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Mercurio AC, Maniar AB, Wei AZ, Carvajal RD. Targeting the IL-2 pathway for the treatment of mucosal melanoma. Expert Opin Orphan Drugs 2022. [DOI: 10.1080/21678707.2022.2134776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Ann C. Mercurio
- Columbia University Irving Medical Center Department of Medicine, Division of Hematology & Oncology, 177 Fort Washington Avenue, 10032, New York, NY, USA
- New York Medical College, School of Medicine, 40 Sunshine Cottage Road, 10595, Valhalla, NY, USA
| | - Ashray B. Maniar
- Columbia University Irving Medical Center Department of Medicine, Division of Hematology & Oncology, 177 Fort Washington Avenue, 10032, New York, NY, USA
| | - Alexander Z. Wei
- Columbia University Irving Medical Center Department of Medicine, Division of Hematology & Oncology, 177 Fort Washington Avenue, 10032, New York, NY, USA
| | - Richard D. Carvajal
- Columbia University Irving Medical Center Department of Medicine, Division of Hematology & Oncology, 177 Fort Washington Avenue, 10032, New York, NY, USA
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Maniyar RR, Chakraborty S, Jarboe T, Suriano R, Wallack M, Geliebter J, Tiwari RK. Interacting Genetic Lesions of Melanoma in the Tumor Microenvironment: Defining a Viable Therapy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1350:123-143. [PMID: 34888847 DOI: 10.1007/978-3-030-83282-7_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Melanoma is the most aggressive form of skin cancer with an estimated 106,110 newly diagnosed cases in the United States of America in 2021 leading to an approximated 7180 melanoma-induced deaths. Cancer typically arises from an accumulation of somatic mutations and can be associated with mutagenic or carcinogenic exposure. A key characteristic of melanoma is the extensive somatic mutation rate of 16.8 mutations/Mb, which is largely attributed to UV exposure. Bearing the highest mutational load, many of them occur in key driver pathways, most commonly the BRAFV600E in the mitogen-activated protein kinase (MAPK) pathway. This driver mutation is targeted clinically with FDA-approved therapies using small molecule inhibitors of oncogenic BRAFV600E and MEK, which has greatly expanded therapeutic intervention following a melanoma diagnosis. Up until 2011, therapeutic options for metastatic melanoma were limited, and treatment typically fell under the spectrum of surgery, radiotherapy, and chemotherapy.Attributed to the extensive mutation rate, as well as having the highest number of neoepitopes, melanoma is deemed to be extremely immunogenic. However, despite this highly immunogenic nature, melanoma is notorious for inducing an immunosuppressive microenvironment which can be relieved by checkpoint inhibitor therapy. The two molecules currently approved clinically are ipilimumab and nivolumab, which target the molecules CTLA-4 and PD-1, respectively.A plethora of immunomodulatory molecules exist, many with redundant functions. Additionally, these molecules are expressed not only by immune cells but also by tumor cells within the tumor microenvironment. Tumor profiling of these cell surface checkpoint molecules is necessary to optimize a clinical response. The presence of immunomodulatory molecules in melanoma, using data from The Cancer Genome Atlas and validation of expression in two model systems, human melanoma tissues and patient-derived melanoma cells, revealed that the expression levels of B and T lymphocyte attenuator (BTLA), TIM1, and CD226, concurrently with the BRAFV600E mutation status, significantly dictated overall survival in melanoma patients. These molecules, along with herpesvirus entry mediator (HVEM) and CD160, two molecules that are a part of the HVEM/BTLA/CD160 axis, had a higher expression in human melanoma tissues when compared to normal skin melanocytes and have unique roles to play in T cell activation. New links are being uncovered between the expression of immunomodulatory molecules and the BRAFV600E genetic lesion in melanoma. Small molecule inhibitors of the MAPK pathway regulate the surface expression of this multifaceted molecule, making BTLA a promising target for immuno-oncology to be targeted in combination with small molecule inhibitors, potentially alleviating T regulatory cell activation and improving patient prognosis.
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Affiliation(s)
- R R Maniyar
- Human Oncology and Pathogenesis Program, Ludwig Collaborative and Swim Across America Laboratory, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - S Chakraborty
- Department of Medicine, Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY, USA
| | - T Jarboe
- Departments of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, NY, USA
| | - R Suriano
- Division of Natural Sciences, College of Mount Saint Vincent, Bronx, NY, USA
| | - M Wallack
- Department Surgery, Metropolitan Hospital, New York, NY, USA
| | - J Geliebter
- Departments of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, NY, USA
| | - R K Tiwari
- Departments of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, NY, USA.
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Bong CY, Smithers BM, Chua TC. Pulmonary metastasectomy in the era of targeted therapy and immunotherapy. J Thorac Dis 2021; 13:2618-2627. [PMID: 34012610 PMCID: PMC8107521 DOI: 10.21037/jtd.2020.03.120] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Metastatic melanoma is a fatal malignancy with a high mortality and morbidity. Since the early 1970s, available medical therapies were limited in improving survival. Surgery represented the best chance for a cure. However, surgery could only be offered to selected patients. The current landscape of treatment has radically evolved since the introduction of targeted and immunotherapies including BRAF and MEK inhibitors, and checkpoint blockers, like PD-1 and CTLA-4 antibodies. These new therapies have seen survival rates matching, and in some cases surpassing, that of surgery. Anti-PD1 and CTLA-4 combination treatments are associated with severe side effects and BRAF and MEK inhibitor combinations may trigger initial tumour responses but prolonged use have resulted in the development of resistant tumour clones and disease relapse. This review examines the role of pulmonary metastasectomy for lung metastasis from malignant melanoma in the current landscape of effective targeted therapy and immunotherapy.
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Affiliation(s)
- Christopher Y Bong
- Department of Surgery, Logan Hospital, Metro South Health, Meadowbrook, Queensland, Australia
| | - B Mark Smithers
- Upper Gastrointestinal and Soft Tissue Unit, Department of Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Discipline of Surgery, Faculty of Medicine, The University of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Terence C Chua
- Department of Surgery, Logan Hospital, Metro South Health, Meadowbrook, Queensland, Australia.,Discipline of Surgery, Faculty of Medicine, The University of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
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Sasse AD, Sasse EC, Clark LGO, Clark OAC. WITHDRAWN: Chemoimmunotherapy versus chemotherapy for metastatic malignant melanoma. Cochrane Database Syst Rev 2018; 2:CD005413. [PMID: 29409139 PMCID: PMC6491196 DOI: 10.1002/14651858.cd005413.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Malignant melanoma, one of the most aggressive of all skin cancers, is increasing in incidence throughout the world. Surgery remains the cornerstone of curative treatment in earlier stages. Metastatic disease is incurable in most affected people, because melanoma does not respond to most systemic treatments. A number of novel approaches are under evaluation and have shown promising results, but they are usually associated with increased toxicity and cost. The combination of chemotherapy and immunotherapy has been reported to improve treatment results, but it is still unclear whether evidence exists to support this choice, compared with chemotherapy alone. No language restrictions were imposed. OBJECTIVES To compare the effects of therapy with chemotherapy and immunotherapy (chemoimmunotherapy) versus chemotherapy alone in people with metastatic malignant melanoma. SEARCH METHODS We searched the Cochrane Skin Group Specialised Register (14 February 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005), MEDLINE (2003 to 30 January 2006 ), EMBASE (2003 to 20 July 2005) and LILACS (1982 to 20 February 2006). References, conference proceedings, and databases of ongoing trials were also used to locate trials. SELECTION CRITERIA All randomised controlled trials that compared the use of chemotherapy versus chemoimmunotherapy on people of any age, diagnosed with metastatic melanoma. DATA COLLECTION AND ANALYSIS Two authors independently assessed each study to determine whether it met the pre-defined selection criteria, with differences being resolved through discussion with the review team. Two authors independently extracted the data from the articles using data extraction forms. Quality assessment included an evaluation of various components associated with biased estimates of treatment effect. Whenever possible, a meta-analysis was performed on the extracted data, in order to calculate a weighed treatment effect across trials. MAIN RESULTS Eighteen studies met our criteria and were included in the meta-analysis, with a total of 2625 participants. We found evidence of an increase of objective response rates in people treated with chemoimmunotherapy, in comparison with people treated with chemotherapy. Nevertheless, the impact of these increased response rates was not translated into a survival benefit. We found no difference in survival to support the addition of immunotherapy to chemotherapy in the systemic treatment of metastatic melanoma, with a hazard ratio of 0.89 (95% CI 0.72 to 1.11, P = 0.31). Additionally, we found increased hematological and non-hematological toxicities in people treated with chemoimmunotherapy. AUTHORS' CONCLUSIONS We failed to find any clear evidence that the addition of immunotherapy to chemotherapy increases survival of people with metastatic melanoma. Further use of combined immunotherapy and chemotherapy should only be done in the context of clinical trials.
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Affiliation(s)
- Andre D Sasse
- UNICAMP (Universidade Estadual de Campinas)Internal MedicineAv Dr. Luiz de Tella 1515Cidade UniversitariaCampinasSao PauloBrazil13083 000
| | - Emma C Sasse
- UNICAMP (Universidade Estadual de Campinas)Internal MedicineAv Dr. Luiz de Tella 1515Cidade UniversitariaCampinasSao PauloBrazil13083 000
| | - Luciana GO Clark
- Hospital Celso Pierro/PUC‐Campinas e Instituto do Radium de CampinasOncologyAv. Dr. Luiz de Tella 970Cidade UniveristariaCampinasSão PauloBrazilCEP 13083 000
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Pasquali S, Hadjinicolaou AV, Chiarion Sileni V, Rossi CR, Mocellin S. Systemic treatments for metastatic cutaneous melanoma. Cochrane Database Syst Rev 2018; 2:CD011123. [PMID: 29405038 PMCID: PMC6491081 DOI: 10.1002/14651858.cd011123.pub2] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The prognosis of people with metastatic cutaneous melanoma, a skin cancer, is generally poor. Recently, new classes of drugs (e.g. immune checkpoint inhibitors and small-molecule targeted drugs) have significantly improved patient prognosis, which has drastically changed the landscape of melanoma therapeutic management. This is an update of a Cochrane Review published in 2000. OBJECTIVES To assess the beneficial and harmful effects of systemic treatments for metastatic cutaneous melanoma. SEARCH METHODS We searched the following databases up to October 2017: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase and LILACS. We also searched five trials registers and the ASCO database in February 2017, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA We considered RCTs of systemic therapies for people with unresectable lymph node metastasis and distant metastatic cutaneous melanoma compared to any other treatment. We checked the reference lists of selected articles to identify further references to relevant trials. DATA COLLECTION AND ANALYSIS Two review authors extracted data, and a third review author independently verified extracted data. We implemented a network meta-analysis approach to make indirect comparisons and rank treatments according to their effectiveness (as measured by the impact on survival) and harm (as measured by occurrence of high-grade toxicity). The same two review authors independently assessed the risk of bias of eligible studies according to Cochrane standards and assessed evidence quality based on the GRADE criteria. MAIN RESULTS We included 122 RCTs (28,561 participants). Of these, 83 RCTs, encompassing 21 different comparisons, were included in meta-analyses. Included participants were men and women with a mean age of 57.5 years who were recruited from hospital settings. Twenty-nine studies included people whose cancer had spread to their brains. Interventions were categorised into five groups: conventional chemotherapy (including single agent and polychemotherapy), biochemotherapy (combining chemotherapy with cytokines such as interleukin-2 and interferon-alpha), immune checkpoint inhibitors (such as anti-CTLA4 and anti-PD1 monoclonal antibodies), small-molecule targeted drugs used for melanomas with specific gene changes (such as BRAF inhibitors and MEK inhibitors), and other agents (such as anti-angiogenic drugs). Most interventions were compared with chemotherapy. In many cases, trials were sponsored by pharmaceutical companies producing the tested drug: this was especially true for new classes of drugs, such as immune checkpoint inhibitors and small-molecule targeted drugs.When compared to single agent chemotherapy, the combination of multiple chemotherapeutic agents (polychemotherapy) did not translate into significantly better survival (overall survival: HR 0.99, 95% CI 0.85 to 1.16, 6 studies, 594 participants; high-quality evidence; progression-free survival: HR 1.07, 95% CI 0.91 to 1.25, 5 studies, 398 participants; high-quality evidence. Those who received combined treatment are probably burdened by higher toxicity rates (RR 1.97, 95% CI 1.44 to 2.71, 3 studies, 390 participants; moderate-quality evidence). (We defined toxicity as the occurrence of grade 3 (G3) or higher adverse events according to the World Health Organization scale.)Compared to chemotherapy, biochemotherapy (chemotherapy combined with both interferon-alpha and interleukin-2) improved progression-free survival (HR 0.90, 95% CI 0.83 to 0.99, 6 studies, 964 participants; high-quality evidence), but did not significantly improve overall survival (HR 0.94, 95% CI 0.84 to 1.06, 7 studies, 1317 participants; high-quality evidence). Biochemotherapy had higher toxicity rates (RR 1.35, 95% CI 1.14 to 1.61, 2 studies, 631 participants; high-quality evidence).With regard to immune checkpoint inhibitors, anti-CTLA4 monoclonal antibodies plus chemotherapy probably increased the chance of progression-free survival compared to chemotherapy alone (HR 0.76, 95% CI 0.63 to 0.92, 1 study, 502 participants; moderate-quality evidence), but may not significantly improve overall survival (HR 0.81, 95% CI 0.65 to 1.01, 2 studies, 1157 participants; low-quality evidence). Compared to chemotherapy alone, anti-CTLA4 monoclonal antibodies is likely to be associated with higher toxicity rates (RR 1.69, 95% CI 1.19 to 2.42, 2 studies, 1142 participants; moderate-quality evidence).Compared to chemotherapy, anti-PD1 monoclonal antibodies (immune checkpoint inhibitors) improved overall survival (HR 0.42, 95% CI 0.37 to 0.48, 1 study, 418 participants; high-quality evidence) and probably improved progression-free survival (HR 0.49, 95% CI 0.39 to 0.61, 2 studies, 957 participants; moderate-quality evidence). Anti-PD1 monoclonal antibodies may also result in less toxicity than chemotherapy (RR 0.55, 95% CI 0.31 to 0.97, 3 studies, 1360 participants; low-quality evidence).Anti-PD1 monoclonal antibodies performed better than anti-CTLA4 monoclonal antibodies in terms of overall survival (HR 0.63, 95% CI 0.60 to 0.66, 1 study, 764 participants; high-quality evidence) and progression-free survival (HR 0.54, 95% CI 0.50 to 0.60, 2 studies, 1465 participants; high-quality evidence). Anti-PD1 monoclonal antibodies may result in better toxicity outcomes than anti-CTLA4 monoclonal antibodies (RR 0.70, 95% CI 0.54 to 0.91, 2 studies, 1465 participants; low-quality evidence).Compared to anti-CTLA4 monoclonal antibodies alone, the combination of anti-CTLA4 plus anti-PD1 monoclonal antibodies was associated with better progression-free survival (HR 0.40, 95% CI 0.35 to 0.46, 2 studies, 738 participants; high-quality evidence). There may be no significant difference in toxicity outcomes (RR 1.57, 95% CI 0.85 to 2.92, 2 studies, 764 participants; low-quality evidence) (no data for overall survival were available).The class of small-molecule targeted drugs, BRAF inhibitors (which are active exclusively against BRAF-mutated melanoma), performed better than chemotherapy in terms of overall survival (HR 0.40, 95% CI 0.28 to 0.57, 2 studies, 925 participants; high-quality evidence) and progression-free survival (HR 0.27, 95% CI 0.21 to 0.34, 2 studies, 925 participants; high-quality evidence), and there may be no significant difference in toxicity (RR 1.27, 95% CI 0.48 to 3.33, 2 studies, 408 participants; low-quality evidence).Compared to chemotherapy, MEK inhibitors (which are active exclusively against BRAF-mutated melanoma) may not significantly improve overall survival (HR 0.85, 95% CI 0.58 to 1.25, 3 studies, 496 participants; low-quality evidence), but they probably lead to better progression-free survival (HR 0.58, 95% CI 0.42 to 0.80, 3 studies, 496 participants; moderate-quality evidence). However, MEK inhibitors probably have higher toxicity rates (RR 1.61, 95% CI 1.08 to 2.41, 1 study, 91 participants; moderate-quality evidence).Compared to BRAF inhibitors, the combination of BRAF plus MEK inhibitors was associated with better overall survival (HR 0.70, 95% CI 0.59 to 0.82, 4 studies, 1784 participants; high-quality evidence). BRAF plus MEK inhibitors was also probably better in terms of progression-free survival (HR 0.56, 95% CI 0.44 to 0.71, 4 studies, 1784 participants; moderate-quality evidence), and there appears likely to be no significant difference in toxicity (RR 1.01, 95% CI 0.85 to 1.20, 4 studies, 1774 participants; moderate-quality evidence).Compared to chemotherapy, the combination of chemotherapy plus anti-angiogenic drugs was probably associated with better overall survival (HR 0.60, 95% CI 0.45 to 0.81; moderate-quality evidence) and progression-free survival (HR 0.69, 95% CI 0.52 to 0.92; moderate-quality evidence). There may be no difference in terms of toxicity (RR 0.68, 95% CI 0.09 to 5.32; low-quality evidence). All results for this comparison were based on 324 participants from 2 studies.Network meta-analysis focused on chemotherapy as the common comparator and currently approved treatments for which high- to moderate-quality evidence of efficacy (as represented by treatment effect on progression-free survival) was available (based on the above results) for: biochemotherapy (with both interferon-alpha and interleukin-2); anti-CTLA4 monoclonal antibodies; anti-PD1 monoclonal antibodies; anti-CTLA4 plus anti-PD1 monoclonal antibodies; BRAF inhibitors; MEK inhibitors, and BRAF plus MEK inhibitors. Analysis (which included 19 RCTs and 7632 participants) generated 21 indirect comparisons.The best evidence (moderate-quality evidence) for progression-free survival was found for the following indirect comparisons:• both combinations of immune checkpoint inhibitors (HR 0.30, 95% CI 0.17 to 0.51) and small-molecule targeted drugs (HR 0.17, 95% CI 0.11 to 0.26) probably improved progression-free survival compared to chemotherapy;• both BRAF inhibitors (HR 0.40, 95% CI 0.23 to 0.68) and combinations of small-molecule targeted drugs (HR 0.22, 95% CI 0.12 to 0.39) were probably associated with better progression-free survival compared to anti-CTLA4 monoclonal antibodies;• biochemotherapy (HR 2.81, 95% CI 1.76 to 4.51) probably lead to worse progression-free survival compared to BRAF inhibitors;• the combination of small-molecule targeted drugs probably improved progression-free survival (HR 0.38, 95% CI 0.21 to 0.68) compared to anti-PD1 monoclonal antibodies;• both biochemotherapy (HR 5.05, 95% CI 3.01 to 8.45) and MEK inhibitors (HR 3.16, 95% CI 1.77 to 5.65) were probably associated with worse progression-free survival compared to the combination of small-molecule targeted drugs; and• biochemotherapy was probably associated with worse progression-free survival (HR 2.81, 95% CI 1.54 to 5.11) compared to the combination of immune checkpoint inhibitors.The best evidence (moderate-quality evidence) for toxicity was found for the following indirect comparisons:• combination of immune checkpoint inhibitors (RR 3.49, 95% CI 2.12 to 5.77) probably increased toxicity compared to chemotherapy;• combination of immune checkpoint inhibitors probably increased toxicity (RR 2.50, 95% CI 1.20 to 5.20) compared to BRAF inhibitors;• the combination of immune checkpoint inhibitors probably increased toxicity (RR 3.83, 95% CI 2.59 to 5.68) compared to anti-PD1 monoclonal antibodies; and• biochemotherapy was probably associated with lower toxicity (RR 0.41, 95% CI 0.24 to 0.71) compared to the combination of immune checkpoint inhibitors.Network meta-analysis-based ranking suggested that the combination of BRAF plus MEK inhibitors is the most effective strategy in terms of progression-free survival, whereas anti-PD1 monoclonal antibodies are associated with the lowest toxicity.Overall, the risk of bias of the included trials can be considered as limited. When considering the 122 trials included in this review and the seven types of bias we assessed, we performed 854 evaluations only seven of which (< 1%) assigned high risk to six trials. AUTHORS' CONCLUSIONS We found high-quality evidence that many treatments offer better efficacy than chemotherapy, especially recently implemented treatments, such as small-molecule targeted drugs, which are used to treat melanoma with specific gene mutations. Compared with chemotherapy, biochemotherapy (in this case, chemotherapy combined with both interferon-alpha and interleukin-2) and BRAF inhibitors improved progression-free survival; BRAF inhibitors (for BRAF-mutated melanoma) and anti-PD1 monoclonal antibodies improved overall survival. However, there was no difference between polychemotherapy and monochemotherapy in terms of achieving progression-free survival and overall survival. Biochemotherapy did not significantly improve overall survival and has higher toxicity rates compared with chemotherapy.There was some evidence that combined treatments worked better than single treatments: anti-PD1 monoclonal antibodies, alone or with anti-CTLA4, improved progression-free survival compared with anti-CTLA4 monoclonal antibodies alone. Anti-PD1 monoclonal antibodies performed better than anti-CTLA4 monoclonal antibodies in terms of overall survival, and a combination of BRAF plus MEK inhibitors was associated with better overall survival for BRAF-mutated melanoma, compared to BRAF inhibitors alone.The combination of BRAF plus MEK inhibitors (which can only be administered to people with BRAF-mutated melanoma) appeared to be the most effective treatment (based on results for progression-free survival), whereas anti-PD1 monoclonal antibodies appeared to be the least toxic, and most acceptable, treatment.Evidence quality was reduced due to imprecision, between-study heterogeneity, and substandard reporting of trials. Future research should ensure that those diminishing influences are addressed. Clinical areas of future investigation should include the longer-term effect of new therapeutic agents (i.e. immune checkpoint inhibitors and targeted therapies) on overall survival, as well as the combination of drugs used in melanoma treatment; research should also investigate the potential influence of biomarkers.
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Affiliation(s)
- Sandro Pasquali
- Sarcoma Service, Fondazione IRCCS 'Istituto Nazionale Tumori', Via G. Venezian 1, Milano, Italy, 20133
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Sullivan RJ, Flaherty KT. New Strategies in Melanoma: Entering the Era of Combinatorial Therapy. Clin Cancer Res 2015; 21:2424-35. [DOI: 10.1158/1078-0432.ccr-14-1650] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Ferrari de Andrade L, Ngiow SF, Stannard K, Rusakiewicz S, Kalimutho M, Khanna KK, Tey SK, Takeda K, Zitvogel L, Martinet L, Smyth MJ. Natural killer cells are essential for the ability of BRAF inhibitors to control BRAFV600E-mutant metastatic melanoma. Cancer Res 2014; 74:7298-308. [PMID: 25351955 DOI: 10.1158/0008-5472.can-14-1339] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BRAF(V600E) is a major oncogenic mutation found in approximately 50% of human melanoma that confers constitutive activation of the MAPK pathway and increased melanoma growth. Inhibition of BRAF(V600E) by oncogene targeting therapy increases overall survival of patients with melanoma, but is unable to produce many durable responses. Adaptive drug resistance remains the main limitation to BRAF(V600E) inhibitor clinical efficacy and immune-based strategies could be useful to overcome disease relapse. Tumor microenvironment greatly differs between visceral metastasis and primary cutaneous melanoma, and the mechanisms involved in the antimetastatic efficacy of BRAF(V600E) inhibitors remain to be determined. To address this question, we developed a metastatic BRAF(V600E)-mutant melanoma cell line and demonstrated that the antimetastatic properties of BRAF inhibitor PLX4720 (a research analogue of vemurafenib) require host natural killer (NK) cells and perforin. Indeed, PLX4720 not only directly limited BRAF(V600E)-induced tumor cell proliferation, but also affected NK cell functions. We showed that PLX4720 increases the phosphorylation of ERK1/2, CD69 expression, and proliferation of mouse NK cells in vitro. NK cell frequencies were significantly enhanced by PLX4720 specifically in the lungs of mice with BRAF(V600E) lung metastases. Furthermore, PLX4720 also increased human NK cell pERK1/2, CD69 expression, and IFNγ release in the context of anti-NKp30 and IL2 stimulation. Overall, this study supports the idea that additional NK cell-based immunotherapy (by checkpoint blockade or agonists or cytokines) may combine well with BRAF(V600E) inhibitor therapy to promote more durable responses in melanoma.
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Affiliation(s)
- Lucas Ferrari de Andrade
- Laboratorio de Pesquisa em Células Inflamatórias e Neoplásicas Group, Universidade Federal do Paraná, Curitiba, Paraná, Brazil. Immunology in Cancer and Infection Laboratory, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Shin F Ngiow
- Immunology in Cancer and Infection Laboratory, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Kimberley Stannard
- Immunology in Cancer and Infection Laboratory, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Sylvie Rusakiewicz
- Gustave Roussy Cancer Campus, Villejuif, France. INSERM U1015, Villejuif, France. Center of Clinical Investigations in Biotherapies of Cancer (CICBT) 1428, Villejuif, France
| | - Murugan Kalimutho
- Signal Transduction Laboratory, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Kum Kum Khanna
- Signal Transduction Laboratory, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Siok-Keen Tey
- Bone Marrow Transplant Laboratory, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Kazuyoshi Takeda
- Department of Immunology, Juntendo University School of Medicine, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Laurence Zitvogel
- Gustave Roussy Cancer Campus, Villejuif, France. INSERM U1015, Villejuif, France. Université Paris Sud-XI, Faculté de Médecine, Le Kremlin Bicêtre, France. Department of Medical Oncology, IGR, Villejuif, France
| | - Ludovic Martinet
- Immunology in Cancer and Infection Laboratory, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Mark J Smyth
- Immunology in Cancer and Infection Laboratory, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia. School of Medicine, University of Queensland, Herston, Queensland, Australia.
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Effects of surgery, general anesthesia, and perioperative epidural analgesia on the immune function of patients with non-small cell lung cancer. J Clin Anesth 2013; 25:255-62. [PMID: 23659826 DOI: 10.1016/j.jclinane.2012.12.007] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Revised: 12/04/2012] [Accepted: 12/07/2012] [Indexed: 02/03/2023]
Abstract
STUDY OBJECTIVE To assess preoperative and postoperative immune function in patients undergoing surgical resection of non-small cell lung cancer during general anesthesia and postoperative epidural analgesia. DESIGN Observational single-center study. SETTING University-affiliated academic center. PATIENTS 24 adult, ASA physical status 3 and 4 patients with stage 1, 2, or 3 non-small cell lung cancer. No study patient received preoperative chemotherapy or radiation. INTERVENTIONS Patients underwent thoracotomy with general anesthesia and postoperative epidural analgesia. MEASUREMENTS Bispectral index monitoring, sevoflurane requirements, and intraoperative transfusions were recorded. Total fentanyl consumption and pain (verbal numeric rating scale) were recorded 24 hours after surgery. Preoperative and 24-hour postoperative natural killer cell percentage and function and percentages of natural killer T cells, T helper cells (CD4+), and cytotoxic T lymphocytes (CD8+) were measured. Plasma concentrations of the TH1 cytokine interleukin-2 and interferon-gamma and the TH2 cytokines interleukin-4 were measured at the same time points. RESULTS The percentage (preoperative, 13.07 ± 9.81% vs postoperative, 9.6 ± 6.57%, P < 0.001) and function (preoperative, 31.61 ± 21.96%; postoperative, 13.61 ± 9.36%; P < 0.001) of natural killer cells was significantly decreased after surgery, but the percentage of natural killer T cells, T helper cells (CD4+), and cytotoxic T lymphocytes (CD8+) remained unchanged postoperatively; thus, the CD4/CD8 ratio remained unchanged. Postoperative plasma concentrations of the three cytokines were similar to preoperative levels; therefore, the TH1/TH2 ratio also remained unchanged. CONCLUSIONS Innate immunity is depressed in patients with non-small cell lung cancer after surgical resection, and immunity is not preserved by the use of postoperative epidural analgesia.
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Dillman RO, Barth NM, VanderMolen LA, Mahdavi K, McClure SE. Should high-dose interleukin-2 still be the preferred treatment for patients with metastatic melanoma? Cancer Biother Radiopharm 2012; 27:337-43. [PMID: 22804456 DOI: 10.1089/cbr.2012.1220] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
For more than 20 years interleukin-2 (IL2) was the preferred treatment for medically fit metastatic melanoma patients, but recently two new agents, ipilimumab and vemurafenib, were approved for stage IV disease. Single-institution data were used to determine the long-term survival rate for IL2-treated melanoma patients, and whether use of inpatient IL2 had declined recently. Between May 1987 and April 2010, 150 patients were hospitalized for high-dose, intravenous (i.v.) IL2. The average number of IL2 patients increased from 5.4 per year during 1987-1991 to 5.8 during 1992-1997 after regulatory approval of IL2, to 8.3 during 1998-2006 after a marketing indication in metastatic melanoma was granted, but dropped to 3.0 during 2007-2010. At the time of treatment, median age was 52 years; 27% were 60 years of age or older. At the time of analysis 122 patients were deceased. Median survival from the start date of IL2 treatment was 15.6 months, with a 20% 5-year survival. Among patients enrolled in clinical trials, there were as many nonresponders who survived 5 years as responders, which is consistent with a delayed immunotherapy benefit. In the absence of long-term survival data for these newer agents, IL2 probably should still be the preferred initial treatment for most patients with metastatic melanoma who are medically fit.
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Affiliation(s)
- Robert O Dillman
- Medical Oncology Department, Hoag Institute for Research and Education and Hoag Family Cancer Institute, Newport Beach, CA 92658, USA.
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10
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Velho TR. Metastatic melanoma - a review of current and future drugs. Drugs Context 2012; 2012:212242. [PMID: 24432031 PMCID: PMC3885142 DOI: 10.7573/dic.212242] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 08/20/2012] [Indexed: 12/21/2022] Open
Abstract
Background: Melanoma is one of the most aggressive cancers, and it is estimated that 76,250 men and women will be diagnosed with melanoma of the skin in the USA in 2012. Over the last few decades many drugs have been developed but only in 2011 have new drugs demonstrated an impact on survival in metastatic melanoma. Methods: A systematic search of literature was conducted, and studies providing data on the effectiveness of current and/or future drugs used in the treatment of metastatic melanoma were selected for review. This review discusses the advantages and limitations of these agents, evaluating past, current and future clinical trials designed to overcome such limitations. Results: To date, there are four drugs approved by the Food and Drug Administration for melanoma (dacarbazine, interleukin-2, ipilimumab and vemurafenib). Despite efforts to develop new drugs, few of them have demonstrated any clinical benefits. Approved in 1975, dacarbazine remains the gold standard in chemotherapy, although ipilimumab and vemurafenib have raised many hopes in the last few years. Combining dacarbazine or other chemotherapy agents with new pharmacological agents may be a new way to achieve better clinical responses in patients with metastatic melanoma. Discussion: Advances in the molecular knowledge of melanoma have led to major improvements in the treatment of patients with metastatic melanoma, providing new targets and insights. However, heterogeneity amongst study populations, different approaches to treatment and the different melanoma types and localisations included in the trials makes their comparison difficult. New studies focusing on drugs developed in recent decades are warranted.
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11
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Dequen P, Lorigan P, Jansen JP, van Baardewijk M, Ouwens MJNM, Kotapati S. Systematic review and network meta-analysis of overall survival comparing 3 mg/kg ipilimumab with alternative therapies in the management of pretreated patients with unresectable stage III or IV melanoma. Oncologist 2012; 17:1376-85. [PMID: 23024154 PMCID: PMC3500357 DOI: 10.1634/theoncologist.2011-0427] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Accepted: 08/24/2012] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To compare the overall survival (OS) of patients treated with 3 mg/kg ipilimumab versus alternative systemic therapies in pretreated unresectable stage III or IV melanoma patients. METHODS A systematic literature search was performed to identify relevant randomized clinical trials. From these trials, Kaplan-Meier survival curves for each intervention were digitized and combined by means of a Bayesian network meta-analysis (NMA) to compare different drug classes. RESULTS Of 38 trials identified, 15 formed one interlinked network by drug class to allow for an NMA. Ipilimumab, at a dose of 3 mg/kg, was associated with a greater mean OS time (18.8 months; 95% credible interval [CrI], 15.5-23.0 months) than single-agent chemotherapy (12.3 months; 95% CrI, 6.3-28.0 months), chemotherapy combinations (12.2 months; 95% CrI, 7.1-23.3 months), biochemotherapies (11.9 months; 95% CrI, 7.0-22.0 months), single-agent immunotherapy (11.1 months; 95% CrI, 8.5-16.2 months), and immunotherapy combinations (14.1 months; 95% CrI, 9.0-23.8 months). CONCLUSION Results of this NMA were in line with previous findings and suggest that OS with ipilimumab is expected to be greater than with alternative systemic therapies, alone or in combination, for the management of pretreated patients with unresectable stage III or IV melanoma.
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12
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Abstract
Cancer immunotherapy consists of approaches that modify the host immune system, and/or the utilization of components of the immune system, as cancer treatment. During the past 25 years, 17 immunologic products have received regulatory approval based on anticancer activity as single agents and/or in combination with chemotherapy. These include the nonspecific immune stimulants BCG and levamisole; the cytokines interferon-α and interleukin-2; the monoclonal antibodies rituximab, ofatumumab, alemtuzumab, trastuzumab, bevacizumab, cetuximab, and panitumumab; the radiolabeled antibodies Y-90 ibritumomab tiuxetan and I-131 tositumomab; the immunotoxins denileukin diftitox and gemtuzumab ozogamicin; nonmyeloablative allogeneic transplants with donor lymphocyte infusions; and the anti-prostate cancer cell-based therapy sipuleucel-T. All but two of these products are still regularly used to treat various B- and T-cell malignancies, and numerous solid tumors, including breast, lung, colorectal, prostate, melanoma, kidney, glioblastoma, bladder, and head and neck. Positive randomized trials have recently been reported for idiotype vaccines in lymphoma and a peptide vaccine in melanoma. The anti-CTLA-4 monoclonal antibody ipilumumab, which blocks regulatory T-cells, is expected to receive regulatory approval in the near future, based on a randomized trial in melanoma. As the fourth modality of cancer treatment, biotherapy/immunotherapy is an increasingly important component of the anticancer armamentarium.
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Affiliation(s)
- Robert O Dillman
- Hoag Cancer Institute of Hoag Hospital , Newport Beach, California 92658, USA.
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13
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Abstract
The incidence of melanoma has been increasing worldwide. A relationship between melanoma and the immune system was established years ago. Modulating the immune system in the management of different stages of melanoma has been the focus of numerous large randomized trials worldwide. This article reviews the current status of immunotherapy for melanoma, with a focus on the recent promising results from using vaccines, cytotoxic T-lymphocyte antigen-4 (CTLA-4) antibodies, and adoptive cell therapy.
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Affiliation(s)
- Jade Homsi
- Department of Melanoma Medical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 430, Houston, TX 77030, USA.
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Schadendorf D, Algarra SM, Bastholt L, Cinat G, Dreno B, Eggermont AMM, Espinosa E, Guo J, Hauschild A, Petrella T, Schachter J, Hersey P. Immunotherapy of distant metastatic disease. Ann Oncol 2009; 20 Suppl 6:vi41-50. [PMID: 19617297 PMCID: PMC2712591 DOI: 10.1093/annonc/mdp253] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Immunotherapy of metastatic melanoma consists of various approaches leading to specific or non-specific immunomodulation. The use of FDA-approved interleukin (IL)-2 alone, in combination with interferon alpha, and/or with various chemotherapeutic agents (biochemotherapy) is associated with significant toxicity and poor efficacy that does not improve overall survival of 96% of patients. Many studies with allogeneic and autologous vaccines have demonstrated no clinical benefit, and some randomised trials even showed a detrimental effect in the vaccine arm. The ongoing effort to develop melanoma vaccines based on dendritic cells and peptides is driven by advances in understanding antigen presentation and processing, and by new techniques of vaccine preparation, stabilisation and delivery. Several agents that have shown promising activity in metastatic melanoma including IL-21 and monoclonal antibodies targeting cytotoxic T lymphocyte-associated antigen 4 (anti-CTLA-4) or CD137 are discussed. Recent advances of intratumour gene transfer technologies and adoptive immunotherapy, which represents a promising although technically challenging direction, are also discussed.
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Affiliation(s)
- D Schadendorf
- Department of Dermatology, University Hospital Essen, Essen, Germany.
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15
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Mansfield AS, Markovic SN. Novel therapeutics for the treatment of metastatic melanoma. Future Oncol 2009; 5:543-57. [PMID: 19450181 DOI: 10.2217/fon.09.15] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Metastatic malignant melanoma is an incurable disease with a median survival of 8.5 months and a probability of surviving 5 years after the diagnosis of less than 5%. To date, no systemic therapy has meaningfully changed these survival end points. Currently, in the USA the FDA has approved three agents for the treatment of metastatic melanoma: hydroxyurea, dacarbazine and interleukin-2. None of these have demonstrated a meaningfully prolonged survival of patients with metastatic melanoma. Therefore, a number of innovative therapeutic strategies have been pursued to improve outcomes, including immune therapy, tyrosine kinase inhibitors and angiogenesis inhibitors. Herein, we review some of the recent advances in novel therapeutic developments for the treatment of metastatic melanoma.
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Affiliation(s)
- Aaron S Mansfield
- Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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16
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Eapen S, Dutcher JP. A Review of Evidence-Based Treatment of Stage IIB to Stage IV Melanoma. Cancer Invest 2009; 23:323-37. [PMID: 16100945 DOI: 10.1081/cnv-58865] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Saji Eapen
- Our Lady of Mercy Cancer Center, New York Medical College, Bronx, New York 10466, USA
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17
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Bedikian AY, Johnson MM, Warneke CL, Papadopoulos NE, Kim K, Hwu WJ, McIntyre S, Hwu P. Prognostic Factors That Determine the Long-Term Survival of Patients with Unresectable Metastatic Melanoma. Cancer Invest 2009; 26:624-33. [DOI: 10.1080/07357900802027073] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Bedikian AY, Johnson MM, Warneke CL, McIntyre S, Papadopoulos N, Hwu WJ, Kim K, Hwu P. Systemic Therapy for Unresectable Metastatic Melanoma: Impact of Biochemotherapy on Long-Term Survival. J Immunotoxicol 2008; 5:201-7. [DOI: 10.1080/15476910802131519] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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20
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Hamm C, Verma S, Petrella T, Bak K, Charette M. Biochemotherapy for the treatment of metastatic malignant melanoma: a systematic review. Cancer Treat Rev 2008; 34:145-56. [PMID: 18077098 DOI: 10.1016/j.ctrv.2007.10.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2007] [Revised: 10/10/2007] [Accepted: 10/15/2007] [Indexed: 01/02/2023]
Abstract
BACKGROUND The incidence of malignant melanoma has increased in recent years. Current therapies for metastatic melanoma include chemotherapy and a variety of immunotherapeutic choices. With no established standard treatment option, the evaluation of biochemotherapy is warranted. METHODS A systematic review of the literature was conducted to locate randomized controlled trials, meta-analyses, systematic reviews, and evidence-based practice guidelines published up to April 2007. RESULTS Nine eligible randomized controlled trials were identified, including six comparing chemotherapy alone to biochemotherapy (chemotherapy combined with interleukin-2 and interferon). Response rates were significantly higher with biochemotherapy in only two trials, although when data were pooled, biochemotherapy was superior to chemotherapy on response (relative risk, 1.52; 95% confidence interval, 1.24-1.87; p<0.0001) but did not delay time to progression (Hazard ratio, 0.80; 95% confidence interval, 0.63-1.01; p=0.06). Biochemotherapy was not associated with a statistically significant survival benefit in any of the individual trials or in a pooled analysis (Hazard ratio, 0.95; 95% confidence interval, 0.78-1.17; p=0.64). Biochemotherapy is a toxic therapy, and patients are likely to experience serious hematologic, gastrointestinal, cutaneous, and constitutional toxicities, although when conducted in the correct setting, grade 3 and 4 effects appear to be manageable, and treatment-related death can be minimized. CONCLUSION The results of available studies are inconsistent with regard to benefit (response, time-to-progression, and survival) and show consistently high toxicity rates. Therefore, biochemotherapy is not recommended for the treatment of metastatic malignant melanoma in adults.
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Affiliation(s)
- Caroline Hamm
- Windsor Regional Hospital, 2220 Kildare Road, Windsor, Canada N8W 2X3.
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21
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Ives NJ, Stowe RL, Lorigan P, Wheatley K. Chemotherapy compared with biochemotherapy for the treatment of metastatic melanoma: a meta-analysis of 18 trials involving 2,621 patients. J Clin Oncol 2007; 25:5426-34. [PMID: 18048825 DOI: 10.1200/jco.2007.12.0253] [Citation(s) in RCA: 168] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To assess the effect of adding interferon-alpha (IFN) +/- interleukin-2 (IL-2) to chemotherapy in patients with metastatic melanoma. METHODS A published data meta-analysis of trials of biochemotherapy versus chemotherapy in patients with metastatic melanoma was undertaken. End points evaluated were rates of partial response (PR), complete response (CR) and overall (partial + complete) response (OR); response duration; progression-free survival; overall survival (OS); and toxicity. The only subgroup analysis performed was by type of immunotherapy, with trials divided according to whether IFN only or IFN and IL-2 were administered in the biochemotherapy arm. RESULTS Eighteen randomized trials were identified: 11 trials of chemotherapy +/- IFN and seven trials of chemotherapy +/- IFN and IL-2. More than 2,600 patients were entered onto the trials, with 555 responses and 2,039 deaths. There was a clear benefit for biochemotherapy for PR (odds ratio = 0.66; 95% CI, 0.53 to 0.82; P = .0001), CR (odds ratio = 0.50; 95% CI, 0.35 to 0.73; P = .0003) and OR (odds ratio = 0.59; 95% CI, 0.49 to 0.72; P < .00001). For OR, these benefits were significant for both the IFN (odds ratio = 0.60; 95% CI, 0.46 to 0.79; P = .0002) and IFN + IL-2 (odds ratio = 0.58; 95% CI, 0.44 to 0.77; P = .0001) subgroups. In contrast, there was no benefit overall in OS (odds ratio = 0.99; 95% CI, 0.91 to 1.08; P = .9), but there was evidence of heterogeneity of treatment effect between the individual trials (P = .006). CONCLUSION This meta-analysis provides a comprehensive summary of all the data currently available, and shows that although biochemotherapy clearly improves response rates, this does not appear to translate into a survival benefit.
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Affiliation(s)
- Natalie J Ives
- Birmingham Clinical Trials Unit, Division of Medical Sciences, Robert Aitken Institute, University of Birmingham, Edgbaston, Birmingham, United Kingdom.
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22
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Nashan D, Müller ML, Grabbe S, Wustlich S, Enk A. Systemic therapy of disseminated malignant melanoma: an evidence-based overview of the state-of-the-art in daily routine. J Eur Acad Dermatol Venereol 2007; 21:1305-18. [DOI: 10.1111/j.1468-3083.2007.02475.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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23
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Treatments for metastatic melanoma: synthesis of evidence from randomized trials. Cancer Treat Rev 2007; 33:665-80. [PMID: 17919823 DOI: 10.1016/j.ctrv.2007.06.004] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Revised: 06/08/2007] [Accepted: 06/12/2007] [Indexed: 11/23/2022]
Abstract
BACKGROUND Advanced melanomas (non-resectable Stage-III/IV) are fatal, with few effective treatments. It remains unclear if other drugs offer improvements over the standard, dacarbazine. PURPOSE We quantified objective response rates (Complete+Partial response) of dacarbazine versus comparators for advanced cutaneous melanoma. METHODS We retrieved all head-to-head randomized controlled trials involving dacarbazine and other drugs/combinations. Two reviewers searched MEDLINE (1966-Jan 2006), EMBASE (1980-2006), CINAHL (1982-2006) and Cochrane library, then compared results. Differences were resolved through consensus. Rates were combined using random effects meta-analysis. chi2 tested heterogeneity; points from Jadad's method were assessed to examine study quality. RESULTS We found 48 studies having 111 active treatment arms [24 with dacarbazine monotherapy (n=1390), 75 with dacarbazine combinations (n=4962), and 12 with non-dacarbazine treatments (n=783)] treating 7135 patients. Overall, study quality was poor. Response to dacarbazine monotherapy ranged between 5.3% and 28.0% (average 15.3%), OR=1.31, CI(95%): 1.06-1.61; N=3356. Partial responses comprised 73% of successes. Only adding interferons improved response rates (OR=1.69, CI(95%): 1.07-2.68, N=778) but survival duration was not significantly longer (P=0.32), and trials with larger sample sizes found lower success rates. All other treatments alone or in combination were ineffective P>0.05. CONCLUSIONS Dacarbazine generally produces poor outcomes. Adding other therapies offers minimal clinical advantages (possibly with interferons). In general, study quality was poor and sample sizes were small. This meta-analysis highlights the unmet need for effective treatment options for advanced melanoma.
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Hofmann MA, Sterry W, Trefzer U. Complex Combination Biochemotherapy Regimen in Advanced Metastatic Melanoma in a Non-intensive Care Unit: Toxicity or Benefit? Jpn J Clin Oncol 2007; 37:224-9. [PMID: 17472972 DOI: 10.1093/jjco/hym009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is currently no chemotherapy or chemoimmunotherapy regimen that has shown impact on survival in patients with metastatic melanoma. Different biochemotherapy protocols showed promise with high response rates, but again without significant impact on survival. METHODS We report the results of a retrospective analysis of a regimen consisting of dacarbazine, cisplatin, vindesine, interleukin-2 and interferon-alpha2b in 25 consecutively treated patients with regard to toxicity, efficacy and practicability. The treatment was performed on a regular dermatological ward. RESULTS Grade III and IV toxicities were mainly haematological, with few cases of infection because of neutropenia seen. Best overall responses were CR 2/25, PR 2/25 and SD 9/25. The median progression free interval was 4 months (range 0-19) for all patients and the median survival time was 12 months (range 2-26). From a safety and practical point of view, there was no draw-back on treating patients in a non-intensive care unit. The median survival time is in the range of the one reported for monochemotherapy regimen. While there are some responding patients, the responses are short lived and go in parallel with high toxicity and impaired performance status. CONCLUSION This complex and highly toxic chemoimmunotherapeutic regimen should not be considered as standard therapy in patients with metastatic malignant melanoma.
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Affiliation(s)
- Maja A Hofmann
- Department of Dermatology and Allergy, Skin Cancer Centre, Charité-Universitätsmedizin Berlin, Berlin, Germany.
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25
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Koon HB, Atkins MB. Update on therapy for melanoma: opportunities for patient selection and overcoming tumor resistance. Expert Rev Anticancer Ther 2007; 7:79-88. [PMID: 17187522 DOI: 10.1586/14737140.7.1.79] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The incidence of malignant melanoma is rising faster than any other malignancy. Although earlier stage patients can be cured with surgical resection with or without adjuvant therapy, a significant number of patients go on to develop disseminated disease. Currently, limited therapeutic options exist for patients with metastatic melanoma. Recent studies suggest that patient selection is feasible and may enable the restriction of treatment to those most likely to benefit. Additionally, several potential mechanisms of tumor resistance have been identified creating opportunities for circumventing them. This article will review current strategies for patient selection and overcoming therapeutic resistance. These strategies hold the promise of extending the clinical benefits of current therapies as well as facilitating the development of additional and more active treatments.
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Affiliation(s)
- Henry B Koon
- Beth Israel Deaconess Medical Center, Biologic Therapeutics Program, 330 Brookline Avenue, Boston, Massachusetts 02215, USA.
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26
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Sasse AD, Sasse EC, Clark LGO, Ulloa L, Clark OAC. Chemoimmunotherapy versus chemotherapy for metastatic malignant melanoma. Cochrane Database Syst Rev 2007:CD005413. [PMID: 17253556 DOI: 10.1002/14651858.cd005413.pub2] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Malignant melanoma, one of the most aggressive of all skin cancers, is increasing in incidence throughout the world. Surgery remains the cornerstone of curative treatment in earlier stages. Metastatic disease is incurable in most affected people, because melanoma does not respond to most systemic treatments. A number of novel approaches are under evaluation and have shown promising results, but they are usually associated with increased toxicity and cost. The combination of chemotherapy and immunotherapy has been reported to improve treatment results, but it is still unclear whether evidence exists to support this choice, compared with chemotherapy alone. No language restrictions were imposed. OBJECTIVES To compare the effects of therapy with chemotherapy and immunotherapy (chemoimmunotherapy) versus chemotherapy alone in people with metastatic malignant melanoma. SEARCH STRATEGY We searched the Cochrane Skin Group Specialised Register (14 February 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005), MEDLINE (2003 to 30 January 2006 ), EMBASE (2003 to 20 July 2005) and LILACS (1982 to 20 February 2006). References, conference proceedings, and databases of ongoing trials were also used to locate trials. SELECTION CRITERIA All randomised controlled trials that compared the use of chemotherapy versus chemoimmunotherapy on people of any age, diagnosed with metastatic melanoma. DATA COLLECTION AND ANALYSIS Two authors independently assessed each study to determine whether it met the pre-defined selection criteria, with differences being resolved through discussion with the review team. Two authors independently extracted the data from the articles using data extraction forms. Quality assessment included an evaluation of various components associated with biased estimates of treatment effect. Whenever possible, a meta-analysis was performed on the extracted data, in order to calculate a weighed treatment effect across trials. MAIN RESULTS Eighteen studies met our criteria and were included in the meta-analysis, with a total of 2625 participants. We found evidence of an increase of objective response rates in people treated with chemoimmunotherapy, in comparison with people treated with chemotherapy. Nevertheless, the impact of these increased response rates was not translated into a survival benefit. We found no difference in survival to support the addition of immunotherapy to chemotherapy in the systemic treatment of metastatic melanoma, with a hazard ratio of 0.89 (95% CI 0.72 to 1.11, p=0.31). Additionally, we found increased hematological and non-hematological toxicities in people treated with chemoimmunotherapy. AUTHORS' CONCLUSIONS We failed to find any clear evidence that the addition of immunotherapy to chemotherapy increases survival of people with metastatic melanoma. Further use of combined immunotherapy and chemotherapy should only be done in the context of clinical trials.
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Affiliation(s)
- A D Sasse
- Oncology Department, Av Dr Luiz de Tella 970, Cidade Universitaria, Campinas, Sao Paulo, Brazil. 13083-000.
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Abstract
No effective therapy for metastatic melanoma exists. Polychemotherapy or chemoimmunotherapy have not shown survival benefits. Vaccines have shown little activity in stage IV disease. To advance the identification of effective agents, new drugs can and should be offered as first-line treatment. Efforts must be made to improve understanding of the biology of malignant melanoma. Too many phase III trials have been conducted with a poor understanding of the mechanism of action of the involved drugs.
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Affiliation(s)
- Alexander M M Eggermont
- Erasmus Medical Center, Daniel den Hoed Cancer Center, 301 Groene Hilledijk, EA 3075, Rotterdam, the Netherlands.
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28
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Abstract
Despite the limited efficacy of systemic chemotherapy in the treatment of metastatic melanoma, it remains the gold standard in the case of patients with a good performance status and no major comorbidities for whom radical surgery is unsuitable. Various drugs have been employed as monochemotherapy with response rates ranging from 0 to 20%. Many Phase III trials have compared the role of polychemotherapy with that of single-agent chemotherapy, or evaluated the impact of biological response modifiers alone or in combination with chemotherapeutic agents. However, the current scenario does not seem to be significantly different from the situation of 20 or 30 years ago. To date, no single drug, combination chemotherapy in addition to a hormonal or biotherapy compound, has demonstrated an overall survival benefit in a randomized clinical trial.
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Affiliation(s)
- Marta Mandarà
- Department of Clinical and Experimental Medicine, University of Verona, P.le Stefani 1, 37126 Verona, Italy.
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29
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González Cao M, Malvehy J, Martí R, Conill C, Sánchez M, Martín M, Carrera C, Herrero J, Gascón P, Mellado B, Castel T, Puig S. Biochemotherapy with temozolomide, cisplatin, vinblastine, subcutaneous interleukin-2 and interferon-α in patients with metastatic melanoma. Melanoma Res 2006; 16:59-64. [PMID: 16432457 DOI: 10.1097/01.cmr.0000195697.58013.b7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to determine the efficacy and tolerability of a biochemotherapy regimen, including low-dose subcutaneous interleukin-2 and temozolomide, in patients with metastatic melanoma. Treatment consisted of temozolomide (150 mg/m per day on days 1-5), cisplatin (20 mg/m per day intravenously on days 1-4), vinblastine (1.5 mg/m per day on days 1-4), interleukin-2 (4.5 MU/m per day subcutaneously on days 5-8) and interferon-alpha2b (5 MU subcutaneously on days 5-9, 11, 13, 15, every 28 days). Thirty-six patients were included. Patients with poor prognostic factors were not excluded. Seventeen patients (47%) had been treated previously in an adjuvant setting with interferon-alpha. Four patients (11%) had been treated previously with chemotherapy and six (17%) had been treated with other biochemotherapy regimens. The distribution by American Joint Committee on Cancer staging was as follows: M1a in two patients (6%), M1b in 11 patients (31%) and M1c in 23 patients (64%). At inclusion, seven patients (19.4%) had cerebral metastases that had previously been treated with whole brain radiotherapy. For thirty-four evaluable patients, seven (20.5%) achieved an objective response. Overall, metastatic disease was substantially decreased or temporarily stabilized in 11 patients (32.4%; 95% confidence interval, 17.4-50.5). Responses were observed for all locations. The central nervous system was the initial site of relapse in two responding patients. The median survival was 10 months. The main toxicities noted were haematological (grades 3-4): neutropenia (1.8%), thrombocytopenia (1.8%) and anaemia (1.2%). It can be concluded that this regimen is well tolerated and has a modest activity despite the poor prognosis of our patient population. The low haematological toxicity rate obtained suggests that higher doses could be tried.
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Affiliation(s)
- María González Cao
- Medical Oncology Department, Clinic Institute of Hematologic and Oncologic Diseases (ICHMO), Clinic Hospital, Barcelona, Spain.
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Alexandrescu DT, Dutcher JP, Wiernik PH. Metastatic melanoma: is biochemotherapy the future? Med Oncol 2005; 22:101-11. [PMID: 15965272 DOI: 10.1385/mo:22:2:101] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2004] [Revised: 12/30/2004] [Accepted: 01/07/2005] [Indexed: 11/11/2022]
Abstract
Current treatment options in metastatic melanoma are of limited efficacy. Achievement of durable responses with biological agents, and the possibility to complement the higher response rate of chemotherapy and combined chemotherapy by prolonged duration of responses, led to development of biochemotherapy. Although a clear improvement in response rate (40-60% OR) resulted in some studies of the combined modality, several phase III studies had mixed results on the duration of survival. Various timeframes between the administration of chemotherapy and biologics have been tested, ranging between concurrent biochemotherapy, 1 d (immediately sequential), and up to 3 wk (long sequence or alternating). An analysis of the trend of responses and survival versus the duration of the chemobiotherapy sequence showed that, as the timeframe between chemo and bio components increases, the overall survival, survival of complete responders, and survival of partial responders appear to increase, but the effect is only present for the chemo-bio, and not for the bio-chemo sequence. Because there is no current explanation for this observation, it appears possible that the interaction between components of biochemotherapy results in a double effect: an increase in the immediate response reflected in the OR, CR, PR on one side, and an increase in survival on the other side. An analysis of mechanisms involved in the response leads us hypothesize that macrophage activation, as measured by the neopterin levels, may correlate with the survival of patients undergoing biochemotherapy, while the generation of nitric oxide, acting synergistically with chemotherapy in producing tumor cell killing, may be reflected in the overall response rate seen with the biochemotherapy combinations.
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Affiliation(s)
- Doru T Alexandrescu
- New York Medical College, Our Lady of Mercy Medical Center, Comprehensive Cancer Center, Bronx, NY 10466, USA.
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31
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Keilholz U, Punt CJA, Gore M, Kruit W, Patel P, Lienard D, Thomas J, Proebstle TM, Schmittel A, Schadendorf D, Velu T, Negrier S, Kleeberg U, Lehman F, Suciu S, Eggermont AMM. Dacarbazine, cisplatin, and interferon-alfa-2b with or without interleukin-2 in metastatic melanoma: a randomized phase III trial (18951) of the European Organisation for Research and Treatment of Cancer Melanoma Group. J Clin Oncol 2005; 23:6747-55. [PMID: 16170182 DOI: 10.1200/jco.2005.03.202] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Based on phase II trial results, chemoimmunotherapy combinations have become the preferred treatment for patients with metastatic melanoma in many institutions. This study was performed to determine whether interleukin-2 (IL-2) as a component of chemoimmunotherapy influences survival of patients with metastatic melanoma. PATIENTS AND METHODS Patients with advanced metastatic melanoma were randomly assigned to receive dacarbazine 250 mg/m2 and cisplatin 30 mg/m2 on days 1 to 3 combined with interferon-alfa-2b 10 x 10(6) U/m2 subcutaneously on days 1 through 5 without (arm A) or with (arm B) a high-dose intravenous decrescendo regimen of IL-2 on days 5 through 10 (18 x 10(6) U/m2/6 hours, 18 x 10(6) U/m2/12 hours, 18 x 10(6) U/m2/24 hours, and 4.5 x 10(6) U/m2 for 3 x 24 hours). Treatment cycles were repeated in the absence of disease progression every 28 days to a maximum of four cycles. RESULTS Three hundred sixty-three patients with advanced metastatic melanoma were accrued. The median survival was 9 months in both arms, with a 2-year survival rate of 12.9% and 17.6% in arms A and B, respectively (P = .32; hazard ratio, 0.90; 95% CI, 0.72 to 1.11). There was also no statistically significant difference regarding progression-free survival (median, 3.0 v 3.9 months) and response rate (22.8% v 20.8%). CONCLUSION Despite its activity in melanoma as a single agent or in combination with interferon-alfa-2b, the chosen schedule of IL-2 added to the chemoimmunotherapy combination had no clinically relevant activity.
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Affiliation(s)
- Ulrich Keilholz
- Department of Medicine III, Charité, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany.
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32
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Affiliation(s)
- Alexander M M Eggermont
- Department of Surgical Oncology, Erasmus University Medical Center--Daniel den Hoed Cancer Center, Rotterdam, The Netherlands.
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33
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Eklund JW, Kuzel TM. Interleukin-2 in the treatment of renal cell carcinoma and malignant melanoma. Cancer Treat Res 2005; 126:263-87. [PMID: 16209070 DOI: 10.1007/0-387-24361-5_11] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- John W Eklund
- The Robert H Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
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González Cao M, Puig S, Malvehy J, Herrero JE, Martí RM, Conill C, Sánchez M, Mellado B, Gascón P, Castel T. Biochemotherapy with low doses of subcutaneous interleukin-2 in patients with melanoma: results of a phase II trial. Clin Transl Oncol 2005; 7:250-4. [PMID: 16131448 DOI: 10.1007/bf02710171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Metastatic melanoma has an ominous prognosis. Bio-chemotherapy regimens can increase the response rate but with a high degree of toxicity due, mainly, to the use of high-dose intravenous interleukin-2. OBJECTIVES To test the feasibility and activity profile of a bio-chemotherapy regimen of low-dose subcutaneous interleukin-2. MATERIAL AND METHODS Administration scheme: dacarbazine at 200 mg/m2/d on days 1-4, cisplatin at 20 mg/m2/d intravenous on days 1-4, vinblastine at 1.5 mg/m2/d on days 1-4, IL-2 at 4.5 MUI/m2/d subcutaneous on days 5-8, IFN-alpha at 5 MU subcutaneous on days 5-9, 11, 13, 15 of every 21-day cycle. RESULTS Objective response was obtained in 11 patients (39.3%; 95%CI: 21-59) including 4 with complete response (14.3%; 95%CI: 4-33). With an extended follow-up of 49 months and 60 months, respectively, 2 patients continue with complete response. The main toxicities were haematological: grade 3-4 neutropenia in 8.2% of cycles, thrombocytopenia in 1.2% and anaemia in 3.2%. CONCLUSIONS The regimen is safe and has a good activity profile. The presence of long-term survivors, despite the use of lower doses and subcutaneous IL-2, is encouraging.
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Affiliation(s)
- María González Cao
- Servicio de Oncología Médica (ICHMO), Hospital Clinic, Barcelona, IDIBAPS, Spain
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Hayes AJ, Clark MA, Harries M, Thomas JM. Management of in-transit metastases from cutaneous malignant melanoma. Br J Surg 2004; 91:673-82. [PMID: 15164434 DOI: 10.1002/bjs.4610] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Abstract
Background
In-transit metastases from cutaneous malignant melanoma (cutaneous or subcutaneous deposits between the primary melanoma and regional lymph nodes) represent late-stage disease, and their treatment should be tailored accordingly. This article reviews the pathology, clinical significance and treatment options for in-transit disease from melanoma.
Methods
An initial Medline search was undertaken using the keywords ‘melanoma and in-transit’ and ‘melanoma and non-nodal regional recurrence’. Additional original articles were obtained from citations in articles identified by the initial search.
Results and conclusion
In-transit metastases carry a poor prognosis. The method of treatment should be tailored to the extent of cutaneous disease. The first line of treatment remains complete excision with negative histopathological margins. There is no need for wide excision. Carbon dioxide laser therapy is valuable for multiple small cutaneous deposits. Isolated limb perfusion has a role for numerous or bulky advanced in-transit metastases in the limbs that are beyond the scope of simpler techniques. Systemic chemotherapy has response rates of about 25 per cent and is reserved for patients for whom surgery is no longer feasible.
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Affiliation(s)
- A J Hayes
- Sarcoma and Melanoma Unit, Department of Surgery, Royal Marsden Hospital, London, UK
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36
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Eigentler TK, Caroli UM, Radny P, Garbe C. Palliative therapy of disseminated malignant melanoma: a systematic review of 41 randomised clinical trials. Lancet Oncol 2003; 4:748-59. [PMID: 14662431 DOI: 10.1016/s1470-2045(03)01280-4] [Citation(s) in RCA: 239] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We undertook a systematic review of 41 randomised studies in disseminated melanoma, identified by a comprehensive search. We aimed to investigate rates of response to various treatment modalities and the outcome for the patients. We analysed seven studies that compared polychemotherapy with single-agent dacarbazine, six that compared different chemotherapeutic schedules with each other, five on the addition of tamoxifen to a reference therapy, and six that included non-specific immunostimulators. In 17 studies, the addition of interferon alfa, interleukin 2, or both, to a reference therapy was investigated, including trials with biochemotherapy. Many trials had small sample sizes and did not report a power analysis; not all were analysed by intention to treat. Although some treatment regimens, especially polychemotherapeutic schedules, seem to increase response rates, none of the treatment schedules was proven to prolong overall survival. Patients with disseminated melanoma should be treated with well-tolerated drug regimens, such as single-agent treatments or in combination with interferon alfa. Systemic treatments should preferably be investigated in randomised trials so that the potential benefits of new treatment concepts can be thoroughly examined.
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Konjević G, Jović V, Jurisić V, Radulović S, Jelić S, Spuzić I. IL-2-mediated augmentation of NK-cell activity and activation antigen expression on NK- and T-cell subsets in patients with metastatic melanoma treated with interferon-alpha and DTIC. Clin Exp Metastasis 2003; 20:647-55. [PMID: 14669796 DOI: 10.1023/a:1027387930868] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Considering that well-defined and comprehensive immunological monitoring is the basis for the evaluation of the obtained immunmodulatory effects, we evaluated NK-cell activity, the number of CD3+ CD4+, CD3+ CD8+ T cells and CD16+ CD56+ NK cells, as well as the expression of activation antigens, CD69, CD38 and HLA-DR on CD56+ NK cells, CD8+ and CD3+ T cells, simultaneously with IL-2 and TNF-alpha production, during chemoimmunotherapy with dacarbazine (DTIC) and interferon-alpha (IFN-alpha) in 39 patients with metastatic melanoma. In the first cycle of therapy, there was a significant rise in NK-cell activity, CD4+ T helper cell number, CD4/CD8 T-cell ratio, and the expression of activation antigens CD69 and CD38, on NK and T cells, respectively. However, in the following cycles there was a significant increase only in activation antigens without an increase in the percent or activity of NK cells. The early, but transient, immunopotentiation, present only in the first cycle of combined DTIC and IFN-alpha therapy, suggests that, in spite of increased IL-2 level, associated with augmented NK-cell activity, this therapy has a limited effect probably owing to the adverse effect of persistently high level of TNF-alpha in metastatic disease.
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Affiliation(s)
- Gordana Konjević
- Department of Experimental Immunology, Institute for Oncology and Radiology of Serbia, Belgrade, Yugoslavia.
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38
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Eggermont AMM, Punt CJA. Does adjuvant systemic therapy with interferon-alpha for stage II-III melanoma prolong survival? Am J Clin Dermatol 2003; 4:531-6. [PMID: 12862495 DOI: 10.2165/00128071-200304080-00002] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The experience with interferon-alpha in malignant melanoma resembles, to some degree, the experience with various kinds of adjuvant immunotherapeutic agents where 25 years of phase III trials of adjuvant therapy in stage II-IIII melanoma have not defined a standard therapy. Most trials failed to demonstrate an impact on disease-free survival and overall survival. Currently, data from 12 randomized interferon-alpha trials are available. The data in almost 3000 patients, approximately 50% of the total patient population, is immature and thus, inconclusive. Mature trials show that interferon-alpha significantly prolongs disease-free survival, but does not prolong overall survival, across different dose levels. Ultra-low-dose (1 MIU flat dose), interferon-alpha failed to even have an effect on disease-free survival. Although two trials with high-dose (10-20 MIU/m(2)) interferon-alpha have shown an impact on overall survival, these data are inconclusive since this impact was transient, inconsistent in subsequent trials, and the data was somewhat immature. Inconsistent results have also been observed for intermediate- (5-10 MIU flat dose) and low-dose (3 MIU flat dose) interferon-alpha regimens. The results, overall, suggest that these doses do have an impact on disease-free survival, but not on overall survival. Preliminary results regarding distant metastasis-free survival (the closest surrogate for overall survival available) of the very large European Organisation for Research and Treatment of Cancer (EORTC) 18952 trial suggests that there is a benefit with long-term low intermediate doses and support the anti-angiogenic concept of long-term maintenance treatment with interferon-alpha. The efficacy of short-term high-dose and long-term intermediate-dose treatment is being investigated in new trials. For now the role of interferon-alpha still remains to be determined and its use should be restricted to the setting of clinical trials.
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Affiliation(s)
- Alexander M M Eggermont
- Department of Surgical Oncology, Erasmus University Medical Center Rotterdam, Daniel den Hoed Cancer Center, Rotterdam, The Netherlands.
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39
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Neuber K. Treosulfan in the treatment of metastatic melanoma: from chemosensitivity testing to clinical trials. Recent Results Cancer Res 2003; 161:159-79. [PMID: 12528807 DOI: 10.1007/978-3-642-19022-3_14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
The therapy of metastatic malignant melanoma is limited by poor responses and short overall survival. Thus it remains important to identify and test potential new drugs in this disease. To examine the effects of the bifunctional alkylating cytostatic treosulfan, an in vitro microplate ATP bioluminescence assay (ATP-TCA) was used. Five highly chemoresistant melanoma cell lines and melanoma cells freshly isolated from metastases surgically resected from stage IV melanoma patients (n = 10) were incubated with treosulfan. Three cell lines and eight of ten tested tumor cells isolated from melanoma metastases showed tumor growth inhibition after incubation with treosulfan. Therefore, 14 patients with rapidly progressing stage IV malignant melanoma who were pretreated with at least one standard chemotherapy regimen received treosulfan. In this population of patients with highly refractory advanced melanoma one complete remission (7.1%), two partial remissions (14.3%), and three cases of stable disease (21.4%) were observed. Median time to progression and median overall survival for all patients measured from the beginning of treosulfan treatment were 5 months [95% confidence interval (CI) 1.98-2.57 months] and 9 months (95% CI 3.92-8.69 months), respectively. On the basis of these data a multicenter phase II trial was initiated. A total of 31 patients with stage IV melanoma were included and treated second-line with 8 g/m2 i.v. treosulfan. From this group 26 patients were evaluable. No objective remission (CR, PR) was observed, 5 of 26 patients (19%) had stable disease, and 21 patients had progressive disease. Median overall survival was 6.5 months (95% CI 3.1-10 months). Toxicity of treosulfan was moderate. Patients with treosulfan-sensitive melanoma metastases showed better response rates and prolonged survival compared with patients who were not tested before treosulfan treatment. We therefore suggest further studies with first-line treosulfane alone or in combination with gemcitabine or cytosine arabinoside together with pretherapeutic chemosensitivity testing that may help to select patients who might benefit from specific chemotherapy.
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Affiliation(s)
- Karsten Neuber
- Department of Dermatology, University Hospital Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.
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40
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Dillman RO, O'Connor AA, Simpson L, Barth NM, VanderMolen LA, Vanderplas P. Does continuous-infusion interleukin-2 increase survival in metastatic melanoma? Am J Clin Oncol 2003; 26:141-5. [PMID: 12714884 DOI: 10.1097/00000421-200304000-00008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pharmacy logbooks and clinical trial records were used to identify all 60 patients with metastatic melanoma who were treated as inpatients with intermediate-dose, continuous-infusion interleukin-2 (IL-2) in Hoag Hospital during 1987 to 1998. The hospital tumor registry was used to identify contemporary controls who had not received inpatient IL-2, matched for having distant metastatic melanoma, and by year and stage at original diagnosis, gender, and age. The mean time from original diagnosis to the documentation of distant metastatic disease was similar in both groups, 24 to 26 months. From the date of starting IL-2 therapy, patients had a median survival of 8.8 months, 38% 1-year survival, and 20% 5-year survival, with 8 patients alive beyond 5 years. However, there was no difference in survival from the first date of distant metastatic disease (median 25.8 months for IL-2 versus 31.5 months for controls, with survival rates 5 years after metastatic disease of 26% versus 31%). There was also no difference in overall survival from the date of original diagnosis (60.1 months for the IL-2 group versus 86.3 months for controls, with 5-year survival rates of 51% versus 64%, and 10-year survival rates of 29% versus 33%). This single-institution study failed to establish a survival advantage for patients with metastatic melanoma who received intermediate-dose, continuous-infusion IL-2 administered in the inpatient setting, compared to contemporary, matched-control patients who never received inpatient IL-2 therapy. However, the 5-year survival rates after a diagnosis of distant metastatic disease were a surprisingly high 26% to 31% in both groups. In the absence of a control group, the survival impact of IL-2 has probably been overestimated from single-arm phase II and III trials.
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Affiliation(s)
- Robert O Dillman
- Hoag Cancer Center, One Hoag Drive, Building 41, Newport Beach, CA 92658, U.S.A.
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41
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Neuber K, Reinhold U, Deutschmann A, Pföhler C, Mohr P, Pichlmeier U, Baumgart J, Hauschild A. Second-line chemotherapy of metastatic malignant melanoma with intravenous treosulfan: a phase II multicentre trial. Melanoma Res 2003; 13:81-5. [PMID: 12569289 DOI: 10.1097/00008390-200302000-00013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The purpose of this multicentre phase II trial was to evaluate time to progression, survival time, rate of objective tumour response and toxicity of second-line intravenous treosulfan chemotherapy in stage IV melanoma patients. Thirty-one patients with measurable stage IV malignant melanoma and prior chemotherapy with a dacarbazine-containing regimen were included. Of this group, 26 patients were evaluable. All patients received treosulfan (8 g/m intravenously on day 1; cycle repeated every 28 days up to six courses). Patients were evaluated for tumour response, survival time and toxicity. No objective responses (complete or partial) were observed. Five patients (19%) showed no change and 21 had progressive disease after treosulfan treatment. Four patients experienced a minor or mixed response. The median time to progression was 1.8 months (95% confidence interval [CI] 1.6-2.1 months) and the median overall survival was 6.5 months (95% CI 3.1-10 months). The 1 year survival rate was 33.9% (95% CI 15.4-52.3%). Leukocytopenia and thrombocytopenia (Common Toxicity Criteria grades 3 and 4) occurred in 15% and 18% of cases, respectively. The non-haematological toxicity of this outpatient regimen was mild. In conclusion, intravenous treosulfan treatment does not induce objective response rates when used as a second-line treatment of metastatic malignant melanoma.
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Affiliation(s)
- Karsten Neuber
- Department of Dermatology, University Hospital Hamburg, Martinistr. 52, D-20246 Hamburg, Germany.
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42
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Abstract
The combination of cisplatin-based chemotherapy with interleukin-2 and interferon-alpha, referred to as biochemotherapy or chemoimmunotherapy, has shown promising antitumor activity in patients with metastatic melanoma. Phase II studies have reported overall response rates ranging from 40 to 60%, with durable complete remissions in approximately 10% of the patients. Although the results of the phase II single institutional studies were encouraging, phase III studies have not shown consistent results. Many factors may explain this finding including small number of patients, lack of a proper phase II study to define the antitumor activity of a given biochemotherapy regimen, and principally lack of a multicenter phase II study to better define the response rate as well as to gain experience with an IL-2-based regimen in the community setting prior to conducting a phase III trial. Large randomized studies are ongoing and should better clarify the long-term impact of biochemotherapy on survival in patients with advanced melanoma.
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Affiliation(s)
- Antonio C Buzaid
- Oncology Center, Hospital Sirio-Libanes, Rua Adma Jafet 91, São Paulo, SP 01308-050, Brazil.
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43
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Abstract
The outcome of chemotherapy for patients with stage IV melanoma is unsatisfactory, since durable responses are rarely achieved. More experimental treatments, such as vaccine approaches, antibody treatments, and gene therapy are being developed and are of high scientific interest; however, their efficacy in advanced melanoma patients has so far been very limited. Based on the observation of a small proportion of long-term responses, the use of biotherapy or biochemotherapy is currently preferred in many institutions as first-line treatment in stage IV melanoma. Various interleukin-2 (IL-2) dosing schedules and combinations with interferon alpha (IFN-alpha) have been tested in patients with advanced melanoma during the past decade. The response rates reported with IL-2 as a single agent or in combination with IFN-alpha varies from 10% to 41%, with a small, but remarkable proportion of durable responses. Subsequently, biochemotherapy regimens combining IL-2, IFN-alpha, and chemotherapy have been evaluated in phase II trials, which have suggested improved response rates. Recent randomized trials have investigated the role of biochemotherapy as compared to biotherapy alone or as compared to chemotherapy for the treatment of advanced melanoma. So far, none of the approaches has been proven to confer a survival benefit and thus the uniform desire is to include as many patients as possible in controlled clinical trials.
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Affiliation(s)
- Ulrich Keilholz
- Department of Medicine III (Hematology, Oncology, and Transfusion Medicine), University Hospital Benjamin Franklin, Free University of Berlin, Berlin, Germany
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Abstract
The role of systemic chemotherapy in the treatment of patients with metastatic melanoma remains of questionable benefit. Despite encouraging phase II data from multiple institutions that suggested an improved overall response rate for patients treated with the Dartmouth regimen, recently completed phase III trials have failed to demonstrate a significant benefit in survival. Of concern is the fact that there have been relatively few new chemotherapeutic agents in the past several years that have demonstrated any activity in this disease. More recently there has been a shift away from combination chemotherapy to biochemotherapy. However, this approach has yet to be clearly defined as superior. The basis for optimism in the future in this field resides in the realm of molecular oncology. As mechanisms of resistance are identified, new molecules such as antisense oligonucleotides may provide the basis for increasing the sensitivity of melanoma to chemotherapeutic and/or immunotherapeutic treatments.
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Affiliation(s)
- Yan Li
- Division of Hematology/Oncology, University of California, San Diego, CA, USA
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45
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Keilholz U, Martus P, Punt CJA, Kruit W, Mooser G, Schadendorf D, Liénard D, Dummer R, Koller J, Voit C, Eggermont AMM. Prognostic factors for survival and factors associated with long-term remission in patients with advanced melanoma receiving cytokine-based treatments: second analysis of a randomised EORTC Melanoma Group trial comparing interferon-alpha2a (IFNalpha) and interleukin 2 (IL-2) with or without cisplatin. Eur J Cancer 2002; 38:1501-11. [PMID: 12110497 DOI: 10.1016/s0959-8049(02)00123-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The aim of this study was to define prognostic factors for survival, and especially for long-term survival in a mature data-set of patients with stage IV melanoma treated within a randomised trial of cytokine-based protocols. Long-term follow-up data on patients enrolled into a European Organization for Research and Treatment of Cancer (EORTC) trial comparing interferon-alpha (IFNalpha) plus interleukin-2 (IL-2) with or without cisplatin were collected. Univariate and multivariate Cox regression analyses were performed to define prognostic factors for survival. The characteristics of patients alive at 2 and 5 years after randomisation were compared with the entire cohort using the chi(2) test. The minimum potential follow-up of the 131 evaluable patients was 5 years. 18 patients (14%) were alive 2 years after randomisation, and 11 (8%) 5 years after randomisation. Pretreatment performance status (PS), serum lactate dehydrogenase (LDH) and tumour mass were significant predictors for survival, whereas site of metastases and number of sites were non-significant. PS and LDH were the only independent prognostic factors. All except 1 patient alive at 2 and 5 years had a pretreatment PS of 100%, and only three long-term survivors had elevated pretreatment LDH. There was no association between the site of metastases and long-term survival. Response to treatment was a major predictor for long-term survival, whereas addition of cisplatin did not impact upon overall survival probability or on long-term survival. The probability of long-term survival in stage IV melanoma patients after IL-2-based treatments is governed by pretreatment PS, serum LDH and response to treatment. Site of metastases, the basis for the M-subcategories of the new AJCC staging system, was not informative in this study.
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Affiliation(s)
- U Keilholz
- Medizinische Klinik III, UKBF, Free University Berlin, Hindenburgdamm 30, 12200, Berlin, Germany.
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46
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Abstract
The European approach to the treatment of each stage of malignant melanoma can be characterized as cautious, avoiding unwarranted mutilation or toxicity, because phase III trials have demonstrated that an aggressive approach in surgical management, adjuvant therapy, and treatment of stage IV disease has met with little success. Phase III trials have demonstrated that wide margins, elective lymph node dissections, and prophylactic isolated limb perfusions bring no survival benefit. Primary melanoma is excised with a margin of 1 cm to maximally 2 cm and primary closure as a rule. There is no standard adjuvant therapy. High-dose interferon treatment is practiced only sporadically in Europe because its high toxicity profile and an unclear long-term impact on survival are not popular. Long-term nontoxic lower-dose interferon regimens and vaccines are currently being explored. Phase III trials have shown that highly toxic polychemotherapy or biochemotherapy has not produced a survival benefit over simple treatment with dacarbazide alone. In Europe biochemotherapy is being abandoned and various less toxic or nontoxic approaches with vaccines and antiangiogenic agents are under study.
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Affiliation(s)
- Alexander M M Eggermont
- Department of Surgical Oncology, Erasmus University Medical Center, Daniel den Hoed Cancer Center, Rotterdam, The Netherlands.
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47
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Jelić S, Babovic N, Kovcin V, Milicevic N, Milanovic N, Popov I, Radosavljevic D. Comparison of the efficacy of two different dosage dacarbazine-based regimens and two regimens without dacarbazine in metastatic melanoma: a single-centre randomized four-arm study. Melanoma Res 2002; 12:91-8. [PMID: 11828263 DOI: 10.1097/00008390-200202000-00013] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aim of this randomized four-arm phase III study was to evaluate whether there is a difference in activity between regimens containing dacarbazine and regimens without dacarbazine in metastatic melanoma, whether there is a dose-effect relationship for dacarbazine, and whether non-dacarbazine-containing aggressive regimens are in any way superior to non-aggressive ones. A total of 219 patients with metastatic cutaneous melanoma were included in this study; 196 of them were evaluable for activity. The patients were randomized into four treatment arms: arm A (standard dose dacarbazine arm), vincristine 1.4 mg/m2 on day 1, carmustine (BCNU) 60 mg/m2 on day 1, and dacarbazine 300 mg/m2 per 24 h on days 2-5; arm B (high-dose dacarbazine arm), vincristine and BCNU as in arm A and dacarbazine 600 mg/m2 per 24 h on days 2-5; arm C ('aggressive' regimen without dacarbazine), vindesine 3 mg/m2 on day 1, bleomycin 7 mg/m2 per 24 h on days 1-4, and cisplatin 30 mg/m2 per 24 h on days 5-8; arm D ('non-aggressive' regimen without dacarbazine), BCNU 100 mg/m2 on day 1 and procarbazine 90 mg/m2 per 24 h on days 1-10. The four arms were well balanced with regard to patient- and disease-related characteristics. On an intend-to-treat basis, the response rate was 11 out of 49 (22%) in arm A, nine out of 47 (19%) in arm B, 16 out of 63 (25%) in arm C and nine out of 60 (15%) in arm D. There was a large overlap between the 95% confidence intervals and no significant differences in the response rates between the four arms. Median survival in the four treatment arms was 4, 5, 6 and 4 months, respectively, again with no significant differences. Median survival for responders (8, 11, 10 and 13 months, respectively) in all four arms was significantly longer than in non-responders (4, 3, 5 and 4 months, respectively). Arms A, B and C were significantly more toxic compared with arm D, which was for all practical purposes devoid of toxicities. The efficacy of all four regimens thus appeared comparable both in terms of response rate and survival. Responders in all four arms achieved a survival benefit. There does not seem to be a dose-effect relationship for dacarbazine in metastatic melanoma. Chemotherapy from arm D, might be well suited for 'fragile' or elderly patients due to the lack of toxicity.
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Affiliation(s)
- S Jelić
- Institute for Oncology and Radiology of Serbia, Department of Medical Oncology, Pasterova 14, 11000 Belgrade, Yugoslavia.
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48
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Atzpodien J, Neuber K, Kamanabrou D, Fluck M, Bröcker EB, Neumann C, Rünger TM, Schuler G, von den Driesch P, Müller I, Paul E, Patzelt T, Reitz M. Combination chemotherapy with or without s.c. IL-2 and IFN-alpha: results of a prospectively randomized trial of the Cooperative Advanced Malignant Melanoma Chemoimmunotherapy Group (ACIMM). Br J Cancer 2002; 86:179-84. [PMID: 11870502 PMCID: PMC2375173 DOI: 10.1038/sj.bjc.6600043] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2001] [Revised: 10/22/2001] [Accepted: 10/31/2001] [Indexed: 11/08/2022] Open
Abstract
The purpose of this randomized trial was to evaluate the efficacy of combination chemoimmunotherapy compared with chemotherapy alone. A total of 124 patients were randomized to receive intravenous cisplatin (35 mg m(-2), days 1-3), carmustine (150 mg m(-2), day 1, cycles 1 and 3 only), dacarbacine (220 mg m(-2), days 1-3) and oral tamoxifen (20 mg m(-2), daily) in combination with (n=64) or without (n=60) sequential subcutaneous IL-2 and IFN-alpha. In those patients who received sequential immunotherapy, each cycle of chemotherapy was followed by outpatient s.c. IL-2 (10 x 10(6) IU m(-2), days 3-5, week 4; 5 x 10(6) IU m(-2), days 1, 3, 5, week 5) and s.c. IFN-alpha (5 x 10(6) IU m(-2), day 1, week 4; days 1, 3, 5, week 5). The overall response rate of patients treated with the combination of chemotherapy and IL-2/IFN-alpha was 34.3% with seven complete responses (10.9%) and 15 partial responses (23.4%). In patients treated with chemotherapy, only, the overall response rate was 29.9% with eight complete responses (13.3%) and 10 partial responses (16.6%). There was no significant difference in median progression free survival (0 months vs 4 months) and in median overall survival (12 months vs 13 months) for combined chemoimmunotherapy and for chemotherapy, respectively.
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Affiliation(s)
- J Atzpodien
- European Institute for Tumor Immunology and Prevention (EUTIP), Gotenstr. 152, 53175 Bonn, Germany.
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49
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Weinreich DM, Rosenberg SA. Response rates of patients with metastatic melanoma to high-dose intravenous interleukin-2 after prior exposure to alpha-interferon or low-dose interleukin-2. J Immunother 2002; 25:185-7. [PMID: 12074048 PMCID: PMC2505181 DOI: 10.1097/00002371-200203000-00006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We evaluated 567 patients with metastatic melanoma who were treated with high-dose intravenous interleukin-2 (IL-2) to determine whether prior treatment with either alpha-interferon or low-dose IL-2 altered the rates of response to subsequent high-dose IL-2. Of the 567 patients treated, 46 patients had received low-dose IL-2 before, and 78 had received alpha-interferon before. The response rate for patients who had received IL-2 before compared with IL-2 naïve patients was 15% versus 21% respectively (p = 0.39). The response rate for patients who had received alpha-interferon before compared with patients who had not was 13% versus 21% (p = 0.084). Therefore, prior low-dose IL-2 therapy does not appear to prevent a subsequent response to high-dose IL-2. There is a trend for patients who received alpha-interferon before to have a lower-response rate to subsequent high-dose IL-2, but the number of patients evaluated in this study is too small to definitively answer this question.
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Affiliation(s)
- David M Weinreich
- Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892, USA
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50
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Abstract
Interferon-alpha (IFNalpha) is a pleiotropic cytokine with various direct and indirect inflammatory response modulating activities. Some of these activities may have direct or indirect antitumour effects. For such a wide range of biological activities, the dose for optimal biological activity may differ greatly from the maximally tolerated dose as different effects are mediated by different concentrations of IFNalpha. Because of its immunomodulatory effects, it has been extensively studied in melanoma patients. Little antitumour activity has been demonstrated in metastatic stage IV melanoma, with overall response rates of 10-15%, which were not dose-related. Yet, IFNalpha has been widely studied in the adjuvant setting for stage II and III disease. Many trials have been underpowered, have used very heterogeneously mixed patient populations, a wide variety of doses and treatment schedules, and have suffered from early and unplanned analyses. Mature data are still pending in some 3000 patients of the overall approximately 6000 patients that participated in the adjuvant trials. A meta-analysis has demonstrated a similar impact on relapse-free survival across various dose ranges of IFNalpha, but no significant impact on overall survival (OS). In light of the lack of impact on OS and the considerable to serious dose-dependent toxicity of IFNalpha, we do not have a clearly dose- and schedule-defined role for IFNalpha in the adjuvant setting and have no evidence for a benefit of IFNalpha in stage IV melanoma. For the adjuvant setting, the main question: efficacy of very toxic high dose therapy versus efficacy of non-toxic long-term treatment will be answered by the mature data from the large US-Intergroup high-dose and EORTC intermediate-dose and long-term maintenance therapy trials.
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Affiliation(s)
- A M Eggermont
- Department of Surgical Oncology, Erasmus University Medical Center--Daniel den Hoed Cancer Center, 301 Groene Hilledijk, 3075 EA Rotterdam, The Netherlands.
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