Evaluation of treatment patterns in patients with BRAF-mutant cutaneous melanoma in adjuvant setting in real practice

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Background: Mutation in BRAF is a crucial biomarker for treatment choice in patient with locally advanced or metastatic melanoma. In patient with BRAF wild-type (WT) melanoma aPD1 is the preferred treatment regimen. In patients with BRAF V600 mutant melanoma combined targeted therapy (cTT) could also be chosen as adjuvant treatment, which significantly improves OS. Methods: We conducted a retrospective continuous study of all melanoma patients, who were tested for BRAF mutation by RT-PCR in 2020 (COIVD-19 pandemic year) in our institution and analyzed adjuvant therapy options they received. Patient demographics, mutational status, disease stage, treatment regimens and treatment outcomes were collected from electronic medical records. Results: Between January 2020 and December 2020, tumor samples from 297 pts were tested for BRAF mutations. The mean pts age was 58.2 years (95% CI 51.2 to 60.3) and 130 (43.7%) were male. BRAF mutations were detected in 147 (49.5%) patients. Most common mutation was V600E (140 out of 147 samples, 88.4%) and V600K (13 out of 147, 8.84%). We also found K601N, K601E, L597R and V600M mutations (in one sample each). Among 150 BRAF wild type samples 44 were also tested for NRAS mutations and in 13 (29.54%) pts NRAS mutations were detected: Q61R – in 6 (46.15%) pts, Q61L – in 2 (15.38%) pts, Q61K – in 3 (23.08%) pts, G12E – in 1 (7.69%) pt, and G12D - in 1 (7.69%) pt . Also among 150 BRAF wild type samples 56 were tested for KIT mutations and only one sample were found to harbour D186V mutation . Among BRAF-positive pts at time of the genetic test performed stage I CM had 11 (7.48%) out of 147 pts, stage II - 13 (8.84%) pts, stage III - 67 (45.57%) pts, and stage IV - 43 (29.25%) pts. In 13 (8.84%) pts stage could not be clearly identified. In most cases (32 out of 67, 47.76%) monotherapy with aPD1 was given as adjuvant treatment in stage III pts where as only 6 (8.95%) patients received cTT, 7 pts (10.41%) received IFN-alfa and 22 pts (32.84%) received no or were given with other treatment (Table). Median DFS did not differ significantly between treatment cohorts. Conclusions: In our retrospective study we found that among stage III BRAF-mutant patients monotherapy with aPD1 was the most common adjuvant treatment regimen. In some patients with stage III disease IFN-alfa is still given. More studies are needed to define best adjuvant treatment for BRAF mutant stage III melanoma pts.[Table: see text]

Multicenter prospective clinical trial of molecular genetic markers for non-invasive differential diagnosis of benign and malignant melanocytic skin lesions

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Background: Improving the accuracy of non-invasive diagnosis of skin tumors is becoming an urgent problem, given the clear increase in the incidence of melanoma in many countries. Dermoscopy and examination by an experienced dermatologist can reduce the NNE to 5–10 per melanoma (M) detected, however, achieving even this, clearly suboptimal, rate requires a long specialist training. Methods: We report results of prospective nonrandomized trial evaluating sensitivity and specificity of RNA profiling of cytological samples from adhesive transparent patches (ATP) applied to skin lesions. Routine pathology reports were obtained for all surgery samples. RNA extracted from ATP specimens (N = 126) was tested for mRNA expression of PRAME and LINC00518 genes. GAPDH was used as a reference gene. Sample was considered marker-positive if either PRAME or LINC00518 expression was detected. Results: Between June 2021 and November 2021, 126 pts undegoing excisional biopsy of skin lesions were included in the study at 5 centers. On pathology, invasive M was detected in 49 (38.9%) patients (mean Breslow thickness was 2.41 mm [95%CI 1,44 to 3.37]), M in situ in 6 (4.8%), non-melanoma skin cancer in 4 (3.2%) and dysplastic nevus in 56 (44.4%). In the day of preplanned excision ATP was applied to the target lesion for 5–6 min and sent to the central lab. Amplifiable mRNA was found in all 126 ATP samples. 82 samples of 126 (65,1%) tested marker-positive. Sensitivity of RNA profiling for detection of skin cancers reached 88.14% (95% CI 77.07% – 95.09%), while specificity was only 53.85% (41.03% – 66.30%), with PPV of 63.41% (56.74% – 69.61%), NPV of 83.33% (70.65% – 91.22%) and accuracy of 70.16% (61.29% – 78.04%). Among the seven false negative results there were 3 M in situ and 4 invasive M. Conclusions: RNA profiling of skin ATP specimens is feasible and has high sensitivity but rather low specificity. Randomized studies are needed to evaluate if this technique can add anything to dermoscopy or other noninvasive diagnostic modalities. Clinical trial information: NCT04353050. [Table: see text]

Talimogene laherparepvec upregulates immune-cell populations in non-injected lesions: findings from a phase II, multicenter, open-label study in patients with stage IIIB-IVM1c melanoma

Background

Talimogene laherparepvec (T-VEC), an oncolytic virus, was designed to selectively replicate in and lyse tumor cells, releasing tumor-derived antigen to stimulate a tumor-specific immune response.

Methods

In this phase II study in patients with unresectable stage IIIB–IV melanoma, we evaluated non-injected lesions to establish whether baseline or change in intratumoral CD8⁺ T-cell density (determined using immunohistochemistry) correlated with T-VEC clinical response.

Results

Of 112 enrolled patients, 111 received ≥1 dose of T-VEC. After a median follow-up of 108.0 weeks, objective/complete response rates were 28%/14% in the overall population and 32%/18% in patients with stage IIIB–IVM1a disease. No unexpected toxicity occurred. Baseline and week 6 change from baseline CD8⁺ T-cell density results were available for 91 and 65 patients, respectively. Neither baseline nor change in CD8⁺ T-cell density correlated with objective response rate, changes in tumor burden, duration of response or durable response rate. However, a 2.4-fold median increase in CD8⁺ T-cell density in non-injected lesions from baseline to week 6 was observed. In exploratory analyses, multiparameter immunofluorescence showed that after treatment there was an increase in the proportion of infiltrating CD8⁺ T-cells expressing granzyme B and checkpoint markers (programmed death-1, programmed death-ligand 1 (PD-L1) and cytotoxic T-lymphocyte antigen-4) in non-injected lesions, together with an increase in helper T-cells. Consistent with T-cell infiltrate, we observed an increase in the adaptive resistance marker PD-L1 in non-injected lesions.

Conclusions

This study indicates that T-VEC induces systemic immune activity and alters the tumor microenvironment in a way that will likely enhance the effects of other immunotherapy agents in combination therapy.

Trial registration number

NCT02366195.

Immune Pathogenesis of COVID-19 Intoxication: Storm or Silence?

Dysregulation of the immune system undoubtedly plays an important and, perhaps, determining role in the COVID-19 pathogenesis. While the main treatment of the COVID-19 intoxication is focused on neutralizing the excessive inflammatory response, it is worth considering an equally significant problem of the immunosuppressive conditions including immuno-paralysis, which lead to the secondary infection. Therefore, choosing a treatment strategy for the immune-mediated complications of coronavirus infection, one has to pass between Scylla and Charybdis, so that, in the fight against the "cytokine storm," it is vital not to miss the point of the immune silence that turns into immuno-paralysis.

Preoperative conventional axillary ultrasound (AUS) and sonoelastography (SE) for predicting axillary lymph node metastasis in breast cancer patients

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Background: Patients with operable breast cancer (BC) and clinically negative lymph nodes (CNLN) usually undergo sentinel lymph node biopsy (SNLB) or axillary lymph nodes dissection (ALND). AUS followed by fine-needle aspiration (FNA) or core-needle biopsy (CNB) could decrease number of unnecessary SNLBs and allow to assign patient to ALND directly. On the other hand, new AUS techniques such as SWE could enhance AUS specificity and allow to avoid SNLB in some patients. Aim: To assess sensitivity, specificity and negative predictive value of the AUS+SWE followed by FNA or CNB in patients with operable BC. Methods: Since Sep 2012 to Jan 2018 150 pts with operable BC and were enrolled. We include 30 pts in training cohort with clinically positive lymph nodes to verify AUS+SWE sensitivity and specificity. In validation cohort only those pts who were candidates for SNLB and who presented with tumor staging up to T3, and clinically negative axillae were included (n=120). All patients underwent preoperative AUS in B-mode, SWE, followed by FNA or CNB in case of suspicious nodes were detected. All pts underwent axilla surgery (SNLB = 46, ALND =74) and final pathology outcomes were available for all pts. Results: In training cohort of 30 patients with clinically positive lymph nodes the overall AUS+SWE sensitivity was set at 89.2%. The positive predictive value was calculated to be 96.1%. In the assessment of invasive breast tumors stages T1- T3 with clinically negative lymph nodes the sensitivity was 74.2%, specificity 95.5% positive predictive value was 85.2% and negative predictive value 91.4% If FNA or CNB follow the AUS+SWE in patients with CNLN the sensitivity was 86.7%, specificity 85.7% positive predictive value was 92.8% and negative predictive value was 75% (FNA or CNB was performed in 40 patients of 120 in validation set). Area under the ROC-curve was calculated as 0.860 [95% CI 0.766 to 0.954] for the US+SWE and 0.705 [95% CI 0.581 to 0.828] for the US+SWE followed by FNA or CNB. Conclusions: Axillary US+SWE should be included in the preoperative staging of all patients with invasive breast cancer. The addition US+SWE (not obviously followed by FNA or CNB) could lead to avoiding of unnecessary SNLB or ALND in patients with clinically and pathologically negative lymph nodes with negative predictive value of 91.4%. On the other hand in patients with US+SWE positive lymph nodes SNLB could also be skipped and the time interval to definitive therapy became shorter. Clinical trial information: BCA_US_SWE_001.

Recurrence-free survival (RFS) and objective response rate (ORR) phase 1/2 study of intralesional (IL) neoadjuvant (neo) anti-PD1 agents (aPD1) for stage IIIB-IV melanoma (MEL)

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Background: We previously reported that aPD1 agents could be safely administered IL in patients (pts) with metastatic MEL with superficial lesions, providing local and bystander tumor response (Samoylenko, I., et al. (ASCO-SITC 2018)). We present results from an interim 6 mos analysis of RFS and ORR for IL neo aPD1 therapy. Methods: Pts with unresectable stage IIIC/D/IVM1a-c MEL (safety cohort, N = 7) and resectable stage IIIC/D/IVM1a (expansion cohort, N = 18), with ≥ 1 injectable cutaneous, subcutaneous, or nodal lesions ≥ 10 mm were allocated to 6 doses/12 of nivolumab or pembrolizumab before surgery (surg). aPD1 was given at scale-based dosing regimen reported previously. Tumor sampling for biomarker analysis and pCR confirmation (or core-needle biopsy, CNB) was performed prior to treatment and at week 13-18. The analysis was conducted on the ITT basis to estimate RFS at 6 mos and ORR. An RFS event was defined as disease progression or death due to any cause after surg and assessed in the expansion cohort. ORR for the both cohorts was evaluated. Results: Since Apr 2016 to Dec 2018 25 pts were enrolled. Baseline characteristics are summarized in Table. ORR was 47,6% (10/21 pts assessed), with 5 (24%) clinical CR and 4 pathological CR (19%). Among 18 pts considered for surg 2 refused from surg when CNB confirmed no residual tumor. 89% of pts (16/18 pts) from the expansion cohort remained recurrence free at 6 mos FU. Baseline immune phenotype of tumor infiltrating lymphocytes (TILs) was available for 20 of 21 pts assessed. Baseline percent of TILs assessed by flow cytometry (FCT) was higher in responders vs non-responders (7.54±7.51% vs 1.51±2.93, p < .05), whereas CD3-CD16+CD56+ and CD4+CD25+ values were lower in responders vs non-responders (0.94±1.45% vs 7.88±6.84, p < .05, and 6.68±3.46% vs 20.50±16.79, p < 0.05, respectively). PD1, PDL-1 and PDL-2 expression in tumor cells and TILs assessed by FCT did not differ significantly between responders and non-responders. Conclusions: We demonstrated the potential clinical efficacy of IL aPD1 in melanoma pts. Further studies are needed to determine if unsuccessful IL administration could predict failure to adjuvant treatment. Primary analysis of RFS at 1-yr is expected. Clinical trial information: NA. [Table: see text]

Intralesional anti-PD1 treatment in patients with metastatic melanoma: The pilot study

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Background: Systemic anti-PD1 treatment is major advantage for metastatic melanoma patients over the last five years. Nevertheless up to the moment there are no solid predictive factors discovered. On the other hand immune related adverse events develop quite frequent and sometimes could be dangerous. Methods: Patient with advanced cutaneous melanoma with known BRAF status and at least one superficial lesion (suitable for injection) are eligible. One of two commercially available anti-PD1 drugs (nivolumab or pembrolizumab) is administered intralesionaly to patients every 2 weeks with total daily dose not more than 50 mg (5 ml) using a scale-base approach depending on lesions size. Clinical and immunological outcomes assessed every 12 weeks. For assessing lymphoid infiltrate tumor biopsy performed before treatment and on week 12. To detect a systemic objective response rate of 50% with sensitivity of 80% and error type alfa 5% at least 25 patients to be included. Interim analysis was preplanned when 3 (25%) of events occurred. Results: Among 7 pts OR was detected in 4 (54.7%), PD in 3 (42.9%). Bystander effect was seen in 2 of 4 patients (50%). Among 3 non-responders 2 failed to salvage systemic anti-PD1 treatment and one is now on anti-CTLA4. The most common adverse event was injection site pain, which was self-limiting. Baseline immune phenotype of tumor infiltrating lymphocytes (TILs) was available for 5 of 7 pts included. Baseline percent of TILs, CD3+CD8+ and CD8+CD279+ was higher in responders vs non-responders (3.6±4.08% vs 0.8±0, NS, 75.1±20.6% vs 54.8±1.13, NS; 36.75±18.7% vs 42.8±13.1, NS respectively ). Baseline difference in CD11b+CD28- between responders (7.06±7.768) and non-responders (25.0 ±0.00) was statistically significant. Conclusions: these results demonstrates feasibility, tolerability and potential clinical efficacy of intralesional anti-PD1 in melanoma patients. Further study are needed to determine if unsuccessful intralesional administration could predict failure to systemic treatment as well as TILs phenotype could predict intralesional or systemic anti-PD1 clincal benefit Clinical trial information: MEL004IL.

Biochemical and immunologic markers in patients with metastatic melanoma treated with chemotherapy and dendritic cell vaccine

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Background: The purpose of this sub study was to identify peripheral blood biomarkers associated with the therapeutic effect of immunotherapy with dendritic cell vaccine in patients with metastatic melanoma (MM). Methods: Patients (pts) with low disease burden achieved disease control after two cycles of chemo (cisplatine, vinbalstie, DTIC) were randomized dendritic cell vaccine (DC) or three cycles of chemo. Vaccination schedule consisted of 5 subcutaneous injections of dendritic cell (DC) vaccine (2×106 cells pulsed with autologous lysate) with 14 days intervals. S100B level, LDH level, and peripheral blood lymphocytes immune phenotype were assessed before treatment, after two cycles of chemo and after each vaccination cycle. Results: 104 pts were included in the study, 30 pts were randomized to DC arm, 29 pts were randomized to continue chemo. In pts with rapid disease progression baseline serum S100b level was significantly higher compared to patients with objective response or stable disease (0.874±1.15 mcg/L vs. 0.361±0.66 mcg/L, P=0.002). Similar results were found for baseline serum LDH level (559.8±469.7 U/L vs. 412.5±184.4 U/L, P=0.005) and serum S100b level after 2 cycles of chemo (0.688±0.855 mcg/L vs. 0.187±0,29 mcg/L, P<0.001). Contrary, baseline CD3+HLA-DR+ and CD4+CD25+ lymphocytes levels after 2 cycles of chemo were significantly higher in pts with disease control (11.9±8.9% vs. 8.9±5.3%, P=0.047 and 14.4±8.3% vs. 11.3±5.5%, P=0.036 respectively).In pts randomized to DC arm following markers were associated with long lasting objective response or stable disease course (>6 months): lower baseline S100b level (0.133±0.120 mcg/L vs. 0.445±0.406 mcg/L, P=0.014), lower S100b level after 2 cycles of chemo (0.105±0.095 mcg/L vs. 0.255±0.154 mcg/L, P=0.048), higher proportion of active CD8+lymphocytes prior to vaccination (74.7±3.6% vs. 51.7±14.2%, P=0.05); and more prominent increase of NK-cells CD3-CD16+CD56+ from baseline (increase in 76.5%±41.12% vs. 4.5±28.8%, P=0.01). Conclusions: Biochemical and immunological markers may be helpful when selecting patients with metastatic melanoma for immunotherapy with dendritic cell vaccine.