1
|
Funchain P, Ni Y, Heald B, Bungo B, Arbesman M, Behera TR, McCormick S, Song JM, Kennedy LB, Nielsen SM, Esplin ED, Nizialek E, Ko J, Diaz-Montero CM, Gastman B, Stratigos AJ, Artomov M, Tsao H, Arbesman J. Germline Cancer Susceptibility in Individuals with Melanoma. J Am Acad Dermatol 2024:S0190-9622(24)00504-8. [PMID: 38513832 DOI: 10.1016/j.jaad.2023.11.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 11/05/2023] [Accepted: 11/27/2023] [Indexed: 03/23/2024]
Abstract
BACKGROUND Prior studies have estimated a small number of individuals with melanoma (2-2.5%) have germline cancer predisposition, yet a recent twin study suggested melanoma has the highest hereditability among cancers. OBJECTIVE To determine the incidence of hereditary melanoma and characterize the spectrum of cancer predisposition genes that may increase the risk of melanoma. METHODS 400 individuals with melanoma and personal or family history of cancers underwent germline testing of >80 cancer predisposition genes. Comparative analysis of germline data was performed on 3 additional oncologic and dermatologic datasets. RESULTS Germline pathogenic/likely pathogenic (P/LP) variants were identified in 15.3% (61) individuals with melanoma. Most variants (41, 67%) involved genes considered unrelated to melanoma (BLM, BRIP1, CHEK2, MLH1, MSH2, PMS2, RAD51C). A third (20, 33%) were in genes previously associated with familial melanoma (BAP1, BRCA2, CDKN2A, MITF, TP53). Nearly half (30, 46.9%) of P/LP variants were in HRD genes. Validation cohorts demonstrated P/LP rates of 10.6% from an unselected oncologic cohort, 15.8% from a selected commercial testing cohort and 14.5% from a highly selected dermatologic study. LIMITATIONS Cohorts with varying degrees of selection, some retrospective. CONCLUSION Germline predisposition in individuals with melanoma is common, with clinically actionable findings diagnosed in 10.6% to 15.8%.
Collapse
Affiliation(s)
- P Funchain
- Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Y Ni
- Center for Immunotherapy & Precision Immuno-Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - B Heald
- Genomic Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH, USA; Invitae Corporation, South San Francisco, CA, USA
| | - B Bungo
- Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - M Arbesman
- Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - T R Behera
- Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, USA; Center for Immunotherapy & Precision Immuno-Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - S McCormick
- Center Cancer Risk Assessment, Massachusetts General Hospital, Cambridge, MA, USA
| | - J M Song
- Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, USA; Department of Hematology/Oncology, MetroHealth, Cleveland, USA
| | - L B Kennedy
- Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - S M Nielsen
- Invitae Corporation, South San Francisco, CA, USA
| | - E D Esplin
- Invitae Corporation, South San Francisco, CA, USA
| | - E Nizialek
- Department of Medical Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - J Ko
- Pathology and Laboratory Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - C M Diaz-Montero
- Center for Immunotherapy & Precision Immuno-Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - B Gastman
- Dermatology and Plastic Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - A J Stratigos
- A. Sygros Hospital Medical School, University of Athens, Athens, Greece
| | | | - H Tsao
- Department of Dermatology, Massachusetts General Hospital, Cambridge, MA, USA
| | - J Arbesman
- Dermatology and Plastic Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| |
Collapse
|
2
|
Bouferraa Y, Fares C, Bou Zerdan M, Boyce Kennedy L. Microbial Influences on Immune Checkpoint Inhibitor Response in Melanoma: The Interplay between Skin and Gut Microbiota. Int J Mol Sci 2023; 24:ijms24119702. [PMID: 37298653 DOI: 10.3390/ijms24119702] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023] Open
Abstract
Immunotherapy has revolutionized the treatment of melanoma, but its limitations due to resistance and variable patient responses have become apparent. The microbiota, which refers to the complex ecosystem of microorganisms that inhabit the human body, has emerged as a promising area of research for its potential role in melanoma development and treatment response. Recent studies have highlighted the role of microbiota in influencing the immune system and its response to melanoma, as well as its influence on the development of immune-related adverse events associated with immunotherapy. In this article, we discuss the complex multifactorial mechanisms through which skin and gut microbiota can affect the development of melanoma including microbial metabolites, intra-tumor microbes, UV light, and the immune system. In addition, we will discuss the pre-clinical and clinical studies that have demonstrated the influence of different microbial profiles on response to immunotherapy. Additionally, we will explore the role of microbiota in the development of immune-mediated adverse events.
Collapse
Affiliation(s)
- Youssef Bouferraa
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Callie Fares
- Faculty of Medicine, American University of Beirut, Beirut 2020, Lebanon
| | - Maroun Bou Zerdan
- Department of Internal Medicine, SUNY Upstate Medical University, New York, NY 13205, USA
| | - Lucy Boyce Kennedy
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| |
Collapse
|
3
|
Lopetegui-Lia N, Dima D, Osantowski B, Davis R, Song JM, McNamara MJ, Suh JH, Chao ST, Funchain P, Kennedy LB. Bevacizumab for radiation necrosis of the brain or steroid-refractory edema in patients with melanoma receiving immune checkpoint inhibitors. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e14008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e14008 Background: For patients with melanoma brain metastasis (MBM) treated with stereotactic radiosurgery (SRS), 5-6.5% develop radiation necrosis of the brain (RNB), which is commonly treated with corticosteroids (CS). Nonetheless, high-dose CS may reduce efficacy of immunotherapy (IO). Bevacizumab (BV) has been shown to reduce symptoms and peritumoral edema associated with RNB. However, data on the efficacy and toxicity of BV in patients with MBM who also receive IO is limited. We aimed to describe clinical features and outcomes of patients with MBM who received BV and were also treated with IO. Methods: Under an IRB-approved protocol, patients with MBM who developed RNB or steroid-refractory edema (SRE) and were treated with BV were identified. The selection criteria were as follows: (1) one or more MBM; (2) prior SRS for MBM; (3) development of RNB or SRE detected radiographically or based on expert opinion; (4) treatment with one or more cycles of BV; (5) treatment with IO for metastatic melanoma. Results: In this single-center retrospective series, 8 patients received IO and BV: 4 concurrently and 4 patients received IO immediately prior to or after BV. IO therapy included ipilimumab-nivolumab, nivolumab alone or pembrolizumab. Median number of MBM was 3.6 (range, 1-8) and median number of RNB/SRE foci were 1.125 (range, 1-2). Median time from diagnosis of RNB/SRE to initiation of BV was 1.4 months (range, 0.5-3 months). BV dosing regimen was 5 mg/kg every 2 weeks, 7.5 mg/kg every 3 weeks or 10 mg/kg every 2 weeks. 71% (5 of 7) patients who required CS for RNB/peritumoral edema symptoms at the time of starting BV were able to taper CS after receiving BV or stop CS completely. This allowed for 4 of these patients to subsequently start or resume IO. 28% (2 of 7) patients had increasing neurological symptoms during CS taper and required an increase in CS dosing. Only 1 patient was not on CS at the time of BV initiation. 75% (6 of 8) cases attained intracranial radiologic response, with documented decreased edema or tumor size, or resolution of enhancement on MRI; 1 patient had stable disease after BV; and 1 patient had continued clinical deterioration despite BV. 62.5% (5 of 8) patients had no adverse events from BV, but 37.5% (3 of 8) had DVT/PE, 1 requiring a thrombectomy, and 1 additionally had perforated diverticulitis. Median follow-up time from BV administration was 17.94 months (range, 1-58 months), with 75% (6 of 8) patients with survival > 10 months. Conclusions: Treatment of RNB/SRE with BV in patients with MBM receiving IO appears to be effective and relatively well tolerated, though with occasional serious adverse events. BV led to improvement of symptoms and allowed for CS taper in a substantial proportion of patients. By reducing CS requirement, BV may permit continuation of IO, which leads to durable survival in a large proportion of patients.
Collapse
Affiliation(s)
| | - Danai Dima
- Cleveland Clinic Foundation - Taussig Cancer Institute, Cleveland, OH
| | | | - Robin Davis
- Cleveland Clinic Foundation - Taussig Cancer Institute, Cleveland, OH
| | - Jung Min Song
- Cleveland Clinic Foundation - Taussig Cancer Institute, Cleveland, OH
| | | | - John H. Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Pauline Funchain
- Cleveland Clinic Foundation - Taussig Cancer Institute, Cleveland, OH
| | | |
Collapse
|
4
|
Dima D, Lopetegui-Lia N, Ogbue O, Osantowski B, Ahmed R, Basali D, Chamseddine F, Eicher DM, Song JM, Gastman B, Kennedy LB, Funchain P. Immunotherapy versus targeted therapy in the adjuvant setting for resected stage III melanoma: A single institution study. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e21578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e21578 Background: Both immunotherapy (IO) and targeted therapy (TT) are approved as adjuvant (Adj) treatment for stage III melanoma, as they have proven to significantly decrease disease recurrence. While there is evidence to suggest overall survival (OS) benefit with TT, data demonstrating OS advantage with Adj IO is lacking. There are no prospective head-to-head trials to date comparing these two treatment modalities. Our aim is to determine whether Adj IO equally improves outcomes compared to Adj TT. Methods: We retrospectively analyzed 104 patients (pts) with resected stage III melanoma who received Adj IO or TT from 1/2016 - 12/2021. Relapse free survival (RFS), distant metastasis free survival (DMFS) and OS rates were assessed between the 2 groups. Results: Of 104 pts, 78 received IO (91% nivolumab, 7% pembrolizumab, 2% other) and 26 pts TT (100% dabrafenib/trametinib). Median follow up was 21 months. At data cutoff, among the 26 pts who received TT, 50% completed 1 year of planned therapy, whereas 50% discontinued TT prematurely (42% due to adverse events [AEs], 8% due to disease relapse). Among the 78 pts who received IO, 70% completed 1 year of planned treatment or continued to receive IO at the end of the study, whereas 30% discontinued IO prematurely (18% due to disease relapse, 12% due to AEs). Relapsed disease was noted in 6/26 (23%) and 27/78 (34.6%) pts of the TT and IO groups, respectively. With regards to location of recurrence, in the TT group 2/6 pts relapsed locally and 4/6 distally, whereas in the IO group 14/27 pts relapsed locally and 13/27 distally. The estimated median RFS of the TT vs IO groups was not reached (NA) (95% Cl: 17 months, NA) vs. 30 months (95% CI: 17 months, NA) respectively, which was not statistically significant (p = 0.49). Comparison of DMFS rate was found not to be statistically significant between the 2 groups (p = 0.86). Finally, median OS was NA in either group. At the end of the study 91% and 90.5% of the pts in the TT and IO arms, respectively, were still alive. The most common AEs in the TT group were fatigue (23%), fever (23%), nausea/vomiting (19%), whereas in the IO group were fatigue (22%), hypothyroidism (14%), diarrhea/colitis (10%), pruritic rash (9%). Conclusions: Both TT and IO appear to equally decrease disease recurrence, locally or distally, when given as Adj therapy for stage III melanoma. Prospective, randomized control trials with longer follow up and larger sample size are warranted to determine any difference in potential OS benefit.[Table: see text]
Collapse
Affiliation(s)
- Danai Dima
- Cleveland Clinic Foundation - Taussig Cancer Institute, Cleveland, OH
| | | | | | | | | | | | | | | | - Jung Min Song
- Cleveland Clinic Foundation - Taussig Cancer Institute, Cleveland, OH
| | - Brian Gastman
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH
| | | | - Pauline Funchain
- Cleveland Clinic Foundation - Taussig Cancer Institute, Cleveland, OH
| |
Collapse
|
5
|
Kennedy LB, Salama AKS. A Marathon Not a Sprint: Improving Outcomes for Patients With Metastatic Melanoma in 2022 and Beyond. JCO Oncol Pract 2022; 18:353-354. [PMID: 35196070 DOI: 10.1200/op.22.00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/02/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - April K S Salama
- Duke Cancer Institute, Duke University Medical Center, Durham, NC
| |
Collapse
|
6
|
Truong TG, Kennedy LB, Patel SP. 25 Years of Adjuvant Therapy in Melanoma: A Perspective on Current Approvals and Insights into Future Directions. Curr Oncol Rep 2022; 24:533-542. [PMID: 35192117 DOI: 10.1007/s11912-022-01232-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Thach-Giao Truong
- Kaiser Permanente Northern California, 975 Sereno Drive, Vallejo, CA, 94589, USA
| | - Lucy Boyce Kennedy
- The Cleveland Clinic Foundation, 9500 Euclid Ave CA-60, Cleveland, OH, 44195, USA
| | - Sapna P Patel
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 0430, Houston, TX, 77030, USA.
| |
Collapse
|
7
|
Kennedy LB, Van Swearingen AED, Sheng J, Zhang D, Qin X, Lipp E, Kumar S, Zhang G, Hanks B, Davies M, Owzar K, Anders CK, Salama AKS. OTHR-14. An immunogenomic analysis of melanoma brain metastases (MBM) compared to extracranial metastases (ECM). Neurooncol Adv 2021. [PMCID: PMC8351192 DOI: 10.1093/noajnl/vdab071.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background MBM have a unique molecular profile compared to ECM. Methods We analyzed a previously published dataset from MD Anderson Cancer Center, including RNA-seq on surgically resected, FFPE MBM and ECM from the same patients. STAR pipeline was used to estimate mRNA abundance. DESeq2 package was used to perform differential gene expression (DGE) analyses. Pathway analysis was performed using Gene Set Enrichment Analysis (GSEA). Paired DGE and GSEA compared MBM vs. lymph node (LN) metastases (n = 16) and MBM vs. skin mets (n = 10). CIBERSORTx estimated relative abundance of immune cell types in MBM and ECM. GATK Mutect2 pipeline was used to call somatic mutations using paired normal tumor samples. Mutations were annotated using the Ensembl Variant Effect Predictor and visualized using the Maftools package in R. RNA-seq was available on 54 human primary cutaneous melanomas (CM). Gene Ontology or KEGG Pathway analysis was performed using goana function of limma package in R. Results Paired GSEA found that autophagy pathways may be up-regulated in MBM vs. LN and MBM vs. skin mets. On a single-gene level, the most strongly up-regulated genes in autophagy pathways were GFAP and HBB. Fold changes in other autophagy-related genes were low and did not reach significance. Comparison between CM which recurred in brain vs. CM which did not recur identified up-regulation of autophagy pathways. CIBERSORTx identified an increased proportion of immune suppressive M2 macrophages compared to tumor suppressive M1 macrophages in MBMs and ECMs. Conclusion Up-regulation of autophagy pathways was observed in patient-matched MBM vs. LN and skin mets. This finding was driven by up-regulation of GFAP and HBB, which could reflect changes in the tumor microenvironment. Higher M2:M1 ratio may contribute to an immune suppressive tumor microenvironment and may be targetable. Validation of our findings in an independent Duke dataset is ongoing.
Collapse
Affiliation(s)
| | | | - Jeff Sheng
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Dadong Zhang
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Xiaodi Qin
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Eric Lipp
- Duke Cancer Institute, Durham, NC, USA
| | - Swaminathan Kumar
- Department of Melanoma Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gao Zhang
- Duke Cancer Institute, Durham, NC, USA
| | | | - Michael Davies
- Department of Melanoma Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kouros Owzar
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Carey K Anders
- Duke Cancer Institute, Durham, NC, USA
- Duke Center for Brain and Spine Metastasis, Durham, NC, USA
| | - April K S Salama
- Duke Cancer Institute, Durham, NC, USA
- Duke Center for Brain and Spine Metastasis, Durham, NC, USA
| |
Collapse
|
8
|
Abstract
Cancer immunotherapies, including checkpoint inhibitors and adoptive cell therapy, manipulate the immune system to recognize and attack cancer cells. These therapies have the potential to induce durable responses in multiple solid and hematologic malignancies and thus have transformed treatment algorithms for numerous tumor types. Cancer immunotherapies lead to unique toxicity profiles distinct from the toxicities of other cancer therapies, depending on their mechanism of action. These toxicities often require specific management, which can include steroids and immune-modulating therapy and for which consensus guidelines have been published. This review will focus on the toxicities of checkpoint inhibitors and chimeric antigen receptor T cells, including pathophysiology, diagnosis, and management.
Collapse
Affiliation(s)
| | - April K S Salama
- Division of Medical Oncology, Duke University, Durham, North Carolina
| |
Collapse
|
9
|
Abstract
The use of checkpoint inhibitor-based immunotherapy has transformed the treatment landscape for melanoma as well as many other cancer types. With the ability to potentiate tumor-specific immune responses, these agents can result in durable tumor control. However, this activation of the immune system can lead to a unique constellation of side effects, distinct from other cancer therapies, collectively termed immune-mediated adverse events (irAEs). This review will focus on irAEs and guidelines for management related to the most clinically relevant checkpoint inhibitors, those that target programmed death receptor-1 (PD-1) and cytotoxic T lymphocyte antigen-4 (CTLA-4).
Collapse
|
10
|
Kennedy LB, Li Z, Savani BN, Ljungman P. Measuring Immune Response to Commonly Used Vaccinations in Adult Recipients of Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2017. [DOI: 10.1016/j.bbmt.2017.06.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|