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Ernst M, Giubellino A. The Current State of Treatment and Future Directions in Cutaneous Malignant Melanoma. Biomedicines 2022; 10:822. [PMID: 35453572 PMCID: PMC9029866 DOI: 10.3390/biomedicines10040822] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/25/2022] [Accepted: 03/29/2022] [Indexed: 02/01/2023] Open
Abstract
Malignant melanoma is the leading cause of death among cutaneous malignancies. While its incidence is increasing, the most recent cancer statistics show a small but clear decrease in mortality rate. This trend reflects the introduction of novel and more effective therapeutic regimens, including the two cornerstones of melanoma therapy: immunotherapies and targeted therapies. Immunotherapies exploit the highly immunogenic nature of melanoma by modulating and priming the patient's own immune system to attack the tumor. Treatments combining immunotherapies with targeted therapies, which disable the carcinogenic products of mutated cancer cells, have further increased treatment efficacy and durability. Toxicity and resistance, however, remain critical challenges to the field. The present review summarizes past treatments and novel therapeutic interventions and discusses current clinical trials and future directions.
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Affiliation(s)
| | - Alessio Giubellino
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN 55455, USA;
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Shi LZ, Bonner JA. Bridging Radiotherapy to Immunotherapy: The IFN-JAK-STAT Axis. Int J Mol Sci 2021; 22:12295. [PMID: 34830176 PMCID: PMC8619591 DOI: 10.3390/ijms222212295] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 12/12/2022] Open
Abstract
The unprecedented successes of immunotherapies (IOs) including immune checkpoint blockers (ICBs) and adoptive T-cell therapy (ACT) in patients with late-stage cancer provide proof-of-principle evidence that harnessing the immune system, in particular T cells, can be an effective approach to eradicate cancer. This instills strong interests in understanding the immunomodulatory effects of radiotherapy (RT), an area that was actually investigated more than a century ago but had been largely ignored for many decades. With the "newly" discovered immunogenic responses from RT, numerous endeavors have been undertaken to combine RT with IOs, in order to bolster anti-tumor immunity. However, the underlying mechanisms are not well defined, which is a subject of much investigation. We therefore conducted a systematic literature search on the molecular underpinnings of RT-induced immunomodulation and IOs, which identified the IFN-JAK-STAT pathway as a major regulator. Our further analysis of relevant studies revealed that the signaling strength and duration of this pathway in response to RT and IOs may determine eventual immunological outcomes. We propose that strategic targeting of this axis can boost the immunostimulatory effects of RT and radiosensitizing effects of IOs, thereby promoting the efficacy of combination therapy of RT and IOs.
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Affiliation(s)
- Lewis Zhichang Shi
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL 35233, USA
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL 35233, USA
- Programs in Immunology, University of Alabama at Birmingham, Birmingham, AL 35233, USA
- O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - James A. Bonner
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL 35233, USA
- O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL 35233, USA
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Schoenhals JE, Skrepnik T, Selek U, Cortez MA, Li A, Welsh JW. Optimizing Radiotherapy with Immunotherapeutic Approaches. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 995:53-71. [PMID: 28321812 DOI: 10.1007/978-3-319-53156-4_3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Several factors must be considered to successfully integrate immunotherapy with radiation into clinical practice. One such factor is that concepts arising from preclinical work must be tested in combination with radiation in preclinical models to better understand how combination therapy will work in patients; examples include checkpoint inhibitors, tumor growth factor-beta (TGF-β) inhibitors, and natural killer (NK) cell therapy. Also, many radiation fields and fractionation schedules typically used in radiation therapy had been standardized before the introduction of advanced techniques for radiation planning and delivery that account for changes in tumor size, location, and motion during treatment, as well as uncertainties introduced by variations in patient setup between treatment fractions. As a result, radiation therapy may involve the use of large treatment volumes, often encompassing nodal regions that may not be irradiated with more conformal techniques. Traditional forms of radiation in particular pose challenges for combination trials with immunotherapy. This chapter explores these issues in more detail and provides insights as to how radiation therapy can be optimized to combine with immunotherapy.
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Affiliation(s)
- Jonathan E Schoenhals
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tijana Skrepnik
- Department of Radiation Oncology, University of Arizona, Tucson, AZ, USA
| | - Ugur Selek
- Department of Radiation Oncology, Koc University, Istanbul, Turkey
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Anderson Central (Y2.5316), 1515 Holcombe Blvd., Unit 0097, Houston, TX, 77030, USA
| | - Maria A Cortez
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ailin Li
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - James W Welsh
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Anderson Central (Y2.5316), 1515 Holcombe Blvd., Unit 0097, Houston, TX, 77030, USA.
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Caruso JP, Cohen-Inbar O, Bilsky MH, Gerszten PC, Sheehan JP. Stereotactic radiosurgery and immunotherapy for metastatic spinal melanoma. Neurosurg Focus 2015; 38:E6. [PMID: 25727228 DOI: 10.3171/2014.11.focus14716] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The management of metastatic spinal melanoma involves maximizing local control, preventing recurrence, and minimizing treatment-associated toxicity and spinal cord damage. Additionally, therapeutic measures should promote mechanical stability, facilitate rehabilitation, and promote quality of life. These objectives prove difficult to achieve given melanoma's elusive nature, radioresistant and chemoresistant histology, vascular character, and tendency for rapid and early metastasis. Different therapeutic modalities exist for metastatic spinal melanoma treatment, including resection (definitive, debulking, or stabilization procedures), stereotactic radiosurgery, and immunotherapeutic techniques, but no single treatment modality has proven fully effective. The authors present a conceptual overview and critique of these techniques, assessing their effectiveness, separately and combined, in the treatment of metastatic spinal melanoma. They provide an up-to-date guide for multidisciplinary treatment strategies. Protocols that incorporate specific, goal-defined surgery, immunotherapy, and stereotactic radiosurgery would be beneficial in efforts to maximize local control and minimize toxicity.
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Wargo JA, Reuben A, Cooper ZA, Oh KS, Sullivan RJ. Immune Effects of Chemotherapy, Radiation, and Targeted Therapy and Opportunities for Combination With Immunotherapy. Semin Oncol 2015; 42:601-16. [PMID: 26320064 DOI: 10.1053/j.seminoncol.2015.05.007] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
There have been significant advances in cancer treatment over the past several years through the use of chemotherapy, radiation therapy, molecularly targeted therapy, and immunotherapy. Despite these advances, treatments such as monotherapy or monomodality have significant limitations. There is increasing interest in using these strategies in combination; however, it is not completely clear how best to incorporate molecularly targeted and immune-targeted therapies into combination regimens. This is particularly pertinent when considering combinations with immunotherapy, as other types of therapy may have significant impact on host immunity, the tumor microenvironment, or both. Thus, the influence of chemotherapy, radiation therapy, and molecularly targeted therapy on the host anti-tumor immune response and the host anti-host response (ie, autoimmune toxicity) must be taken into consideration when designing immunotherapy-based combination regimens. We present data related to many of these combination approaches in the context of investigations in patients with melanoma and discuss their potential relationship to management of patients with other tumor types. Importantly, we also highlight challenges of these approaches and emphasize the need for continued translational research.
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Affiliation(s)
- Jennifer A Wargo
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX; Department of Genomic Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alexandre Reuben
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Zachary A Cooper
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX; Department of Genomic Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kevin S Oh
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ryan J Sullivan
- Department of Medical Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
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Abstract
Although melanoma is generally considered a relative radioresistant tumor, radiation therapy (RT) remains a valid and effective treatment option in definitive, adjuvant, and palliative settings. Definitive RT is generally only used in inoperable patients. Despite a high-quality clinical trial showing adjuvant RT following lymphadenectomy in node-positive melanoma patients prevents local and regional recurrence, the role of adjuvant RT in the treatment of melanoma remains controversial and is underused. RT is highly effective in providing symptom palliation for metastatic melanoma. RT combined with new systemic options, such as immunotherapy, holds promise and is being actively evaluated.
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Affiliation(s)
- Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, 111 South 11th Street, Suite G301, Philadelphia, PA 19107, USA.
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Barker CA, Postow MA. Combinations of radiation therapy and immunotherapy for melanoma: a review of clinical outcomes. Int J Radiat Oncol Biol Phys 2014; 88:986-97. [PMID: 24661650 PMCID: PMC4667362 DOI: 10.1016/j.ijrobp.2013.08.035] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 08/19/2013] [Accepted: 08/26/2013] [Indexed: 01/12/2023]
Abstract
Radiation therapy has long played a role in the management of melanoma. Recent advances have also demonstrated the efficacy of immunotherapy in the treatment of melanoma. Preclinical data suggest a biologic interaction between radiation therapy and immunotherapy. Several clinical studies corroborate these findings. This review will summarize the outcomes of studies reporting on patients with melanoma treated with a combination of radiation therapy and immunotherapy. Vaccine therapies often use irradiated melanoma cells, and may be enhanced by radiation therapy. The cytokines interferon-α and interleukin-2 have been combined with radiation therapy in several small studies, with some evidence suggesting increased toxicity and/or efficacy. Ipilimumab, a monoclonal antibody which blocks cytotoxic T-lymphocyte antigen-4, has been combined with radiation therapy in several notable case studies and series. Finally, pilot studies of adoptive cell transfer have suggested that radiation therapy may improve the efficacy of treatment. The review will demonstrate that the combination of radiation therapy and immunotherapy has been reported in several notable case studies, series and clinical trials. These clinical results suggest interaction and the need for further study.
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Affiliation(s)
- Christopher A Barker
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York.
| | - Michael A Postow
- Department of Medicine, Melanoma and Sarcoma Oncology Service, Memorial Sloan-Kettering Cancer Center, New York, New York
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Loco-regional control after postoperative radiotherapy for patients with regional nodal metastases from melanoma. Clin Transl Oncol 2009; 11:688-93. [DOI: 10.1007/s12094-009-0425-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Mendenhall WM, Amdur RJ, Grobmyer SR, George TJ, Werning JW, Hochwald SN, Mendenhall NP. Adjuvant radiotherapy for cutaneous melanoma. Cancer 2008; 112:1189-96. [DOI: 10.1002/cncr.23306] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Conill C, Jorcano S, Domingo-Domènech J, Marruecos J, Vilella R, Malvehy J, Puig S, Sánchez M, Gallego R, Castel T. Toxicity of combined treatment of adjuvant irradiation and interferon alpha2b in high-risk melanoma patients. Melanoma Res 2007; 17:304-9. [PMID: 17885585 DOI: 10.1097/cmr.0b013e3282c3a6ed] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Surgically resected stage III melanoma patients commonly receive adjuvant therapy with interferon (IFN) alpha2b. For those patients with high-risk features of draining node recurrence, radiation therapy can also be considered as a treatment option. The purpose of this retrospective study was to assess the efficacy and radiation-related toxicity of this combined therapy. Eighteen patients receiving adjuvant IFNalpha2b therapy during radiation therapy, or within 1 month of its completion, were reviewed retrospectively and analysed for outcome. Radiation was delivered at 600 cGy dose per fraction, in 16 out of 18 patients, twice a week, and at 200 cGy dose per fraction in two patients five times a week. Total radiation dose and number of fractions were as follows: 30 Gy/5 fr (n=8), 36 Gy/6 fr (n=8) and 50 Gy/25 fr (n=2). The percentage of disease-free patients, with no local recurrence, at 3 years was 88%. In 10 patients, IFNalpha2b was administered concurrently with radiotherapy; in three, within 30 days before or after radiation; and in five, more than 30 days after radiation. All the patients experienced acute skin reactions, grade I on the Radiation Therapy Oncology Group (RTOG) scale. Late radiation-related toxicity was seen in one patient with grade III (RTOG) skin reaction and two with grade IV (RTOG) radiation-induced myelitis. Concurrent use of adjuvant radiotherapy and IFNalpha2b might enhance radiation-induced toxicity, and special care should be taken when the spinal cord is included in the radiation field.
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Affiliation(s)
- Carlos Conill
- Department of Radiation Oncology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain.
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Cheng YF, Lai CC, Ho CY, Shu CH, Lin CZ. Toward a better understanding of sinonasal mucosal melanoma: clinical review of 23 cases. J Chin Med Assoc 2007; 70:24-9. [PMID: 17276929 DOI: 10.1016/s1726-4901(09)70296-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Primary sinonasal mucosal melanoma is a rare disease, occurring far less often than cutaneous lesions. The objective of this study was to review the records of patients diagnosed with primary sinonasal mucosal melanoma. METHODS We performed a retrospective review of the medical records of 23 patients with sinonasal mucosal melanoma who were treated at Taipei Veterans General Hospital between 1982 and 2002. RESULTS Sixteen of the 23 patients were male and 7 were female; their mean age was 68.2 years (range, 39-87 years). At diagnosis, the melanoma was limited to lesions located in the sinonasal area in 20 patients, and had spread in 3 patients. Local recurrence developed in 9 patients, neck metastasis in 5, and distant metastasis in 19. The 5-year disease-specific survival and local control rates were 22.26% and 52.30%, respectively. CONCLUSION In our experience, primary sinonasal mucosa melanoma is prone to spread from the site of origin. The major obstacle in improving overall survival is achieving systemic control.
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Affiliation(s)
- Yen-Fu Cheng
- Department of Otorhinolaryngology, Taipei Veterans General Hospital, and Department of Otorhinolaryngology, National Yang-Ming University School of Medicine, Taipei, Taiwan, R.O.C
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Lesinski GB, Sharma S, Varker KA, Sinha P, Ferrari M, Carson WE. Release of Biologically Functional Interferon-Alpha from a Nanochannel Delivery System. Biomed Microdevices 2005; 7:71-9. [PMID: 15834523 DOI: 10.1007/s10544-005-6174-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Metastatic melanoma lesions often are unresectable due to their size and/or location near critical structures. These lesions represent a significant challenge for the oncologist, because radiation therapy and chemotherapy are infrequently successful in halting tumor growth. Of primary concern is the fact that these lesions are usually painful and present a cosmetic dilemma. We hypothesized that the development of a silicon-based nano-device capable of delivering antitumor compounds (e.g. immune modulators), locally, at a constant rate, to the tumor microenvironment could avoid the toxicity of systemic administration and the inconvenience of frequent clinic visits for local injections. Because of its diminutive size, such a device could be implanted using a minimally invasive procedure in close proximity to unresectable melanoma lesions. The current report uses interferon alpha-2b (IFN-alpha) as a model antitumor agent, since it is commonly used in the treatment of malignant melanoma and metastatic renal cell carcinoma. In this system, IFN-alpha is delivered directly to the tumor microenvironment by a novel nanochannel delivery system (nDS) that is capable of zero order release of small molecules. We have demonstrated that the IFN-alpha released from the nDS is functionally active on both host immune cells and a human melanoma cell line in vitro. This drug delivery platform could be used to develop alternative strategies for the treatment of unresectable tumors.
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Affiliation(s)
- Gregory B Lesinski
- Department of Human Cancer Genetics, Division of Hematology and Oncology, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University, Columbus, OH 43210, USA
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Gyorki DE, Ainslie J, Joon ML, Henderson MA, Millward M, McArthur GA. Concurrent adjuvant radiotherapy and interferon-α2b for resected high risk stage III melanoma – a retrospective single centre study. Melanoma Res 2004; 14:223-30. [PMID: 15179193 DOI: 10.1097/01.cmr.0000129375.14518.ab] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Interferon-alpha2b (IFNalpha2b) is the only form of systemic adjuvant therapy for stage III melanoma with documented survival benefit. Radiotherapy can also be utilized in the adjuvant setting in patients at high risk of nodal basin recurrence. As IFNalpha2b is associated with substantial toxicity, we sought to determine both the systemic and radiation-related toxicities in patients treated with combined adjuvant IFNalpha2b and regional adjuvant radiotherapy delivered in the setting of a single institution. Eighteen consecutive patients who commenced adjuvant IFNalpha2b between November 1997 and August 2002 were analysed retrospectively for toxicities associated with the combination of IFNalpha2b and adjuvant radiotherapy (40-50 Gy in 15-25 fractions) to nodal basins delivered during the maintenance phase of IFNalpha2b therapy (median dose during radiotherapy of 6.5 MU/m three times per week). Seven out of 18 patients who received concurrent radiotherapy and IFNalpha2b displayed grade 3 skin reactions. Severe radiation-induced toxicity was seen in three further patients, one who developed radiation pneumonitis, one who developed severe oral mucositis, and one who developed wound dehiscence that took 10 months to resolve. Non-radiation-related toxicity to IFNalpha2b therapy was typical for this dose and schedule. We conclude that concurrent use of adjuvant radiotherapy and IFNalpha2b may enhance radiation-induced toxicity. However, overall we found concurrent radiation and IFNalpha2b could be safely delivered with appropriate clinical monitoring.
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Affiliation(s)
- David E Gyorki
- Peter MacCallum Cancer Centre, Skin and Melanoma Service, St. Andrew's Place, East Melbourne, Victoria 3002, Australia
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