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O’Hare P, Cooney T, de Blank P, Gutmann DH, Kieran M, Milde T, Fangusaro J, Fisher M, Avula S, Packer R, Fukuoka K, Mankad K, Mueller S, Waanders AJ, Opocher E, Bouffet E, Raabe E, Werle NE, Azizi AA, Robison NJ, Hernáiz Driever P, Russo M, Schouten N, van Tilburg CM, Sehested A, Grill J, Bandopadhayay P, Kilday JP, Witt O, Ashley DM, Ertl-Wagner BB, Tabori U, Hargrave DR. Resistance, rebound, and recurrence regrowth patterns in pediatric low-grade glioma treated by MAPK inhibition: A modified Delphi approach to build international consensus-based definitions-International Pediatric Low-Grade Glioma Coalition. Neuro Oncol 2024; 26:1357-1366. [PMID: 38743009 PMCID: PMC11300023 DOI: 10.1093/neuonc/noae074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024] Open
Abstract
Pediatric low-grade glioma (pLGG) is the most common childhood brain tumor group. The natural history, when curative resection is not possible, is one of a chronic disease with periods of tumor stability and episodes of tumor progression. While there is a high overall survival rate, many patients experience significant and potentially lifelong morbidities. The majority of pLGGs have an underlying activation of the RAS/MAPK pathway due to mutational events, leading to the use of molecularly targeted therapies in clinical trials, with recent regulatory approval for the combination of BRAF and MEK inhibition for BRAFV600E mutated pLGG. Despite encouraging activity, tumor regrowth can occur during therapy due to drug resistance, off treatment as tumor recurrence, or as reported in some patients as a rapid rebound growth within 3 months of discontinuing targeted therapy. Definitions of these patterns of regrowth have not been well described in pLGG. For this reason, the International Pediatric Low-Grade Glioma Coalition, a global group of physicians and scientists, formed the Resistance, Rebound, and Recurrence (R3) working group to study resistance, rebound, and recurrence. A modified Delphi approach was undertaken to produce consensus-based definitions and recommendations for regrowth patterns in pLGG with specific reference to targeted therapies.
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Affiliation(s)
- Patricia O’Hare
- Department of Paediatric Oncology, Royal Belfast Hospital for Sick Children, Northern Ireland, UK
| | - Tabitha Cooney
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Broad Institute, Cambridge, Massachusetts, USA
- Day One Biopharmaceuticals, Boston, Massachusetts, USA
| | - Peter de Blank
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Broad Institute, Cambridge, Massachusetts, USA
- University of Cincinnati College of Medicine and Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - David H Gutmann
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Mark Kieran
- Day One Biopharmaceuticals, Boston, Massachusetts, USA
| | - Till Milde
- Clinical Pediatric Oncology, Hopp Children’s Cancer Center (KiTZ), Heidelberg, Germany
- Heidelberg University Hospital, Heidelberg, Germany
- German Cancer Research Center, National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Jason Fangusaro
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael Fisher
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shivaram Avula
- Department of Radiology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Roger Packer
- Brain Tumor Institute, Center for Neuroscience and Behavioral Medicine, Children’s National Hospital, Washington, District of Columbia, USA
| | - Kohei Fukuoka
- Department of Hematology/Oncology, Saitama Children’s Medical Center, Saitama, Japan
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Department of Radiology, London, UK
| | - Sabine Mueller
- Department of Neurology, Neurosurgery and Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Angela J Waanders
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Enrico Opocher
- Paediatric Haematology, Oncology and Stem Cell Transplant Division, Padua University Hospital, Padua, Italy
| | - Eric Bouffet
- The Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Eric Raabe
- Division of Pediatric Oncology, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Natacha Entz Werle
- Pediatric Onco-Hematology Department, University Hospital of Strasbourg. UMR CNRS 7021, University of Strasbourg, Strasbourg, France
| | - Amedeo A Azizi
- Department of Pediatrics and Adolescent Medicine and Comprehensive Centre of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Nathan J Robison
- Division of Hematology & Oncology, Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Pablo Hernáiz Driever
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, German HIT-LOGGIC-Registry for LGG in children and adolescents, Department of Pediatric Oncology/Hematology, Berlin, Germany
| | - Mark Russo
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Netteke Schouten
- Princess Maxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Cornelis M van Tilburg
- Clinical Pediatric Oncology, Hopp Children’s Cancer Center (KiTZ), Heidelberg, Germany
- Heidelberg University Hospital, Heidelberg, Germany
- German Cancer Research Center, National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Astrid Sehested
- Department of Paediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jacques Grill
- Department of Pediatric and Adolescent Oncology, Villejuif, France
| | - Pratiti Bandopadhayay
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Broad Institute, Cambridge, Massachusetts, USA
| | - John-Paul Kilday
- The Centre for Paediatric, Teenage and Young Adult Cancer, Institute of Cancer Sciences, University of Manchester, and Royal Manchester Children’s Hospital, Manchester, UK
| | - Olaf Witt
- Clinical Pediatric Oncology, Hopp Children’s Cancer Center (KiTZ), Heidelberg, Germany
- Heidelberg University Hospital, Heidelberg, Germany
- German Cancer Research Center, National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - David M Ashley
- Department of Neurosurgery, The Preston Robert Tisch Brain Tumor Center. Pediatric Neuro-Oncology, Preuss Laboratory for Brain Tumor Research, Durham, North Carolina, USA
| | | | - Uri Tabori
- The Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Darren R Hargrave
- UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, UK
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Lee J, Ahmed T, Maurichi A, Di Guardo L, Stagno AM, Warburton L, Taylor AM, Livingstone E, Rehman S, Khattak A, Kahler KC, Vanella V, Atkinson V, Millward M, Schadendorf D, Johnson DB, Ascierto PA, Hauschild A, Lo SN, Long GV, Menzies AM, Carlino MS. BRAF inhibitor cessation prior to disease progression in metastatic melanoma: Long-term outcomes. Eur J Cancer 2023; 179:87-97. [PMID: 36509002 DOI: 10.1016/j.ejca.2022.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 11/01/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND BRAF mutant melanoma treated with BRAF ± MEK inhibitor (targeted therapy) has a high response rate; however, most patients progress (PD). Some patients have durable response, but it is unknown whether treatment can be discontinued in these patients. We describe the recurrence risk, progression patterns, response to subsequent treatment, and survival of patients with advanced melanoma who ceased targeted therapy prior to PD. PATIENTS AND METHODS Ninety-four patients who ceased targeted therapy without progression were identified retrospectively from 11 centres: 45 were male; 81 V600E; 88 stage IV. Fifty-nine were treated with BRAF + MEK inhibitor, and 35 were treated with BRAF inhibitor alone. Median treatment duration was 29.6 months (range 0.36-77.9). At cessation, 67 were in complete response, 21 in partial response, and 2 stable disease. RESULTS After median follow-up from cessation of 42.9 months (range 0.0-88.7), 36 (38%) progressed; median time to progression was 4.7 months (range 0.7-56.9); 30 (83%) were asymptomatic and 7 (19%) had new brain metastases. Progression rates did not differ by best response: 34% for complete response and 43% for partial response (P = 0.65). Treatment duration was strongly associated with risk of progression: Median treatment duration was 18.3 (range 0.85-65.7) months for those who progressed and 34.6 (range 0.36-77.9) months for those who did not (P = 0.0004). Twenty-two received further targeted therapy with 15 (68%) responses. CONCLUSION Risk of progression after cessation of targeted therapy is strongly associated with treatment duration. Response to retreatment with targeted therapy is high.
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Affiliation(s)
| | - Tasnia Ahmed
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
| | - Andrea Maurichi
- Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Lorenzo Di Guardo
- Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Anna M Stagno
- SC Medical Oncology/ASST-Monza San Gerardo Hospital, Monza, Italy
| | | | - Amelia M Taylor
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
| | | | - Saba Rehman
- Vanderbilt University Medical Centre, Nashville, USA
| | - Adnan Khattak
- Fiona Stanley Hospital, Perth, Australia; Edith Cowan University, Perth, Australia
| | | | - Vito Vanella
- Istituto Nazionale Tumori IRCCS Fondazione Pascale, Naples, Italy
| | - Victoria Atkinson
- Princess Alexandra Hospital, Brisbane, Australia; University of Queensland, Brisbane, Australia; Greenslopes Private Hospital, Brisbane, Australia
| | - Michael Millward
- School of Medicine/University of Western Australia, Perth, Australia
| | - Dirk Schadendorf
- University Hospital Essen & German Cancer Consortium, Partner Site Essen, Germany
| | | | - Paolo A Ascierto
- Istituto Nazionale Tumori IRCCS Fondazione Pascale, Naples, Italy
| | - Axel Hauschild
- University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Serigne N Lo
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health/The University of Sydney, Sydney, Australia; Royal North Shore & Mater Hospitals, Sydney, Australia; Charles Perkins Centre/The University of Sydney, Sydney, Australia
| | - Alexander M Menzies
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health/The University of Sydney, Sydney, Australia; Royal North Shore & Mater Hospitals, Sydney, Australia
| | - Matteo S Carlino
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health/The University of Sydney, Sydney, Australia; Blacktown and Westmead Hospitals, Sydney, Australia.
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Bédouelle E, Nguyen JM, Varey E, Khammari A, Dreno B. Should Targeted Therapy Be Continued in BRAF-Mutant Melanoma Patients after Complete Remission? Dermatology 2021; 238:517-526. [PMID: 34818219 DOI: 10.1159/000518718] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 07/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Targeted therapy is used to treat patients with a BRAF-mutated metastatic melanoma and is continued until disease progression or severe toxicity. No robust data on the management of patients achieving a complete remission (CR) are available. MAIN OBJECTIVE To determine the relapse rate in the first year after targeted therapy discontinuation in patients in CR. SECONDARY OBJECTIVES To determine the relapse rates throughout the follow-up and to identify prognostic factors for relapse at 1 year. METHODS A retrospective, monocentric observational study was conducted in patients with advanced melanoma included in the RIC-Mel database who discontinued targeted therapy after achieving a CR confirmed by CT scan and PET/CT scan. RESULTS Twenty-nine patients were included. Seventeen (58.6%) patients were treated with BRAF inhibitor (BRAFi) alone and 12 (41.4%) with a BRAFi combined with a MEK inhibitor (BRAFi + MEKi). The median treatment duration was 9.7 months. The relapse rates after discontinuation were 69% at 12 months (BRAFi: 70.6%; BRAFi + MEKi: 66.7%) and 76% at 36 months (BRAFi: 76.5%; BRAFi + MEKi: 75%). A non-significant trend towards a higher risk of relapse was found in women (p = 0.1; RR 3.36; 95% CI 0.77-17.07), in patients with an LDH level greater than the upper limits of normal (p = 0.58; RR 2.43; 95% CI 0.10-56.71), and when more than two metastatic sites were involved (p = 0.19; RR 4.6; 95% CI 0.46-46.51). After relapse, targeted therapy was resumed in 17 patients (7 with BRAFi; 10 with BRAFi + MEKi) with a response rate of 53%. CONCLUSIONS This real-life study provided long-term data in patients who discontinued targeted therapy after CR. Most patients experienced a relapse in the first year after targeted therapy discontinuation, of whom 50% were in the first 3 months. After targeted therapy resumption, 53% of relapsing patients achieved an objective response. Patients should be followed during the first year after treatment discontinuation. In addition, patients with less than 3 metastatic sites, a baseline LDH level with normal ranges, men, and patients responding rapidly to treatment would be more likely to maintain a CR after treatment discontinuation.
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Affiliation(s)
- Eve Bédouelle
- Department of Dermatology, CHU Nantes, CIC 1413, CRCINA Inserm U 1232, Nantes University, Nantes, France
| | | | - Emilie Varey
- Department of Dermatology, CHU Nantes, CIC 1413, CRCINA Inserm U 1232, Nantes University, Nantes, France
| | - Amir Khammari
- Department of Dermatology, CHU Nantes, CIC 1413, CRCINA Inserm U 1232, Nantes University, Nantes, France
| | - Brigitte Dreno
- Department of Dermatology, CHU Nantes, CIC 1413, CRCINA Inserm U 1232, Nantes University, Nantes, France
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Di Guardo L, Randon G, Corti F, Vallacchi V, Raimondi A, Fucà G, Bini M, Maurichi A, Patuzzo R, Gallino G, Mattavelli I, Ruggeri R, Angi M, Cossa M, Valeri B, Cimminiello C, Santinami M, Rivoltini L, de Braud F, Rodolfo M, Vecchio MD. Liquid biopsy and radiological response predict outcomes following discontinuation of targeted therapy in patients with BRAF mutated melanoma. Oncologist 2021; 26:1079-1084. [PMID: 34355463 PMCID: PMC8649022 DOI: 10.1002/onco.13926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/23/2021] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Outcomes of patients with metastatic melanoma discontinuing BRAF-targeted therapy for cumulative toxicity after sustained response are unknown. PATIENTS AND METHODS This retrospective case series analysis conducted at a single Cancer Center in Italy included patients with BRAF mutated metastatic melanoma treated with a BRAF inhibitor as a single agent or in combination with a MEK inhibitor between June 1, 2011 and January 1, 2020 and interrupting treatment after achieving complete response (CR) or long-lasting partial response (PR - i.e. > 12 months) due to cumulative toxicity. RESULTS We included 24 patients with a median treatment duration of 59.4 months (95%CI 55.4-63.4 - range 12-88). CR and PR were achieved in 71% and 29% of patients, respectively. At a median follow-up after treatment discontinuation of 37.8 months (95%CI 33.7-41.9), 12-months progression free survival after discontinuation (dPFS) rate was 70.8% (95%CI 54.8 - 91.6) and 24-months dPFS rate was 58.3% (95%CI 41.6 - 81.8). Baseline patients and tumor characteristics as well as treatment duration and best response did not significantly impact on dPFS. Patients with CR and negative circulating tumor DNA (ctDNA) at time of discontinuation had a significantly improved dPFS compared to patients with either radiological residual disease or ctDNA positivity (P = 0.007). No patient in CR with undetectable ctDNA experienced progression. CONCLUSION The risk of progression is high even in patients with sustained sensitivity to BRAF/MEK inhibitors. Integration of liquid biopsy in clinical trials investigating optimal management of patients with sustained sensitivity to BRAF/MEK inhibitors is warranted. IMPLICATIONS FOR PRACTICE Outcomes of patients with metastatic melanoma discontinuing BRAF-targeted therapy for cumulative toxicity are unknown. We analyzed patients with sustained responses (median treatment duration 59.4 months). Twelve and 24-months progression free survival following discontinuation were 70.8% and 58.3% respectively. Complete response and negative ctDNA at time of discontinuation are promising prognostic biomarkers in this setting.
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Affiliation(s)
- Lorenza Di Guardo
- Department of Medical OncologyFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Giovanni Randon
- Department of Medical OncologyFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Francesca Corti
- Department of Medical OncologyFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Viviana Vallacchi
- Unit of Immunotherapy of Human TumorsFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Alessandra Raimondi
- Department of Medical OncologyFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Giovanni Fucà
- Department of Medical OncologyFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Marta Bini
- Department of Medical OncologyFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Andrea Maurichi
- Melanoma and Sarcoma Surgery UnitFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Roberto Patuzzo
- Department of Medical OncologyFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Gianfrancesco Gallino
- Melanoma and Sarcoma Surgery UnitFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Ilaria Mattavelli
- Melanoma and Sarcoma Surgery UnitFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Roberta Ruggeri
- Melanoma and Sarcoma Surgery UnitFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Martina Angi
- Ocular Oncology Service, Department of SurgeryFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Mara Cossa
- Department of PathologyFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Barbara Valeri
- Department of PathologyFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Carolina Cimminiello
- Department of Medical OncologyFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Mario Santinami
- Melanoma and Sarcoma Surgery UnitFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Licia Rivoltini
- Unit of Immunotherapy of Human TumorsFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Filippo de Braud
- Department of Medical OncologyFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
- Oncology and Hemato‐Oncology DepartmentUniversity of MilanMilanItaly
| | - Monica Rodolfo
- Unit of Immunotherapy of Human TumorsFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
| | - Michele Del Vecchio
- Department of Medical OncologyFondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei TumoriMilanItaly
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Discontinuation of BRAF/MEK-Directed Targeted Therapy after Complete Remission of Metastatic Melanoma-A Retrospective Multicenter ADOReg Study. Cancers (Basel) 2021; 13:cancers13102312. [PMID: 34065877 PMCID: PMC8151093 DOI: 10.3390/cancers13102312] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 12/13/2022] Open
Abstract
The advent of BRAF/MEK inhibitors (BRAFi/MEKi) has significantly improved progression-free (PFS) and overall survival (OS) for patients with advanced BRAF-V600-mutant melanoma. Long-term survivors have been identified particularly among patients with a complete response (CR) to BRAF/MEK-directed targeted therapy (TT). However, it remains unclear which patients who achieved a CR maintain a durable response and whether treatment cessation might be a safe option in these patients. Therefore, this study investigated the impact of treatment cessation on the clinical course of patients with a CR upon BRAF/MEK-directed-TT. We retrospectively selected patients with BRAF-V600-mutant advanced non-resectable melanoma who had been treated with BRAFi ± MEKi therapy and achieved a CR upon treatment out of the multicentric skin cancer registry ADOReg. Data on baseline patient characteristics, duration of TT, treatment cessation, tumor progression (TP) and response to second-line treatments were collected and analyzed. Of 461 patients who received BRAF/MEK-directed TT 37 achieved a CR. TP after initial CR was observed in 22 patients (60%) mainly affecting patients who discontinued TT (n = 22/26), whereas all patients with ongoing TT (n = 11) maintained their CR. Accordingly, patients who discontinued TT had a higher risk of TP compared to patients with ongoing treatment (p < 0.001). However, our data also show that patients who received TT for more than 16 months and who discontinued TT for other reasons than TP or toxicity did not have a shorter PFS compared to patients with ongoing treatment. Response rates to second-line treatment being initiated in 21 patients, varied between 27% for immune-checkpoint inhibitors (ICI) and 60% for BRAFi/MEKi rechallenge. In summary, we identified a considerable number of patients who achieved a CR upon BRAF/MEK-directed TT in this contemporary real-world cohort of patients with BRAF-V600-mutant melanoma. Sustained PFS was not restricted to ongoing TT but was also found in patients who discontinued TT.
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6
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Clinical Implications of Acquired BRAF Inhibitors Resistance in Melanoma. Int J Mol Sci 2020; 21:ijms21249730. [PMID: 33419275 PMCID: PMC7766699 DOI: 10.3390/ijms21249730] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/17/2020] [Accepted: 12/17/2020] [Indexed: 12/13/2022] Open
Abstract
Understanding the role of mitogen-activated protein kinase (MAPK) pathway-activating mutations in the development and progression of melanoma and their possible use as therapeutic targets has substantially changed the management of this neoplasm, which, until a few years ago, was burdened by severe mortality. However, the presence of numerous intrinsic and extrinsic mechanisms of resistance to BRAF inhibitors compromises the treatment responses’ effectiveness and durability. The strategy of overcoming these resistances by combination therapy has proved successful, with the additional benefit of reducing side effects derived from paradoxical activation of the MAPK pathway. Furthermore, the use of other highly specific inhibitors, intermittent dosing schedules and the association of combination therapy with immune checkpoint inhibitors are promising new therapeutic strategies. However, numerous issues related to dose, tolerability and administration sequence still need to be clarified, as is to be expected from currently ongoing trials. In this review, we describe the clinical results of using BRAF inhibitors in advanced melanoma, with a keen interest in strategies aimed at overcoming resistance.
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7
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Warburton L, Meniawy TM, Calapre L, Pereira M, McEvoy A, Ziman M, Gray ES, Millward M. Stopping targeted therapy for complete responders in advanced BRAF mutant melanoma. Sci Rep 2020; 10:18878. [PMID: 33139839 PMCID: PMC7606504 DOI: 10.1038/s41598-020-75837-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 10/21/2020] [Indexed: 12/27/2022] Open
Abstract
BRAF inhibitors revolutionised the management of melanoma patients and although resistance occurs, there is a subgroup of patients who maintain durable disease control. For those cases with durable complete response (CR) it is not clear whether it is safe to cease therapy. Here we identified 13 patients treated with BRAF +/- MEK inhibitors, who cease therapy after prolonged CR (median = 34 months, range 20-74). Recurrence was observed in 3/13 (23%) patients. In the remaining 10 patients with sustained CR off therapy, the median follow up after discontinuation was 19 months (range 8-36). We retrospectively measured ctDNA levels using droplet digital PCR (ddPCR) in longitudinal plasma samples. CtDNA levels were undetectable in 11/13 cases after cessation and remained undetectable in patients in CR (10/13). CtDNA eventually became detectable in 2/3 cases with disease recurrence, but remained undetectable in 1 patient with brain only progression. Our study suggests that consideration could be given to ceasing targeted therapy in the context of prolonged treatment, durable response and no evidence of residual disease as measured by ctDNA.
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Affiliation(s)
- L Warburton
- Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - T M Meniawy
- Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley, WA, Australia
| | - L Calapre
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - M Pereira
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - A McEvoy
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - M Ziman
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
- School of Biomedical Science, University of Western Australia, Crawley, WA, Australia
| | - E S Gray
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia.
| | - M Millward
- Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley, WA, Australia
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8
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Repeated complete response with long-term control of BRAF-mutant melanoma by multiple rechallenges with dabrafenib plus trametinib. Eur J Cancer 2020; 139:37-40. [DOI: 10.1016/j.ejca.2020.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/17/2020] [Accepted: 08/05/2020] [Indexed: 11/22/2022]
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Keilholz U, Ascierto PA, Dummer R, Robert C, Lorigan P, van Akkooi A, Arance A, Blank CU, Chiarion Sileni V, Donia M, Faries MB, Gaudy-Marqueste C, Gogas H, Grob JJ, Guckenberger M, Haanen J, Hayes AJ, Hoeller C, Lebbé C, Lugowska I, Mandalà M, Márquez-Rodas I, Nathan P, Neyns B, Olofsson Bagge R, Puig S, Rutkowski P, Schilling B, Sondak VK, Tawbi H, Testori A, Michielin O. ESMO consensus conference recommendations on the management of metastatic melanoma: under the auspices of the ESMO Guidelines Committee. Ann Oncol 2020; 31:1435-1448. [PMID: 32763453 DOI: 10.1016/j.annonc.2020.07.004] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/08/2020] [Accepted: 07/08/2020] [Indexed: 12/19/2022] Open
Abstract
The European Society for Medical Oncology (ESMO) held a consensus conference on melanoma on 5-7 September 2019 in Amsterdam, The Netherlands. The conference included a multidisciplinary panel of 32 leading experts in the management of melanoma. The aim of the conference was to develop recommendations on topics that are not covered in detail in the current ESMO Clinical Practice Guideline and where available evidence is either limited or conflicting. The main topics identified for discussion were (i) the management of locoregional disease; (ii) targeted versus immunotherapies in the adjuvant setting; (iii) targeted versus immunotherapies for the first-line treatment of metastatic melanoma; (iv) when to stop immunotherapy or targeted therapy in the metastatic setting; and (v) systemic versus local treatment for brain metastases. The expert panel was divided into five working groups to each address questions relating to one of the five topics outlined above. Relevant scientific literature was reviewed in advance. Recommendations were developed by the working groups and then presented to the entire panel for further discussion and amendment before voting. This manuscript presents the results relating to the management of metastatic melanoma, including findings from the expert panel discussions, consensus recommendations and a summary of evidence supporting each recommendation. All participants approved the final manuscript.
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Affiliation(s)
- U Keilholz
- Charité Comprehensive Cancer Center, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - P A Ascierto
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - R Dummer
- Department of Dermatology, University Hospital Zürich, Zürich, Switzerland
| | - C Robert
- Department of Dermatology, Gustave Roussy, Villejuif, France; Paris-Saclay University, Le Kremlin-Bicêtre, France
| | - P Lorigan
- Division of Cancer Sciences, The University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | - A van Akkooi
- Department of Surgical Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - A Arance
- Department of Medical Oncology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - C U Blank
- Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - V Chiarion Sileni
- Department of Experimental and Clinical Oncology, Istituto Oncologico Veneto, IOV-IRCCS, Padova, Italy
| | - M Donia
- National Center for Cancer Immune Therapy, Department of Oncology, Herlev and Gentofte Hospital, Herlev, Denmark; University of Copenhagen, Copenhagen, Denmark
| | - M B Faries
- Department of Surgery, The Angeles Clinic, Cedars Sinai Medical Center, Los Angeles, USA
| | - C Gaudy-Marqueste
- Department of Dermatology and Skin Cancer, Aix Marseille University, Hôpital De La Timone, Marseille, France
| | - H Gogas
- First Department of Medicine, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - J J Grob
- Department of Dermatology and Skin Cancer, Aix Marseille University, Hôpital De La Timone, Marseille, France
| | - M Guckenberger
- Department of Radio-Oncology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - J Haanen
- Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - A J Hayes
- Department of Academic Surgery, Royal Marsden NHS Foundation Trust, London, UK
| | - C Hoeller
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - C Lebbé
- AP-HP Dermatology, Université de Paris, Paris, France; INSERM U976, Hôpital Saint Louis, Paris, France
| | - I Lugowska
- Early Phase Clinical Trials Unit, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - M Mandalà
- Department of Oncology and Haematology, Papa Giovanni XXIII Cancer Center Hospital, Bergamo, Italy
| | - I Márquez-Rodas
- Department of Medical Oncology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - P Nathan
- Department of Medical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - B Neyns
- Department of Medical Oncology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - R Olofsson Bagge
- Sahlgrenska Cancer Center, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden; Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Sweden
| | - S Puig
- Dermatology Service, Hospital Clínic of Barcelona and University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; CIBER, Instituto de Salud Carlos III, Barcelona, Spain
| | - P Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - B Schilling
- Department of Dermatology, University Hospital Würzburg, Würzburg, Germany
| | - V K Sondak
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, USA
| | - H Tawbi
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - A Testori
- Department of Dermatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - O Michielin
- Department of Oncology, University Hospital Lausanne, Lausanne, Switzerland
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Rechallenge with BRAF-directed treatment in metastatic melanoma: A multi-institutional retrospective study. Eur J Cancer 2018; 91:116-124. [DOI: 10.1016/j.ejca.2017.12.007] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 12/02/2017] [Indexed: 12/11/2022]
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