Improved overall survival in melanoma with combined dabrafenib and trametinib

Systemic Therapy for Melanoma: What Surgeons Need to Know

Immune checkpoint inhibitors and targeted therapies (BRAF/MEK inhibitors) have transformed the care of patients with stage IV melanoma, now with 5-year overall survival rates around 50%. Surgeons should be acquainted with these drugs, the multidisciplinary considerations of their use, and the unique immune-related adverse events (irAEs) they can cause. In this review, we discuss systemic therapies for cutaneous melanoma, including the biology of immune checkpoint inhibition, treatment indications, and toxicities. We also explain how these irAEs and other toxicities can impact surgical planning and perioperative management.

Clinical and imaging strategies for the assessment of the ocular side effects of systemic targeted anti-cancer therapies

Systemic targeted anti-cancer therapies selectively target cancerous cells whilst limiting systemic side effects. The eye however, is a particularly sensitive organ and the expanding use of the newer targeted chemotherapy agents has been associated with multiple ocular side effects. In this review we provide an update of the ocular side effects of the newer targeted chemotherapy agents along with suggested minimum, pragmatic, evidence-based strategies for effective screening or monitoring for potential ocular side effects. This framework is designed to guide oncologists, trial managers, protocol developers and regulatory authorities so that appropriate ophthalmic clinical examinations and non-invasive modern imaging can be requested and commissioned according to a patient's specific treatment.

Melanoma in Special Populations: Pediatrics, Elders, Pregnant Women

Melanomas in special populations constitute a unique challenge. Pediatric melanomas present with atypical histopathological features, and the most common subtypes include congenital nevi-associated, Spitzoid, and conventional melanomas. Although they present in more advanced stages than in adults, pediatric melanomas show better prognosis. In the elderly, melanomas are common and often more aggressive than in younger adults, contributing to poorer outcomes and lower survival rates. Pregnancy-associated melanomas (PAMs) do not present with a worse prognosis than all other melanomas. PAM management involves balancing maternal and fetal safety and tailoring surgical treatment according to pregnancy timeline and tumor stage.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Bristol Myers Squibb and Pierre Fabre.

Relation between dabrafenib plus trametinib-induced pyrexia and age in BRAF V600-mutated metastatic melanoma patients: A post hoc analysis of the real-world ELDERLYMEL study

Pyrexia is the most common adverse event in patients treated with dabrafenib plus trametinib. However, the pathogenesis of pyrexia and factors to identify patients at higher risk of developing pyrexia remain unknown. The ELDERLYMEL study was a multicenter, noninterventional, retrospective, real-world study comparing the effectiveness and safety of dabrafenib plus trametinib between elderly (≥75 years, n  = 29) and younger (<75 years, n  = 130) advanced melanoma BRAF V600-mutated patients in Spain. Surprisingly, pyrexia was significantly less frequent in elderly patients (13.8%) than in younger (42.3%). The post hoc analysis presented here aimed to investigate the relationship between age and pyrexia, applying logistic regression models. Patients <75 years had 4.59 more possibilities to develop pyrexia than elderly patients. The possibility of developing pyrexia increased by 1.03 as age decreased by 1 year. Receiver operating characteristics curves identified 61.5 years as the optimal cutoff value to predict the onset of pyrexia. The age-adjusted regression model revealed that patients <61.5 years had 2.53 more possibilities to develop pyrexia than those ≥61.5. This study demonstrates, for the first time, that age significantly influences the development of pyrexia in patients with BRAF V600-mutated advanced melanoma receiving dabrafenib plus trametinib. Age should be considered in the management and follow-up of these patients but should not limit treatment decisions. These findings provide important insights for clinical practice and contribute to a better understanding of pyrexia in elderly patients. The constructed nomogram based on age could serve as a useful tool for estimating the risk of pyrexia in patients receiving this treatment.

Metabolic parameters on baseline and early [18F]FDG PET/CT as a predictive biomarker for resistance to BRAF/MEK inhibition in advanced cutaneous BRAFV600-mutated melanoma

BACKGROUND

[18F]FDG PET/CT plays a crucial role in evaluating cancer patients and assessing treatment response, including in BRAF-mutated melanoma. Metabolic tumor volume (MTV) and total lesion glycolysis (TLG) have emerged as promising alternatives to standardized uptake value (SUV)-based measures for tumor assessment. This study evaluates the predictive value of SUVpeak, MTV, and TLG in predicting progression-free survival (PFS) in advanced BRAF-mutated melanoma treated with BRAF/MEK inhibitors.

RESULTS

Seventy-five patients with metastatic melanoma were enrolled in a multi-center trial and treated with vemurafenib/cobimetinib. [18F]FDG-PET/CT scans were performed at baseline, week-2, and week-7. Imaging analysis included SUVpeak, MTV, and TLG of summed metastases, as well as percentage changes over time (∆). Baseline median PET-parameters were SUVpeak 12.59 (range 3.13-50.59), MTV 159mL (range 0-1897 mL), and TLG 1013 (range 1-13162). Baseline MTV was the strongest predictor (AUCT=6 months=0.714), while early changes in MTV, TLG, and especially week-7 ΔSUVpeak% showed similar or improved performance (P = 0.017 vs. baseline SUVpeak). Patients with TLG below the median had significantly prolonged PFS (15.4 vs. 8.5 months, P = 0.024). MTV above optimal cutoff (45.3 mL) was associated with an increased risk of progression/death, even after adjusting for LDH, ECOG status, and metastatic sites (HR = 2.97, 95% CI 1.17-7.52, P = 0.022). At week-2, ∆SUVpeak% was not predictive in a multivariable analysis, but became predictive at week-7 (median ∆SUVpeak%: 64), with a more than three-fold hazard of progression for patients with ∆SUVpeak% below 64% (P = 0.0014); PFS was 5.0 months (95% CI: 4.3-NA) for patients below the median versus 14.7 months (95% CI: 9.2-20.2) for those above or with non-quantifiable scans (P = 0.0002). Median ∆MTV was 95.5% at week-2 and 97.6% at week-7, with significant PFS differences at both time points (week-2: P = 0.020, week-7: P < 0.001). As expected, TLG mirrored MTV. Patients with MTV increases at week-7 after an initial response at week-2 had a median PFS of 5.3 vs. 12.6 months for those with stable or declining MTV (P = 0.0023). Intra-patient metabolic heterogeneity was also associated with outcome, with early reductions in SUVpeak variation between lesions correlating with better PFS.

CONCLUSION

This study supports the use of MTV and TLG as robust predictive markers for PFS in advanced melanoma treated with BRAF/MEK-inhibitors. Monitoring early PET parameters changes can provide valuable insights into therapeutic response and disease progression.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02414750. Registered 10 April 2015, retrospectively registered.

Resistance to BRAF inhibitors drives melanoma sensitivity to Chk1 inhibition

BRAF inhibitor-resistant melanomas (BRAFiR) acquire (epi)genetic and functional alterations that enable them to evade alternative treatments. Identifying these alterations is critical to advancing treatment strategies. Here, we explored the effect of Chk1 inhibition (Chk1i) on BRAFiR cells, revealing higher sensitivity compared to treatment-naïve cells both in vitro and in vivo. Using FUCCI-labeling and time-lapse microscopy, we show that S phase progression is required for Chk1i-induced cytotoxicity in BRAFiR cells, but not in treatment-naïve cells. Replication stress markers, including reduced BrdU incorporation and increased phospho-RPA and γH2AX, were observed mostly in BRAFiR cells with increased sensitivity to Chk1i. Untreated BRAFiR cells exhibited upregulated DNA replication genes, reduced progressing forks and increased origin firing, suggesting intrinsic replication changes. MAPK pathway reactivation in treatment-naïve cells mimicked BRAFiR traits, increasing sensitivity to Chk1i. These findings indicate that Chk1i exploits elevated replication stress specifically in BRAFiR cells, highlighting its therapeutic potential in overcoming MAPK inhibitor resistance in BRAF600-mutant melanoma.

Cost per outcome of nivolumab + relatlimab vs BRAF + MEK inhibitor combinations for first-line treatment of BRAF-mutant advanced melanoma

BACKGROUND

The National Comprehensive Cancer Network guidelines list combination immunotherapy as the preferred first-line (1L) treatment for unresectable or metastatic melanoma over BRAF and MEK inhibitor (BRAFi/MEKi) therapy, regardless of BRAF mutation status. However, the economic impact of 1L treatment with nivolumab plus relatlimab (NIVO + RELA) vs BRAFi/MEKi therapies for BRAF-mutated advanced melanoma has not been assessed.

OBJECTIVE

To compare the health care costs, cost per progression-free life-year (PFLY), and cost per life-year (LY) of NIVO + RELA vs dabrafenib plus trametinib (DAB + TRAM), encorafenib plus binimetinib (ENCO + BINI), and vemurafenib plus cobimetinib (VEM + COBI) as 1L treatment for BRAF-mutated, unresectable or metastatic melanoma.

METHODS

A cost-per-outcome model compared the economic value of NIVO + RELA vs each BRAFi/MEKi therapy. Clinical inputs were derived from previous matching-adjusted indirect comparisons using individual patient data from the BRAF-mutant subgroup of RELATIVITY-047 and published data pooled from COMBI-d, COMBI-v, COLUMBUS, and coBRIM. LYs, PFLYs per investigator, and treatment duration were estimated using the restricted mean survival time. Health care costs (2024 US dollars), including drug acquisition and administration costs, disease management costs over the preprogression and postprogression periods, and adverse event management costs, were calculated over 5 years. Several scenario analyses were performed, including adding subsequent treatment costs.

RESULTS

Over 5 years, NIVO + RELA was associated with improved PFLYs and LYs compared with DAB + TRAM (mean PFLY: 1.94 vs 1.82 years, mean LY: 3.41 vs 2.77 years), ENCO + BINI (1.87 vs 1.78 years and 3.40 vs 2.91 years, respectively), and VEM + COBI (2.12 vs 1.80 years and 3.39 vs 2.63 years). The estimated total costs over 5 years were lower for NIVO + RELA vs DAB + TRAM ($300,479 vs $519,770), ENCO + BINI ($343,996 vs $572,556), and VEM + COBI ($296,361 vs $317,851). Main cost drivers were drug acquisition and administration costs. NIVO + RELA had lower costs per PFLY and per LY than DAB + TRAM ($155,107 vs $285,617 and $88,203 vs $187,699, respectively); ENCO + BINI ($183,628 vs $322,113 and $101,151 vs $196,924); and VEM + COBI ($139,688 vs $176,645 and $87,315 vs $121,086). The sensitivity analyses' results supported the base-case results.

CONCLUSIONS

NIVO + RELA showed improved LYs and PFLYs at lower cost than all 3 BRAFi/MEKi comparators over 5 years. These results support the economic value of NIVO + RELA for patients with previously untreated, BRAF-mutated, unresectable or metastatic melanoma.

Discovery of 2-Amino-7-Amide Quinazoline Derivatives as Potent and Orally Bioavailable Inhibitors Targeting Extracellular Signal-Regulated Kinase 1/2

Aberrant activation of the ERK/MAPK pathway is closely associated with various cancers. Directly targeting ERK1/2, the most distal node of this cascade, is not only a rational therapeutic approach for cancers harboring pathway-activating alterations, but also provides a potential solution for overcoming resistance from upstream signaling. Herein, we described the discovery of potent and orally bioavailable ERK1/2 inhibitors featuring 2-amino-7-amide quinazoline skeletons through structure-based drug design. Among them, the optimal compound 23 inhibited ERK1/2 at single-digital nanomolar concentrations with good specificity, and exhibited great potencies in preventing cell growth, migration and invasion, disrupting cell cycle, and inducing cell apoptosis. Further mechanism studies demonstrated that 23 dose-dependently suppressed the phosphorylation of the downstream substrate RSK. Remarkably, 23 exerted favorable ADMET and PK profiles, as well as significant in vivo antitumor efficacy with excellent tolerance. Collectively, this work offers a novel and highly promising candidate targeting ERK1/2 for further drug development.

Is One Year Enough? Extended Adjuvant Dabrafenib Plus Trametinib for Chinese Patients With Resected Stage III Melanoma

BACKGROUND

Pathogenic BRAF mutations drive constitutive MAPK pathway activation in melanoma, and targeted therapies with dabrafenib plus trametinib have improved outcomes in the adjuvant setting. However, the optimal duration of adjuvant therapy remains unclear. This retrospective study examined whether extending dabrafenib plus trametinib beyond 1 year offers additional clinical benefit in Chinese patients with resected Stage III melanoma.

METHODS

Medical records from six centers were reviewed for adults with BRAF V600E/K-positive, completely resected Stage III melanoma who received at least 12 months of adjuvant dabrafenib plus trametinib. Patients were divided into a 1-year therapy group and a more-than-1-year therapy group. Relapse-free survival (RFS) was the primary end point; adverse events were also assessed.

RESULTS

Of the 122 patients included, 77 received more than 1 year of adjuvant therapy. The more-than-1-year group experienced significantly better RFS (log-rank p = 0.04), and longer therapy independently reduced recurrence risk in multivariate analysis (HR, 2.42; p = 0.035). Adverse event profiles did not differ between groups, and toxicity-related treatment modifications occurred primarily within the first year.

CONCLUSIONS

Extending dabrafenib plus trametinib beyond 1 year may provide improved RFS without increasing toxicity. Further prospective trials are warranted to confirm the impact on overall survival and identify optimal patient subsets for prolonged therapy.

The 2024 revised clinical guidelines on the management of thyroid tumors by the Japan Association of Endocrine Surgery

The Japan Association of Endocrine Surgery published the first edition of the "Clinical guidelines on the management of thyroid tumors" in 2010 and the revised edition in 2018. The guideline presented herein is the English translation of the revised third edition, issued in 2024. The aim is to enhance health outcomes for patients suffering from thyroid tumors by facilitating evidence-based shared decision-making between healthcare providers and patients, as well as standardizing the management of thyroid tumors. The focus is on adult patients with thyroid tumors, addressing clinically significant issues categorized into areas such as an overview of the diagnosis and treatment of thyroid nodules, treatment strategies by histological type, radioactive iodine therapy, treatment of advanced differentiated carcinoma, pharmacotherapy, and complications and safety management associated with thyroid surgery. Thirty-two clinical questions were established in these areas. Following a comprehensive search of the literature and systematic review to evaluate the overall evidence, we aimed to present optimal recommendations by considering the balance of benefits and harms from the patient's perspective. We integrated evidence and clinical experience to determine the "Certainty of evidence" and "Strength of recommendations". Based on these, we illustrated overall flows of care as "Clinical algorithms". Necessary background knowledge of diseases and established clinical procedures for understanding the recommendations are presented in "Notes", while information that may be clinically useful but for which evidence remains insufficient is included in "Columns", based on the current state of evidence. Finally, future challenges for the next revision are presented as "Future research questions".

Realigned transsulfuration drives BRAF-V600E-targeted therapy resistance in melanoma

BRAF V600E-inhibition effectively treats melanoma, but acquired resistance rapidly develops. Protein expression profiles, mitochondrial energetics, metabolomics and fluxomics data in cell line, xenograft, and patient-derived xenograft systems revealed that concerted reprogramming of metabolic pathways (including glutaminolysis, glycolysis, TCA cycle, electron transport chain [ETC], and transsulfuration), along with an immediate cytoprotective response to drug-induced oxidative stress, underpins drug-tolerant persister cancer cell survival. Realignment of cysteine (Cys) metabolism, in particular an immediate upregulation of cystathionine-γ-lyase (CSE), was vital in persister cells. The oxidative cellular environment, drug-induced elevated cystine uptake and oxidative Cys catabolism, increased intracellular cystine/Cys ratios, thereby favoring cystine as a CSE substrate. This produces persulfides and hydrogen sulfide to protect protein thiols and support elevated energy demand in persister cells. Combining BRAF V600E inhibitors with CSE inhibitors effectively diminished proliferative relapse in culture models and increased progression-free survival of xenografted mice. This, together with induced CSE expression in patient samples under BRAF-V600E-inhibition, reveals an approach to increase BRAF-V600E-targeted therapeutic efficacy.

Cancer immune evasion, immunoediting and intratumour heterogeneity

Cancers can avoid immune-mediated elimination by acquiring traits that disrupt antitumour immunity. These mechanisms of immune evasion are selected and reinforced during tumour evolution under immune pressure. Some immunogenic subclones are effectively eliminated by antitumour T cell responses (a process known as immunoediting), which results in a clonally selected tumour. Other cancer cells arise to resist immunoediting, which leads to a tumour that includes several distinct cancer cell populations (referred to as intratumour heterogeneity (ITH)). Tumours with high ITH are associated with poor patient outcomes and a lack of responsiveness to immune checkpoint blockade therapy. In this Review, we discuss the different ways that cancer cells evade the immune system and how these mechanisms impact immunoediting and tumour evolution. We also describe how subclonal antigen presentation in tumours with high ITH can result in immune evasion.

[New systemic treatment approaches for conjunctival melanoma]

Conjunctival melanoma is a rare disease that nevertheless has a high tumor-associated mortality rate. A resection in sano with adjuvant local treatment currently represents the therapeutic gold standard and systemic treatment is used for metastasized conjunctival melanoma and/or very advanced nonresectable local findings. New knowledge on molecular changes in conjunctival melanoma shows a clear similarity to those of cutaneous melanoma. Therefore, many findings on new systemic forms of treatment for cutaneous melanoma can be transferred to conjunctival melanoma. In the clinical application BRAF/MEK inhibitors and immune checkpoint inhibitors are already in use and good response rates have been shown in small retrospective studies and case reports. Due to the rarity of conjunctival melanoma, there are no larger prospective studies comparing different systemic therapeutic agents. In a nonrandomized retrospective comparison, a better overall survival was shown for a combination of BRAF/MEK inhibitors (progression-free 1‑year survival probability of 54.7%; overall survival of 29.1 months) compared to a combination of PD1/CTLA4 antibodies (progression-free 1‑year survival probability of 42%; overall survival of 18 months). The current recommendation is to perform genomic profiling for every conjunctival melanoma, particularly to investigate a BRAF mutation. If a BRAF mutation is present, BRAF/MEK inhibitor treatment should preferably be initiated. Treatment with immune checkpoint inhibitors can be used in the case of BRAF-negative mutation status or treatment failure with BRAF/MEK inhibitors. Monotherapy with the CTLA4 antibody ipilimumab is not recommended due to its inferiority to PD1 antibodies. New knowledge in the genomic profiling of conjunctival melanoma could enable further targeted treatment options in the future.

Advances in sporadic brain arteriovenous malformations: Novel genetic insights, innovative animal models and emerging therapeutic approaches

Brain arteriovenous malformations (bAVMs) are a notable cause of intracranial hemorrhage, strongly associated with severe morbidity and mortality. Contemporary treatment options include surgery, stereotactic radiosurgery, and endovascular embolization, each of which has limitations. Hence, development of pharmacological interventions is urgently needed. The recent discovery of the presence of activating Kirsten rat sarcoma (KRAS) viral oncogene homologue mutations in most sporadic bAVMs has opened the door for a more comprehensive understanding of the pathogenesis of bAVMs and has pointed to entirely novel possible therapeutic targets. Herein, we review the status quo of genetics, animal models, and therapeutic approaches in bAVMs.

Elevated HDAC4 Expression Is Associated with Reduced T-Cell Inflamed Tumor Microenvironment Gene Signatures and Immune Checkpoint Inhibitor Effectiveness in Melanoma

Background/Objectives: Melanoma remains a difficult malignancy to treat because it employs tolerance mechanisms like negative immune checkpoint (IC) molecules to avoid antitumor immune responses. Thus, immune checkpoint inhibitors (ICIs) are increasingly used to treat melanoma. However, many patients do not respond, indicating resistance mechanisms like intrinsic tumor characteristics and an immunosuppressive tumor microenvironment (TME). An inflamed TME was associated with improved ICI efficacy by upregulating the T-cell inflamed TME gene signatures, an array of genes associated with dendritic cells (DCs) and cytotoxic CD8+ T-cell-mediated anti-tumor responses. As histone deacetylases (HDACs) have been shown to play crucial roles in regulating gene expression and aberrant HDAC expression has been reported in melanoma and also implicated in the regulation of IC, programmed cell death protein 1 (PD-1), and its ligand (PD-L1) and various immune evasion genes, we investigated the relationship between T-cell inflamed TME gene signatures and the HDAC family, particularly HDAC4. Methods: We used the skin cutaneous melanoma (SKCM) database, ICI-pretreated melanoma dataset, and other platforms including cBioPortal, TIMER 2.0, TISIDB, and UALCAN for the analysis. Results: We identified that high HDAC4 expression negatively modulated the TME by decreasing the abundance of DCs and cytotoxic CD8+ T-cells. The group of melanoma patients with elevated HDAC4 expression exhibited not only poor prognosis but also diminished transcription of T-cell inflamed TME gene signatures and increased DNA methylation of T-cell inflamed TME gene signatures. Importantly, elevated HDAC4 expression was associated with decreased CD8+ T-cells and a decreased ESTIMATE immune score in ICI-pretreated melanoma patients. Conclusions: Our findings suggest that HDAC4 may transform the TME into a non-inflamed phenotype, thereby reducing ICI efficacy in melanoma. Overall, this research shows that a combination of HDAC4 inhibitors and ICIs could result in better melanoma prognosis.

BRAF Targeting Across Solid Tumors: Molecular Aspects and Clinical Applications

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

Mechanistic Characterization of the Potency of THIOMAB Antibody-Drug Conjugates Targeting Staphylococcus aureus and ETbR-Expressing Tumor Cells Using Quantitative LC-MS/MS Analysis of Intracellular Drug Accumulation

THIOMAB drug conjugate (TDC) technology provides site-specific conjugation of linker drugs to antibodies, allowing for targeted delivery of the payload. While a direct measurement of TDC cytotoxic potency allows efficient screening and confirmation that new drugs conjugated to antibodies result in proper processing in cells, additional mechanistic characterization is often needed to provide information-rich data to guide further optimization of TDC design. For example, a quantitative understanding of how TDCs are processed intracellularly can help determine which processing step is impacting payload delivery and thereby inform the basis of the TDC efficacy. Here, we measure the cellular accumulation of two different TDC drug payloads: MAPK (mitogen-activated protein kinase) pathway inhibitor targeting ETbR-expressing tumor cells and an antibiotic active against Staphylococcus aureus with an in vitro cell-based drug release LC-MS/MS assay in a 96-well format. This assay allowed us to correlate the cellular potency of each unconjugated molecule with the amount of payload that accumulated inside the cell. In the case of the pathway inhibitor drug, the biochemical characterization of TDC processing by cathepsin B and purified human liver enzyme extract demonstrated a correlation between the efficiency of the linker drug cleavage and intracellular payload accumulation. For the antibody-antibiotic conjugate, kinetic analysis of intracellular free drug retention provided valuable insight into the chemistry modifications needed for an efficient TDC. Taken together, we demonstrated the utility of quantitative LC-MS/MS assays as one tool in guiding the design of more effective TDCs via the mechanistic release characterization of two distinct payloads.

Optimizing targeted therapy for metastatic melanoma: a combination of encorafenib and trametinib beyond standard protocols

Only three combinations of BRAF inhibitor (BRAFi) and MEK inhibitor (MEKi) targeted therapies are marketed for the treatment of BRAF-mutated metastatic melanoma. The use of these combinations can be limited by the occurrence of severe adverse events (AEs) that may lead to discontinuation of treatment or contraindication. We present the case of a 45-year-old male diagnosed with stage III melanoma of the left thigh, as classified by the 8th edition of the American Joint Committee on Cancer (AJCC), exhibiting rapid recurrence of inguinal lymph node metastasis following complete surgical resection. Molecular biology revealed a mutated BRAFV600E status, indicating treatment associated with BRAFi/MEKi. First-line treatments were introduced successively with dabrafenib-trametinib and then encorafenib-binimetinib, both stopped for fever and severe digestive AEs. After the failure of a third line with an immune checkpoint inhibitor, a new rechallenge of targeted therapy (TT) was introduced with encorafenib-trametinib to increase tolerance. This unusual and innovative combination allowed a spectacular tolerance and complete oncological response for 39 months after the failure of the usual combinations. This is the first case in the literature to show the potential efficacy of a non-standard combination of encorafenib and trametinib, which are commercialized in two different market combinations. A pharmacological evidence-based analysis was performed to understand these good clinical results.

Cardiotoxicity in patients with metastatic melanoma treated with BRAF/MEK inhibitors: a real-world analysis of incidence, risk factors, and reversibility

BACKGROUND

BRAF/MEK inhibitors (BRAFi/MEKi) improve outcome in patients with BRAF-mutated metastatic melanoma but are associated with cardiotoxicity, leading to a decline in left ventricular ejection fraction (LVEF). This study aimed to evaluate the incidence, timeline, risk factors, and reversibility of BRAFi/MEKi-induced cardiotoxicity in a real-world setting.

PATIENTS/MATERIALS AND METHODS

Patients with metastatic melanoma (n = 170) treated with Encorafenib/Binimetinib, Vemurafenib/Cobimetinib, or Dabrafenib/Trametinib at Aarhus and Odense University Hospital, Denmark, from 2015 to 2023 were included. Cardiac function was assessed at baseline and every 3 months during treatment with either echocardiograms or multigated acquisition scans. Cardiotoxicity was defined as a reduction of LVEF by ≥10 percentage points (pp) to an LVEF < 50% (Major cardiotoxicity) or a reduction of LVEF by ≥15 pp but remaining > 50% (Minor cardiotoxicity).

RESULTS

Cardiotoxicity occurred in 21% of patients, with 14% experiencing major cardiotoxicity. The mean time to LVEF decline was 187 days, with 92% of major cardiotoxicity cases occurring within the first year. Cardiotoxicity was reversible in 79% of patients following dose reduction, treatment pauses, heart failure therapy, or continued treatment with monitoring. Baseline atrial fibrillation (odds ratio 13.67, p = 0.008) was identified as a risk factor for major cardiotoxicity.

INTERPRETATION

BRAFi/MEKi-induced cardiotoxicity is a significant but manageable complication, often reversible with timely interventions. Routine LVEF monitoring is recommended. The majority (92%) of major cardiac events were diagnosed within the first year of treatment, which might warrant a discontinuation of routine LVEF monitoring after 1 year of BRAFi/MEKi treatment.

Impact of Tyrosine Kinase Inhibitors on the Expression Pattern of Epigenetic Regulators

Background: Advances in molecular genetic diagnostics and emerging opportunities for targeted treatment have opened new horizons in precision oncology. Tyrosine kinase inhibitors (TKI) are the subgroup of these agents with which the most clinical experience has been gathered so far. However, little data is available on the effect of TKI agents on the expression levels of molecules responsible for epigenetic regulation. Methods: In this study, we investigated the effect of in vitro and in vivo treatment with tyrosine kinase inhibitor agents on the expression of epigenetic regulators in hematological malignancies and solid tumors, based on data included in the functional genomics repository Gene Expression Omnibus. Results: Statistical analysis of datasets and series of gene expression patterns revealed numerous significant changes in the levels of epigenetic writers, erasers, microRNAs and members of chromatin-remodeling complexes following TKI treatment. Previously published data about the role of these epigenetic modifiers in malignant diseases has also been summarized. Conclusions: Our results may contribute to the establishment of novel treatment strategies aiming at the combinatorial administration of TKI and epidrugs in cancer, leading to less toxic therapy with further improved results.

Novel TEAD1 Inhibitor VT103 Enhances Dabrafenib Efficacy in BRAF V600E Mutated Lung Adenocarcinoma via Survivin Downregulation

The BRAF V600E mutation is observed in 2% of the patients with lung adenocarcinoma (LUAD), and combination therapy targeting BRAF and mitogen-activated protein kinase (MEK) is the standard treatment for this population. However, acquired resistance inevitably develops, which highlights the need for novel therapeutic strategies. In this study, we established a patient-derived BRAF V600E-mutated LUAD cell line, KTOR81, and investigated the potential of targeting the Yes-associated protein 1 (YAP1)/transcriptional enhanced associate domain 1 (TEAD1) pathway in combination with BRAF inhibition. We observed that the novel TEAD1 inhibitor VT103 enhanced the efficacy of the BRAF inhibitor dabrafenib in KTOR81 cells and xenograft models. The combination of dabrafenib and VT103 downregulated the expression of the antiapoptotic protein survivin, which is transcriptionally regulated by the YAP1/TEAD1 complex, leading to increased apoptosis. Moreover, we used a LUAD tissue microarray to compare the staining patterns of YAP1, TEAD1, and survivin, and examined their association with prognosis. These analyses revealed a strong correlation between YAP1, TEAD1, and survivin expression in LUAD, suggesting the relevance of the YAP1/TEAD1-survivin axis beyond BRAF V600E-mutated cases. While no statistically significant association was observed between survivin expression and prognosis, when limited to driver oncogene-positive patients, high survivin expression was suggested to be associated with poor prognosis. These findings provide preclinical evidence for the efficacy of combining TEAD1 inhibition with BRAF-targeted therapy in BRAF V600E-mutated LUAD and highlight the YAP1/TEAD1-survivin axis as a potential therapeutic target especially in the driver oncogene-positive LUAD patients.

Patient-reported outcomes in randomized controlled trials evaluating BRAF inhibitors in patients with cutaneous melanoma: a systematic scoping review of quality of reporting and trial results

The objective of this study was to provide an overview of the current practice of patient-reported outcome (PRO) assessments in trials investigating treatment with BRAF inhibitors in patients with advanced melanomas. In addition, we extracted information on symptomatic adverse events (AEs) reported by clinicians to inform future PRO measurement strategies. For our systematic scoping review, we investigated randomized controlled trials (RCTs) evaluating treatment with BRAF inhibitors that had a primary, secondary or exploratory PRO endpoint and were indexed on PubMed. Two independent reviewers extracted information on general RCT characteristics, clinical results (e.g. survival, treatment response and symptomatic AEs) and the PRO measurement and results. Quality of PRO reporting using the CONSORT-PRO checklist was also assessed. We identified nine RCTs meeting the inclusion criteria, in which PROs were secondary or exploratory endpoints. In all trials but one, PROs were measured with the generic EORTC QLQ-C30 questionnaire. The quality of PRO reporting showed substantial variation across the different types of information, with information on handling of missing data and on PRO hypotheses lacking most frequently. Our analysis identified 29 relevant symptomatic AEs that could be reported directly by patients. Our findings may inform the planning of the PRO component of future RCTs, in particular regarding what symptoms and AEs should be covered by PRO measures to provide a comprehensive assessment of treatment tolerability. Our results also indicate a need for improving the quality of PRO reporting, to maximize the impact of PRO findings in real-word practice.

Post-marketing surveillance of encorafenib in combination with binimetinib in Japanese patients with BRAF-mutant melanoma

BACKGROUND

A BRAF inhibitor, encorafenib, combined with a MEK inhibitor, binimetinib, was approved in Japan in early 2019 for the treatment of BRAF V600-mutant, unresectable malignant melanoma based on results of the global phase III trial, COLUMBUS, conducted in various countries including Japan. This post-marketing surveillance (PMS) assessed the combination in real-world clinical practice in Japan.

METHODS

We performed a prospective, multicentre, 12-month PMS of the safety and effectiveness of encorafenib plus binimetinib for radically unresectable, BRAF-mutant malignant melanoma in Japan.

RESULTS

Among 174 survey forms collected from 85 centres between February 2019 and August 2020, 172 were included for safety and effectiveness analysis. Patients (male [52.3%], median age 62.0 years) had Eastern Cooperative Oncology Group Performance Status 0 or 1 (91.8%) and comorbidities (55.2%). Respective encorafenib and binimetinib median dosages were 450 mg/day and 90 mg/day; median treatment duration, 24.1 and 24.2 weeks, and discontinuation, 71.5% for each, primarily for disease progression (56.9%) and adverse drug reactions (ADRs, 38.2%). Safety assessment ADRs occurred in 99 patients (57.6%), including eye disorders (40.7%), hepatic dysfunction (20.3%), rhabdomyolysis (4.7%), haemorrhage (2.3%), palmar-plantar erythrodysaesthesia syndrome (1.7%), and hypertension (1.7%); 19.8% were grade ≥ 3, none were grade 5, most resolved with/without treatment modification. At 12 months, the objective response rate was 48.8% (95% CI 41.2, 56.6; complete [19.2%], partial [29.7%]), overall survival was 40.1%.

CONCLUSION

The safety and effectiveness of encorafenib plus binimetinib in Japanese patients with BRAF-mutant malignant melanoma were similar to data reported in COLUMBUS; no new safety concerns were identified.

Melanoma neoadjuvant treatment: review and update of recent trials

INTRODUCTION

Neoadjuvant immunotherapy is emerging as an effective approach for resectable stage III/IV melanoma, showing improvements in disease response and survival outcomes.

AREAS COVERED

This review summarizes findings from neoadjuvant treatment trials in melanoma patients. Using the PubMed search engine and including the keywords 'neoadjuvant,' 'immunotherapy,' and 'melanoma,' we selected 18 trials that showed efficacy in patients with melanoma, mainly testing checkpoint inhibitors alone or in combination. Across all trials examined, treatments showed objective disease responses, which frequently translated into improved disease-free survival.

EXPERT OPINION

Additional phase III studies comparing neoadjuvant and adjuvant therapies are needed to establish the optimal standard of care. The variety of regimens and dosing schedules investigated highlights the need for further research to determine the most appropriate treatments in this clinical setting. Advances in the study of biomarkers that can identify specific subgroups of patients will guide future research in this field.

Therapeutic Strategies for Drug-resistant Melanoma and Their Clinical Implications

Melanoma is a malignant tumor originating from melanocytes, characterized by its high invasiveness and metastasis, leading to poor prognosis and high mortality. Early-stage melanoma is primarily treated with surgery; however, due to its metastatic nature, surgery becomes challenging in advanced stages. Treatment strategies for advanced or metastatic melanoma include chemotherapy, radiation therapy, and targeted therapy. However, melanoma's propensity for rapid drug resistance remains a significant clinical challenge. This review summarizes the developments in the treatment of drug-resistant melanoma over the past decade and discusses the advantages and disadvantages of various therapeutic approaches and their clinical significance implications.

Assessing cancer therapeutic efficacy in vivo using [2H7]glucose deuterium metabolic imaging

Metabolic imaging produces powerful visual assessments of organ function in vivo. Current techniques can be improved by safely increasing metabolic contrast. The gold standard, 2-[18F]fluorodeoxyglucose-positron emission tomography (FDG-PET) imaging, is limited by radioactive exposure and sparse assessment of metabolism beyond glucose uptake and retention. Deuterium magnetic resonance imaging (DMRI) with [6,6-2H2]glucose is nonradioactive, achieves tumor metabolic contrast, but can be improved by enriched contrast from deuterated water (HDO) based imaging. Here, we developed a DMRI protocol employing [2H7]glucose. Imaging 2H-signal and measuring HDO production in tumor-bearing mice detected differential glucose utilization across baseline tumors, tumors treated with vehicle control or anti-glycolytic BRAFi and MEKi therapy, and contralateral healthy tissue. Control tumors generated the most 2H-signal and HDO. To our knowledge this is the first application of DMRI with [2H7]glucose for tumoral treatment monitoring. This approach demonstrates HDO as a marker of tumor glucose utilization and suggests translational capability in humans due to its safety, noninvasiveness, and suitability for serial monitoring.

Self-assembled patient-derived tumor-like cell clusters for personalized drug testing in diverse sarcomas

Several patient-derived tumor models have emerged recently. However, soft tissue sarcomas (STSs) present a challenge in developing preclinical drug-testing models due to their non-epithelial and complex nature. Here, we report a model termed patient-derived tumor-like cell clusters (PTCs) derived from STS patients. PTCs result from the self-assembly and proliferation of mesenchymal stem cells (MSCs), epithelial cells, and immune cells, faithfully recapitulating the morphology and function of the original tumors. Through standardized culture and drug-response assessment protocols, PTCs facilitate personalized drug testing, evaluating hundreds of therapies within two weeks. Notably, PTCs exhibit 100% accuracy in distinguishing between complete or partial response and disease progression. We demonstrate the utility of PTCs in guiding chemotherapy selection for a patient with relapse and metastases following conventional therapy, who exhibited a positive response after non-conventional therapy identified through PTC. These findings underscore the potential of PTCs for prospective use in clinical decision-making regarding therapy selection.

Frequency and outcomes of BRAF alterations identified by liquid biopsy in metastatic, non-colorectal gastrointestinal cancers

BACKGROUND

Impact of BRAF V600E mutations (BRAFV600E), a poor prognostic factor in metastatic colorectal cancer, is lacking in non-CRC gastrointestinal (GI) cancers including pancreatic (PDAC), gastric/gastroesophageal (GEA), hepatocellular carcinoma (HCC), and cholangiocarcinoma (CCA). Due to tumor-agnostic approvals for patients with BRAFV600E, understanding the frequency and impact of BRAF alterations across non-CRC GI cancers is essential for clinical decision-making.

METHODS

Patients with PDAC, GEA, HCC, or CCA who had cell-free DNA detected on Guardant360 (Guardant Health) from 2020 to 2023 were queried. Prevalence of characterized BRAF genomic alterations (GA) was calculated; GAs were grouped by class (Class I/II/III). The Chi-squared test assessed differences between cancer types. A subset of patients had outcomes analysis using GuardantINFORM, a real-world clinicogenomic database, to derive real-world overall survival (rwOS).

RESULTS

Of 32 480 included patients, BRAF GAs were identified in 4.4%; 19% were BRAFV600E (0.81% prevalence overall). CCA had the highest rate of BRAF GAs and BRAFV600E (P < .01); HCC and GEA had the highest rates of BRAF class II/III alterations. There were no significant differences in rwOS by alteration class or cancer type; numeric differences were observed by alteration class. Few patients were treated with BRAF inhibitors (2.2%). Prevalence of co-occurring alterations was unique by cancer type.

CONCLUSIONS

Frequency of BRAF GAs, including BRAFV600E, in non-CRC GI cancers detected by liquid biopsy is similar to tissue-based rates and can be reliably used to assess BRAF status. BRAF GAs have mixed prognostic implications on survival for patients with non-CRC GI malignancies that warrant further exploration.

FAK inhibition combined with the RAF-MEK clamp avutometinib overcomes resistance to targeted and immune therapies in BRAF V600E melanoma

Widespread BRAF mutations result in persistent RAS-RAF-MEK-ERK (MAPK) signaling in melanoma. BRAF (BRAFi) and MEK (MEKi) inhibitors are approved for BRAF V600E melanomas, including those progressing on immunotherapy; however, rapid resistance to these agents highlights the need for novel strategies. Here, transcriptome analysis of BRAF V600E melanomas from patients resistant to BRAFi and MEKi shows activation of focal adhesion signaling. Consistently, BRAFi, MEKi, and the RAF-MEK clamp avutometinib activate focal adhesion kinase (FAK) in melanoma cells. Mechanistically, inhibition of an MAPK-RhoE (RND3) feedback loop results in the adaptive activation of RhoA-FAK-AKT. In turn, FAK inhibitors (FAKi) exert potent pro-apoptotic activity when combined with MAPK pathway inhibition. FAKi plus avutometinib overcomes resistance in multiple models derived from BRAFi plus MEKi-resistant melanoma patients and immunotherapy-resistant syngeneic mouse models. These findings provide a rationale for the development of avutometinib in combination with FAKi for patients with BRAF V600E melanoma progressing on BRAFi plus MEKi or immunotherapy.

An 8-year-old girl with secondary histiocytic sarcoma with BRAFV600 mutation following T-cell acute lymphoblastic leukemia demonstrating stable disease for 3 years on dabrafenib and trametinib - a case report and literature review

BACKGROUND

Histiocytic sarcoma as a secondary malignancy following childhood leukemia is extremely uncommon with fewer than 20 cases reported worldwide. They often pose a diagnostic challenge and prognosis is dismal. There is a lack of well-established clinical treatment protocols owing to rarity of disease. Majority were managed with chemotherapy with variable outcomes.

CASE PRESENTATION

Herein we report a rare case of an 8-year-old girl with secondary BRAFV600-mutant histiocytic sarcoma following T-cell acute lymphoblastic leukemia. After poor disease control with salvage chemotherapy, she was treated with MAPK-targeted therapy with dabrafenib and trametinib. She demonstrated excellent response and remained in partial remission with no signs of disease progression 3 years later.

CONCLUSIONS

There is yet to be consensus on the optimal management for this neoplasm. Description of our successful clinical experience highlights that investigation for BRAF mutations in histiocytic sarcoma is potentially advantageous. It also adds to the growing evidence that precision medicine may be a promising avenue to target this aggressive tumor and lays the foundation for future research.

Spatiotemporal Profiling Defines Persistence and Resistance Dynamics during Targeted Treatment of Melanoma

Resistance of BRAF-mutant melanomas to targeted therapy arises from the ability of cells to enter a persister state, evade treatment with relative dormancy, and repopulate the tumor when reactivated. A better understanding of the temporal dynamics and specific pathways leading into and out of the persister state is needed to identify strategies to prevent treatment failure. Using spatial transcriptomics in patient-derived xenograft models, we captured clonal lineage evolution during treatment. The persister state showed increased oxidative phosphorylation, decreased proliferation, and increased invasive capacity, with central-to-peripheral gradients. Phylogenetic tracing identified intrinsic and acquired resistance mechanisms (e.g., dual-specific phosphatases, reticulon-4, and cyclin-dependent kinase 2) and suggested specific temporal windows of potential therapeutic susceptibility. Deep learning-enabled analysis of histopathologic slides revealed morphologic features correlating with specific cell states, demonstrating that juxtaposition of transcriptomics and histologic data enabled identification of phenotypically distinct populations from using imaging data alone. In summary, this study defined state change and lineage selection during melanoma treatment with spatiotemporal resolution, elucidating how choice and timing of therapeutic agents will impact the ability to eradicate resistant clones. Significance: Tracking clonal progression during treatment uncovers conserved, global transcriptional changes and local clone-clone and spatial patterns underlying the emergence of resistance, providing insights into therapy-induced tumor evolution.

Histone H3E50K remodels chromatin to confer oncogenic activity and support an EMT phenotype

Sequencing of human patient tumors has identified recurrent missense mutations in genes encoding core histones. We report that mutations that convert histone H3 amino acid 50 from a glutamate to a lysine (H3E50K) support an oncogenic phenotype. Expression of H3E50K is sufficient to transform human cells as evidenced by an increase in cell migration and invasion, and an increase in proliferation and clonogenicity. H3E50K also increases the invasive phenotype in the context of co-occurring BRAF mutations, which are present in patient tumors characterized by H3E50K. H3E50 lies on the globular domain surface in a region that contacts H4 within the nucleosome. We find that H3E50K selectively increases chromatin accessibility and perturbs proximal H3 post-translational modifications including H3K27me3; together these changes to chromatin dynamics dysregulate gene expression to support the epithelial-to-mesenchymal transition. Functional studies using Saccharomyces cerevisiae reveal that, while yeast cells that express H3E50K as the sole copy of histone H3 show sensitivity to cellular stressors, including caffeine, H3E50K cells display some genetic interactions that are distinct from the characterized H3K36M oncohistone yeast model. Taken together, these data suggest that additional H3 mutations have the potential to support oncogenic activity and function through distinct mechanisms that dysregulate gene expression.

PTPN9 promotes melanoma progression by regulating the ferroptosis pathway

In recent years, there has been a gradual increase in the incidence and mortality rates of melanoma, posing a significant threat to human health and life. Protein tyrosine phosphatases (PTPNs) have been implicated in the progression of various human cancers, including breast, lung, and cervical cancer. To investigate PTPN9 expression in melanoma, impacting the disease's survival and prognosis. Our study, which involved an analysis of The Cancer Genome Atlas database and immunohistochemical staining of pathological sections, identified an upregulation of PTPN9 expression in melanoma, impacting the disease's survival and prognosis. At the cellular level, we investigated the effects of PTPN9 on the proliferation, invasion, and metastasis of A375 and SK-MEL-28 cells. Through various experimental techniques such as Western blot protein detection, electron microscopy, and oil red O staining, we observed that PTPN9 potentially contributes to the development of skin cutaneous melanoma (SKCM) by regulating ferroptosis-related proteins ACSL4, FTH1, and P53, thereby influencing lipid metabolism. The results of this study highlight the unique role of PTPN9 in SKCM and suggest its potential as a biomarker for the disease.

Real-life evidence of encorafenib plus binimetinib in patients with unresectable advanced or metastatic BRAFV600-mutant melanoma in Spain: the BECARE (GEM-2002) trial

Purpose

Combined BRAF/MEK inhibition with encorafenib (E) plus binimetinib (B) has demonstrated efficacy and tolerability in phase III clinical trials, and is the standard of care for advanced/metastatic BRAFV600-mutant melanoma. However, real-life evidence is limited, particularly in patients pre-treated with immune checkpoint inhibitors (ICI).

Patients and methods

BECARE GEM 2002 was a retrospective, non-interventional study aimed at investigating the real-world effectiveness and tolerability of EB in patients with unresectable or metastatic BRAFV600-mutant melanoma conducted at 21 sites in Spain. The primary objective of this study was to characterise the population of patients receiving EB and assess the efficacy and tolerability of EB in real life. The study included patients treated according to standard clinical practice with EB as the 1st line or 2nd line after progression to ICI for an unresectable or metastatic stage. Patients who previously received treatment with BRAF and/or MEK inhibitor, other than as adjuvants, that ended ≥ 6 m before EB were not eligible.

Results

From September 2021 to March 2023, 117 patients were included; 89 (76.1%) and 28 (23.9%) patients received EB as 1st line and 2nd line, respectively. The median follow-up was 13.8 months (95% CI: 12.0-17.4). In patients with EB as 1st line treatment, ORR and median PFS were 75% and 12 months (95% CI: 9.4-18.6), respectively. In patients with EB as 2nd line treatment after ICI, ORR and median PFS were 77.8% and 12.5 months (95% CI: 6.6-NA), respectively. In patients with brain metastasis ORR and median PFS were 70.8% and 6.3 months (95% CI: 6.1-10.3). Treatment-related adverse events of grade ≥3 were reported in 17 (14.5%) patients; transaminitis (9.4%) and diarrhoea (2.6%) were the most frequent adverse events.

Conclusion

In this real-world study, EB treatment demonstrated effectiveness and a consistent safety profile in patients with BRAFV600-mutant melanoma treated according to standard clinical practice, including in those with prior ICI treatment and of brain metastasis; therefore, EB is a feasible treatment option for unresectable and metastatic melanoma.Clinical trial identification: REec: 0004-2021-OBS.

Clinical trial identification

REec: 0004-2021-OBS.

Incidence and Management of Retinopathy and Uveitis in Patients Receiving BRAF/MEK Inhibitor Therapy

PURPOSE

To assess the clinical features of ocular adverse events in patients receiving BRAF/MEK inhibitor therapy.

METHODS

In this retrospective study, 65 patients were treated with BRAF/MEK inhibitors (dabrafenib/trametinib or encorafenib/binimetinib).

RESULTS

Of the 65 patients, 28 had malignant melanoma and 37 had non-melanoma malignancies. Bilateral MEK-associated retinopathy was observed in nine cases; none experienced vision loss due to MEK-associated retinopathy. Uveitis was diagnosed in four patients (6.1%), three of whom presented with Vogt-Koyanagi-Harada (VKH)-like uveitis. All VKH-like uveitis cases were observed in patients with melanoma and their incidences were significantly higher in these patients than in those without melanoma (p = .04). Treatment with corticosteroids resulted in either resolution or control of symptoms in all cases of VKH-like uveitis, enabling continuation of BRAF/MEK inhibitor therapy.

CONCLUSION

VKH-like uveitis was found to be significantly more frequent in patients with melanoma than in those with other malignancies.

Clinical Approaches for the Management of Skin Cancer: A Review of Current Progress in Diagnosis, Treatment, and Prognosis for Patients with Melanoma

Melanoma represents a significant public health challenge due to its increasing incidence and potential for metastasis. This review will explore the current clinical approaches to the management of melanoma, focusing on advancements in diagnosis, treatment, and prognosis. Methods for early detection and accurate staging have been enhanced by new diagnostic strategies. Treatment modalities have expanded beyond traditional surgical excision to include targeted therapy and immunotherapy. Prognostic assessment has benefited from the development of novel biomarkers and genetic profiling. This review will highlight the progress made in the multidisciplinary management of melanoma, underscoring the importance of continuous research to improve patient outcomes.

Presence of brain metastasis differentially impacts long-term survival after first-line therapy in melanoma depending on BRAF mutation status

Background

Modern therapeutic strategies have significantly improved the prognosis of advanced melanoma patients. Predictive factors of therapy response include serum LDH; however, predictive markers for long-term survival are currently largely lacking.

Patients and methods

Patients diagnosed with stage IV melanoma (AJCCv8) of cutaneous origin or unknown primary were identified from the prospective multicenter German Dermatologic Cooperative Oncology Group (DeCOG) skin cancer registry ADOREG. Baseline characteristics were compared between patient groups with short-term versus long-term survival. Statistical analysis included ROC analysis and multinomial regression analysis.

Results

Of 3066 stage IV melanoma patients entered into the ADOREG between 05/2014 and 06/2021, 395 were identified for this study, of whom 301 (76.2%) survived ≤1 year, and 94 (23.8%) survived ≥5 years after stage IV diagnosis. The median follow-up time was 6 months (range 0-129 months). Regarding the baseline characteristics, only elevated serum LDH (P <0.001) was found to be independently predicting survival ≤1 year. Type of first-line therapy, immune checkpoint inhibition (ICI) versus BRAF/MEK targeted therapy (TT), was not predictive of long-term survival ≥5 years. For survival ≤1 year, the presence of brain metastases at treatment start was an independent predictor in BRAF-mutated patients regardless if they received TT (N=113; P=0<0.001) or ICI (N=69; P=0.015), but not in BRAF-wildtype patients who received ICI (N=161; P=0.47).

Conclusions

Low serum LDH independently predicts long-term survival of stage IV melanoma patients in every subgroup of treatment type and BRAF status. Brain metastasis has a negative impact on long-term survival in BRAF-mutated, but not in BRAF-wildtype patients. Investigation of molecular features of brain metastases in BRAF-mutated vs. BRAF-wildtype melanomas may lead to new insights in tumor biology and may yield new therapeutic approaches.

An Overview of Liver Directed Locoregional Therapies

An overview of all liver-directed locoregional therapies, including surgical resection for melanoma liver metastases (MLMs), is provided. MLM patients are divided by their primary melanoma location; cutaneous, uvea (eye), and mucosal melanoma. If patients with isolated cutaneous MLMs are considered for surgical resection, treatment with systemic therapy should be part of the treatment course. For uveal MLMs, complete surgical or ablative treatment of all MLMs suggests superior results compared with other liver-directed or systemic therapies, based on current evidence, no recommendations for any liver-directed regional therapy in the treatment of mucosal MLMs can be made.

New therapies for unresectable or metastatic cutaneous eyelid and orbital melanoma

PURPOSE

Newer treatment options offer the promise of improved outcomes for metastatic and unresectable melanoma. This investigation was performed to review these modalities for cutaneous eyelid and orbital disease.

METHODS

A search for articles that were related to this subject was performed in the PubMed database, and the bibliographies of these manuscripts were reviewed to ensure capture of the appropriate literature. Data was abstracted and analyzed.

RESULTS

Historically, patients who suffer from melanoma of the ocular adnexa have fared poorly. Approaches that employ BRAF and mitogen-associated protein kinase inhibitors, immunotherapy, and novel cellular therapies improve outcomes and survival rates, although the side effect profiles of these agents are problematic. Most of the existing strategies have not explored ocular adnexal disease specifically, and treatment plans are generally adapted from the general cutaneous oncology literature.

CONCLUSIONS

Thanks to advances in our comprehension of the cellular biology of the disease, the management of unresectable and metastatic melanoma has evolved considerably over the past several years. Newer modalities will likely continue to improve survival and reduce adverse events.

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

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

Adaptive Plasticity Tumor Cells Modulate MAPK-Targeting Therapy Response in Colorectal Cancer

MAPK pathway inhibitors (MAPKi) are increasingly used in the treatment of advanced colorectal cancer, but often produce short-lived responses in patients. Although acquired resistance by de novo mutations in tumors have been found to reduce response in some patients, additional mechanisms underlying the limited response durability of MAPK targeting therapy remain unknown. Here, we denote new contributory tumor biology and provide insight on the impact of tumor plasticity on therapy response. Analysis of MAPKi treated patients revealed activation of stemness programs and increased ASCL2 expression, which are associated with poor outcomes. Greater ASCL2 with MAPKi treatment was also seen in patient-derived CRC models, independent of driver mutations. We find ASCL2 denotes a distinct cell population, arising from phenotypic plasticity, with a proliferative, stem-like phenotype, and decreased sensitivity to MAPKi therapy, which were named adaptive plasticity tumor (APT) cells. MAPK pathway suppression induces the APT phenotype in cells, resulting in APT cell enrichment in tumors and limiting therapy response in preclinical and clinical data. APT cell depletion improved MAPKi treatment efficacy and extended MAPKi response durability in mice. These findings uncover a cellular program that mitigates the impact of MAPKi therapies and highlights the importance of addressing tumor plasticity to improve clinical outcomes.

The metastatic cascade through the lens of therapeutic inhibition

Metastasis is a main cause of cancer-related death, and a deeper understanding of the metastatic process will inform more targeted and mechanistic approaches that can abrogate challenges in treatment efficacy and toxicity. Several steps throughout the metastatic cascade, from angiogenesis to secondary tumor formation, offer specific vulnerabilities to therapies that can lead to the decline or cessation of metastatic progression. A deeper understanding of the metastatic cascade also allows combination systemic therapies to be used synergistically. In this review, we describe current treatment modalities in the context of multiple steps of the metastatic cascade. We highlight their mechanisms and present their efficacy across multiple cancers. This work also presents targets within the metastatic cascade in need of more research that can advance the landscape of treatments and lead to the goal of metastatic cancer remission.

A comprehensive review of targeting RAF kinase in cancer

RAF kinases, particularly the BRAF isoform, play a crucial role in the MAPK/ERK signaling pathway, regulating key cellular processes such as proliferation, differentiation, and survival. Dysregulation of this pathway often caused by mutations in the BRAF gene or alterations in upstream regulators like Ras and receptor tyrosine kinases contributes significantly to cancer development. Mutations, such as BRAF-V600E, are present in a variety of malignancies, with the highest prevalence in melanoma. Targeted therapies against RAF kinases have achieved substantial success, especially in BRAF-V600E-mutant melanomas, where inhibitors like vemurafenib and dabrafenib have demonstrated remarkable efficacy, leading to improved patient outcomes. These inhibitors have also shown clinical benefits in cancers such as thyroid and colorectal carcinoma, although to a lesser extent. Despite these successes, therapeutic resistance remains a major hurdle. Resistance mechanisms, including RAF dimerization, feedback reactivation of the MAPK pathway, and paradoxical activation of ERK signaling, often lead to diminished efficacy over time, resulting in disease progression or even secondary malignancies. In response, current research is focusing on novel therapeutic strategies, including combination therapies that target multiple components of the pathway simultaneously, such as MEK inhibitors used in tandem with RAF inhibitors. Additionally, next-generation RAF inhibitors are being developed to address resistance and enhance therapeutic specificity. This review discusses the clinical advancements in RAF-targeted therapies, with a focus on ongoing efforts to overcome therapeutic resistance and enhance outcomes for cancer patients. It also underscores the persistent challenges in effectively targeting RAF kinase in oncology.

Inequalities in Drug Access for Advanced Melanoma: The Prognostic Impact Resulting From the Approval Delay of the Combined Ipilimumab/Nivolumab Treatment in Portugal

Introduction A combination of ipilimumab/nivolumab has demonstrated a median overall survival (mOS) of 71.9 months in advanced melanoma, establishing it as the standard first-line (1L) therapy. However, the approval of this combination by the Portuguese Regulatory Authority occurred 76 months after its approval by the European Authority, leaving tyrosine kinase inhibitors as the only 1L option available for the BRAF-mutated melanoma population. Our study aims to evaluate real-world data from patients with advanced melanoma and assess the potential prognostic impact of the delayed availability of ipilimumab/nivolumab combination therapy on this population. Methods This was an observational, retrospective cohort study conducted at a Portuguese Comprehensive Cancer Center. The study included adult patients with melanoma who received innovative therapies in the 1L between May 2016 and December 2021 and who would meet the criteria for treatment with ipilimumab/nivolumab. The primary outcome measure was mOS; secondary outcome measures included median progression-free survival (mPFS), objective response rate (ORR), and safety data. Results Our study included 172 patients, of which 50% were male, and 32.6% (n = 56) had BRAF-mutated melanoma. In 1L setting, 70.9% received anti-programmed cell death protein 1 (anti-PD-1) monotherapy, while the rest were treated with targeted therapies. The median follow-up time was 57 months. Patients treated with anti-PD-1 had ORR of 36.0%, mPFS of seven months (95% CI 2.9-11.1), and mOS of 19 months (95% CI 7.5-30.4). Among patients treated with targeted therapies, the ORR was 56.0%, mPFS seven months (95% CI 5.1-8.9), and mOS 14 months (95% CI 5.9-22.1). In our population, 10% presented grade 3 or higher adverse events, with no drug-related deaths reported. Conclusion These findings underscore significant disparities in access to innovative therapies in Portugal, which may have adversely impacted patients' outcomes. The delay raises ethical concerns regarding equity in healthcare access and highlights the need for policy measures to expedite the approval and availability of life-extending treatments.

Response and outcome of patients with melanoma skin metastases and immune checkpoint inhibition

It is known, that different metastatic organ systems respond differently to immune checkpoint inhibitors (ICIs). In this study, we aimed to investigate the extent to which skin/subcutaneous metastases respond to ICI or targeted therapies (TTs) and whether the response rate differs from that of distant metastases in the same patient. Patients with melanoma diagnosed between January 2021 and September 2023 with at least one skin/subcutaneous metastasis who had received therapy with ICI or TT in an advanced setting were included in the analysis. Best overall response (BOR) was classified according to the revised response evaluation criteria in solid tumors (RECIST). The BOR of skin metastases and visceral metastases to ICI and TT was compared using the chi-square test. Skin metastases treated with ICI a first-line setting showed an overall response rate (ORR) of 44.1%. In contrast, visceral metastases had a higher ORR of 51.1%. However, the difference was not statistically significant (p = .77). Regarding TT, the ORR for skin metastases was 57.1%, compared to 38.5% for visceral metastases (p = .59). Interestingly, the ORR for skin/subcutaneous metastases was notably lower with ICI compared to visceral metastases, in contrast to patients who underwent TT. Skin metastases showed a poorer response to ICI than visceral metastases. Therefore, careful monitoring is recommended to detect non-response early in patients with skin metastases as skin metastases may have a worse response than TT. A larger cohort is needed for a comprehensive analysis and confirmation of our results.

Actionable Gene Alterations Identified in Patients With Malignant Melanoma by Targeted Sequencing in Japan

PURPOSE

Precision medicine plays an important role in the treatment of patients with advanced melanoma. Despite its high incidence in White patients, advanced melanoma is rare in Asian countries, hampering prospective clinical trials targeting the Asian population. This retrospective study aimed to elucidate the real-world molecular diagnoses and outcomes of Japanese patients with melanoma using comprehensive genome profiling (CGP).

MATERIALS AND METHODS

Patients with melanoma who completed standard anticancer medical treatments (including those expected to complete the treatments) underwent CGP, which is covered by the National Health Insurance. We analyzed the results and clinical annotations of 569 patients registered before August 2023 in a national database.

RESULTS

Skin, mucosal, and uveal melanomas accounted for 64%, 28%, and 7% of cases, respectively. Patients with BRAF, NRAS, NF1, and KIT variants represented 25%, 20%, 17%, and 17%, respectively. Eighty-two percent of BRAF, 97% of NRAS, 69% of NF1, and 54% of KIT were actionable alterations (ie, BRAF classes I, II, and III, NRAS Q61, G12, G13, NF1 loss-of-function, KIT gain-of-function variants). BRAF V600E/K variants occurred in 22% of skin and 2% of mucosal melanomas, but not in uveal melanomas. The mean tumor mutation burden in cutaneous melanomas was 4.2 variants/Mb. Patients previously treated with BRAF-targeted therapy harbored amplifications of BRAF and cell cycle genes more frequently than therapy-naive patients. Thirty-six patients (6.3%) were treated following the molecular tumor board (MTB) recommendations.

CONCLUSION

Actionable gene alterations in BRAF, NRAS, NF1, and KIT are common in Japanese patients with melanoma. However, few patients were treated according to the MTB recommendations, suggesting that there is an unmet need to increase accessibility to gene-matched clinical trials in Japan.

Annals of Surgical Oncology Practice Guidelines Series: Adjuvant and Neoadjuvant Therapy for Melanoma

Surgery has always been the mainstay of melanoma treatment, but the risk of recurrence after curative-intent surgery remains high for some stages of the disease. In this Annals of Surgical Oncology Guidelines Review, we provide an overview of practice changing studies, review international guidelines, and highlight current recommendations and areas of controversy when treating melanoma patients in the adjuvant and neoadjuvant setting. Recent clinical trials have established important roles for adjuvant and neoadjuvant therapy in conjunction with surgery for selected patients with stage II, stage III, and even resectable stage IV melanoma. Patients with melanoma should be evaluated for multimodality therapy, including a combination of surgery, systemic therapy (i.e., BRAF-targeted therapy or checkpoint blockade immunotherapy), and at times radiotherapy. With the rapid pace of advances in the field, it is crucial for surgical oncologists to remain updated on the latest guidelines and recommendations for adjuvant and neoadjuvant therapy and to continue to be leaders in this paradigm shift. Given the complex and evolving nature of treatment, this report reviews the latest practice guidelines in the context of modern multidisciplinary management of melanoma.