Dabrafenib plus trametinib in patients with BRAFV600-mutant melanoma brain metastases (COMBI-MB): a multicentre, multicohort, open-label, phase 2 trial

Beyond Checkpoint Inhibition: Keeping Therapeutic Options Open

Combination immune checkpoint inhibitor therapy (ICI) with ipilimumab (anti-cytotoxic T-lymphocyte-associated protein 4) + nivolumab (anti-PD-1) in untreated, metastatic melanoma has achieved a ten-year melanoma-specific survival of 52%. However, approximately 40%-55% of patients with metastatic melanoma have primary resistance and do not initially respond to anti-PD-1, and an additional 25% of patients develop secondary resistance, exhibiting an initial response followed by disease progression. In PD-1-refractory melanoma, treatment options are limited. Addition of ipilimumab, relatlimab (anti-LAG3), or lenvatinib (VEGFR TKI) has minimal to modest efficacy. Switching to targeted BRAF/MEK inhibition improves survival for BRAF-mutant disease. MEK and KIT inhibitors have limited activity in NRAS- and KIT-mutant metastatic melanoma, respectively. Recently, personalized, autologous tumor-infiltrating lymphocyte therapy has become a US Food and Drug Administration-approved second-line option; lifileucel demonstrates durable response (approximately 30%) in heavily pretreated, metastatic melanoma. Emerging therapeutics that show promising clinical benefit in ongoing clinical trials include novel engineered oncolytic viral and human leukocyte antigen (HLA)-restricted immune-mediated T-cell therapies. As a therapy which is limited to patients who are HLA-A*02:01, T-cell receptor (TCR) engineered T cells (TCR-T) iterates on personalized adoptive cell transfer, and immune mobilizing monoclonal TCRs against cancer are CD3 bispecifics that bind glycoprotein 100 (tebentafusp, approved for metastatic uveal melanoma) or PRAME to activate T cells. Finally, in patients at high risk for immune-related adverse events (irAEs), ICI should still be considered. ICI may be given with modified immunosuppression in patients with autoimmune disease or previous organ transplantation. Cumulative data support safe administration in older patients and in ICI rechallenge for patients with previous irAE.

Combination of encorafenib and binimetinib followed by ipilimumab and nivolumab versus ipilimumab and nivolumab in patients with advanced melanoma with BRAFV600E or BRAFV600K mutations (EBIN): an international, open-label, randomised, controlled, phase 2 study

BACKGROUND

Current first-line treatment for patients with metastatic melanoma with BRAFV600E or BRAFV600K mutations includes immunotherapy with immune checkpoint inhibitors and targeted therapy; however, the optimal sequencing of these treatments is unclear. We aimed to investigate the use of a targeted-therapy induction regimen before treatment with immune checkpoint inhibitors.

METHODS

This open-label, randomised, controlled, phase 2 trial (EBIN) was conducted at 37 centres in eight European countries. Eligible patients were 18 years or older and had previously untreated, unresectable, stage III or IV melanoma with BRAFV600E or BRAFV600K mutations and an Eastern Cooperative Oncology Group performance status of 0 or 1. Patients were randomly assigned (1:1) to one of two groups. Those in the induction group received targeted therapy (oral encorafenib 450 mg once a day plus oral binimetinib 45 mg twice a day for 12 weeks) followed by immune checkpoint inhibitors (intravenous nivolumab 3 mg/kg plus intravenous ipilimumab 1 mg/kg once every 3 weeks for four doses, followed by intravenous nivolumab 480 mg once every 4 weeks until unacceptable toxicity, disease progression, or 2 years of treatment). Patients in the control group received immune checkpoint inhibitors as above without any induction targeted therapy. Randomisation was conducted using a minimisation technique and was stratified by centre and a variable defined using stage and lactate dehydrogenase activity. The primary outcome was progression-free survival in the intention-to-treat population. Safety was assessed in all patients who initiated the protocol treatment. In this Article we report the primary analysis. The study is registered with ClinicalTrials.gov, NCT03235245, and is ongoing.

FINDINGS

Between Nov 12, 2018, and July 11, 2022, 271 patients were randomly assigned: 136 to the induction group and 135 to the control group. 103 (38%) patients were female, 168 (62%) were male, and the median age was 55 years (IQR 43-66). The median follow-up time was 21 months (IQR 13-33). There was no evidence of a longer progression-free survival in the induction group than in the control group (hazard ratio 0·87, 90% CI 0·67-1·12; p=0·36). The median progression-free survival was 9 months (95% CI 7-13) in the induction group and 9 months (5-14) in the control group. Grade 3-5 treatment-related adverse events occurred in 57 (42%) of 136 patients who started treatment in the induction group and in 42 (32%) of 131 patients who started treatment in the control group. The most common grade 3-4 treatment-related adverse event was hepatitis (17 [13%] of 136 patients in the induction group and nine [7%] of 131 patients in the control group). Serious treatment-related adverse events occurred in 45 (33%) of 136 patients in the induction group and 33 (25%) of 131 patients in the control group. There were three treatment-related deaths: two from cardiac events (heart failure and arrhythmia) in the induction group and one from meningitis in the control group.

INTERPRETATION

The targeted-therapy induction regimen did not improve progression-free survival compared with first-line treatment with immune checkpoint inhibitors in unselected patients with advanced melanoma with BRAFV600E or BRAFV600K mutations.

FUNDING

Bristol Myers Squibb and Pierre Fabre.

Improved Survival and Prognostication in Melanoma Patients With Brain Metastases: An Update of the Melanoma Graded Prognostic Assessment

PURPOSE

Survival for patients with melanoma has recently improved. The propensity of melanoma to metastasize to the brain remains a common and serious feature of this disease. The purposes of this study were to evaluate prognostic factors for patients with newly diagnosed melanoma brain metastases (MBMs) in a large cohort treated with modern multimodal therapies, compare those results with those in prior eras, and update the Melanoma Graded Prognostic Assessment (GPA).

METHODS

Univariable and multivariable (MVA) analyses of prognostic factors and treatments associated with survival were performed on 1,796 patients with newly diagnosed MBM treated between January 01, 2015, and December 31, 2021, using a multi-institutional retrospective database. Multiple imputation was used to address missingness of potential predictors. Significant variables in combined MVA were used to update the Melanoma GPA. Comparisons were made with legacy cohorts.

RESULTS

Median survivals for cohorts A (1985-2007, n = 481), B (2006-2015, n = 823), and C (2015-2021, n = 1,796) were 6.7, 9.8, and 16.6 months and median follow-up times were 40.1, 43.6, and 48.8 months, respectively. In combined MVA, significant prognostic factors for survival were higher Karnofsky Performance Status, fewer MBMs, absence of extracranial metastases, lower serum lactate dehydrogenase, and no immunotherapy before MBM. These factors were incorporated into the updated Melanoma GPA. The combined median and 3-year survivals for patients with GPA 0-1, 1.5-2, and 2.5-4.0 were 5.4, 13.2, and 43.2 months and 12.4%, 28.8%, and 51.6%, respectively.

CONCLUSION

Prognostic factors have changed and survival has improved for patients with MBM but varies widely by GPA. The updated Melanoma GPA calculator (BrainMetGPA), available free online, can be used to estimate survival, individualize treatment, stratify clinical trials, guide surveillance, and augment clinical trial eligibility. Multidisciplinary treatment is essential. Trials are needed to elucidate the optimal sequencing of various therapeutic modalities.

Co-inhibition of Notch1 and ChK1 triggers genomic instability and melanoma cell death increasing the lifespan of mice bearing melanoma brain metastasis

BACKGROUND

Melanoma brain metastases (MBM) are a leading cause of death in patients with advanced disease. MBM treatment relay on targeted and immunotherapy and on stereotactic radiosurgery as gold standard. Life expectancy has improved significantly with these therapies however, targeted therapy is short lived and only about half of the patients respond to immunotherapy, while radiation is limited by melanoma cells intrinsic resistance to DNA damage. New therapeutic approaches are therefore needed to treat MBM. Here we investigate a new role of Notch1 in genomic instability and demonstrate that blockade of both Notch1 and the DNA repair factor ChK1 causes extensive DNA damage and tumor cell death increasing survival in MBM bearing mice.

METHODS

Anti-Notch1 (anti-N1) was previously described. Prexaserib, a ChK1 inhibitor, is currently in clinical trials. K457 and A375 melanoma cells were used. RNA sequencing was performed in K457 cells treated with anti-N1 and Gene Set Enrichment Analysis performed. DNA damage was evaluated by a DNA fiber assay to assess replication fork speed; and γH2AX foci count and neutral comet assay to quantify double strand breaks. Cell survival was evaluated by trypan blue and a colony formation assay. Luciferase expressing A375 cells were orthotopically inoculated in the right cerebral cortex of athymic nude mice, for in vivo evaluation of a therapy with anti-N1 and prexasertib. Survival was assessed by Kaplan-Meyer survival curves and significance assessed by a Log-rank test.

RESULTS

Notch1 blockade caused genomic instability by reducing histone availability, leading to DNA replication stress and DNA damage. This in turn, resulted in the activation of the DNA Damage Response pathway ATR/ChK1 to counter the damage. Co-inhibition of Notch1, via anti-N1, and ChK1, via prexasertib (prex), exacerbated DNA damage increasing melanoma cell death. Importantly, combination anti-N1/prex significantly improved survival of mice bearing MBMs.

CONCLUSIONS

A therapy with anti-N1/prexasertib could represent a novel treatment strategy, alone or in combination with current treatment regimens, for melanoma brain metastases.

Tumor Microenvironment in Melanoma Brain Metastasis: A New Potential Target?

Melanoma, a malignant skin tumor, is the third skin tumor and the third cause of brain metastases. The development and introduction of systemic therapies, such as Braf inhibitors and checkpoint inhibitors, have guaranteed an increase in overall survival. The appearance of brain metastases, which determines a median survival of less than 5 months, represents a sign of systemic disease progression and tumor instability. In this view, in addition to systemic therapy, the therapeutic options can be surgery, stereotactic surgery, and whole-brain radiation therapy. However, it has been observed that the response to systemic therapies of brain metastatic lesions, compared to extracerebral ones, does not guarantee complete local tumor control, thus increasing the mortality and morbidity of patients. This phenomenon, tumor escape, makes systemic therapy partly ineffective. How melanoma cells migrate, cross the blood-brain barrier, and invade brain tissue is still being studied. The melanocytic metastatic brain tumor microenvironment and its assay seem to have a key role in the response and therefore in the progression of metastatic lesions. Through this work, the intent is to underline the importance of the brain tumor microenvironment and how it can influence tumor growth, its response to therapy, and the patient's overall survival.

Efficacy of encorafenib plus binimetinib in patients with BRAF-mutated melanoma brain metastases: Results from the Dutch Melanoma Treatment Registry

AIM

Data on the effectiveness of encorafenib/binimetinib in melanoma patients with brain metastases (BMs) are limited.

METHODS

All patients with BRAF V600-mutated melanoma and BMs treated with encorafenib/binimetinib between 2019 and 2022 in the Netherlands were included from the nationwide Dutch Melanoma Treatment Registry. Patients previously treated with other BRAF/MEK inhibitors were excluded. We analyzed objective response rates (ORR), progression-free survival (PFS), and overall survival (OS). Multivariable Cox regression identified factors associated with survival. Subgroup analyses included asymptomatic versus symptomatic BMs and line of treatment (first-line versus later-line).

RESULTS

In total, 190 patients were included. Symptomatic BMs were present in 63 % of patients. Encorafenib/binimetinib was the first-line treatment in 64 % of all patients, while 36 % had prior immunotherapy. Overall, the ORR was 69.4 %, median PFS was 5.5 months (95 %CI 4.9-6.2), and median OS 11.9 months (95 %CI 10.0-15.7). Age ≥ 70, ECOG PS ≥ 2, symptomatic BMs, and elevated LDH were significantly associated with worse survival. Patients with prior immunotherapy had a median PFS of 6.9 months (95 %CI 4.3-9.6) and OS of 17.9 months (95 %CI 13.7-31.2), while this was 4.9 months (95 %CI 4.3-5.5) and 10.1 months (95 %CI 8.1-13.0) in treatment-naïve patients. Median PFS and OS in patients with asymptomatic versus symptomatic BMs were 6.1 months (95 %CI 4.9-9.8) and 20.5 (95 %CI 14.0-NA) versus 5.3 months (95 %CI 4.9-6.3) and 10.7 (95 %CI 8.9-13.7), respectively.

CONCLUSIONS

Encorafenib/binimetinib has clinical activity in real-world melanoma patients with BMs. Their prognosis is determined by the presence of symptomatic BMs, age, ECOG PS, and LDH levels.

RANO criteria for response assessment of brain metastases based on amino acid PET imaging

Novel diagnostic and therapeutic opportunities are needed to improve medical care and outcome of patients with brain metastases, a frequent and severe complication of several cancer types. Currently, magnetic resonance imaging (MRI) is the primary method used for detection, treatment planning and disease monitoring in patients with brain metastases, but this method has limitations. These limitations mean that MRI can inform on lesion size but cannot directly measure the activity or viability of tumor tissue. Positron emission tomography (PET) imaging, however, can visualize metabolically active tumor cells and is therefore increasingly incorporated into cancer care to assess tumor burden and response to treatment. Here, we define the PET Response Assessment in Neuro-Oncology (RANO) for brain metastasis (BM) 1.0 criteria for metabolic response assessment of brain metastases using amino acid PET. By introducing an innovative endpoint for next-generation clinical trials, the PET RANO BM 1.0 criteria aim to facilitate development of novel therapies for patients with brain metastases.

Prognostic relevance of the neurological symptom burden in brain metastases from breast cancer

BACKGROUND

Existing prognostic models for breast cancer (BC) brain metastases (BM) overlook neurological symptoms. Thus, we explored the incidence and prognostic relevance of neurological symptoms in a real-world cohort of BC patients with BM.

METHODS

The Vienna Brain Metastasis Registry identified BC patients with BM between 1992 and 2020, categorised by subtype: hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-), HER2 overexpressing (HER2+), and triple-negative (TN).

RESULTS

A total of 716 patients with BM from BC were included. In total, 80% (573/716) of the patients presented with neurological symptoms at BM diagnosis. Across all BC subtypes, asymptomatic patients presented with a significantly longer median OS from diagnosis of BM compared to symptomatic patients (p < 0.05; log-rank test; HR+ BC 29 vs. 9 months; HER2+ BC 24 vs. 12 months; TN 12 vs. 6 months). In multivariate analysis with the BC-specific Graded Prognostic Assessment (Breast-GPA: HR:1.4; 95% CI:1.3-1.5; p < 0.001), the presence of neurological symptoms at diagnosis (HR:1.6; 95% CI: 1.4-1.9; p < 0.001) presented as independently associated with OS from time of BM diagnosis, respectively.

CONCLUSIONS

Neurological burden at BM diagnosis independently predicts survival in BC patients. Our findings emphasise incorporating the symptom status in the prognostic evaluation and reassessing BM screening in high-risk patients during prospective clinical trials.

The role of upfront radiation therapy for brain metastases in the era of CNS-active systemic therapies: a narrative review of clinical trial design and lessons learned

PURPOSE

Systemic therapies are increasingly being considered as primary treatments for brain metastases (BM), deferring the upfront use of local treatment modalities. However, evidence to support this paradigm shift is difficult to interpret given the volume of data published and the intricacies of the outcomes reported. The objective of this narrative review is to evaluate the current evidence guiding treatment selection for BM patients by assembling and analyzing a detailed dataset of clinical trials, completed and published during the last two decades.

METHODS

Obstacles in interpreting the results of prospective systemic therapy clinical trials are detailed, including non-standardized study cohorts, inconsistent use of response assessment criteria, insufficient endpoint definition for central nervous system (CNS) efficacy, and under-reporting of previous radiotherapy. The paucity of prospective data to guide radiation therapy options is also addressed, and caveats of the available published evidence are detailed.

RESULTS

Proposed treatment and follow-up recommendations for patient with newly diagnosed BM are provided based on currently available evidence.

CONCLUSION

Prospective trials evaluating contemporary treatment paradigms and defining the respective roles of systemic and local therapies are eagerly awaited.

Stereotactic radiosurgery for patients with brain metastases: current principles, expanding indications and opportunities for multidisciplinary care

The management of brain metastases is challenging and should ideally be coordinated through a multidisciplinary approach. Stereotactic radiosurgery (SRS) has been the cornerstone of management for most patients with oligometastatic central nervous system involvement (one to four brain metastases), and several technological and therapeutic advances over the past decade have broadened the indications for SRS to include polymetastatic central nervous system involvement (>4 brain metastases), preoperative application and fractionated SRS, as well as combinatorial approaches with targeted therapy and immune-checkpoint inhibitors. For example, improved imaging and frameless head-immobilization technologies have facilitated fractionated SRS for large brain metastases or postsurgical cavities, or lesions in proximity to organs at risk. However, these opportunities come with new challenges and questions, including the implications of tumour histology as well as the role and sequencing of concurrent systemic treatments. In this Review, we discuss these advances and associated challenges in the context of ongoing clinical trials, with insights from a global group of experts, including recommendations for current clinical practice and future investigations. The updates provided herein are meaningful for all practitioners in clinical oncology.

Two Cases of Malignant Melanoma with Long-term Survival after the Appearance of Brain Metastases

Brain metastases from malignant tumors are generally known to have a poor prognosis. One of the major reasons for this is the lack of efficacy of anti-tumor drugs compared to other organs. One of the major reasons for this is the lack of efficacy of anti-tumor drugs compared to other organs. Malignant melanoma is a highly malignant tumor that occurs mainly in the skin and is relatively prone to brain metastasis. In this case report, we report two cases of malignant melanoma with brain metastases that were treated with a combination of radiotherapy and chemotherapy and had long-term survival. Case 1 was a 51-year-old Japanese man with primary melanoma of the chest; the pathological staging was pT4aN1aM0, stage IIIC. He developed multiple brain metastases two years and three months after the initial resection. Case 2 was a 23-year-old Japanese woman with primary melanoma of the upper extremities; the pathological staging was pT1bN1aM0, stage IIIA. She developed brain metastases one year and nine months after the initial resection. Both patients had positive BRAF gene mutations in their primary tumors. The combination of BRAF inhibitors, immune checkpoint inhibitors, and stereotactic radiotherapy resulted in long-term survival of more than 5 years for Case 1 and more than 6 years for Case 2. With advances in chemotherapy and radiotherapy, the prognosis for patients with brain metastases, not only malignant melanoma, is expected to improve further in the future. Although rare, malignant melanoma is known to occur in various organs other than the skin. We report this case because we believe that our case report will be of interest to physicians who treat the above organs.

BRAF Targeting Across Solid Tumors: Molecular Aspects and Clinical Applications

BRAF mutations are critical drivers in cancers such as melanoma, colorectal cancer, and non-small-cell lung cancer. The most common mutation, BRAF V600E, is a key therapeutic target. Targeted treatments with BRAF and MEK inhibitors have significantly improved progression-free and overall survival in melanoma patients. However, in cancers like metastatic colorectal cancer, BRAF mutations are associated with poor outcomes due to aggressive disease behavior and resistance to conventional chemotherapy. Despite progress, resistance to BRAF/MEK inhibitors remains a major challenge, often driven by secondary mutations in the mitogen-activated protein kinase (MAPK) pathway, activation of alternative pathways such as phosphoinositide 3-kinases (PI3Ks)/protein kinase B (AKT), or changes in the tumor microenvironment. These challenges have motivated ongoing research into combining BRAF inhibitors with immunotherapies to enhance and prolong treatment effectiveness. Future research must also account for the role of the cancer's tissue of origin, as the biological context significantly influences response to targeted therapies, highlighting the need for a deeper understanding of tumor biology, micro-environment, and genetics.

LIN28B-mediated PI3K/AKT pathway activation promotes metastasis in colorectal cancer models

Colorectal cancer (CRC) remains a leading cause of cancer death because of metastatic spread. LIN28B is overexpressed in 30% of CRCs and promotes metastasis, yet its mechanisms remain unclear. In this study, we genetically modified CRC cell lines to overexpress LIN28B, resulting in enhanced PI3K/AKT pathway activation and liver metastasis in mice. We developed genetically modified mouse models with constitutively active Pik3ca that form intestinal tumors progressing to liver metastases with an intact immune system, addressing the limitations of previous Pik3ca-mutant models, including long tumor latency, mixed histology, and lack of distant metastases. The PI3Kα-specific inhibitor alpelisib reduced migration and invasion in vitro and metastasis in vivo. We present a comprehensive analysis of vertical inhibition of the PI3K/AKT pathway in CRC using the FDA-approved drugs alpelisib and capivasertib (an AKT inhibitor) in combination with LY2584702 (a ribosomal protein S6 kinase inhibitor) in CRC cell lines and mouse- and patient-derived organoids. Tissue microarrays from patients with CRC verified that LIN28B and PI3K/AKT pathway activation correlate with CRC progression. These findings highlight the critical role of the LIN28B-mediated PI3K/AKT pathway in CRC metastasis, the therapeutic potential of targeted inhibition, and the promise of patient-derived organoids in precision medicine in metastatic CRC.

Impact of brain metastasis size at the time of radiotherapy on local control and radiation necrosis

PURPOSE

No consensus has been reached regarding whether upfront versus deferred radiation to small, asymptomatic brain metastases is most optimal. We sought to assess the relationship between tumor size at radiation and subsequent development of local recurrence and radiation necrosis to make data-driven recommendations regarding timing of radiation utilization.

METHODS

We identified 2268 patients with 6308 newly diagnosed brain metastases between 2010 and 2022 managed with brain-directed radiotherapy at Brigham and Women's Hospital/Dana-Farber Cancer Institute (Boston, MA). Tumors were grouped by maximal unidimensional size: <0.5 cm, 0.5 to < 1 cm, 1 cm to < 2 cm, and ≥ 2 cm; local recurrence and radiation necrosis by tumor size were assessed using competing risks regression.

RESULTS

Among metastases initially treated with stereotactic radiation or whole brain radiotherapy, lesions 1 to < 2 cm (HR 2.30 [95% CI, 1.38-3.81], p = 0.001 and HR 2.61 [95% CI 1.76-3.89], p < 0.001, respectively) and ≥ 2 cm (HR 3.10 [95% CI, 1.62-5.94], p < 0.001 and HR 3.03 [95% CI 1.92-4.79], p < 0.001, respectively) displayed greater local recurrence compared to tumors < 0.5 cm. In addition, among patients treated with stereotactic radiation, significantly higher risk of radiographic and symptomatic necrosis was observed in tumors ≥ 0.5 cm versus < 0.5 cm at radiotherapy, with hazard ratios ranging from 3.27 to 18.90.

CONCLUSION

Larger metastasis size is associated with markedly poorer local control and increased necrosis following brain-directed radiation, suggesting a role for earlier utilization of radiation therapy in patients with small, asymptomatic metastases and a favorable prognosis.

Immune checkpoint inhibitor therapy is associated with a decreased risk of developing melanoma brain metastases

BACKGROUND

Despite recent advancements in metastatic melanoma treatment, the emergence of melanoma brain metastases (MBM) continues to pose a challenge. This study aimed to explore factors associated with MBM development.

METHODS

This retrospective study included patients diagnosed with advanced melanoma (unresectable stages III and IV [M1a-c]) between 2013 and 2019 at Sahlgrenska University Hospital, Gothenburg, Sweden. Differences in baseline and primary tumor characteristics, mutational status, biomarker levels, and first-line treatment between patients who developed MBM (BM+) and patients who did not develop MBM (BM-) were analyzed using univariable and multivariable Cox proportional hazard regression.

RESULT

Of 395 patients, 91 subsequently developed MBM. Patients who received immune checkpoint inhibitors (ICI) as first-line treatment had a reduced risk of MBM development (p ≤ 0.001). None of the eleven patients who received CTLA-4 inhibitors as monotherapy or in combination with PD-1 inhibitors as first-line treatment developed brain metastases. Elevated plasma levels of S100B (p = 0.021) and higher metastatic stage (p = 0.047) were also associated with an increased risk of MBM development.

CONCLUSION

ICI treatment is associated with a decreased risk of MBM development, suggesting a protective role. Elevated S100B levels and stage IV disease at advanced melanoma diagnosis might indicate an increased risk of MBM development.

Cutaneous melanoma

Cutaneous melanoma is a common cancer in Australia and New Zealand, Europe, and North America, and its incidence is still increasing in many regions. Ultraviolet (UV) radiation exposure (for example, through excessive sunlight exposure) remains the primary risk factor for melanoma; however, public awareness campaigns have led to a marked reduction in mortality. In addition to genetic damage from UV radiation, specific genetic alterations have been linked to melanoma. The stage of the tumour at the time of diagnosis is of greater importance for melanoma prognosis than in almost any other cancer. Context-dependent genetic mutations that attenuate tumour-suppressive mechanisms or activate growth-promoting signalling pathways are crucial factors in the development of cutaneous melanoma. In addition to external factors such as UV radiation, the tumour microenvironment can contribute to melanoma progression, invasion and metastasis. Cutaneous melanoma treatment has improved considerably over the past decade with the discovery and development of immune checkpoint inhibitors and therapy targeting BRAF and MEK. Over the next decade, several priorities are likely to influence melanoma research and management, including the continued advance of precision medicine methods to identify the most suitable patients for the most effective treatment, with the aim of improving clinical outcomes.

Multidisciplinary management strategies for recurrent brain metastasis after prior radiotherapy: An overview

As cancer patients with intracranial metastatic disease experience increasingly prolonged survival, the diagnosis and management of recurrent brain metastasis pose significant challenges in clinical practice. Prior to deciding upon a management strategy, it is necessary to ascertain whether patients have recurrent/progressive disease vs adverse radiation effect, classify the recurrence as local or distant in the brain, evaluate the extent of intracranial disease (size, number and location of lesions, and brain metastasis velocity), the status of extracranial disease, and enumerate the interval from the last intracranially directed intervention to disease recurrence. A spectrum of salvage local treatment options includes surgery (resection and laser interstitial thermal therapy [LITT]) with or without adjuvant radiotherapy in the forms of external beam radiotherapy, intraoperative radiotherapy, or brachytherapy. Nonoperative salvage local treatments also range from single fraction and fractionated stereotactic radiosurgery (SRS/FSRS) to whole brain radiation therapy (WBRT). Optimal integration of systemic therapies, preferably with central nervous system (CNS) activity, may also require reinterrogation of brain metastasis tissue to identify actionable molecular alterations specific to intracranial progressive disease. Ultimately, the selection of the appropriate management approach necessitates a sophisticated understanding of patient, tumor, and prior treatment-related factors and is often multimodal; hence, interdisciplinary evaluation for such patients is indispensable.

Short-term survivors with brain metastases have modest benefits from focal and systemic therapies and remain frequent despite improving treatment landscape

Purpose

Therapeutic options for patients with brain metastases (BM) increase. While these lead to considerable survival effects in subgroups, there is limited knowledge about characteristics, prognosticators and treatment effects in patients with BM and short survival.

Methods

Patients with a survival time of ≤ 6 months (short-term survivors, STS), diagnosed with BM between 2009-2021 at a large tertiary cancer center were analysed. Clinical and treatment characteristics, pathological data and causes of death were documented. Descriptive statistics, treatment-specific univariate Kaplan-Meier estimator analyses and multivariate Cox regression were performed.

Results

Among 1248 patients with BM, 480 (38 %) were STS. 256 STS with detailed clinical records were included in this analysis. In univariate and multivariate analysis, Karnofsky Performance Status (KPS) (p < 0.001) and number of BM (p = 0.004) were prognostic. In 75 % of patients, the ds-GPA score predicted short-term survival. Use of resection with focal radiotherapy (p < 0.001) and systemic treatment (p < 0.001) appeared prognostically favourable compared to whole brain radiotherapy (WBRT) alone. However, survival benefits were very modest, with a median gain of 6 weeks following resection and focal radiotherapy compared to whole-brain radiotherapy, and 3 weeks from systemic treatment. Systemic tumor progression was documented as the cause of death in the majority of patients. Over the examined time period, the ratio between STS and other patients remained without significant change.

Conclusion

Within STS, KPS and number of BM are of prognostic relevance. There is benefit from local and systemic therapy to a limited extent. Shared and carefully discussed individual therapy decisions are necessary.

Ipilimumab plus nivolumab versus nivolumab alone in patients with melanoma brain metastases (ABC): 7-year follow-up of a multicentre, open-label, randomised, phase 2 study

BACKGROUND

Patients with melanoma brain metastases respond well to immunotherapy, but long-term comparative survival data are scarce. We aimed to assess the efficacy of ipilimumab plus nivolumab versus nivolumab alone in patients with melanoma brain metastases at 7 years.

METHODS

This open-label, randomised, phase 2 study was conducted at four sites (two research institute cancer centres and two university teaching hospitals) in Australia. Patients aged 18 years or older with active, immunotherapy-naive melanoma brain metastases and Eastern Cooperative Oncology Group performance status of 0-2 were eligible. Asymptomatic patients with no previous brain-directed therapy were randomly assigned (5:4) using the biased-coin minimisation method (after a safety run-in of six patients) to cohort A (intravenous ipilimumab 3 mg/kg plus nivolumab 1 mg/kg every 3 weeks for four doses, then nivolumab 3 mg/kg every 2 weeks) or cohort B (intravenous nivolumab 3 mg/kg every 2 weeks). Patients with previous brain-directed therapy, neurological symptoms, or leptomeningeal disease were assigned to cohort C (non-randomised; intravenous nivolumab 3 mg/kg every 2 weeks). The primary endpoint was best intracranial response (complete or partial response) from week 12. Secondary survival endpoints included intracranial progression-free survival and overall survival. Safety was assessed from the first dose of treatment to at least 100 days after treatment discontinuation. Analyses were performed in patients who received at least one dose of study drug. The main analysis has been reported, and this is a long-term follow up of the ABC trial. This trial is registered with ClinicalTrials.gov, NCT02374242, and is ongoing.

FINDINGS

Between Nov 4, 2014, and April 21, 2017, 89 patients were assessed for eligibility, 79 of whom were enrolled and assigned to cohort A (n=36), cohort B (n=27), or cohort C (n=16). Three patients (one in cohort A and two in cohort B) were excluded due to ineligibility. 17 (22%) of 76 patients were female and 59 (78%) were male. At data cutoff (March 26, 2024), the median follow-up was 7·6 years (IQR 6·9-8·2). Overall intracranial responses occurred in 18 (51% [95% CI 34-69]) patients from cohort A, five (20% [7-41]) from cohort B, and one (6% [0-30]) from cohort C. 7-year intracranial progression-free survival was 42% (95% CI 29-63) in cohort A, 15% (6-39) in cohort B, and 6% (1-42) in cohort C. 7-year overall survival was 48% (34-68) in cohort A, 26% (13-51) in cohort B, and 13% (3-46) in cohort C. Safety results were consistent with the primary analysis. 50 patients died, including 18 (51%) from cohort A, 18 (72%) from cohort B, and 14 (88%) from cohort C.

INTERPRETATION

Our findings suggest that ipilimumab plus nivolumab maintains efficacy to at least 7 years in patients with active asymptomatic brain metastasis. Upfront ipilimumab plus nivolumab should be the standard of care for patients with melanoma brain metastasis; a trial investigating the role of stereotactic surgery in this new paradigm is ongoing.

FUNDING

Melanoma Institute Australia and Bristol Myers Squibb.

Navigating the landscape of immune checkpoint inhibitors and novel immunotherapies in melanoma: long-term outcomes, progress, and challenges

INTRODUCTION

Melanoma has become the poster child for transformative outcomes in advanced malignancy from the use of immunotherapy over the last 10-15 years with median survival improving from ~ 1 to > 5 years. With the increasing repertoire of immune checkpoint inhibitors (ICI) and other novel immunotherapeutic approaches, integrating and sequencing treatments to create new paradigms has gained prominence, with focus on optimizing toxicity management and complex scenarios such as immunotherapy resistance, brain metastases, fertility, and duration of follow-up.

AREAS COVERED

In this review, we summarize the progress and emerging evidence in melanoma treatments to date and consider management and possible future directions to improve outcomes for above-mentioned specific patient cohorts.

EXPERT OPINION

Personalized care with integration of novel prognostic and predictive biomarkers is the way forward in tailoring not only patient selection and choice of therapy, but also duration of treatment and surveillance to allow for early recurrence detection and access to newer therapies such as tumor infiltrating lymphocytes (TIL) to maximize the curative fraction of melanoma patients. Further research is needed in optimizing ICI and other immunotherapy toxicity management, including reducing steroid exposure for better patient outcomes and preserving quality of life.

Pathological diagnosis of central nervous system tumours in adults: what's new?

In the course of the last decade, the pathological diagnosis of many tumours of the central nervous system (CNS) has transitioned from a purely histological to a combined histological and molecular approach, resulting in a more precise 'histomolecular diagnosis'. Unfortunately, translation of this refinement in CNS tumour diagnostics into more effective treatment strategies is lagging behind. There is hope though that incorporating the assessment of predictive markers in the pathological evaluation of CNS tumours will help to improve this situation. The present review discusses some novel aspects with regard to the pathological diagnosis of the most common CNS tumours in adults. After a brief update on recognition of clinically meaningful subgroups in adult-type diffuse gliomas and the value of assessing predictive markers in these tumours, more detailed information is provided on predictive markers of (potential) relevance for immunotherapy especially for glioblastomas, IDH-wildtype. Furthermore, recommendations for improved grading of meningiomas by using molecular markers are briefly summarised, and an overview is given on (predictive) markers of interest in metastatic CNS tumours. In the last part of this review, some 'emerging new CNS tumour types' that may occur especially in adults are presented in a table. Hopefully, this review provides useful information on 'what's new' for practising pathologists diagnosing CNS tumours in adults.

Precision radiotherapy with molecular-profiling of CNS tumours

Diagnoses of CNS malignancies in the primary and metastatic setting have significantly advanced in the last decade with the advent of molecular pathology. Using a combination of immunohistochemistry, next-generation sequencing, and methylation profiling integrated with traditional histopathology, patient prognosis and disease characteristics can be understood to a much greater extent. This has recently manifested in predicting response to targeted drug therapies that are redefining management practices of CNS tumours. Radiotherapy, along with surgery, still remains an integral part of treating the majority of CNS tumours. However, the rapid advances in CNS molecular diagnostics have not yet been effectively translated into improving CNS radiotherapy. We explore several promising strategies under development to integrate molecular oncology into radiotherapy, and explore future directions that can serve to use molecular diagnostics to personalize radiotherapy. Evolving the management of CNS tumours with molecular profiling will be integral to supporting the future of precision radiotherapy.

Survival improvements in patients with melanoma brain metastases and leptomeningeal disease in the modern era: Insights from a nationwide study (2015-2022)

INTRODUCTION

Advances in modern therapies have improved outcomes for patients with melanoma brain metastases (MBM), though prognosis remains poor. The optimal treatment strategy for patients who do not meet clinical trial inclusion criteria is unclear.

METHODS

This study included all patients with MBM diagnosed in Denmark between 2015 and 2022, identified through the Danish Metastatic Melanoma Database (DAMMED) and local surgical and radiotherapy records. Data were collected from electronic patient records.

RESULTS

A total of 838 patients were included, with a median overall survival (OS) of 9.0 months. Of these, 112 (19.4 %) survived beyond 3 years post-diagnosis. Patients treated with immune checkpoint inhibitors (ICI) as first line treatment, specifically ipilimumab + nivolumab, demonstrated an intracranial overall response rate (icORR) of 46 % and a 2-year OS of 49 %. Those treated with BRAF/MEK inhibitors (BRAF/MEKi) had an icORR of 56 % but a 2-year OS of 20 %. Patients with leptomeningeal disease (LMD, n = 67) had a median OS of 8.4 months. Systemic therapy was associated with a superior OS for patients with LMD, though no survival benefit was seen with ICI compared to BRAF/MEKi. Among the 230 patients who underwent surgery, 30 received postoperative stereotactic radiosurgery (SRS); however, there was no difference in OS or intracranial progression-free survival between the groups.

CONCLUSION

A considerable proportion of patients with brain metastases diagnosed after 2015 survived more than 3 years. Patients with LMD appeared to obtain limited benefit of ICI with only few patients alive > 3 years post-diagnosis.

Invasion and metastasis in cancer: molecular insights and therapeutic targets

The progression of malignant tumors leads to the development of secondary tumors in various organs, including bones, the brain, liver, and lungs. This metastatic process severely impacts the prognosis of patients, significantly affecting their quality of life and survival rates. Research efforts have consistently focused on the intricate mechanisms underlying this process and the corresponding clinical management strategies. Consequently, a comprehensive understanding of the biological foundations of tumor metastasis, identification of pivotal signaling pathways, and systematic evaluation of existing and emerging therapeutic strategies are paramount to enhancing the overall diagnostic and treatment capabilities for metastatic tumors. However, current research is primarily focused on metastasis within specific cancer types, leaving significant gaps in our understanding of the complex metastatic cascade, organ-specific tropism mechanisms, and the development of targeted treatments. In this study, we examine the sequential processes of tumor metastasis, elucidate the underlying mechanisms driving organ-tropic metastasis, and systematically analyze therapeutic strategies for metastatic tumors, including those tailored to specific organ involvement. Subsequently, we synthesize the most recent advances in emerging therapeutic technologies for tumor metastasis and analyze the challenges and opportunities encountered in clinical research pertaining to bone metastasis. Our objective is to offer insights that can inform future research and clinical practice in this crucial field.

Genomic Profiling Reveals SMARCA4 Mutations Are Associated with Shorter Overall and Intracranial Progression-Free Survival in Patients with Melanoma Brain Metastases

PURPOSE

Melanoma brain metastases (MBM) are a common and lethal complication of metastatic melanoma. Despite improvements in treatments, subsets of patients with MBM experience rapid clinical decline, and currently, few prognostic biomarkers have been identified. An improved understanding of the molecular features specifically associated with MBM overall survival (OS) and intracranial progression-free survival (PFS) could facilitate the development of more effective clinical management strategies.

EXPERIMENTAL DESIGN

We established an initial cohort of 102 MBMs, 970 unmatched melanoma extracranial metastases (ECM), and 569 unmatched melanoma primaries with available targeted exome sequencing data covering 182 genes and a validation cohort of 50 MBMs with SMARCA4 genomically profiled. Kaplan-Meier analysis, log-rank test, and Cox proportional hazards model were used to evaluate associations between pathogenic genomic alterations and OS and intracranial PFS. We evaluated 14 MBMs and 19 ECMs with paired RNA sequencing and whole-exome sequencing data to identify genotype-transcriptome correlations.

RESULTS

Of 43 genes significantly mutated among MBMs, only pathogenic mutations in SMARCA4 significantly associated with shorter OS and intracranial PFS on univariable and multivariable analyses in patients with MBM but not from first ECM or primary tumor diagnosis. SMARCA4 mutations significantly associated with enrichment of oxidative phosphorylation and depletion of immune signaling gene sets.

CONCLUSIONS

Pathogenic SMARCA4 mutations independently predict an association with shorter OS and intracranial PFS in patients with MBM and associate with expression of pathways known to mediate melanoma virulence. These findings add to our understanding of MBM pathogenesis and suggest their potential use as prognostic biomarkers in patients with MBM and possible therapeutic opportunities.

The clinical benefit of adding radiotherapy to ipilimumab in patients with melanoma brain metastasis: a systematic review and meta-analysis

Combining radiotherapy (RT) with Ipilimumab, a CTLA-4 inhibitor, holds promise in treating metastatic brain melanoma (MBM). Despite promising preclinical evidence, clinical studies evaluating their combined efficacy are limited and varied, necessitating a systematic review and meta-analysis to consolidate evidence and identify predictors of response or resistance in this challenging patient population. This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The electronic databases of PubMed, Embase, Scopus, and Web of science were searched on July 9th, 2024, using the relevant key terms without filters. All statistical analysis was performed by STATA v.17. A total of 26 studies with 1059 participants were included. The 1, 2, and 3-year overall survival rates were 0.44 [95% CI: 0.32-0.55], 0.28 [95% CI: 0.17, 0.39], and 0.19 [95% CI: 0.06-0.32], respectively. The pooled 12-month local control and 1-year progression-free survival rate were 0.53 [95% CI: 0.34-0.71] and 0.20 [95%CI: 0.10-0.30]. The pooled overall response rate, partial response rates, and stable disease rate were 0.26 [95% CI: 0.10-0.41], 0.10 [95% CI:0.05-0.15], 0.17 [95%CI:0.10-0.23], and 0.58 [95%CI: 0.45-0.70]. This study demonstrated promising results regarding adding RT to ipilimumab which was associated with significantly higher 1-year OS, 18-month OS, 2-year OS, 3-year OS, overall radiological response rate, and stable disease rate and significantly lower rate of progressive disease rate compared to ipilimumab without RT. However, no significant difference was observed between two groups in 6-month OS, 12-month LC, 1-year PFS, and partial response rate.

Challenges and perspectives in the management of BRAF-mutated metastatic melanoma: Systemic treatment sequencing and brain metastases

The global incidence of metastatic melanoma with BRAF mutations, characterized by aggressive behavior and poor prognosis, is rising. Recent treatment advances, including immune checkpoint inhibitors (ICI) and targeted therapies (TT) such as BRAF and MEK inhibitors, have significantly enhanced patient outcomes. Although guidelines recommend sequencing strategies, real-world implementation can be influenced by clinical scenarios. This article highlights the importance of tailored treatment strategies, emphasizing that the decision to initiate immunotherapy (IT) or TT hinges on multiple factors, including tumor burden, LDH levels, presence of brain metastases, and patient symptomatic status. Managing brain metastases also poses a challenge, as these patients are typically excluded from pivotal clinical trials. While insights from phase II studies provide some guidance, there is a critical need for more quality data to inform comprehensive recommendations. Furthermore, although triple therapy combining IT and TT was initially thought to be promising, it has failed to clearly demonstrate benefit over current treatments. For all these reasons, there is an imperative need for further research on biomarkers and predictive factors, as well as real-world studies, that will help tailor treatment strategies across diverse patient subsets, thereby refining therapeutic approaches for BRAF-mutated metastatic melanoma.

Rethinking metastatic brain cancer as a CNS disease

Advances in molecular biology, genetics, and epigenetics have refined our understanding of metastatic brain cancer and underscored the need for better classification and targeted approaches. The heterogeneity of brain metastases highlights the differences from their primary source of origin and contributes to therapeutic resistance. Before colonising the brain, tumour cells acquire specialised proficiencies that enable them to capitalise on the unique microenvironment of the brain. The tumour cells further orchestrate key adaptations to adjust to the brain microenvironment by manipulating the blood-brain barrier, evading immune surveillance, rewiring metabolic profiles, and reprogramming astrocytes. These adaptations facilitate tumour survival, growth, and treatment resistance. Recognising metastatic brain cancer as a distinctive CNS disease, rather than an extension of the primary cancer, would support the development of rational approaches that target its molecular and genetic features and improve research funding in this area. Here, we delve into the distinct genetic and phenotypic characteristics of metastatic brain cancer, and reflect on how a change in the perception of this disease could accelerate the development of more effective therapies and drive continued progress in the field of neuro-oncology.

Real-world outcomes in patients with melanoma brain metastasis: a US multisite retrospective chart review study of systemic treatments

OBJECTIVE

This study examined real-world treatment patterns and outcomes in patients with melanoma brain metastasis (MBM) treated with first-line immunotherapy consisting of nivolumab plus ipilimumab or anti-programmed death-1 (PD-1) monotherapy (nivolumab or pembrolizumab) or targeted therapy consisting of BRAF/MEK inhibitors.

DESIGN

Retrospective chart review study.

SETTING

Academic medical centres, community hospitals and private practice offices.

PARTICIPANTS

Included patients diagnosed with melanoma with brain metastasis in the USA.

OUTCOME MEASURES

The statistical analysis was descriptive in nature. Overall survival (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method and compared between treatments in a univariate Cox proportional hazards model.

RESULTS

In total, 472 patients with MBM who received first-line nivolumab plus ipilimumab (n=246), anti-PD-1 monotherapy (n=112) or BRAF/MEK inhibitors (n=114) were identified. Patients receiving nivolumab plus ipilimumab, compared with patients receiving anti-PD-1 monotherapy or BRAF/MEK inhibitors, had favourable baseline prognostic factors, such as younger age, fewer or smaller brain metastases, better Eastern Cooperative Oncology Group performance status and less frequently elevated lactate dehydrogenase. Median follow-up times were 15.4 months (range 0.1 to 37.0), 13.3 months (range 0.3 to 36.6) and 13.9 months (range 1.9 to 36.5), respectively. Numerically longer OS was observed with nivolumab plus ipilimumab versus anti-PD-1 monotherapy (HR 0.47, 95% CI 0.34 to 0.67) or BRAF/MEK inhibitors (HR 0.72, 95% CI 0.50 to 1.04) and numerically longer PFS was observed with nivolumab plus ipilimumab versus anti-PD-1 monotherapy (HR 0.74, 95% CI 0.53 to 1.02) or BRAF/MEK inhibitors (HR 0.82, 95% CI 0.60 to 1.12). With nivolumab plus ipilimumab, anti-PD-1 monotherapy and BRAF/MEK inhibitors, 1-year OS rates were 79%, 60% and 72%, respectively; 1-year PFS rates were 68%, 58% and 59%.

CONCLUSIONS

In this real-world study, first-line nivolumab plus ipilimumab appeared to provide benefit versus anti-PD-1 monotherapy and BRAF/MEK inhibitors in patients with MBM, consistent with pivotal trial data. However, the observed benefit may have been due to confounding and selection bias, given that patients receiving nivolumab plus ipilimumab had favourable baseline prognostic factors compared with patients receiving anti-PD-1 monotherapy or BRAF/MEK inhibitors.

Progress in immunotherapy for brain metastatic melanoma

Melanoma is highly aggressive, with brain metastasis being a significant contributor to poor outcomes. Immunotherapy has emerged as a crucial treatment modality for melanoma, particularly for addressing brain metastases. This review explores recent developments in immunotherapy for patients with melanoma brain metastasis, with such treatments encompassing immune checkpoint inhibitors and various immunotherapy combination approaches, such as dual immunotherapy, immunotherapy combined with chemotherapy, immunotherapy combined with targeted drugs, and immunotherapy combined with radiotherapy. This article also discusses existing treatment obstacles and potential future avenues for research and clinical practice.

Repurposing neuroleptics: clozapine as a novel, adjuvant therapy for melanoma brain metastases

The blood-brain barrier and the distinct brain immunology provide challenges in translating commonly used chemotherapeutics to treat intracranial tumors. Previous reports suggest anti-tumoral effects of antipsychotics, encouraging investigations into potential treatment effects of neuroleptics on brain metastases. For the first time, the therapeutic potential of the antipsychotic drug clozapine in treating melanoma brain metastases (MBM) was investigated using three human MBM cell lines. Through in vitro cell culture and viability experiments, clozapine displayed potent anti-tumoral effects on MBM cells with an exploitable therapeutic window when compared to normal human astrocytes or rat brain organoids. Further, it was shown that clozapine inhibited migration, proliferation, and colony formation in a dose-dependent manner. Through flow cytometry and proteome screening, we found that clozapine induced apoptosis in MBM cells and potentially altered the tumor immunological environment by upregulating proteins such as macrophage inflammatory protein-1 alpha (MIP-1α) and interleukin-8 (IL-8). In conclusion, clozapine shows significant and selective anti-tumoral effects on MBM cell lines in vitro. Further in vivo experiments are warranted to translate these results into clinical use.

Oxidative Phosphorylation (OXPHOS) Promotes the Formation and Growth of Melanoma Lung and Brain Metastases

Melanoma mortality is driven by the formation and growth of distant metastases. Here, we interrogated the role of tumor oxidative phosphorylation (OXPHOS) in the formation of distant metastases in melanoma. OXPHOS was the most upregulated metabolic pathway in primary tumors that formed distant metastases in the RCAS-TVA mouse model of spontaneous lung and brain metastases, and in melanoma patients that developed brain or other distant metastases. Knockout of PGC1α in melanocytes in the RCAS-TVA melanoma mouse model had no impact on primary tumor formation, but markedly reduced the incidence of lung and brain metastases. Genetic knockout of a component of electron transport chain complex I, NDUFS4, in B16-F10 and D4M-UV2 murine melanoma cell lines did not impact tumor incidence following subcutaneous, intravenous, or intracranial injection, but decreased tumor burden specifically in the lungs and brain. Together, these data demonstrate that OXPHOS is critical for the formation of metastases in melanoma.

STRUCTURED ABSTRACT

Purpose: Melanoma mortality is driven by the formation and growth of distant metastases. However, the process and pathogenesis of melanoma metastasis remain poorly understood. Here, we interrogate the role of tumor oxidative phosphorylation (OXPHOS) in the formation of distant metastases in melanoma.Experimental Design: This study includes (1) new RNA-seq analysis of primary melanomas from patients characterized for distant metastasis events; (2) RNA-seq analysis and functional testing of genetic OXPHOS inhibition (PGC1α KO) the RCAS-TVA model, which is the only existing immunocompetent murine model of autochthonous lung and brain metastasis formation from primary melanoma tumors; and (3) functional experiments of genetic OXPHOS inhibition (NDUFS4 KO) in the B16-F10 and D4M-UV2 murine melanoma cell lines, including evaluation of subcutaneous, lung, and brain metastatic site dependencies.Results: OXPHOS was the most upregulated metabolic pathway in primary tumors that formed distant metastases in the RCAS-TVA mouse model of spontaneous lung and brain metastases, and in melanoma patients that developed brain or other distant metastases. Knockout of PGC1a in melanocytes in the RCAS-TVA melanoma mouse model had no impact on primary tumor formation, but markedly reduced the incidence of lung and brain metastases. Genetic knockout of a component of electron transport chain complex I, NDUFS4, in B16-F10 and D4M-UV2 murine melanoma cell lines did not impact tumor incidence following subcutaneous, intravenous, or intracranial injection, but decreased tumor burden specifically in the lungs and brain.Conclusions: Together, these data demonstrate that OXPHOS is critical for the formation of metastases in melanoma.

TRANSLATIONAL RELEVANCE

Melanoma is the most aggressive form of skin cancer. One hallmark of this disease is a high risk of distant metastasis formation. The process and pathogenesis of metastasis in this disease remain poorly understood and there is controversy regarding the role of oxidative phosphorylation (OXPHOS) in melanoma metastasis. This study incorporates RNAseq analysis of primary melanoma tumors from patients characterized for distant metastasis events, RNAseq analysis of the only existing immunocompetent murine model of autochthonous lung and brain metastasis formation from primary melanoma tumors, and functional testing in multiple syngeneic models of melanoma at different tissue sites. This integrated analysis consistently demonstrates that melanoma OXPHOS promotes distant metastasis to the lungs and brain, two of the most common and clinically relevant sites of melanoma metastasis. This improved understanding of tumor OXPHOS may represent novel vulnerabilities for therapeutics development and surveillance/preventative strategies for melanoma metastasis.

European consensus-based interdisciplinary guideline for melanoma. Part 2: Treatment - Update 2024

A unique collaboration of multi-disciplinary experts from the European Association of Dermato-Oncology (EADO), the European Dermatology Forum (EDF), and the European Organization of Research and Treatment of Cancer (EORTC) was formed to make recommendations on cutaneous melanoma diagnosis and treatment, based on systematic literature reviews and the experts' experience. Cutaneous melanomas are excised with one to two-centimeter safety margins. For a correct stage classification and treatment decision, a sentinel lymph node biopsy shall be offered in patients with tumor thickness ≥ 1.0 mm or ≥ 0.8 mm with additional histological risk factors, although there is as yet no clear survival benefit for this approach. Therapeutic decisions should be primarily made by an interdisciplinary oncology team ("Tumor Board"). Adjuvant therapies can be proposed in completely resected stage IIB-IV. In stage II only PD-1 inhibitors are approved. In stage III anti-PD-1 therapy or dabrafenib plus trametinib for patients with BRAFV600 mutated melanoma can be discussed. In resected stage IV, nivolumab can be offered, as well as ipilimumab and nivolumab, in selected, high-risk patients. In patients with clinically detected macroscopic, resectable disease, neoadjuvant therapy with ipilimumab plus nivolumab followed complete surgical resection and adjuvant therapy according to pathological response and BRAF status can be offered. Neoadjuvant therapy with pembrolizumab followed by complete surgical resection and adjuvant pembrolizumab is also recommended. For patients with disease recurrence after (neo) adjuvant therapy, further treatment should consider the type of (neo) adjuvant therapy received as well as the time of recurrence, i.e., on or off therapy. In patients with irresectable stage III/IV disease systemic treatment is always indicated. For first line treatment PD-1 antibodies alone or in combination with CTLA-4 or LAG-3 antibodies shall be considered. In stage IV melanoma with a BRAFV600 mutation, first-line therapy with BRAF/MEK inhibitors can be offered as an alternative to immunotherapy, in selected cases. In patients with primary resistance to immunotherapy and harboring a BRAFV600 mutation, this therapy shall be offered as second line. Other second line therapies include therapy with tumor infiltrating lymphocytes and combinations of immune checkpoint inhibitors not used in first line. This guideline is valid until the end of 2026.

Current and emerging treatment options for BRAFV600-mutant melanoma

INTRODUCTION

BRAF mutations are the most common driver mutation in cutaneous melanoma, present in 40% of cases. Rationally designed BRAF targeted therapy (TT) has been developed in response to this, and alongside immune checkpoint inhibitors (ICI), forms the backbone of systemic therapy options for BRAF-mutant melanoma. Various therapeutic approaches have been studied in the neoadjuvant, adjuvant and advanced settings, and there is a wealth of information to guide clinicians managing these patients. Despite this, certain challenges remain.

AREAS COVERED

We reviewed the available literature regarding BRAF mutation types and resistance mechanisms, neoadjuvant and adjuvant approaches for patients with early-stage disease, management of advanced disease, including patients with brain metastases, as well as identified areas of further research.

EXPERT OPINION

Although there is a significant amount of literature to guide the management of BRAF-mutant melanoma, several questions remain. Thus far, the management of stage III BRAF-mutant patients following neoadjuvant ICI, treatment de-escalation in long-term TT responders in the advanced setting and the management of symptomatic brain metastases remain areas of debate. Further work on predictive and prognostic biomarkers for patients with BRAF-mutant melanoma patients will assist in clinical decision-making.

Distant brain failure after stereotactic radiosurgery for brain metastases in patients receiving novel systemic treatments

Background

Novel systemic therapies, such as immunotherapy and targeted therapies, have shown better systemic disease control in the last decennium. However, the effect of these treatments on distant brain failure (DBF) in patients with brain metastases (BM) remains a topic of discussion. Improving time to DBF leads to longer overall survival (OS), as is reflected in the brain metastasis velocity (BMV). This study presents real world data about the combined effects of local and systemic treatments on DBF and survival.

Methods

A retrospective consecutive cohort study was conducted. Patients with newly diagnosed BM were included between June 2018 and May 2020. Factors associated with DBF were analyzed in multivariate models. The association between BMV and overall survival was analyzed with linear regression analysis.

Results

Three hundred and three patients were included. Two hundred and sixty-two (86%) patients received stereotactic radiotherapy, 41 (14%) awaited in first instance the intracranial effect of newly started or switched systemic treatment. Median time to DBF after radiotherapy was 21 months (95% CI 15-27), median OS was 20 months (IQR 10-36). Receiving immunotherapy or targeted therapy were associated with a lower hazard of DBF, compared with chemotherapy. The presence of > 5 initial BM and progressive or stable extracranial disease were associated with increased DBF. BMV was significantly associated with overall survival.

Conclusions

In this retrospective cohort, patients who received immunotherapy or targeted therapy experienced a reduced risk of DBF in comparison to those treated with chemotherapy. A higher BMV was associated with a decreased OS.

Two-in-one nanoparticle platform induces a strong therapeutic effect of targeted therapies in P-selectin-expressing cancers

Combined therapies in cancer treatment aim to enhance antitumor activity. However, delivering multiple small molecules imposes challenges, as different drugs have distinct pharmacokinetic profiles and tumor penetration abilities, affecting their therapeutic efficacy. To circumvent this, poly(lactic-co-glycolic acid) (PLGA)-polyethylene glycol (PEG)-based nanoparticles were developed as a platform for the codelivery of synergistic drug ratios, improving therapeutic efficacy by increasing the percentage of injected dose reaching the tumor. Nonetheless, extravasation-dependent tumor accumulation is susceptible to variations in tumor vasculature; therefore, PLGA-PEG was modified with sulfates to actively target P-selectin-expressing cancers. Here, we show the potential of our platform in unique three-dimensional (3D) in vitro and in vivo models. The P-selectin-targeted nanoparticles showed enhanced accumulation in 3D spheroids and tissues of P-selectin-expressing BRAF-mutated melanomas and BRCA-mutated breast cancers, resulting in superior in vivo efficacy and safety. This nanoplatform could advance the codelivery of a plethora of anticancer drug combinations to various P-selectin-expressing tumors.

Regorafenib Combined with BRAF/MEK Inhibitors for the Treatment of Refractory Melanoma Brain Metastases

BACKGROUND

There are no active treatment options for patients with progressive melanoma brain metastases (MBM) failing immune checkpoint blockade (ICB) and BRAF/MEK inhibitors (BRAF/MEKi). Regorafenib (REGO), an oral multi-kinase inhibitor (incl. RAF-dimer inhibition), can overcome adaptive resistance to BRAF/MEKi in preclinical models.

METHODS

This is a single-center retrospective case series of patients with refractory MBM treated with REGO plus BRAF/MEKi (compassionate use).

RESULTS

A total of 22 patients were identified (18 BRAF-mutant, 4 NRASQ61-mutant; 19 with progressive MBM; 11 on corticosteroids). Thirteen BRAFV600-mutant patients were progressing on BRAF/MEKi at the time of REGO association. BRAF-mutant patients received REGO (40-80 mg once daily) combined with BRAF/MEKi, NRAS-mutant patients were treated with REGO + MEKi (+low-dose BRAFi to mitigate skin-toxicity). Grade 3 TRAE included arterial hypertension (n = 4) and maculopapular rash (n = 3). There were no G4/5 TRAE. In BRAF-mutant patients, overall and intracranial objective response rates (overall ORR and IC-ORR) were 11 and 29%, and overall and intracranial disease control rates (overall DCR and IC-DCR) were 44 and 59%, respectively. In NRAS-mutant patients overall ORR and IC-ORR were 0 and 25% and overall DCR and IC-DCR were 25 and 50%, respectively. The median PFS and OS were, respectively, 7.1 and 16.4 weeks in BRAF-mutant and 8.6 and 10.1 weeks in NRAS-mutant patients.

CONCLUSIONS

In heavily pretreated patients with refractory MBM, REGO combined with BRAF/MEKi demonstrated promising anti-tumor activity with an acceptable safety profile. In BRAFV600-mutant melanoma patients, responses cannot solely be attributed to BRAF/MEKi rechallenge. Further investigation in a prospective trial is ongoing to increase understanding of the efficacy.

BMScope: A scoping review to chart the evolving clinical study landscape in brain and leptomeningeal metastasis

BACKGROUND

Recent studies have challenged the notion that patients with brain metastasis (BM) or leptomeningeal metastasis (LM) should be excluded from systemic therapy clinical trials. This scoping study summarizes the BM/LM clinical studies published between 2010 and 2023.

METHODS

MEDLINE, CINAHL, CAB Abstracts, PsycINFO, Cochrane Library, HINARI, International Pharmaceutical Abstracts, PubMed, Scopus, Web of Science, and EMBASE electronic databases were searched on June 21, 2021. An updated search was performed on February 21, 2023. Eligible studies investigated a therapeutic intervention in solid tumor patients with BM and/or LM and reported a patient outcome. Extracted study-level data, including study type, publication date, geographical location, number of BM/LM patients in the study, primary tumor type, and type of therapeutic intervention, were collected.

RESULTS

4921 unique studies were eligible for analysis. The key finding is that BM/LM clinical research is expanding globally, both in observational studies and clinical trials. Despite the shift over time toward a higher proportion of systemic therapy trials, the majority still do not include patients with symptomatic disease and lack reporting of BM/LM-specific endpoints. Globally, there has been a trend to more international collaboration in BM/LM clinical studies.

CONCLUSIONS

Our analysis of the BM/LM literature charts the evolving landscape of studies involving this previously excluded population. Given the increasing clinical research activity, particularly involving late-stage systemic therapy trials, it is imperative that due consideration is given to the intracranial activity of new investigational agents. Wider adoption of standardized reporting of intracranial-specific endpoints will facilitate the evaluation of relative intracranial efficacy.

Validation of the graded prognostic assessment and recursive partitioning analysis as prognostic tools using a modern cohort of patients with brain metastases

Background

Prognostic indices for patients with brain metastases (BM) are needed to individualize treatment and stratify clinical trials. Two frequently used tools to estimate survival in patients with BM are the recursive partitioning analysis (RPA) and the diagnosis-specific graded prognostic assessment (DS-GPA). Given recent advances in therapies and improved survival for patients with BM, this study aims to validate and analyze these 2 models in a modern cohort.

Methods

Patients diagnosed with BM were identified via our institution's Tumor Board meetings. Data were retrospectively collected from the date of diagnosis with BM. The concordance of the RPA and GPA was calculated using Harrell's C index. A Cox proportional hazards model with backwards elimination was used to generate a parsimonious model predictive of survival.

Results

Our study consisted of 206 patients diagnosed with BM between 2010 and 2019. The RPA had a prediction performance characterized by Harrell's C index of 0.588. The DS-GPA demonstrated a Harrell's C index of 0.630. A Cox proportional hazards model assessing the effect of age, presence of lung, or liver metastases, and Eastern Cooperative Oncology Group (ECOG) performance status score of 3/4 on survival yielded a Harrell's C index of 0.616. Revising the analysis with an uncategorized ECOG demonstrated a C index of 0.648.

Conclusions

We found that the performance of the RPA remains unchanged from previous validation studies a decade earlier. The DS-GPA outperformed the RPA in predicting overall survival in our modern cohort. Analyzing variables shared by the RPA and DS-GPA produced a model that performed analogously to the DS-GPA.

Immunotherapeutic and Targeted Strategies for Managing Brain Metastases from Common Cancer Origins: A State-of-the-Art Review

PURPOSE OF REVIEW

This review examines contemporary strategies for managing brain metastases (BM) from common cancers such as lung, breast, and melanoma. We evaluate the efficacy and applicability of targeted therapies and immunotherapies, exploring their potential to cross the blood-brain barrier and improve patient outcomes.

RECENT FINDINGS

Recent studies have shown that tyrosine kinase inhibitors, immune checkpoint inhibitors, and ADCs effectively treat BM. These treatments can overcome the challenges posed by the blood-brain barrier and improve therapeutic outcomes. ADCs are promising because they can deliver cytotoxic agents directly to tumor cells, which reduces systemic toxicity and increases drug delivery efficiency to the brain. Personalized medicine is becoming increasingly significant in treatment decisions, with biomarkers playing an essential role. Advances in molecular genetics and drug development have led to more refined treatments, emphasizing the precision medicine framework. The management of BM is evolving, driven by drug efficacy, resistance mechanisms, and the need for personalized medicine. Integrating ADCs into treatment regimens represents a significant advancement in targeting metastatic brain tumors. Despite these advances, BM management still presents considerable challenges, requiring ongoing research and multi-institutional trials to optimize therapeutic strategies. This review outlines the current state and future directions in treating BM, highlighting the critical need for continued innovation and comprehensive clinical evaluations to improve survival rates and quality of life for affected patients.

Network-based analysis of heterogeneous patient-matched brain and extracranial melanoma metastasis pairs reveals three homogeneous subgroups

Melanoma, the deadliest form of skin cancer, can metastasize to different organs. Molecular differences between brain and extracranial melanoma metastases are poorly understood. Here, promoter methylation and gene expression of 11 heterogeneous patient-matched pairs of brain and extracranial metastases were analyzed using melanoma-specific gene regulatory networks learned from public transcriptome and methylome data followed by network-based impact propagation of patient-specific alterations. This innovative data analysis strategy allowed to predict potential impacts of patient-specific driver candidate genes on other genes and pathways. The patient-matched metastasis pairs clustered into three robust subgroups with specific downstream targets with known roles in cancer, including melanoma (SG1: RBM38, BCL11B, SG2: GATA3, FES, SG3: SLAMF6, PYCARD). Patient subgroups and ranking of target gene candidates were confirmed in a validation cohort. Summarizing, computational network-based impact analyses of heterogeneous metastasis pairs predicted individual regulatory differences in melanoma brain metastases, cumulating into three consistent subgroups with specific downstream target genes.

Phase I Clinical Study of a Multi-Kinase Inhibitor TG02 Capsule for the Treatment of Recurrent High-Grade Gliomas with Failed Temozolomide Treatment in Chinese Patients

INTRODUCTION

We report the safety, tolerability, pharmacokinetic characteristics and preliminary efficacy of a multi-kinase inhibitor (TG02 capsule) as a new therapy for patients with recurrent high-grade gliomas in China.

METHODS

This is a single-center, dose-escalation, open-label phase I study, which enrolled patients with recurrent high-grade gliomas who failed to temozolomide. Patients were assigned sequentially into different dose groups and received TG02 every 4 weeks. The dose was increased in a traditional 3 + 3 design. Primary endpoints were the dose-limited toxicity (DLT) and the maximum tolerated dose (MTD).

RESULTS

Twelve patients (8 glioblastomas, 4 diffuse astrocytoma) were enrolled between May 2019 and November 2021. Three patients received 100 mg and 9 received 150 mg TG02 twice a week. The plasma concentration of TG02 reached the maximum at 2 h after administration, and the elimination half-life was about 7 h. No DLT occurred and MTD was not defined in this study. Eleven patients had one or more investigator-assessed treatment-related adverse events (TRAEs). The most frequent TRAEs were vomiting (91.7%) and diarrhea (75.0%), and 50% of the patients had grade 3 or 4 adverse events. There were no treatment-related deaths. The median progression-free survival and overall survival were 1.77 (95% confidence interval [CI]: 0.82-4.24) and 9.63 (95% CI: 2.66-not estimated) months, respectively.

CONCLUSIONS

TG02 capsule 150 mg twice a week is safe and tolerable in Chinese patients with recurrent high-grade gliomas. Patients who failed to temozolomide showed obvious tumor reduction when switching to TG02 capsule. The efficacy of recurrent gliomas warrants further investigation.

Delayed and Concurrent Stereotactic Radiosurgery in Immunotherapy-Naïve Melanoma Brain Metastases

Melanoma remains a formidable challenge in oncology, causing the majority of skin cancer deaths in the United States, with brain metastases contributing substantially to this mortality. This paper reviews the current therapeutic strategies for melanoma brain metastases, with a focus on delayed and concurrent stereotactic radiosurgery (SRS). While surgery and traditional chemotherapy offer limited efficacy, recent advances in immunotherapy, particularly immune checkpoint inhibitors (ICIs), have played a major role in the advancement and improved efficacy of the treatment of cancers, including brain metastases. Recent studies indicate that monotherapy with ICIs may lead to a higher median overall survival compared to historical benchmarks, potentially allowing patients to delay radiosurgery. Other studies have found that combining SRS with ICIs demonstrates promise, with results indicating improved intracranial control. Ongoing clinical trials explore novel combinations of immunotherapies and radiotherapies, aiming to optimize treatment outcomes while minimizing adverse effects. As treatment options expand, future studies will be necessary to understand the interplay between therapies and their optimal sequencing to improve patient outcomes.

Encorafenib and binimetinib followed by radiotherapy for patients with BRAFV600-mutant melanoma and brain metastases (E-BRAIN/GEM1802 phase II study)

BACKGROUND

Encorafenib plus binimetinib (EB) is a standard-of-care treatment for advanced BRAFV600-mutant melanoma. We assessed the efficacy and safety of encorafenib plus binimetinib in patients with BRAFV600-mutant melanoma and brain metastasis (BM) and explored if radiotherapy improves the duration of response.

METHODS

E-BRAIN/GEM1802 was a prospective, multicenter, single-arm, phase II trial that enrolled patients with melanoma BRAFV600-mutant and BM. Patients received encorafenib 450 mg once daily plus binimetinib 45 mg BID, and those who achieved a partial response or stable disease at first tumor assessment were offered radiotherapy. Treatment continued until progression. Primary endpoint was intracranial response rate (icRR) after 2 months of EB, establishing a futility threshold of 60%.

RESULTS

The study included 25 patients with no BM symptoms and 23 patients with BM symptoms regardless of using corticosteroids. Among them, 31 patients (64.6%) received sequential radiotherapy. After 2 months, icRR was 70.8% (95% CI: 55.9-83.1); 10.4% complete response. Median intracranial progression-free survival (PFS) and OS were 8.5 (95% CI: 6.4-11.8) and 15.9 (95% CI: 10.7-21.4) months, respectively (8.3 months for icPFS and 13.9 months OS for patients receiving RDT). Most common grades 3-4 treatment-related adverse event was alanine aminotransferase (ALT) increased (10.4%).

CONCLUSIONS

Encorafenib plus binimetinib showed promising clinical benefit in terms of icRR, and tolerable safety profile with low frequency of high-grade TRAEs, in patients with BRAFV600-mutant melanoma and BM, including those with symptoms and need for steroids. Sequential radiotherapy is feasible but it does not seem to prolong response.

SEOM-GEM clinical guidelines for cutaneous melanoma (2023)

Cutaneous melanoma incidence is rising. Early diagnosis and treatment administration are key for increasing the chances of survival. For patients with locoregional advanced melanoma that can be treated with complete resection, adjuvant-and more recently neoadjuvant-with targeted therapy-BRAF and MEK inhibitors-and immunotherapy-anti-PD-1-based therapies-offer opportunities to reduce the risk of relapse and distant metastases. For patients with advanced disease not amenable to radical treatment, these treatments offer an unprecedented increase in overall survival. A group of medical oncologists from the Spanish Society of Medical Oncology (SEOM) and Spanish Multidisciplinary Melanoma Group (GEM) has designed these guidelines, based on a thorough review of the best evidence available. The following guidelines try to cover all the aspects from the diagnosis-clinical, pathological, and molecular-staging, risk stratification, adjuvant therapy, advanced disease therapy, and survivor follow-up, including special situations, such as brain metastases, refractory disease, and treatment sequencing. We aim help clinicians in the decision-making process.

Effective Personalization of Stereotactic Radiosurgery for Brain Metastases in the Modern Era: Opportunities for Innovation

ABSTRACT

As survival rates improve for patients with metastatic disease, more patients are requiring complex treatment for brain metastases. Stereotactic radiosurgery (SRS) is a conformal radiotherapy technique that allows high ablative dose to be delivered to a specific target and is a standard effective local therapy for the treatment of patients with limited brain metastases. This review highlights the current landscape of SRS treatment in the context of modern therapeutic advances and identifies new research frontiers to personalize SRS and maximize the therapeutic ratio.

Durable complete response in a patient with leptomeningeal melanoma after treatment with dabrafenib, trametinib, and nivolumab

Leptomeningeal disease (LMD) is a devastating complication of melanoma with a dismal prognosis. We present the case of a young man with stage IV BRAF V600E mutant melanoma with lung, lymph node, and brain metastases initially treated with ipilimumab and nivolumab, who subsequently developed LMD. Upon change to BRAF/MEK targeted therapy with nivolumab, a durable complete response was achieved and remains ongoing, off treatment, 7 years from diagnosis. Management of symptomatic LMD remains a critical unmet clinical challenge, with limited clinical trial data. This exceptional case is instructive, as the first published case of the use of the triplet, and the first durable response with therapy discontinuation, in melanoma LMD. The triple-drug regimen may be considered a viable option in fit patients. This case highlights the potential for long-term disease control and the critical and urgent need to develop clinical trials inclusive of patients with LMD to define the best treatment strategies.

Very early symptomatic metastasis pseudoprogression after stereotactic brain radiosurgery in a melanoma patient treated with BRAF/MEK inhibitors: a case report and review of the literature

Introduction

Significant therapeutic changes have recently occurred in the management of melanoma brain metastases (BMs), both in the field of local treatments, with the rise of stereotactic radiotherapy (RT), as well as in systemic ones, with the advent of immunotherapy and targeted therapies (TT). These advances have brought about new challenges, particularly regarding the potential interactions between new TT (notably BRAF/MEK inhibitors) and irradiation. Through a clinical case, we will discuss a side effect not previously described in the literature: ultra-early pseudoprogression (PP) following brain stereotactic radiosurgery (SRS), in a patient treated with dabrafenib-trametinib.

Case presentation

A 61-year-old patient with BRAFV600E-mutated melanoma, receiving second-line dabrafenib-trametinib therapy, was referred for SRS on three progressing meningeal implants, without evidence of systemic progression. Four days after the first RT session (1x6 Gy on a fronto-orbital lesion prescribed 5x6 Gy, and 1x20 Gy single fraction on the other lesions), the patient presented with an epileptic seizure. An MRI, compared to the planning MRI ten days earlier, revealed significant progression of the irradiated lesions. The patient's condition improved with dexamethasone and levetiracetam, and RT was halted out of caution. A follow-up MRI at one month demonstrated a size reduction of all treated lesions. Subsequent imaging at five months revealed further shrinking of the two lesions treated with an ablative dose of 20 Gy, while the under-treated fronto-orbital lesion progressed. These dynamics suggest an initial PP in the three irradiated lesions, followed by good response in the ablatively treated lesions and progression in the partially treated lesion.

Conclusion

To our knowledge, this represents the first documented case of ultra-early PP following brain SRS in a patient receiving concomitant dabrafenib-trametinib. It highlights the need for particular vigilance when using tyrosine kinase inhibitors (TKIs) with SRS, and warrants further research into potential treatment interactions between RT and novel systemic agents, as well as the optimal treatment sequence of melanoma BMs.