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Serra E, Abarzua-Araya Á, Arance A, Martin-Huertas R, Aya F, Olondo ML, Rizo-Potau D, Malvehy J, Puig S, Carrera C, Podlipnik S. Predictive and Prognostic Factors in Melanoma Central Nervous System Metastases-A Cohort Study. Cancers (Basel) 2024; 16:2272. [PMID: 38927977 PMCID: PMC11201698 DOI: 10.3390/cancers16122272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 06/08/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Melanoma is the cancer with the highest risk of dissemination to the central nervous system (CNS), one of the leading causes of mortality from this cancer. OBJECTIVE To identify patients at higher risk of developing CNS metastases and to evaluate associated prognostic factors. METHODS A cohort study (1998-2023) assessed patients who developed CNS melanoma metastases. Multivariate logistic regression was used to identify predictive factors at melanoma diagnosis for CNS metastasis. Cox regression analysis evaluated the CNS-independent metastasis-related variables impacting survival. RESULTS Out of 4718 patients, 380 (8.05%) developed CNS metastases. Multivariate logistic regression showed that a higher Breslow index, mitotic rate ≥ 1 mm2, ulceration, and microscopic satellitosis were significant risk factors for CNS metastasis development. Higher patient age and the location of the primary tumor in the upper or lower extremities were protective factors. In survival analysis, post-CNS metastasis, symptomatic disease, prior non-CNS metastases, CNS debut with multiple metastases, elevated LDH levels, and leptomeningeal involvement correlated with poorer survival. CONCLUSION Predictive factors in the primary tumor independently associated with brain metastases include microscopic satellitosis, ulceration, higher Breslow index, and trunk location. Prognostic factors for lower survival in CNS disease include symptomatic disease, multiple CNS metastases, and previous metastases from different sites.
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Affiliation(s)
- Estefania Serra
- Dermatology Department, Hospital Clinic of Barcelona, University of Barcelona, 08036 Barcelona, Spain; (E.S.); (Á.A.-A.); (D.R.-P.); (J.M.); (S.P.); (S.P.)
| | - Álvaro Abarzua-Araya
- Dermatology Department, Hospital Clinic of Barcelona, University of Barcelona, 08036 Barcelona, Spain; (E.S.); (Á.A.-A.); (D.R.-P.); (J.M.); (S.P.); (S.P.)
- Melanoma and Skin Cancer Unit, Dermatology Department, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago 8320165, Chile
| | - Ana Arance
- Oncology Department, Hospital Clinic of Barcelona, 08036 Barcelona, Spain; (A.A.); (R.M.-H.)
| | - Roberto Martin-Huertas
- Oncology Department, Hospital Clinic of Barcelona, 08036 Barcelona, Spain; (A.A.); (R.M.-H.)
| | - Francisco Aya
- Oncology Department, Hospital Clinic of Barcelona, 08036 Barcelona, Spain; (A.A.); (R.M.-H.)
| | | | - Daniel Rizo-Potau
- Dermatology Department, Hospital Clinic of Barcelona, University of Barcelona, 08036 Barcelona, Spain; (E.S.); (Á.A.-A.); (D.R.-P.); (J.M.); (S.P.); (S.P.)
| | - Josep Malvehy
- Dermatology Department, Hospital Clinic of Barcelona, University of Barcelona, 08036 Barcelona, Spain; (E.S.); (Á.A.-A.); (D.R.-P.); (J.M.); (S.P.); (S.P.)
- Institut d’Investigacions Biomediques August Pi I Sunyer (IDIBAPS), 08036 Barcelona, Spain
- CIBER on Rare Disease, Instituto de Salud Carlos III, 28029 Barcelona, Spain
| | - Susana Puig
- Dermatology Department, Hospital Clinic of Barcelona, University of Barcelona, 08036 Barcelona, Spain; (E.S.); (Á.A.-A.); (D.R.-P.); (J.M.); (S.P.); (S.P.)
- Institut d’Investigacions Biomediques August Pi I Sunyer (IDIBAPS), 08036 Barcelona, Spain
- CIBER on Rare Disease, Instituto de Salud Carlos III, 28029 Barcelona, Spain
| | - Cristina Carrera
- Dermatology Department, Hospital Clinic of Barcelona, University of Barcelona, 08036 Barcelona, Spain; (E.S.); (Á.A.-A.); (D.R.-P.); (J.M.); (S.P.); (S.P.)
- Institut d’Investigacions Biomediques August Pi I Sunyer (IDIBAPS), 08036 Barcelona, Spain
- CIBER on Rare Disease, Instituto de Salud Carlos III, 28029 Barcelona, Spain
| | - Sebastian Podlipnik
- Dermatology Department, Hospital Clinic of Barcelona, University of Barcelona, 08036 Barcelona, Spain; (E.S.); (Á.A.-A.); (D.R.-P.); (J.M.); (S.P.); (S.P.)
- Institut d’Investigacions Biomediques August Pi I Sunyer (IDIBAPS), 08036 Barcelona, Spain
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Pellerino A, Davidson TM, Bellur SS, Ahluwalia MS, Tawbi H, Rudà R, Soffietti R. Prevention of Brain Metastases: A New Frontier. Cancers (Basel) 2024; 16:2134. [PMID: 38893253 PMCID: PMC11171378 DOI: 10.3390/cancers16112134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/29/2024] [Accepted: 06/01/2024] [Indexed: 06/21/2024] Open
Abstract
This review discusses the topic of prevention of brain metastases from the most frequent solid tumor types, i.e., lung cancer, breast cancer and melanoma. Within each tumor type, the risk of brain metastasis is related to disease status and molecular subtype (i.e., EGFR-mutant non-small cell lung cancer, HER2-positive and triple-negative breast cancer, BRAF and NRAF-mutant melanoma). Prophylactic cranial irradiation is the standard of care in patients in small cell lung cancer responsive to chemotherapy but at the price of late neurocognitive decline. More recently, several molecular agents with the capability to target molecular alterations driving tumor growth have proven as effective in the prevention of secondary relapse into the brain in clinical trials. This is the case for EGFR-mutant or ALK-rearranged non-small cell lung cancer inhibitors, tucatinib and trastuzumab-deruxtecan for HER2-positive breast cancer and BRAF inhibitors for melanoma. The need for screening with an MRI in asymptomatic patients at risk of brain metastases is emphasized.
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Affiliation(s)
- Alessia Pellerino
- Division of Neuro-Oncology, Department of Neuroscience ‘Rita Levi Montalcini’, University and City of Health and Science Hospital, 10126 Turin, Italy;
| | - Tara Marie Davidson
- Department of Melanoma Medical Oncology, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (T.M.D.); (H.T.)
| | - Shreyas S. Bellur
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL 33176, USA; (S.S.B.); (M.S.A.)
| | - Manmeet S. Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL 33176, USA; (S.S.B.); (M.S.A.)
| | - Hussein Tawbi
- Department of Melanoma Medical Oncology, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (T.M.D.); (H.T.)
| | - Roberta Rudà
- Division of Neuro-Oncology, Department of Neuroscience ‘Rita Levi Montalcini’, University and City of Health and Science Hospital, 10126 Turin, Italy;
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Cioffi G, Ascha MS, Waite KA, Dmukauskas M, Wang X, Royce TJ, Calip GS, Waxweiler T, Rusthoven CG, Kavanagh BD, Barnholtz-Sloan JS. Sex Differences in Odds of Brain Metastasis and Outcomes by Brain Metastasis Status after Advanced Melanoma Diagnosis. Cancers (Basel) 2024; 16:1771. [PMID: 38730723 PMCID: PMC11083203 DOI: 10.3390/cancers16091771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 04/23/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Sex differences in cancer are well-established. However, less is known about sex differences in diagnosis of brain metastasis and outcomes among patients with advanced melanoma. Using a United States nationwide electronic health record-derived de-identified database, we evaluated patients diagnosed with advanced melanoma from 1 January 2011-30 July 2022 who received an oncologist-defined rule-based first line of therapy (n = 7969, 33% female according to EHR, 35% w/documentation of brain metastases). The odds of documented brain metastasis diagnosis were calculated using multivariable logistic regression adjusted for age, practice type, diagnosis period (pre/post-2017), ECOG performance status, anatomic site of melanoma, group stage, documentation of non-brain metastases prior to first-line of treatment, and BRAF positive status. Real-world overall survival (rwOS) and progression-free survival (rwPFS) starting from first-line initiation were assessed by sex, accounting for brain metastasis diagnosis as a time-varying covariate using the Cox proportional hazards model, with the same adjustments as the logistic model, excluding group stage, while also adjusting for race, socioeconomic status, and insurance status. Adjusted analysis revealed males with advanced melanoma were 22% more likely to receive a brain metastasis diagnosis compared to females (adjusted odds ratio [aOR]: 1.22, 95% confidence interval [CI]: 1.09, 1.36). Males with brain metastases had worse rwOS (aHR: 1.15, 95% CI: 1.04, 1.28) but not worse rwPFS (adjusted hazard ratio [aHR]: 1.04, 95% CI: 0.95, 1.14) following first-line treatment initiation. Among patients with advanced melanoma who were not diagnosed with brain metastases, survival was not different by sex (rwOS aHR: 1.06 [95% CI: 0.97, 1.16], rwPFS aHR: 1.02 [95% CI: 0.94, 1.1]). This study showed that males had greater odds of brain metastasis and, among those with brain metastasis, poorer rwOS compared to females, while there were no sex differences in clinical outcomes for those with advanced melanoma without brain metastasis.
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Affiliation(s)
- Gino Cioffi
- Trans Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD 20892,USA (M.D.)
| | | | - Kristin A. Waite
- Trans Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD 20892,USA (M.D.)
| | - Mantas Dmukauskas
- Trans Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD 20892,USA (M.D.)
| | | | - Trevor J. Royce
- Flatiron Health, Inc., New York, NY 10013, USA (T.J.R.)
- Department of Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
| | - Gregory S. Calip
- Flatiron Health, Inc., New York, NY 10013, USA (T.J.R.)
- Titus Family Department of Clinical Pharmacy, University of Southern California, Los Angeles, CA 90089, USA
| | - Timothy Waxweiler
- Department of Radiation Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Chad G. Rusthoven
- Department of Radiation Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Brian D. Kavanagh
- Department of Radiation Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Jill S. Barnholtz-Sloan
- Trans Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD 20892,USA (M.D.)
- Center for Biomedical Informatics & Information Technology, National Cancer Institute, Bethesda, MD 20892,USA
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Sherman WJ, Romiti E, Michaelides L, Moniz-Garcia D, Chaichana KL, Quiñones-Hinojosa A, Porter AB. Systemic Therapy for Melanoma Brain and Leptomeningeal Metastases. Curr Treat Options Oncol 2023; 24:1962-1977. [PMID: 38158477 DOI: 10.1007/s11864-023-01155-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 01/03/2024]
Abstract
OPINION STATEMENT Melanoma has a high propensity to metastasize to the brain which portends a poorer prognosis. With advanced radiation techniques and targeted therapies, outcomes however are improving. Melanoma brain metastases are best managed in a multi-disciplinary approach, including medical oncologists, neuro-oncologists, radiation oncologists, and neurosurgeons. The sequence of therapies is dependent on the number and size of brain metastases, status of systemic disease control, prior therapies, performance status, and neurological symptoms. The goal of treatment is to minimize neurologic morbidity and prolong both progression free and overall survival while maximizing quality of life. Surgery should be considered for solitary metastases, or large and/or symptomatic metastases with edema. Stereotactic radiosurgery offers a benefit over whole-brain radiation attributed to the relative radioresistance of melanoma and reduction in neurotoxicity. Thus far, data supports a more durable response with systemic therapy using combination immunotherapy of ipilimumab and nivolumab, though targeting the presence of BRAF mutations can also be utilized. BRAF inhibitor therapy is often used after immunotherapy failure, unless a more rapid initial response is needed and then can be done prior to initiating immunotherapy. Further trials are needed, particularly for leptomeningeal metastases which currently require the multi-disciplinary approach to determine best treatment plan.
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Affiliation(s)
- Wendy J Sherman
- Department of Neurology, Division of Neuro-Oncology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA.
| | - Edoardo Romiti
- Vita e Salute San Raffaele University in Milan, Via Olgettina, 58, 20132, Milan, MI, Italy
| | - Loizos Michaelides
- Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Diogo Moniz-Garcia
- Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Kaisorn L Chaichana
- Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | | | - Alyx B Porter
- Department of Neurology, Division of Neuro-Oncology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
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Wu Q, Zhang X, Li H, Tang L, Zeng Y, Lin J, Chen Y, Li J. A modified melanoma-molGPA scoring model: assessment of survival after and efficacy of different radiotherapy modalities in patients with melanoma brain metastases. Discov Oncol 2023; 14:116. [PMID: 37382755 DOI: 10.1007/s12672-023-00722-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/08/2023] [Indexed: 06/30/2023] Open
Abstract
PURPOSE Patients with malignant melanoma brain metastases (MBMs) have poor prognoses. For MBMs, the Melanoma-molGPA is the most widely used predictive score, but its predictive value remains uncertain in patients fully treated with radiotherapy. We identified MBMs prognostic factors and modified the prognostic scoring model. METHODS We retrospectively analyzed patients diagnosed with MBMs between December 2010 and November 2021 for prognostic factors influencing overall survival (OS) by univariate and multivariate analyses. Nomogram plots were based on Cox regression modeling. We evaluated overall survival (OS) using Kaplan-Meier survival curves and log-rank tests. RESULTS The median OS (mOS) was 7.9 months. On multivariate analysis, BRAF mutation status (p < 0.001), number of brain metastases (BM) (p < 0.001), presence of liver metastases (p < 0.001), brain metastases with a midline shift (p = 0.003), Karnofsky Performance Score (p = 0.02), and lymphocyte-to-monocyte ratio (p < 0.0001) were independent OS predictors. These were incorporated into a modified risk-stratification model. Overall, whole-brain radiotherapy (WBRT) did not significantly affect mOS (mOS, 6.89 vs. 8.83 months; p = 0.07). After risk stratification using our model, WBRT resulted in no significant survival benefit in the low-risk group (mOS 10.07 vs. 13.1 months; p = 0.71) but significantly worse prognosis in the high-risk group (mOS, 2.37 vs. 6.92 months; p = 0.026). CONCLUSION We propose a modified model that accurately distinguishes the prognosis of patients with MBMs and guides decision-making for radiotherapy. Based on this novel model, WBRT should be cautiously selected for high-risk patients.
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Affiliation(s)
- Qian Wu
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Xueqing Zhang
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Hui Li
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Lirui Tang
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Yibin Zeng
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Jing Lin
- Department of Medical Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Yu Chen
- Department of Medical Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Jinluan Li
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China.
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Tabatabai MA, Bahri N, Matthews-Juarez P, Alcendor D, Cooper R, Juarez P, Ramesh A, Tabatabai N, Singh KP, Wilus D. The role of histological subtypes in the survival of patients diagnosed with cutaneous or mucosal melanoma in the United States of America. PLoS One 2023; 18:e0286538. [PMID: 37276224 PMCID: PMC10241359 DOI: 10.1371/journal.pone.0286538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 05/18/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Literature presents limited information on histological subtypes and their association with other factors influencing the survival of melanoma patients. To explore the risk of death due to melanoma associated with histological subtypes, this retrospective study used the Surveillance, Epidemiology, and End Results program (SEER) data from 1998 to 2019. METHODS A total of 27,532 patients consisting of 15,527 males and 12,005 females. The Hypertabastic Accelerated Failure Time model was used to analyze the impact of histology on the survival of patients with cutaneous or mucosal melanoma. RESULTS The median survival time (MST) for cutaneous patients was 149 months, whereas those diagnosed with mucosal melanoma was 34 months. Nodular melanoma had a hazard ratio of 3.40 [95% CI: (2.94, 3.94)] compared to lentigo maligna melanoma. Across all histological subtypes, females had a longer MST, when compared to males. The hazard ratio (HR) of distant to localized melanoma was 9.56 [95% CI: (7.58, 12.07)]. CONCLUSIONS Knowledge of patients' histological subtypes and their hazard assessment would enable clinicians and healthcare providers to perform personalized treatment, resulting in a lower risk of complication and higher survivability of melanoma patients. Significant factors were stage of the disease, age, histology, sex, and income. Focus should be placed on high-risk populations with severe and aggressive histological subtypes. Programs that emphasize preventive measures such as awareness, education, and early screening could reduce risk.
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Affiliation(s)
| | - Nader Bahri
- Meharry Medical College, Nashville, TN, United States of America
| | | | - Donald Alcendor
- Meharry Medical College, Nashville, TN, United States of America
| | - Robert Cooper
- Meharry Medical College, Nashville, TN, United States of America
| | - Paul Juarez
- Meharry Medical College, Nashville, TN, United States of America
| | - Aramandla Ramesh
- Meharry Medical College, Nashville, TN, United States of America
| | - Niki Tabatabai
- University of California Los Angeles, Los Angeles, CA, United States of America
| | - Karan P. Singh
- University of Texas Health Sciences Center at Tyler, Tyler, TX, United States of America
| | - Derek Wilus
- Meharry Medical College, Nashville, TN, United States of America
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Internò V, Sergi MC, Metta ME, Guida M, Trerotoli P, Strippoli S, Circelli S, Porta C, Tucci M. Melanoma Brain Metastases: A Retrospective Analysis of Prognostic Factors and Efficacy of Multimodal Therapies. Cancers (Basel) 2023; 15:cancers15051542. [PMID: 36900333 PMCID: PMC10001111 DOI: 10.3390/cancers15051542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/20/2023] [Accepted: 02/27/2023] [Indexed: 03/05/2023] Open
Abstract
Brain metastasis in cutaneous melanoma (CM) has historically been considered to be a dismal prognostic feature, although recent evidence has highlighted the intracranial activity of combined immunotherapy (IT). Herein, we completed a retrospective study to investigate the impact of clinical-pathological features and multimodal therapies on the overall survival (OS) of CM patients with brain metastases. A total of 105 patients were evaluated. Nearly half of the patients developed neurological symptoms leading to a negative prognosis (p = 0.0374). Both symptomatic and asymptomatic patients benefited from encephalic radiotherapy (eRT) (p = 0.0234 and p = 0.011). Lactate dehydrogenase (LDH) levels two times higher than the upper limit normal (ULN) at the time of brain metastasis onset was associated with poor prognosis (p = 0.0452) and identified those patients who did not benefit from eRT. Additionally, the poor prognostic role of LDH levels was confirmed in patients treated with targeted therapy (TT) (p = 0.0015) concerning those who received immunotherapy (IT) (p = 0.16). Based on these results, LDH levels higher than two times the ULN at the time of the encephalic progression identify those patients with a poor prognosis who did not benefit from eRT. The negative prognostic role of LDH levels on eRT observed in our study will require prospective evaluations.
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Affiliation(s)
- Valeria Internò
- Department of Interdisciplinary Medicine, University of Bari Aldo Moro, 70121 Bari, Italy
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria, Policlinico di Bari, 70124 Bari, Italy
- Correspondence: ; Tel.: +39-080-5593674
| | - Maria Chiara Sergi
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria, Policlinico di Bari, 70124 Bari, Italy
| | - Maria Elvira Metta
- Medical Statistic and Biometry Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, 70121 Bari, Italy
| | - Michele Guida
- IRCCS, Istituto Tumori Giovanni Paolo II, 70124 Bari, Italy
| | - Paolo Trerotoli
- Medical Statistic and Biometry Unit, Department of Interdisciplinary Medicine, University of Bari Aldo Moro, 70124 Bari, Italy
| | | | - Salvatore Circelli
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria, Policlinico di Bari, 70124 Bari, Italy
| | - Camillo Porta
- Department of Interdisciplinary Medicine, University of Bari Aldo Moro, 70121 Bari, Italy
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria, Policlinico di Bari, 70124 Bari, Italy
| | - Marco Tucci
- Department of Interdisciplinary Medicine, University of Bari Aldo Moro, 70121 Bari, Italy
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria, Policlinico di Bari, 70124 Bari, Italy
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8
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Tabor JK, Onoichenco A, Narayan V, Wernicke AG, D’Amico RS, Vojnic M. Brain metastasis screening in the molecular age. Neurooncol Adv 2023; 5:vdad080. [PMID: 37484759 PMCID: PMC10358433 DOI: 10.1093/noajnl/vdad080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023] Open
Abstract
The incidence of brain metastases (BM) amongst cancer patients has been increasing due to improvements in therapeutic options and an increase in overall survival. Molecular characterization of tumors has provided insights into the biology and oncogenic drivers of BM and molecular subtype-based screening. Though there are currently some screening and surveillance guidelines for BM, they remain limited. In this comprehensive review, we review and present epidemiological data on BM, their molecular characterization, and current screening guidelines. The molecular subtypes with the highest BM incidence are epithelial growth factor receptor-mutated non-small cell lung cancer (NSCLC), BRCA1, triple-negative (TN), and HER2+ breast cancers, and BRAF-mutated melanoma. Furthermore, BMs are more likely to present asymptomatically at diagnosis in oncogene-addicted NSCLC and BRAF-mutated melanoma. European screening standards recommend more frequent screening for oncogene-addicted NSCLC patients, and clinical trials are investigating screening for BM in hormone receptor+, HER2+, and TN breast cancers. However, more work is needed to determine optimal screening guidelines for other primary cancer molecular subtypes. With the advent of personalized medicine, molecular characterization of tumors has revolutionized the landscape of cancer treatment and prognostication. Incorporating molecular characterization into BM screening guidelines may allow physicians to better identify patients at high risk for BM development and improve patient outcomes.
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Affiliation(s)
| | | | - Vinayak Narayan
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - A Gabriella Wernicke
- Department of Radiation Medicine, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Randy S D’Amico
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Morana Vojnic
- Corresponding Author: Morana Vojnic, MD, MBA, 210 East 64th Street, Floor 4, New York, NY 10065, USA ()
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9
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Tan XL, Le A, Scherrer E, Tang H, Kiehl N, Han J, Jiang R, Diede SJ, Shui IM. Systematic literature review and meta-analysis of clinical outcomes and prognostic factors for melanoma brain metastases. Front Oncol 2022; 12:1025664. [PMID: 36568199 PMCID: PMC9773194 DOI: 10.3389/fonc.2022.1025664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022] Open
Abstract
Background More than 60% of all stage IV melanoma patients develop brain metastases, while melanoma brain metastases (MBM) is historically difficult to treat with poor prognosis. Objectives To summarize clinical outcomes and prognostic factors in MBM patients. Methods A systematic review with meta-analysis was conducted, and a literature search for relevant studies was performed on November 1, 2020. Weighted average of median overall survival (OS) was calculated by treatments. The random-effects model in conducting meta-analyses was applied. Results A total of 41 observational studies and 12 clinical trials with our clinical outcomes of interest, and 31 observational studies addressing prognostic factors were selected. The most common treatments for MBM were immunotherapy (IO), MAP kinase inhibitor (MAPKi), stereotactic radiosurgery (SRS), SRS+MAPKi, and SRS+IO, with median OS from treatment start of 7.2, 8.6, 7.3, 7.3, and 14.1 months, respectively. Improved OS was observed for IO and SRS with the addition of IO and/or MAPKi, compared to no IO and SRS alone, respectively. Several prognostic factors were found to be significantly associated with OS in MBM. Conclusion This study summarizes pertinent information regarding clinical outcomes and the association between patient characteristics and MBM prognosis.
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Affiliation(s)
- Xiang-Lin Tan
- Merck & Co., Inc., Rahway, NJ, United States,*Correspondence: Xiang-Lin Tan,
| | - Amy Le
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN, United States
| | - Emilie Scherrer
- Merck & Co., Inc., Rahway, NJ, United States,Seagen Inc., Bothell, WA, United States
| | - Huilin Tang
- Integrative Precision Health, LLC, Carmel, IN, United States
| | - Nick Kiehl
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN, United States
| | - Jiali Han
- Integrative Precision Health, LLC, Carmel, IN, United States
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Anti-PD-1 Monotherapy in Advanced Melanoma—Real-World Data from a 77-Month-Long Retrospective Observational Study. Biomedicines 2022; 10:biomedicines10071737. [PMID: 35885042 PMCID: PMC9313334 DOI: 10.3390/biomedicines10071737] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/13/2022] [Accepted: 07/14/2022] [Indexed: 12/15/2022] Open
Abstract
Real-world evidence plays an important role in the assessment of efficacy and safety of novel therapies. The increasing use of immune checkpoint inhibitors (ICIs) in patients with advanced melanoma has led to notably improved clinical outcomes, while they are also associated with immune-related adverse events (irAEs). The majority of the available data are based on clinical trials, where the investigated subjects often do not adequately represent the general patient population of the everyday practice. Although there is a niche of objective biomarkers for the future treatment response of ICIs, certain studies suggest that irAEs may be predictive. The aim of this study was to carry out a retrospective analysis of treatment data from patients with advanced melanoma, treated with a single anti-PD-1 agent (pembrolizumab or nivolumab) during a 77-month-long period. Treatment efficacy and occurrence of adverse events were analyzed to identify potential predictive markers. Primary and secondary endpoints were the overall survival (OS) and progression-free survival (PFS). In our cohort, we demonstrated that the occurrence of more than one irAE showed a correlation with response to PD-1 ICI therapy and improved the OS and PFS. Our study suggests, that the grade of toxicity of the irAE may affect the survival rate.
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Holland DO, Gotea V, Fedkenheuer K, Jaiswal SK, Baugher C, Tan H, Fedkenheuer M, Elnitski L. Characterization and clustering of kinase isoform expression in metastatic melanoma. PLoS Comput Biol 2022; 18:e1010065. [PMID: 35560144 PMCID: PMC9132324 DOI: 10.1371/journal.pcbi.1010065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/25/2022] [Accepted: 03/29/2022] [Indexed: 11/18/2022] Open
Abstract
Mutations to the human kinome are known to play causal roles in cancer. The kinome regulates numerous cell processes including growth, proliferation, differentiation, and apoptosis. In addition to aberrant expression, aberrant alternative splicing of cancer-driver genes is receiving increased attention as it could lead to loss or gain of functional domains, altering a kinase's downstream impact. The present study quantifies changes in gene expression and isoform ratios in the kinome of metastatic melanoma cells relative to primary tumors. We contrast 538 total kinases and 3,040 known kinase isoforms between 103 primary tumor and 367 metastatic samples from The Cancer Genome Atlas (TCGA). We find strong evidence of differential expression (DE) at the gene level in 123 kinases (23%). Additionally, of the 468 kinases with alternative isoforms, 60 (13%) had significant difference in isoform ratios (DIR). Notably, DE and DIR have little correlation; for instance, although DE highlights enrichment in receptor tyrosine kinases (RTKs), DIR identifies altered splicing in non-receptor tyrosine kinases (nRTKs). Using exon junction mapping, we identify five examples of splicing events favored in metastatic samples. We demonstrate differential apoptosis and protein localization between SLK isoforms in metastatic melanoma. We cluster isoform expression data and identify subgroups that correlate with genomic subtypes and anatomic tumor locations. Notably, distinct DE and DIR patterns separate samples with BRAF hotspot mutations and (N/K/H)RAS hotspot mutations, the latter of which lacks effective kinase inhibitor treatments. DE in RAS mutants concentrates in CMGC kinases (a group including cell cycle and splicing regulators) rather than RTKs as in BRAF mutants. Furthermore, isoforms in the RAS kinase subgroup show enrichment for cancer-related processes such as angiogenesis and cell migration. Our results reveal a new approach to therapeutic target identification and demonstrate how different mutational subtypes may respond differently to treatments highlighting possible new driver events in cancer.
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Affiliation(s)
- David O. Holland
- Translational and Functional Genomics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Valer Gotea
- Translational and Functional Genomics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Kevin Fedkenheuer
- Translational and Functional Genomics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Sushil K. Jaiswal
- Translational and Functional Genomics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Catherine Baugher
- Translational and Functional Genomics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Hua Tan
- Translational and Functional Genomics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Michael Fedkenheuer
- Lymphocyte Nuclear Biology, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Laura Elnitski
- Translational and Functional Genomics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, United States of America
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Eggen AC, Hospers GAP, Bosma I, Kramer MCA, Reyners AKL, Jalving M. Anti-tumor treatment and healthcare consumption near death in the era of novel treatment options for patients with melanoma brain metastases. BMC Cancer 2022; 22:247. [PMID: 35247992 PMCID: PMC8897874 DOI: 10.1186/s12885-022-09316-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 02/20/2022] [Indexed: 11/18/2022] Open
Abstract
Background Effective systemic treatments have revolutionized the management of patients with metastatic melanoma, including those with brain metastases. The extent to which these treatments influence disease trajectories close to death is unknown. Therefore, this study aimed to gain insight into provided treatments and healthcare consumption during the last 3 months of life in patients with melanoma brain metastases. Methods Retrospective, single-center study, including consecutive patients with melanoma brain metastases diagnosed between June-2015 and June-2018, referred to the medical oncologist, and died before November-2019. Patient and tumor characteristics, anti-tumor treatments, healthcare consumption, presence of neurological symptoms, and do-not-resuscitate status were extracted from medical charts. Results 100 patients were included. A BRAF-mutation was present in 66 patients. Systemic anti-tumor therapy was given to 72% of patients during the last 3 months of life, 34% in the last month, and 6% in the last week. Patients with a BRAF-mutation more frequently received systemic treatment during the last 3 (85% vs. 47%) and last month (42% vs. 18%) of life than patients without a BRAF-mutation. Furthermore, patients receiving systemic treatment were more likely to visit the emergency room (ER, 75% vs. 36%) and be hospitalized (75% vs. 36%) than those who did not. Conclusion The majority of patients with melanoma brain metastases received anti-tumor treatment during the last 3 months of life. ER visits and hospitalizations occurred more often in patients on anti-tumor treatment. Further research is warranted to examine the impact of anti-tumor treatments close to death on symptom burden and care satisfaction.
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Tobar LE, Farnsworth RH, Stacker SA. Brain Vascular Microenvironments in Cancer Metastasis. Biomolecules 2022; 12:biom12030401. [PMID: 35327593 PMCID: PMC8945804 DOI: 10.3390/biom12030401] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/27/2022] [Accepted: 03/01/2022] [Indexed: 01/27/2023] Open
Abstract
Primary tumours, particularly from major solid organs, are able to disseminate into the blood and lymphatic system and spread to distant sites. These secondary metastases to other major organs are the most lethal aspect of cancer, accounting for the majority of cancer deaths. The brain is a frequent site of metastasis, and brain metastases are often fatal due to the critical role of the nervous system and the limited options for treatment, including surgery. This creates a need to further understand the complex cell and molecular biology associated with the establishment of brain metastasis, including the changes to the environment of the brain to enable the arrival and growth of tumour cells. Local changes in the vascular network, immune system and stromal components all have the potential to recruit and foster metastatic tumour cells. This review summarises our current understanding of brain vascular microenvironments, fluid circulation and drainage in the context of brain metastases, as well as commenting on current cutting-edge experimental approaches used to investigate changes in vascular environments and alterations in specialised subsets of blood and lymphatic vessel cells during cancer spread to the brain.
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Affiliation(s)
- Lucas E. Tobar
- Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia; (L.E.T.); (R.H.F.)
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC 3010, Australia
| | - Rae H. Farnsworth
- Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia; (L.E.T.); (R.H.F.)
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC 3010, Australia
| | - Steven A. Stacker
- Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia; (L.E.T.); (R.H.F.)
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC 3010, Australia
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC 3050, Australia
- Correspondence: ; Tel.: +61-3-8559-7106
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Jia S, Zhu T, Shi H, Zong C, Bao Y, Wen X, Ge S, Ruan J, Xu S, Jia R, Fan X. American Joint Committee on Cancer (AJCC) tumor staging system predicts the outcome and metastasis pattern in conjunctival melanoma. Ophthalmology 2022; 129:771-780. [PMID: 35245602 DOI: 10.1016/j.ophtha.2022.02.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 12/22/2022] Open
Abstract
PURPOSE To assess the predictive value of the tumor staging system in the eighth edition of the American Joint Committee on Cancer Cancer Staging Manual (AJCC 8th-Edition) and histologic features for outcomes and metastasis patterns in conjunctival melanoma (CM). DESIGN Retrospective, single-center cohort study. PARTICIPANTS Eighty-three patients with CM were treated at our center between 2000 and 2021. METHODS We reviewed clinical and histopathological parameters and used Kaplan-Meier survival curves and Cox proportional hazards regression models for risk factor analyses. MAIN OUTCOME MEASURES Time to nodal/distant metastasis, disease-specific survival, metastatic pattern, and metastatic site. RESULTS At presentation, five patients (6%) had cT1 disease, 34 (41%) had cT2 disease, and 44 (53%) had cT3 disease. Four (5%) patients had nodal metastasis (N1), and none had distant metastasis (M1). During follow-up, 12 (14%) developed nodal metastasis, 29 (35%) developed distant metastasis, and 26 (31%) died of disease. Brain, liver and lung were common distant metastasis sites. Higher cT category was associated with increased risks of distant metastasis (p<0.001) and disease-specific death (p=0.002). The separate analysis of primary and recurrent tumors at presentation showed that the patients with cT3 tumors took a much higher risk of distant metastasis than those with cT2 tumors. Greater tumor thickness, ulceration, and the presence of regression were correlated with distant metastasis. Previously unreported mutations were detected in the tumor suppressor genes: FAT4 and SYK. Among the 29 patients who developed distant metastasis, we analyzed two patterns of metastasis: 11 patients (38%) developed nodal metastasis prior to distant metastasis, and 18 patients (62%) developed distant metastasis without previously known nodal metastasis. The patients with cT3 tumors were more likely to follow the latter metastasis pattern (p=0.02). CONCLUSION CM presented with mostly advanced stages and high rates of distant metastasis in the current Chinese cohort. This study confirmed the prognostic value of the tumor staging system in the AJCC 8th-Edition in Chinese patients. Histologic features, such as tumor thickness and ulceration, should be emphasized when assessing prognosis and guiding the treatment of CM.
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Affiliation(s)
- Shichong Jia
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, P. R. China
| | - Tianyu Zhu
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, P. R. China
| | - Hanhan Shi
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, P. R. China
| | - Chunyan Zong
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, P. R. China
| | - Yongyang Bao
- Department of Pathology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, P. R. China
| | - Xuyang Wen
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, P. R. China
| | - Shengfang Ge
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, P. R. China
| | - Jing Ruan
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, P. R. China
| | - Shiqiong Xu
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, P. R. China.
| | - Renbing Jia
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, P. R. China.
| | - Xianqun Fan
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, P. R. China.
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Jablonska PA, Fong CH, Kruser T, Weiss J, Liu ZA, Takami H, Narita Y, de Moraes FY, Dasgupta A, Ong CK, Yang JCH, Lee JH, Pavlakis N, Kongkham P, Butler M, Shultz DB. Recommended first-line management of brain metastases from melanoma: A multicenter survey of clinical practice. Radiother Oncol 2022; 168:89-94. [PMID: 35121033 DOI: 10.1016/j.radonc.2022.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/23/2022] [Accepted: 01/25/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Radiotherapy (RT) and surgery (Sx) are effective in treating brain metastases. However, immune checkpoint inhibitors (ICI) have shown activity against asymptomatic melanoma brain metastases (MBM). BRAF/MEK inhibitors can be used to treat BRAF V600 mutation positive (BRAF+) MBM. METHOD We conducted an international survey among experts from medical oncology (MO), clinical oncology (CO), radiation oncology (RO), and neurosurgery (NS) about treatment recommendations for patients with asymptomatic BRAF+ or BRAF mutation negative (BRAF-) MBM. Eighteen specific clinical scenarios were presented and a total of 267 responses were collected. Answers were grouped and compared using Fisher's exact test. RESULTS In most MBM scenarios, survey respondents, regardless of specialty, favored RT in addition to systemic therapy. However, for patients with BRAF+ MBM, MO and CO were significantly more likely than RO and NS to recommend BRAF/MEK inhibitors alone, without the addition of RT, including the majority of MO (51%) for patients with 1-3 MBM, all <2cm. Likewise, for BRAF- MBM, MO and CO more commonly recommended single or dual agent ICI only and dual agent ICI therapy alone was the most common recommendation from MO or CO for MBM <2cm. When at least 1 of 3 MBM (BRAF+ or BRAF-) was >2cm, upfront Sx was recommended by all groups with the exception that MO and RO recommended RT for BRAF- MBM. CONCLUSIONS In most clinical settings involving asymptomatic MBM, experts recommended RT in addition to systemic therapy. However, recommendations varied significantly according to specialty, with MO and CO more commonly recommending dual systemic therapy alone for up to 9 BRAF- MBM <2cm.
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Affiliation(s)
| | - Chin Heng Fong
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
| | | | - Jessica Weiss
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Canada
| | - Zhihui Amy Liu
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Canada
| | - Hirokazu Takami
- Department of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan
| | - Yoshitaka Narita
- Department of Neurosurgery and Neuro-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | | | - Archya Dasgupta
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
| | | | - James C H Yang
- Graduate Institute of Oncology, National Taiwan University, Taipei, Taiwan
| | - Jih Hsiang Lee
- Graduate Institute of Oncology, National Taiwan University, Taipei, Taiwan
| | - Nicholas Pavlakis
- Graduate Institute of Oncology, National Taiwan University, Taipei, Taiwan
| | - Paul Kongkham
- Division of Neurosurgery, Toronto Western Hospital, Canada
| | - Marcus Butler
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - David B Shultz
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.
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Ge Y, Che X, Gao X, Zhao S, Su J. Combination of radiotherapy and targeted therapy for melanoma brain metastases: a systematic review. Melanoma Res 2021; 31:413-420. [PMID: 34406985 DOI: 10.1097/cmr.0000000000000761] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Radiotherapy is a mainstay of efficient treatment of brain metastases from solid tumors. Immunotherapy has improved the survival of metastatic cancer patients across many tumor types. However, targeted therapy is a feasible alternative for patients unable to continue immunotherapy or with poor outcomes of immunotherapy. The combination of radiotherapy and targeted therapy for the treatment of brain metastases has a strong theoretical underpinning, but data on the efficacy and safety of this combination is still limited. A systematic search of PubMed, Embase, Web of Science and the Cochrane library database was conducted. Eleven studies were included for a total of 316 patients. Median OS was about 6.2-17.8 months from radiotherapy. Weighted survival and local control at 1 and 2 years were correlated (50.1 and 17.8%, 90.7 and 14.7% at 1 and 2 year, respectively). Radiotherapy given before or concurrently to targeted therapy provided the best effect on the outcome. For patients with brain metastases from cutaneous melanoma, the addition of concurrent targeted therapy to brain radiotherapy can increase survival and provide long-term control.
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Affiliation(s)
- Yi Ge
- Department of Dermatology, Xiangya Hospital, Central South University
- Hunan Engineering Research Center of Skin Health and Disease
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Central South University, Changsha, China
| | - Xuanlin Che
- Department of Dermatology, Xiangya Hospital, Central South University
- Hunan Engineering Research Center of Skin Health and Disease
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Central South University, Changsha, China
| | - Xin Gao
- Department of Dermatology, Xiangya Hospital, Central South University
- Hunan Engineering Research Center of Skin Health and Disease
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Central South University, Changsha, China
| | - Shuang Zhao
- Department of Dermatology, Xiangya Hospital, Central South University
- Hunan Engineering Research Center of Skin Health and Disease
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Central South University, Changsha, China
| | - Juan Su
- Department of Dermatology, Xiangya Hospital, Central South University
- Hunan Engineering Research Center of Skin Health and Disease
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Central South University, Changsha, China
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Dalmasso C, Pagès C, Chaltiel L, Sibaud V, Moyal E, Chira C, Sol JC, Latorzeff I, Meyer N, Modesto A. Intracranial Treatment in Melanoma Patients with Brain Metastasis Is Associated with Improved Survival in the Era of Immunotherapy and Anti-BRAF Therapy. Cancers (Basel) 2021; 13:cancers13174493. [PMID: 34503304 PMCID: PMC8430519 DOI: 10.3390/cancers13174493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/19/2021] [Accepted: 09/01/2021] [Indexed: 11/16/2022] Open
Abstract
Metastatic melanoma patients are at high risk of brain metastases (BM). Although intracranial control is a prognostic factor for survival, impact of local (intracranial) treatment (LT), surgery and/or radiotherapy (stereotactic or whole brain) in the era of novel therapies remains unknown. We evaluated BM incidence in melanoma patients receiving immune checkpoint inhibitors (ICI) or anti-BRAF therapy and identified prognostic factors for overall survival (OS). Clinical data and treatment patterns were retrospectively collected from all patients treated for newly diagnosed locally advanced or metastatic melanoma between May 2014 and December 2017 with available BRAF mutation status and receiving systemic therapy. Prognostic factors for OS were analyzed with univariable and multivariable survival analyses. BMs occurred in 106 of 250 eligible patients (42.4%), 64 of whom received LT. Median OS in patients with BM was 7.8 months (95% CI [5.4-10.4]). In multivariable analyses, LT was significantly correlated with improved OS (HR 0.21, p < 0.01). Median OS was 17.3 months (95% CI [8.3-22.3]) versus 3.6 months (95% CI [1.4-4.8]) in patients with or without LT. LT correlates with improved OS in melanoma patients with BM in the era of ICI and anti-BRAF therapy. The use of LT should be addressed at diagnosis of BM while introducing systemic treatment.
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Affiliation(s)
- Céline Dalmasso
- Radiation Oncology Department, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, CEDEX 9, 31059 Toulouse, France; (C.D.); (E.M.); (C.C.)
| | - Cécile Pagès
- Dermato-Oncology Department, Institut Universitaire du Cancer, CEDEX 9, 31059 Toulouse, France; (C.P.); (V.S.); (N.M.)
| | - Léonor Chaltiel
- Biostatistics Department, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, CEDEX 9, 31059 Toulouse, France;
| | - Vincent Sibaud
- Dermato-Oncology Department, Institut Universitaire du Cancer, CEDEX 9, 31059 Toulouse, France; (C.P.); (V.S.); (N.M.)
| | - Elisabeth Moyal
- Radiation Oncology Department, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, CEDEX 9, 31059 Toulouse, France; (C.D.); (E.M.); (C.C.)
- Gamma Knife Unit, CHU–Toulouse-Purpan, 31000 Toulouse, France; (J.C.S.); (I.L.)
| | - Ciprian Chira
- Radiation Oncology Department, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, CEDEX 9, 31059 Toulouse, France; (C.D.); (E.M.); (C.C.)
| | - Jean Christophe Sol
- Gamma Knife Unit, CHU–Toulouse-Purpan, 31000 Toulouse, France; (J.C.S.); (I.L.)
- Neuro-Surgery Department, CHU de Toulouse–Purpan, 31000 Toulouse, France
| | - Igor Latorzeff
- Gamma Knife Unit, CHU–Toulouse-Purpan, 31000 Toulouse, France; (J.C.S.); (I.L.)
- Radiation Oncology Department, Oncorad, Clinique Pasteur, 31000 Toulouse, France
| | - Nicolas Meyer
- Dermato-Oncology Department, Institut Universitaire du Cancer, CEDEX 9, 31059 Toulouse, France; (C.P.); (V.S.); (N.M.)
- Dermatology Department, CHU de Toulouse, Hôpital Larrey, CEDEX 9, 31059 Toulouse, France
| | - Anouchka Modesto
- Radiation Oncology Department, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse, CEDEX 9, 31059 Toulouse, France; (C.D.); (E.M.); (C.C.)
- Correspondence:
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Biomarkers of Targeted Therapy and Immuno-Oncology in Cancers Metastatic to the Breast. Appl Immunohistochem Mol Morphol 2021; 28:661-668. [PMID: 31517642 PMCID: PMC7664953 DOI: 10.1097/pai.0000000000000808] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The breast is a rare site for metastases, and their molecular characteristics have not been studied yet. Intrinsic molecular genetics, cancer characteristics, and breast tissue immune responses in diverse metastases to the breast have not been previously studied. We identified 64 patients with cancers metastatic to the breast: 51 carcinomas and 13 melanomas. Programmed death ligand 1 (PD-L1), steroid receptors, and HER2/neu expressions were evaluated using immunohistochemistry. Gene sequencing, copy number alterations, microsatellite instability, and tumor mutational burden were performed using next-generation sequencing platforms. The 3 most common primary sites for metastatic carcinomas were lung (37%), ovary (29%), and fallopian tubes/peritoneum (14%). TP53 mutations were commonly (50%) observed among the carcinoma cases, while other mutations were characteristic for the primary cancers (VHL in renal, BRCA1 in the fallopian tube, and BRAF in melanomas). High tumor mutational burden was detected in 5/14 carcinomas and 3/7 melanomas. Tumor cell PD-L1 expression was detected in 6 carcinomas, but not in any of the melanomas, whereas immune cells' expression of PD-L1 was seen in 17 carcinomas and 6 melanomas. Estrogen receptor status was positive in 13/49 carcinomas including 12 adenocarcinomas originating from the ovary and fallopian tube or peritoneum and 1 duodenal neuroendocrine carcinoma. No carcinoma was HER2/neu positive. Intrinsic genetic characteristics of the metastases to the breast followed the pattern commonly seen in primary tumors. Biomarkers of potential benefit to immune checkpoint inhibition therapy were limited to PD-L1-positive non-small cell lung cancer. No common characteristics of the heterogeneous group of tumor metastases to this organ were identified.
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A Retrospective Analysis of Dabrafenib and/or Dabrafenib Plus Trametinib Combination in Patients with Metastatic Melanoma to Characterize Patients with Long-Term Benefit in the Individual Patient Program (DESCRIBE III). Cancers (Basel) 2021; 13:cancers13102466. [PMID: 34070224 PMCID: PMC8158680 DOI: 10.3390/cancers13102466] [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: 03/10/2021] [Revised: 04/21/2021] [Accepted: 04/23/2021] [Indexed: 11/21/2022] Open
Abstract
Simple Summary Compassionate-use programs provide an opportunity to retrospectively evaluate the treatment patterns and clinical outcomes in a real-world setting to validate the results derived from controlled randomized clinical trials. The COMBI-d and COMBI-v studies established the superior efficacy of dabrafenib + trametinib (dab + tram) versus BRAF inhibitor monotherapy in patients with BRAF V600–mutant metastatic melanoma. In light of their five-year results demonstrating long-term benefit with first-line dab + tram, it is important to get a real-world perspective of the long-term treatment duration for dab + tram. DESCRIBE III was designed to retrospectively evaluate the impact of patient characteristics on the long-term outcomes of dab + tram in a real-world setting based on the duration of clinical benefit. Consistent with the findings from the pooled analysis of COMBI-d and COMBI-v, lower LDH level and <3 metastatic sites at baseline were associated with a longer duration of treatment benefit in a real-world setting. Abstract The dabrafenib plus trametinib (dab + tram) combination has demonstrated durable long-term efficacy in patients with BRAF V600–mutant metastatic melanoma. However, real-world data characterizing patients with long-term benefit are limited. DESCRIBE III was a global, observational, retrospective, chart review study in patients with unresectable or metastatic melanoma treated with dab monotherapy and/or dab + tram combination therapy as part of the Named Patient Program or Individual Patient Program. Overall, 509 patients were enrolled. Patients were categorized into three groups based on their observed treatment duration: long-term (on therapy ≥12 months), intermediate (on therapy ≥6 months and <12 months), and short-term (on therapy <6 months) duration of benefit. More patients in the short-term duration of benefit group had baseline characteristics associated with poor prognosis compared with the other two groups. Median lactate dehydrogenase (LDH) levels (368 U/L) at baseline were also higher in the short-term duration of benefit group. No new safety signals were identified. DESCRIBE III identified baseline characteristics associated with long-term benefit of dab + tram. Lower LDH level and <3 metastatic sites at baseline were associated with a longer duration of benefit, confirming that the findings from COMBI-d and COMBI-v are relevant to patients treated in a real-world setting.
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O'Halloran PJ, Cleary A, Cryan JB, Beausang A, Brett FM, Caird J. Melanoma brain metastases in Ireland: surgical and systemic considerations. Br J Neurosurg 2021; 36:236-240. [PMID: 33904364 DOI: 10.1080/02688697.2021.1918327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
BACKGROUND Cerebral metastases is a common complication in patients with melanoma. There is a paucity of information in the Republic of Ireland regarding the factors associated with melanoma brain metastases (MBM). METHODS Patients diagnosed with melanoma brain metastases in Ireland were retrospectively identified in Beaumont Hospital between 1999 and 2018. Patient demographics; age at diagnosis of primary melanoma, age at detection of MBM, year of detection of MBM, anatomical location of primary melanoma, BRAF mutation analysis and the number of metastases were investigated. Follow-up data were also derived, including overall survival. RESULTS There has being a 158% increase in the incidence of primary melanoma from 1999 compared to 2016. Over the same time period 128 patients with melanoma brain metastases were diagnosed. There was a significant male predominance (n = 77/128; 60%; p < 0.0001). BRAF mutation and leptomeningeal disease were independent prognostic factors in our cohort with a median survival 8 months and 0.5 months, respectively. CONCLUSIONS Male predominance, leptomeningeal disease and BRAF mutation represent important considerations in this population group. The results of this study add to our knowledge concerning outcomes in melanoma brain metastases and may be useful in clinical planning and future treatments.
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Affiliation(s)
- Philip J O'Halloran
- National Neurosurgery Center, Beaumont Hospital, Dublin, Ireland.,Physiology and Medical Physics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Anna Cleary
- Physiology and Medical Physics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Jane B Cryan
- Department of Neuropathology, Beaumont Hospital, Dublin, Ireland
| | - Alan Beausang
- Department of Neuropathology, Beaumont Hospital, Dublin, Ireland
| | | | - John Caird
- National Neurosurgery Center, Beaumont Hospital, Dublin, Ireland
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21
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Bander ED, Yuan M, Carnevale JA, Reiner AS, Panageas KS, Postow MA, Tabar V, Moss NS. Melanoma brain metastasis presentation, treatment, and outcomes in the age of targeted and immunotherapies. Cancer 2021; 127:2062-2073. [PMID: 33651913 DOI: 10.1002/cncr.33459] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 12/17/2020] [Accepted: 12/22/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Historically, the prognosis for patients who have melanoma brain metastasis (MBM) has been dismal. However, breakthroughs in targeted and immunotherapies have improved long-term survival in those with advanced melanoma. Therefore, MBM presentation, prognosis, and the use of multimodality central nervous system (CNS)-directed treatment were reassessed. METHODS In this retrospective study, the authors evaluated patients with MBM who received treatment at Memorial Sloan Kettering Cancer Center between 2010 and 2019. Kaplan-Meier methodology was used to describe overall survival (OS). Recursive partitioning analysis and time-dependent multivariable Cox modeling were used to assess prognostic variables and to associate CNS-directed treatments with OS. RESULTS Four hundred twenty-five patients with 2488 brain metastases were included. The median OS after an MBM diagnosis was 8.9 months (95% CI, 7.9-11.3 months). Patients who were diagnosed with MBM between 2015 and 2019 experienced longer OS compared to those who were diagnosed between 2010 and 2014 (OS, 13.0 months [95% CI, 10.47-17.06 months] vs 7.0 months [95% CI, 6.1-8.3 months]; P = .0003). Prognostic multivariable modeling significantly associated shortened OS independently with leptomeningeal dissemination (P < .0001), increasing numbers of brain metastases at diagnosis (P < .0001), earlier MBM diagnosis year (P = .0008), higher serum levels of lactate dehydrogenase (P < .0001), receipt of immunotherapy before MBM diagnosis (P = .003), and the presence of extracranial disease (P = .02). The use of different CNS-directed treatment modalities was associated with presenting symptoms, diagnosis year, number and size of brain metastases, and the presence of extracranial disease. Multivariable analysis demonstrated improved survival for patients who underwent craniotomy (P = .01). CONCLUSIONS The prognosis for patients with MBM has improved within the last 5 years, coinciding with the approval of PD-1 immune checkpoint blockade and combined BRAF/MEK targeting. Improving survival reflects and may influence the willingness to use aggressive multimodality treatment for MBM. LAY SUMMARY Historically, melanoma brain metastases (MBM) have carried a poor survival prognosis of 4 to 6 months; however, the introduction of immunotherapy and targeted precision medicines has altered the survival curve for advanced melanoma. In this large, single-institution, contemporary cohort, the authors demonstrate a significant increase in survival of patients with MBM to 13 months within the last 5 years of the study. A worse prognosis for patients with MBM was significantly associated with the number of metastases at diagnosis, previous exposure to immunotherapy, spread of disease to the leptomeningeal compartment, serum lactate dehydrogenase elevation, and the presence of extracranial disease. The current age of systemic treatments has also been accompanied by shifts in the use of central nervous system-directed therapies.
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Affiliation(s)
- Evan D Bander
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York
| | - Melissa Yuan
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph A Carnevale
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York
| | - Anne S Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katherine S Panageas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael A Postow
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Viviane Tabar
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nelson S Moss
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
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22
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Liermann J, Winkler JK, Syed M, Neuberger U, Reuss D, Harrabi S, Naumann P, Ristau J, Weykamp F, El Shafie RA, König L, Debus J, Hassel J, Rieken S. Stereotactic Radiosurgery With Concurrent Immunotherapy in Melanoma Brain Metastases Is Feasible and Effective. Front Oncol 2020; 10:592796. [PMID: 33178618 PMCID: PMC7593445 DOI: 10.3389/fonc.2020.592796] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 09/09/2020] [Indexed: 12/25/2022] Open
Abstract
Objective: Stereotactic radiosurgery (SRS) is an established treatment for brain metastases in the management of metastasized melanoma. The increasing use of checkpoint inhibitors in melanoma therapy leads to combined treatment schemes consisting of immunotherapy and SRS that need to be evaluated regarding safety and feasibility. Methods: We retrospectively analyzed 36 patients suffering from cerebral metastasized melanoma. Between November 2011 and May 2016, altogether 66 brain metastases were treated with single-fraction SRS (18-20 Gy prescribed to the 80% isodose) in combination with a checkpoint inhibitor (ipilimumab: 82%, pembrolizumab: 14% or nivolumab: 4%), administered within 3 months before or after SRS. Toxicity was evaluated with focus on the incidence of central nervous system (CNS) radiation necrosis (CRN). Overall survival (OS), freedom from local progression (FFLP), freedom from central nervous system radiation necrosis (FFCRN), and freedom from distant intracranial progression (FFDIP) were analyzed using the Kaplan-Meier method. Results: The median follow-up was 25 months (range: 2-115 months). Two patients (6%) presented with cerebral edema CTCAE °III and another two patients (6%) presented with one-sided muscle weakness CTCAE °III after SRS. One of these four symptomatic cases correlated with an observed CRN, the other three symptomatic cases were related to local tumor progression (n = 2) or related to the performance of additional whole brain radiotherapy (WBRT). No further CTCAE °III or °IV toxicity was seen. During follow-up, seven of the growing contrast-enhanced lesions were resected, revealing two cases of CRN and five cases of local tumor progression. Altogether, the observed CRN rate of the irradiated metastases was 6-17% at the time of analysis, ranging due to the radiologically challenging differentiation between CRN and local tumor progression. The observed ranges of the 1- and 2-years FFLP rates were 82-85% and 73-80%, respectively. The median FFDIP was 6.1 months, the median OS was 22.2 months. Conclusion: In the presented cohort, the combination of SRS and checkpoint inhibitors in the management of cerebral metastasized melanoma was safe and effective. Compared to historic data on SRS only, the observed CRN rate was acceptable. To gain resilient data on the incidence of CRN after combined treatment schemes, prospective trials are needed.
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Affiliation(s)
- Jakob Liermann
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Julia K Winkler
- National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Dermatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Mustafa Syed
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Ulf Neuberger
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - David Reuss
- Heidelberg University Hospital, Institute of Pathology, Heidelberg, Germany
| | - Semi Harrabi
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Patrick Naumann
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Jonas Ristau
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Fabian Weykamp
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Rami A El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Partner Site Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jessica Hassel
- National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Dermatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
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23
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Keung EZ, Gershenwald JE. Clinicopathological Features, Staging, and Current Approaches to Treatment in High-Risk Resectable Melanoma. J Natl Cancer Inst 2020; 112:875-885. [PMID: 32061122 PMCID: PMC7492771 DOI: 10.1093/jnci/djaa012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 12/06/2019] [Accepted: 01/17/2020] [Indexed: 12/12/2022] Open
Abstract
The incidence of melanoma in the United States has been increasing over the past several decades. Prognosis largely depends on disease stage, with 5-year melanoma-specific survival ranging from as high as 99% in patients with stage I disease to less than 10% for some patients with stage IV (distant metastatic) disease. Fortunately, in the last 5-10 years, there have been remarkable treatment advances for patients with high-risk resectable melanoma, including approval of targeted and immune checkpoint blockade therapies. In addition, results of recent clinical trials have confirmed the importance of sentinel lymph node biopsy and continue to refine the approach to regional lymph node basin management. Lastly, the melanoma staging system was revised in the eighth edition AJCC Cancer Staging Manual, which was implemented on January 1, 2018. Here we discuss these changes and the clinicopathological features that confer high risk for locoregional and distant disease relapse and poor survival. Implications regarding the management of melanoma in the metastatic and adjuvant settings are discussed, as are future directions for neoadjuvant therapies.
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Affiliation(s)
- Emily Z Keung
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Gershenwald
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Melanoma and Skin Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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24
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Abstract
OPINION STATEMENT With greater understanding of underlying biology and development of effective BRAF-targeted therapy and immunotherapy, along with remarkable advances in local treatment such as stereotactic radiosurgery, melanoma brain metastasis (MBM) is witnessing continually improving outcome, with 1-year overall survival rate approaching 85%. Given disease complexity and myriad treatment options, all patients with MBM should ideally be evaluated in a multidisciplinary setting to allow an individualized treatment approach based on prognostic groups, molecular classification, number and size of brain metastasis, and performance status. With improving outcome, pendulum has now swayed to focus more on effective treatment modalities with minimal neurological toxicity while maintaining quality of life. Surgery is usually considered in symptomatic and large MBMs, while stereotactic radiosurgery considered in 1-4 lesions, and now also being explored for up to 15 brain metastases for improved local control. The role of whole brain radiotherapy is diminishing given its neurocognitive toxicities and is reserved for patients with diffuse brain involvement. Cytotoxic chemotherapy has largely been ineffective without evidence for survival benefit. Immune checkpoint inhibitors have become the cornerstone of management for melanoma brain metastasis with durable intracranial tumor control and excellent toxicity profile. For patients with asymptomatic MBMs, ipilimumab and nivolumab have shown intracranial response near 60% and provides comparable clinical benefit in MBMs as for extracranial metastases. For patients with driver BRAF mutation, BRAFi-/MEKi-targeted agents are proven to be effective in MBM with high rate intracranial responses (44-59%). However, the durability of intracranial responses induced by BRAFi/MEKi seems to be shorter than that of extracranial disease. Emerging data support novel combination of systemic therapy and stereotactic radiosurgery, which appears to be safe and effective; however, potential benefits and risks should be evaluated prospectively. Promising ongoing trials will further expand therapeutic evidence in MBM, and patients should be encouraged to participate in clinical trials.
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Affiliation(s)
- Anupam Rishi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr, Tampa, FL, 33612, USA
| | - Hsiang-Hsuan Michael Yu
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr, Tampa, FL, 33612, USA.
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25
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Filipczak N, Jaromin A, Piwoni A, Mahmud M, Sarisozen C, Torchilin V, Gubernator J. A Triple Co-Delivery Liposomal Carrier That Enhances Apoptosis via an Intrinsic Pathway in Melanoma Cells. Cancers (Basel) 2019; 11:cancers11121982. [PMID: 31835393 PMCID: PMC6966600 DOI: 10.3390/cancers11121982] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 11/29/2022] Open
Abstract
The effectiveness of existing anti-cancer therapies is based mainly on the stimulation of apoptosis of cancer cells. Most of the existing therapies are somewhat toxic to normal cells. Therefore, the quest for nontoxic, cancer-specific therapies remains. We have demonstrated the ability of liposomes containing anacardic acid, mitoxantrone and ammonium ascorbate to induce the mitochondrial pathway of apoptosis via reactive oxygen species (ROS) production by the killing of cancer cells in monolayer culture and shown its specificity towards melanoma cells. Liposomes were prepared by a lipid hydration, freeze-and-thaw (FAT) procedure and extrusion through polycarbonate filters, a remote loading method was used for dug encapsulation. Following characterization, hemolytic activity, cytotoxicity and apoptosis inducing effects of loaded nanoparticles were investigated. To identify the anticancer activity mechanism of these liposomes, ROS level and caspase 9 activity were measured by fluorescence and by chemiluminescence respectively. We have demonstrated that the developed liposomal formulations produced a high ROS level, enhanced apoptosis and cell death in melanoma cells, but not in normal cells. The proposed mechanism of the cytotoxic action of these liposomes involved specific generation of free radicals by the iron ions mechanism.
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Affiliation(s)
- Nina Filipczak
- Department of Lipids and Liposomes, Faculty of Biotechnology, University of Wroclaw, 50-383 Wroclaw, Poland; (A.J.); (A.P.); (M.M.); (J.G.)
- Correspondence: or ; Tel.: +48-713-756-318
| | - Anna Jaromin
- Department of Lipids and Liposomes, Faculty of Biotechnology, University of Wroclaw, 50-383 Wroclaw, Poland; (A.J.); (A.P.); (M.M.); (J.G.)
| | - Adriana Piwoni
- Department of Lipids and Liposomes, Faculty of Biotechnology, University of Wroclaw, 50-383 Wroclaw, Poland; (A.J.); (A.P.); (M.M.); (J.G.)
| | - Mohamed Mahmud
- Department of Lipids and Liposomes, Faculty of Biotechnology, University of Wroclaw, 50-383 Wroclaw, Poland; (A.J.); (A.P.); (M.M.); (J.G.)
- Department of Food Science and Technology, Faculty of Agriculture, University of Misurata, Misurata 2478, Libya
| | - Can Sarisozen
- Center for Pharmaceutical Biotechnology and Nanomedicine, Northeastern University, Boston, MA 02115, USA; (C.S.); (V.T.)
| | - Vladimir Torchilin
- Center for Pharmaceutical Biotechnology and Nanomedicine, Northeastern University, Boston, MA 02115, USA; (C.S.); (V.T.)
- Department of Oncology, Radiotherapy and Plastic Surgery I.M. Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia
| | - Jerzy Gubernator
- Department of Lipids and Liposomes, Faculty of Biotechnology, University of Wroclaw, 50-383 Wroclaw, Poland; (A.J.); (A.P.); (M.M.); (J.G.)
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26
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Abstract
The melanoma expert panel devised the evidence-based eighth edition American Joint Committee on Cancer staging system by conducting vigorous analyses of stage I, II, and III patients from the International Melanoma Database and Discovery Platform. Key changes in the eighth edition are regarding subcategorization of T1, M1, pathologic stage grouping of stage I and III, and refining the definitions and terminologies used in the staging system. As the knowledge of tumor biology improves, the staging of melanoma will continue to evolve to enable betterment of care.
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Affiliation(s)
- Kirithiga Ramalingam
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Shyam S Allamaneni
- The Jewish Hospital - Mercy Health Surgical Residency Program, Department of Surgery, 4777 East Galbraith Rd, Cincinnati, OH 45236, USA.
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27
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Abstract
Targeted BRAF and MEK inhibition has become an appropriate first-line treatment of BRAF-mutant advanced cutaneous melanoma. The authors present an overview of the MAPK pathway as well as the other major pathways implicated in melanoma development. Melanoma brain metastases are a devastating complication of melanoma that can be traced to derangements in cell signaling pathways, and the current evidence for targeted therapy is reviewed. Finally, activating KIT mutations are rarely found to cause melanomas and may provide an actionable target for therapy. The authors review the current evidence for targeted KIT therapy and summarize the ongoing clinical trials.
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Affiliation(s)
- James Sun
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, 4th Floor, Tampa, FL 33612, USA
| | - Michael J Carr
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, 4th Floor, Tampa, FL 33612, USA
| | - Nikhil I Khushalani
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, 4th Floor, Tampa, FL 33612, USA.
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28
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Incidence and prognosis of brain metastases in cutaneous melanoma patients: a population-based study. Melanoma Res 2019; 29:77-84. [PMID: 30379726 DOI: 10.1097/cmr.0000000000000538] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Brain metastases (BM) from cutaneous melanoma are associated with poor prognosis. Population-based data describing the associated factors of incidence and prognosis of BM from melanoma are still lacking. We identified 121 255 melanoma patients diagnosed during 2010-2015 from the Surveillance, Epidemiology, and End Results program, and identified predictive factors for incidence and survival of BM patients by using multivariable logistic and Cox's proportional hazard regression, respectively. We identified 1547 patients with BM at the time of diagnosis of malignant cutaneous melanoma, representing 1.3% of the entire cohort and 35.4% of the subset with metastatic disease. The characteristics associated with higher BM incidence were male sex, age 40-60 years, melanoma location of face/head/neck, histologic type of nodular, higher T-stage, ulceration and extracranial metastases. The median overall survival and median cutaneous melanoma specific survival of patients with BM was 5 and 6 months, respectively. The relative factors of poor survival were older age and more extracranial metastatic sites. In summary, we provided insight into the epidemiology of BM from cutaneous melanoma. These results may provide significant help to improve the screening strategy of BM strategy and update the existing prognosis evaluation system.
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29
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Hauswald H, Bernhardt D, Krug D, Katayama S, Habl G, Lorenzo Bermejo J, Debus J, Sterzing F. Whole-brain helical tomotherapy with integrated boost for brain metastases in patients with malignant melanoma - final results of the BRAIN-RT trial. Cancer Manag Res 2019; 11:4669-4676. [PMID: 31213892 PMCID: PMC6538835 DOI: 10.2147/cmar.s204729] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 04/10/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Patients with multiple brain metastases (BMs) from malignant melanoma have a poor prognosis. Recent developments in radiation techniques allow simultaneous integrated boost (SIB) concepts while sparing organs at risk. Data on conventional versus dose-escalated radiation approaches in multiple BMs from malignant melanoma are warranted. Methods: In this prospective, single-center, randomized two-armed study (trial ID: DRKS00005127), patients with multiple BMs from malignant melanoma were treated with either conventional whole-brain radiotherapy (WBRT) applying 30 Gy in 10 fractions (standard arm) or helical tomotherapy applying 30 Gy to the whole brain with an integrated boost to metastases of 50 Gy in 10 fractions and sparing of the hippocampus (HA-WBRT, experimental arm). The primary endpoint was treatment-related toxicity, while secondary endpoints were imaging response, intracerebral progression-free survival (PFS), overall survival (OS) and quality of life. Results: The study was stopped early due to slow patient recruitment. A total number of 7 patients were enrolled (standard arm n=3, experimental arm n=4), and were followed-up for a median time of 5 months between August 2013 and July 2017. All patients were treated according to protocol. The median OS, intracerebral PFS and follow-up time were 5 months, 2 months and 5 months, respectively. The local control in every individual BM was significantly longer in the experimental versus the standard arm. No patient developed radiation-related high-grade toxicities. Conclusion: HA-WBRT with SIB results in improved local control in the individual melanoma BMs without radiation-associated high-grade toxicities. Survival times were comparable to published data.
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Affiliation(s)
- Henrik Hauswald
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), 69120 Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, 69120, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), 69120 Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, 69120, Germany
| | - David Krug
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), 69120 Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, 69120, Germany.,Radiologie München, 80331 München, Germany
| | - Sonja Katayama
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), 69120 Heidelberg, Germany
| | - Gregor Habl
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), 69120 Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, 69120, Germany.,Radiologie München, 80331 München, Germany
| | - Justo Lorenzo Bermejo
- Institute of Medical Biometry and Informatics, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), 69120 Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, 69120, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, 69120, Germany.,German Cancer Consortium (DKTK), Partner Site Heidelberg, Heidelberg, Germany
| | - Florian Sterzing
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), 69120 Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, 69120, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Radiation Oncology, Hospital Kempten, 87439, Kempten, Germany
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30
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Amaral T, Tampouri I, Eigentler T, Keim U, Klumpp B, Heinrich V, Zips D, Paulsen F, Gepfner-Tuma I, Skardelly M, Tatagiba M, Tabatabai G, Garbe C, Forschner A. Immunotherapy plus surgery/radiosurgery is associated with favorable survival in patients with melanoma brain metastasis. Immunotherapy 2019; 11:297-309. [PMID: 30606066 DOI: 10.2217/imt-2018-0149] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Melanoma brain metastases (MBM) are associated with a dismal prognosis. Few clinical trials evaluated the impact of immunotherapy (IT) and targeted therapy (TT) alone or in combination with surgery and radiotherapy in this population. PATIENTS & METHODS Retrospective analysis of data from 163 patients diagnosed with MBM between January 2014 and December 2016. Prognostic factors of overall survival were analyzed using Kaplan-Meier survival curves, classification and regression tree and multivariate Cox regression analysis. RESULTS The median follow-up was 25 months; median overall survival (mOS) for all patients was 7 months. For patients receiving IT, the mOS was 13 months and 7 months for patients receiving TT or chemotherapy (CT). The mOS for patients treated with surgery/radiosurgery in combination with IT, TT and CT was 25, 14 and 11 months, respectively. CONCLUSION New systemic therapies, especially IT, improve mOS in patients with MBM, particularly when combined with surgery/radiosurgery upfront.
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Affiliation(s)
- Teresa Amaral
- Center for Dermatooncology, Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany.,Portuguese Air Force Health Direction, Paço do Lumiar, 1649-020, Lisbon, Portugal
| | - Ioanna Tampouri
- Center for Dermatooncology, Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
| | - Thomas Eigentler
- Center for Dermatooncology, Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
| | - Ulrike Keim
- Center for Dermatooncology, Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
| | - Bernhard Klumpp
- Department of Radiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Vanessa Heinrich
- Department of Radiation Oncology, University Hospital Tuebingen, Tuebingen, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University Hospital Tuebingen, Tuebingen, Germany.,Centre for CNS Tumors at the Comprehensive Cancer Centre Tuebingen-Stuttgart, University Hospital Tuebingen, Tuebingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital Tuebingen, Tuebingen, Germany.,Centre for CNS Tumors at the Comprehensive Cancer Centre Tuebingen-Stuttgart, University Hospital Tuebingen, Tuebingen, Germany
| | - Irina Gepfner-Tuma
- Interdisciplinary Division of Neuro-Oncology, Hertie Institute for Clinical Brain Research, University Hospital Tuebingen, Tuebingen, Germany.,Centre for CNS Tumors at the Comprehensive Cancer Centre Tuebingen-Stuttgart, University Hospital Tuebingen, Tuebingen, Germany
| | - Marco Skardelly
- Interdisciplinary Division of Neuro-Oncology, Hertie Institute for Clinical Brain Research, University Hospital Tuebingen, Tuebingen, Germany.,Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany.,Centre for CNS Tumors at the Comprehensive Cancer Centre Tuebingen-Stuttgart, University Hospital Tuebingen, Tuebingen, Germany
| | - Marcos Tatagiba
- Interdisciplinary Division of Neuro-Oncology, Hertie Institute for Clinical Brain Research, University Hospital Tuebingen, Tuebingen, Germany.,Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany.,Centre for CNS Tumors at the Comprehensive Cancer Centre Tuebingen-Stuttgart, University Hospital Tuebingen, Tuebingen, Germany
| | - Ghazaleh Tabatabai
- Interdisciplinary Division of Neuro-Oncology, Hertie Institute for Clinical Brain Research, University Hospital Tuebingen, Tuebingen, Germany.,Centre for CNS Tumors at the Comprehensive Cancer Centre Tuebingen-Stuttgart, University Hospital Tuebingen, Tuebingen, Germany
| | - Claus Garbe
- Center for Dermatooncology, Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
| | - Andrea Forschner
- Center for Dermatooncology, Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
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Tawbi HA, Boutros C, Kok D, Robert C, McArthur G. New Era in the Management of Melanoma Brain Metastases. Am Soc Clin Oncol Educ Book 2018; 38:741-750. [PMID: 30231345 DOI: 10.1200/edbk_200819] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The remarkable advances in the systemic therapy of metastatic melanoma have now extended the 1-year overall survival rate from 25% to nearing 85%. Systemic treatment in the form of BRAF-targeted therapy and immunotherapy is slowly but surely proving its efficacy in the treatment of metatstatic brain metastases (MBM). Single-agent BRAF inhibitors provide an intracranial response rate of 25% to 40%, whereas the combination of BRAFi/MEKi leads to responses in up to 58%. However, the durability of responses induced by BRAFi/MEKi seems to be even shorter than in extracranial disease. On the other hand, single-agent ipilimumab provides comparable clinical benefit in MBMs as it does in extracranial metastases. Single-agent PD-1 anitbodies induce response rates of approximately 20%, and those responses appear durable. Similarly the combination of CTLA-4+ PD-1 antibodies induces durable responses at an impressive rate of 55% and is safe to administer. Although the local treatment approaches with radiation and surgery remain important and are critically needed in the management of MBM, systemic therapy offers a new dimension that can augment the impact of those therapies and come at a potentially lower cost of neurocognitive impairment. Considerations for combining those modalities are direly needed, in addition to considering novel systemic combinations that target mechanisms specific to MBM. In this report, we will discuss the underlying biology of melanoma brain metastases, the clinical outcomes from recent clinical trials of targeted and immunotherapy, and their impact on clinical practice in the context of existing local therapeutic modalities.
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Affiliation(s)
- Hussein A Tawbi
- From The University of Texas MD Anderson Cancer Center, Houston, TX; Institut Gustave Roussy, Paris, France; Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Celine Boutros
- From The University of Texas MD Anderson Cancer Center, Houston, TX; Institut Gustave Roussy, Paris, France; Peter MacCallum Cancer Centre, Melbourne, Australia
| | - David Kok
- From The University of Texas MD Anderson Cancer Center, Houston, TX; Institut Gustave Roussy, Paris, France; Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Caroline Robert
- From The University of Texas MD Anderson Cancer Center, Houston, TX; Institut Gustave Roussy, Paris, France; Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Grant McArthur
- From The University of Texas MD Anderson Cancer Center, Houston, TX; Institut Gustave Roussy, Paris, France; Peter MacCallum Cancer Centre, Melbourne, Australia
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32
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Xia Y, Mashouf LA, Maxwell R, Peng LC, Lipson EJ, Sharfman WH, Bettegowda C, Redmond KJ, Kleinberg LR, Lim M. Adjuvant radiotherapy and outcomes of presumed hemorrhagic melanoma brain metastases without malignant cells. Surg Neurol Int 2018; 9:146. [PMID: 30105140 PMCID: PMC6080145 DOI: 10.4103/sni.sni_140_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 06/14/2018] [Indexed: 12/28/2022] Open
Abstract
Background Patients with melanoma can present with a hemorrhagic intracranial lesion. Upon resection, pathology reports may not detect any malignant cells. However, the hemorrhage may obscure their presence and so physicians may still decide whether adjuvant radiotherapy should be applied. Here, we report on the outcomes of a series of patients with melanoma with hemorrhagic brain lesions that returned with no tumor cells. Methods All melanoma patients who had craniotomies from 2008 to 2017 at a single institution for hemorrhagic brain lesions were identified through retrospective chart review. Those who had pathology reports with no malignant cells were analyzed. Recurrence at the former site of hemorrhage and resection was the primary outcome. Results Ten patients met inclusion criteria, and the median follow-up time was 8.5 (1.8-27.3) months. At the time of craniotomy, the median number of brain lesions was 3 (1-25). Two patients had prior craniotomies, eight had prior radiation, and six had prior immunotherapy to the lesion of interest. After surgery, one patient received stereotactic radiosurgery (SRS) to the resection bed. Only one patient developed subsequent melanoma at the resection site; this patient developed the lesion recurrence once and had not received postoperative SRS. Conclusion Although small foci of metastatic disease as a source of bleeding for some patients cannot be excluded, melanoma patients with a suspected hemorrhagic brain metastasis that shows no tumor cells on pathology may benefit from close observation. The local recurrence risk in such cases appears to be low, even without adjuvant radiation.
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Affiliation(s)
- Yuanxuan Xia
- Department of Neurosurgery, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - Leila A Mashouf
- Department of Neurosurgery, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - Russell Maxwell
- Department of Neurosurgery, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA.,Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - Luke C Peng
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - Evan J Lipson
- Department of Oncology, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - William H Sharfman
- Department of Oncology, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - Michael Lim
- Department of Neurosurgery, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA.,Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA.,Department of Oncology, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
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Bauer-Nilsen K, Trifiletti DM, Chatrath A, Ruiz-Garcia H, Marchan E, Peterson J, May BC, Sheehan JP. Stereotactic radiosurgery for brain metastases from malignant melanoma and the impact of hemorrhagic metastases. J Neurooncol 2018; 140:83-88. [PMID: 29926319 DOI: 10.1007/s11060-018-2933-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 06/14/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Stereotactic radiosurgery (SRS) is a common treatment modality among patients with brain metastases, particularly from malignant melanoma. Our objective was to investigate the difference in local control, toxicity, and survival among patients with hemorrhagic and solid melanoma brain metastases. METHODS We collected demographic, treatment, local control, toxicity, and survival for 134 patients with a total of 936 intracranial melanoma metastases who underwent SRS between 1998 and 2015. Pre-radiosurgical diagnostic imaging was reviewed for evidence of hemorrhage (melanin-containing or clearly hemorrhagic). RESULTS The cohort consisted of 92 men and 42 women with a mea age of 61.7 years (range 21.2-84.9) at the time of radiosurgery. Overall survival of patients with brain metastases from malignant melanoma was 42, 31, 12% at 12, 24, and 72 months from date of first SRS. At 6 months, 43% of the patients with hemorrhagic metastases had local tumor control compared to 83% of solid melanoma metastases (p < 0.001). No significant difference in toxicity was noted between the two groups. Factors that were significantly associated with time to local tumor progression on multivariate analysis include prior WBRT (HR 1.62, p = 0.003), prior chemotherapy (HR 0.69, p = 0.011), margin dose (HR 0.88, p < 0.001) and radiographic features of melanin deposition (HR 3.73, p < 0.001), or clear hemorrhage (HR 2.20, p < 0.001). CONCLUSIONS Our findings demonstrate that hemorrhagic intracranial melanoma metastases are associated with inferior local tumor control when treated with SRS, as compared to solid tumors. These results highlight the importance of early radiosurgery among patients with melanoma brain metastases before hemorrhage occurs.
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Affiliation(s)
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA. .,Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA.
| | - Ajay Chatrath
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
| | - Eduardo Marchan
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
| | - Jennifer Peterson
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA.,Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Byron C May
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
| | - Jason P Sheehan
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA.,Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
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Nieder C, Hintz M, Bilger A, Oehlke O, Grosu AL. Validation of the Graded Prognostic Assessment for Melanoma Using Molecular Markers (Melanoma-molGPA). J Clin Med Res 2018; 10:178-181. [PMID: 29416574 PMCID: PMC5798262 DOI: 10.14740/jocmr3248w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 11/21/2017] [Indexed: 11/29/2022] Open
Abstract
Background It has been suggested to replace the diagnosis-specific graded prognostic assessment (DS-GPA, based on performance status and number of brain metastases) for patients with primary malignant melanoma with the new Melanoma-molGPA. The latter is a more complex assessment, which also includes BRAF mutation status, age and extracranial metastases. To test the performance of the Melanoma-molGPA, we performed a validation study of this new survival prediction tool. Methods A retrospective analysis of patients treated at two different academic institutions was performed. The four-tiered Melanoma-molGPA was calculated as suggested in the original study. Results Median overall survival was 5.4 months (95% confidence interval: 3.1 - 7.7 months). Median survival in the four prognostic classes was 2.1, 7.8, 11.8, and 18.0 months, respectively. The 1-year survival rates were 3%, 25%, 43%, and 80%, respectively. The difference between the Kaplan-Meier curves was significant (P = 0.0001, log-rank test). Conclusions The present survival outcomes support the use of the Melanoma-molGPA. However, survival was better in each of the four groups in the original study. Possible reasons include lead-time bias and different treatment policies.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092 Bodo, Norway.,Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromso, 9037 Tromso, Norway
| | - Mandy Hintz
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany
| | - Angelika Bilger
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany
| | - Oliver Oehlke
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Germany
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