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Amaral T, Meraz-Torres F, Garbe C. Immunotherapy in managing metastatic melanoma: which treatment when? Expert Opin Biol Ther 2017; 17:1523-1538. [PMID: 28891339 DOI: 10.1080/14712598.2017.1378640] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Ten to fifteen percent of melanoma patients develop distant or unresectable metastasis requiring systemic treatment. Around 45% of the patients diagnosed with metastatic cutaneous melanoma harbor a BRAFV600 mutation and derive benefit from combined targeted therapy with MAPK pathway inhibitors. These offer a rapid response that translates into improvement of symptoms and increased quality of life. However, resistance often develops with subsequent progressive disease. Immunotherapy with checkpoint inhibitors may be offered to BRAF-mutated and wild-type patients and is associated with longer and durable responses that can continue over years. Areas covered: In this review, the authors discuss the late evidence for targeted and immunotherapy in melanoma patients, as well as therapy sequencing. Immunotherapy in special populations is also addressed. Expert opinion: Effective treatments are currently available. However, there are still unanswered questions of the best therapy sequence, the clear superiority of combined immunotherapy versus monotherapy in all patients, and therapy duration. Since different promising treatments will become available, clinical trials comparing the diverse options in terms of safety, efficacy and cost- effectiveness are required to make the right decisions. Consequently, patients should be encouraged to participate in clinical trials, whenever possible.
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Affiliation(s)
- Teresa Amaral
- a Center for Dermatooncology, Department of Dermatology , University Hospital Tuebingen , Tuebingen , Germany
- b Portuguese Air Force Health Direction , Lisbon , Portugal
| | - Francisco Meraz-Torres
- a Center for Dermatooncology, Department of Dermatology , University Hospital Tuebingen , Tuebingen , Germany
| | - Claus Garbe
- a Center for Dermatooncology, Department of Dermatology , University Hospital Tuebingen , Tuebingen , Germany
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Yam C, Xu X, Davies MA, Gimotty PA, Morrissette JJD, Tetzlaff MT, Wani KM, Liu S, Deng W, Buckley M, Zhao J, Amaravadi RK, Haas NB, Kudchadkar RR, Pavlick AC, Sosman JA, Tawbi H, Walker L, Schuchter LM, Karakousis GC, Gangadhar TC. A Multicenter Phase I Study Evaluating Dual PI3K and BRAF Inhibition with PX-866 and Vemurafenib in Patients with Advanced BRAF V600-Mutant Solid Tumors. Clin Cancer Res 2017; 24:22-32. [PMID: 29051322 DOI: 10.1158/1078-0432.ccr-17-1807] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 08/29/2017] [Accepted: 10/12/2017] [Indexed: 01/12/2023]
Abstract
Purpose: The objectives of the study were to evaluate the safety of daily oral PX-866 in combination with twice daily vemurafenib and to identify potential predictive biomarkers for this novel combination.Experimental Design: We conducted a phase I, open-label, dose-escalation study in patients with advanced BRAF V600-mutant solid tumors. PX-866 was administered on a continuous schedule in combination with vemurafenib. Patients underwent a baseline and on-treatment biopsy after 1-week of PX-866 monotherapy for biomarker assessment.Results: Twenty-four patients were enrolled. The most common treatment-related adverse events were gastrointestinal side effects. One dose-limiting toxicity (DLT) of grade 3 rash and one DLT of grade 3 pancreatitis were observed in cohort 2 (PX-866 6 mg daily; vemurafenib 960 mg twice daily) and cohort 3 (PX-866 8 mg daily; vemurafenib 960 mg twice daily), respectively. Of 23 response-evaluable patients, seven had confirmed partial responses (PR), 10 had stable disease, and six had disease progression. Decreases in intratumoral pAKT expression were observed following treatment with PX-866. Patients who achieved PRs had higher rates of PTEN loss by IHC (80% vs. 58%) and pathogenic PTEN mutations and/or deletions (57% vs. 25%). Two patients with durable PRs had an increase in intratumoral CD8+ T-cell infiltration following treatment with PX-866.Conclusions: PX-866 was well tolerated at its maximum tolerated single-agent dose when given in combination with a modified dose of vemurafenib (720 mg twice daily). Response to treatment appeared to be associated with PTEN loss and treatment with PX-866 seemed to increase CD8+ T-cell infiltration in some patients. Clin Cancer Res; 24(1); 22-32. ©2017 AACR.
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Affiliation(s)
- Clinton Yam
- Abramson Cancer Center and the Division of Hematology & Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xiaowei Xu
- Abramson Cancer Center and the Division of Hematology & Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael A Davies
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Phyllis A Gimotty
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer J D Morrissette
- Center for Personalized Diagnostics, Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Khalida M Wani
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shujing Liu
- Abramson Cancer Center and the Division of Hematology & Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wanleng Deng
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Meghan Buckley
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jianhua Zhao
- Center for Personalized Diagnostics, Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ravi K Amaravadi
- Abramson Cancer Center and the Division of Hematology & Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Naomi B Haas
- Abramson Cancer Center and the Division of Hematology & Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | - Hussein Tawbi
- The University of Texas MD Anderson Cancer Center, Houston, Texas.,The University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Luke Walker
- Cascadian Therapeutics (formerly Oncothyreon) Inc., Seattle, Washington
| | - Lynn M Schuchter
- Abramson Cancer Center and the Division of Hematology & Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Giorgos C Karakousis
- Abramson Cancer Center and the Division of Hematology & Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tara C Gangadhar
- Abramson Cancer Center and the Division of Hematology & Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Griffin M, Scotto D, Josephs DH, Mele S, Crescioli S, Bax HJ, Pellizzari G, Wynne MD, Nakamura M, Hoffmann RM, Ilieva KM, Cheung A, Spicer JF, Papa S, Lacy KE, Karagiannis SN. BRAF inhibitors: resistance and the promise of combination treatments for melanoma. Oncotarget 2017; 8:78174-78192. [PMID: 29100459 PMCID: PMC5652848 DOI: 10.18632/oncotarget.19836] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 07/25/2017] [Indexed: 12/31/2022] Open
Abstract
Identification of mutations in the gene encoding the serine/threonine-protein kinase, BRAF, and constitutive activation of the mitogen-activated protein kinase (MAPK) pathway in around 50% of malignant melanomas have led to the development and regulatory approval of targeted pathway inhibitor drugs. A proportion of patients are intrinsically resistant to BRAF inhibitors, and most patients who initially respond, acquire resistance within months. In this review, we discuss pathway inhibitors and their mechanisms of resistance, and we focus on numerous efforts to improve clinical benefits through combining agents with disparate modes of action, including combinations with checkpoint inhibitor antibodies. We discuss the merits of combination strategies based on enhancing immune responses or overcoming tumor-associated immune escape mechanisms. Emerging insights into mechanisms of action, resistance pathways and their impact on host-tumor relationships will inform the design of optimal combinations therapies to improve outcomes for patients who currently do not benefit from recent treatment breakthroughs.
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Affiliation(s)
- Merope Griffin
- St John's Institute of Dermatology, Genetics and Molecular Medicine, King's College London, Guy's Hospital, Tower Wing, London, UK
| | - Daniele Scotto
- St John's Institute of Dermatology, Genetics and Molecular Medicine, King's College London, Guy's Hospital, Tower Wing, London, UK
| | - Debra H. Josephs
- St John's Institute of Dermatology, Genetics and Molecular Medicine, King's College London, Guy's Hospital, Tower Wing, London, UK
- Research Oncology, School of Cancer Sciences, King's College London, Guy's Hospital, Bermondsey Wing, London, UK
| | - Silvia Mele
- St John's Institute of Dermatology, Genetics and Molecular Medicine, King's College London, Guy's Hospital, Tower Wing, London, UK
| | - Silvia Crescioli
- St John's Institute of Dermatology, Genetics and Molecular Medicine, King's College London, Guy's Hospital, Tower Wing, London, UK
| | - Heather J. Bax
- St John's Institute of Dermatology, Genetics and Molecular Medicine, King's College London, Guy's Hospital, Tower Wing, London, UK
- Research Oncology, School of Cancer Sciences, King's College London, Guy's Hospital, Bermondsey Wing, London, UK
| | - Giulia Pellizzari
- St John's Institute of Dermatology, Genetics and Molecular Medicine, King's College London, Guy's Hospital, Tower Wing, London, UK
- Research Oncology, School of Cancer Sciences, King's College London, Guy's Hospital, Bermondsey Wing, London, UK
| | - Matthew D. Wynne
- St John's Institute of Dermatology, Genetics and Molecular Medicine, King's College London, Guy's Hospital, Tower Wing, London, UK
| | - Mano Nakamura
- St John's Institute of Dermatology, Genetics and Molecular Medicine, King's College London, Guy's Hospital, Tower Wing, London, UK
| | - Ricarda M. Hoffmann
- St John's Institute of Dermatology, Genetics and Molecular Medicine, King's College London, Guy's Hospital, Tower Wing, London, UK
| | - Kristina M. Ilieva
- St John's Institute of Dermatology, Genetics and Molecular Medicine, King's College London, Guy's Hospital, Tower Wing, London, UK
- Breast Cancer Now Unit, School of Cancer Sciences, King's College London, Guy's Cancer Centre, London, UK
| | - Anthony Cheung
- St John's Institute of Dermatology, Genetics and Molecular Medicine, King's College London, Guy's Hospital, Tower Wing, London, UK
- Breast Cancer Now Unit, School of Cancer Sciences, King's College London, Guy's Cancer Centre, London, UK
| | - James F. Spicer
- Research Oncology, School of Cancer Sciences, King's College London, Guy's Hospital, Bermondsey Wing, London, UK
| | - Sophie Papa
- Research Oncology, School of Cancer Sciences, King's College London, Guy's Hospital, Bermondsey Wing, London, UK
| | - Katie E. Lacy
- St John's Institute of Dermatology, Genetics and Molecular Medicine, King's College London, Guy's Hospital, Tower Wing, London, UK
| | - Sophia N. Karagiannis
- St John's Institute of Dermatology, Genetics and Molecular Medicine, King's College London, Guy's Hospital, Tower Wing, London, UK
- Breast Cancer Now Unit, School of Cancer Sciences, King's College London, Guy's Cancer Centre, London, UK
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