBB) limits the delivery of drugs to invasive regions of GBM, where the efflux transporters P-glycoprotein and breast cancer resistance protein can prevent treatments from reaching the tumor. The purpose of this study was to examine the mechanisms limiting the effectiveness of palbociclib therapy in an orthotopic xenograft model. The in vitro intracellular accumulation results demonstrated that palbociclib is a substrate for both P-glycoprotein and breast cancer resistance protein. In vivo studies in transgenic mice confirmed that efflux transport is responsible for the limited brain distribution of palbociclib. There was an ∼115-fold increase in brain exposure at steady state in the transporter deficient mice when compared with wild-type mice, and the efflux inhibitor elacridar significantly increased palbociclib brain distribution. Efficacy studies demonstrated that palbociclib is an effective therapy when GBM22 tumor cells are implanted in the flank, but ineffective in an orthotopic (intracranial) model. Moreover, doses designed to mimic brain exposure were ineffective in treating flank tumors. These results demonstrate that efflux transport in the BBB is involved in limiting the brain distribution of palbociclib and this has critical implications in determining effective dosing regimens of palbociclib therapy in the treatment of brain tumors.
Collapse
MESH Headings
- ATP Binding Cassette Transporter, Subfamily B, Member 1/genetics
- ATP Binding Cassette Transporter, Subfamily B, Member 1/metabolism
- ATP Binding Cassette Transporter, Subfamily G, Member 2
- ATP-Binding Cassette Transporters/genetics
- ATP-Binding Cassette Transporters/metabolism
- Acridines/pharmacology
- Animals
- Antineoplastic Agents/pharmacokinetics
- Antineoplastic Agents/pharmacology
- Blood-Brain Barrier/metabolism
- Brain Neoplasms/drug therapy
- Brain Neoplasms/metabolism
- Cell Line, Tumor
- Cyclin-Dependent Kinase 4/antagonists & inhibitors
- Cyclin-Dependent Kinase 6/antagonists & inhibitors
- Dogs
- Drug Resistance, Neoplasm
- Drug Synergism
- Female
- Glioblastoma/drug therapy
- Glioblastoma/metabolism
- Heterografts
- Madin Darby Canine Kidney Cells
- Male
- Mice
- Mice, Knockout
- Mice, Nude
- Neoplasm Transplantation
- Piperazines/pharmacokinetics
- Piperazines/pharmacology
- Pyridines/pharmacokinetics
- Pyridines/pharmacology
- Tetrahydroisoquinolines/pharmacology
Collapse
Affiliation(s)
- Karen E Parrish
- Department of Pharmaceutics, Brain Barriers Research Center, University of Minnesota, Minneapolis, Minnesota (K.E.P., R.K.M., W.F.E.); and Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (J.P., K.B., J.N.S.)
| | - Jenny Pokorny
- Department of Pharmaceutics, Brain Barriers Research Center, University of Minnesota, Minneapolis, Minnesota (K.E.P., R.K.M., W.F.E.); and Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (J.P., K.B., J.N.S.)
| | - Rajendar K Mittapalli
- Department of Pharmaceutics, Brain Barriers Research Center, University of Minnesota, Minneapolis, Minnesota (K.E.P., R.K.M., W.F.E.); and Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (J.P., K.B., J.N.S.)
| | - Katrina Bakken
- Department of Pharmaceutics, Brain Barriers Research Center, University of Minnesota, Minneapolis, Minnesota (K.E.P., R.K.M., W.F.E.); and Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (J.P., K.B., J.N.S.)
| | - Jann N Sarkaria
- Department of Pharmaceutics, Brain Barriers Research Center, University of Minnesota, Minneapolis, Minnesota (K.E.P., R.K.M., W.F.E.); and Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (J.P., K.B., J.N.S.)
| | - William F Elmquist
- Department of Pharmaceutics, Brain Barriers Research Center, University of Minnesota, Minneapolis, Minnesota (K.E.P., R.K.M., W.F.E.); and Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (J.P., K.B., J.N.S.)
| |
Collapse
|
35
|
Berghoff AS, Preusser M. The future of targeted therapies for brain metastases. Future Oncol 2015; 11:2315-27. [DOI: 10.2217/fon.15.127] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Brain metastases (BM) are an increasing challenge in the management of patients with advanced cancer. Treatment options for BM are limited and mainly focus on the application of local therapies. Systemic therapies including targeted therapies are only poorly investigated, as patients with BM were frequently excluded from clinical trials. Several targeted therapies have shown promising activity in patients with BM. In the present review we discuss existing and emerging targeted therapies for the most frequent BM primary tumor types. We focus on challenges in the conduction of clinical trials on targeted therapies in BM patients such as patient selection, combination with radiotherapy, the obstacles of the blood–brain barrier and the definition of study end points.
Collapse
Affiliation(s)
- Anna S Berghoff
- Department for Medicine I, Comprehensive Cancer Center Central Nervous System Unit (CCC-CNS), Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria
- Comprehensive Cancer Center – CNS Tumors Unit, Medical University of Vienna, Vienna, Austria
| | - Matthias Preusser
- Department for Medicine I, Comprehensive Cancer Center Central Nervous System Unit (CCC-CNS), Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria
- Comprehensive Cancer Center – CNS Tumors Unit, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
36
|
Goyal S, Silk AW, Tian S, Mehnert J, Danish S, Ranjan S, Kaufman HL. Clinical Management of Multiple Melanoma Brain Metastases: A Systematic Review. JAMA Oncol 2015; 1:668-76. [PMID: 26181286 PMCID: PMC5726801 DOI: 10.1001/jamaoncol.2015.1206] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
IMPORTANCE The treatment of multiple brain metastases (MBM) from melanoma is controversial and includes surgical resection, stereotactic radiosurgery (SRS), and whole-brain radiation therapy (WBRT). Several new classes of agents have revolutionized the treatment of metastatic melanoma, allowing some subsets of patients to have long-term survival. Given this, management of MBM from melanoma is continually evolving. OBJECTIVE To review the current evidence regarding the treatment of MBM from melanoma. EVIDENCE REVIEW The PubMed database was searched using combinations of search terms and synonyms for melanoma, brain metastases, radiation, chemotherapy, immunotherapy, and targeted therapy published between January 1, 1995, and January 1, 2015. Articles were selected for inclusion on the basis of targeted keyword searches, manual review of bibliographies, and whether the article was a clinical trial, large observational study, or retrospective study focusing on melanoma brain metastases. Of 2243 articles initially identified, 110 were selected for full review. Of these, the most pertinent 73 articles were included. FINDINGS Patients with newly diagnosed MBM can be treated with various modalities, either alone or in combination. Level 1 evidence supports the use of SRS alone, WBRT, and SRS with WBRT. Although the addition of WBRT to SRS improves the overall brain relapse rate, WBRT has no significant impact on overall survival and has detrimental neurocognitive outcomes. Cytotoxic chemotherapy has largely been ineffective; targeted therapies and immunotherapies have been reported to have high response rates and deserve further attention in larger clinical trials. Further studies are needed to fully evaluate the efficacy of these novel regimens in combination with radiation therapy. CONCLUSIONS AND RELEVANCE At this time, the standard management for patients with MBM from melanoma includes SRS, WBRT, or a combination of both. Emerging data exist to support the notion that SRS in combination with targeted therapies or immune therapy may obviate the need for WBRT; prospective studies are required to fully evaluate the efficacy of these novel regimens in combination with radiation therapy.
Collapse
Affiliation(s)
- Sharad Goyal
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Ann W. Silk
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Sibo Tian
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Janice Mehnert
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Shabbar Danish
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Sinthu Ranjan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| | - Howard L. Kaufman
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School
| |
Collapse
|
37
|
Cerebrospinal fluid concentrations of vemurafenib in patients treated for brain metastatic BRAF-V600 mutated melanoma. Melanoma Res 2015; 25:302-5. [DOI: 10.1097/cmr.0000000000000162] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
38
|
Parrish KE, Sarkaria JN, Elmquist WF. Improving drug delivery to primary and metastatic brain tumors: strategies to overcome the blood-brain barrier. Clin Pharmacol Ther 2015; 97:336-46. [PMID: 25669487 DOI: 10.1002/cpt.71] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 01/02/2015] [Indexed: 12/21/2022]
Abstract
Brain tumor diagnosis has an extremely poor prognosis, due in part to the blood-brain barrier (BBB) that prevents both early diagnosis and effective drug delivery. The infiltrative nature of primary brain tumors and the presence of micro-metastases lead to tumor cells that reside behind an intact BBB. Recent genomic technologies have identified many genetic mutations present in glioma and other central nervous system (CNS) tumors, and this information has been instrumental in guiding the development of molecularly targeted therapies. However, the majority of these agents are unable to penetrate an intact BBB, leading to one mechanism by which the invasive brain tumor cells effectively escape treatment. The diagnosis and treatment of a brain tumor remains a serious challenge and new therapeutic agents that either penetrate the BBB or disrupt mechanisms that limit brain penetration, such as endothelial efflux transporters or tight junctions, are required in order to improve patient outcomes in this devastating disease.
Collapse
Affiliation(s)
- K E Parrish
- Brain Barriers Research Center, Department of Pharmaceutics, University of Minnesota, Minneapolis, Minnesota, USA
| | | | | |
Collapse
|