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Treatment of melanoma of unknown primary in the era of immunotherapy and targeted therapy: A Dutch population-based study.

ABSTRACT: Melanoma of unknown primary (MUP) may have a different biology to melanoma of known primary, but clinical trials of novel therapies (e.g., immune checkpoint or BRAF/MEK inhibitors) have not reported the outcomes in this population. We therefore evaluated the overall survival (OS) among patients with MUP in the era of novel therapy. Data for stage III or IV MUP were extracted from a nationwide database for the period 2003-2016, with classification based on the eighth edition of the American Joint Committee on Cancer criteria. The population was divided into pre- (2003-2010) and post- (2011-2016) novel therapy eras. Also, OS in the post-novel era was compared between patients with stage IV MUP by whether they received novel therapy. In total, 2028 of 65,110 patients (3.1%) were diagnosed with MUP. Metastatic sites were known in 1919 of 2028 patients, and most had stage IV disease (53.8%). For patients with stage III MUP, the 5-year OS rates were 48.5% and 50.2% in the pre- and post-novel eras, respectively (p?=?0.948). For those with stage IV MUP, the median OS durations were unchanged in the pre-novel era and post-novel era when novel therapy was not used (both 4 months); however, OS improved to 11?months when novel therapy was used in the post-novel era (p?

SUBMITTER: Verver D

PROVIDER: S-EPMC6900034 | biostudies-literature | 2020 Jan

REPOSITORIES: biostudies-literature

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Treatment of melanoma of unknown primary in the era of immunotherapy and targeted therapy: A Dutch population-based study.

Verver D D van der Veldt Aam A van Akkooi Acj A Verhoef C C Grünhagen D J DJ Louwman W J WJ

International journal of cancer 20190320 1

Melanoma of unknown primary (MUP) may have a different biology to melanoma of known primary, but clinical trials of novel therapies (e.g., immune checkpoint or BRAF/MEK inhibitors) have not reported the outcomes in this population. We therefore evaluated the overall survival (OS) among patients with MUP in the era of novel therapy. Data for stage III or IV MUP were extracted from a nationwide database for the period 2003-2016, with classification based on the eighth edition of the American Joint ...[more]

PMID: 30801710

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Project description:Opinion statementMelanoma has several clinically and pathologically distinguishable subtypes, which also differ genetically. Mutation patterns vary among different melanoma subtypes, and efficacy of immune-checkpoint inhibitors differs depending on the subtype of melanoma. In spite of the recent revolution of systemic therapies for advanced melanoma, access to innovative agents is still restricted in many countries. This review article aimed to describe the epidemiology and current status of systemic therapies for melanoma in Japan, where melanoma is rare, but access to innovative agents is available. Acral and mucosal melanomas, which are common in Asian populations, predominantly occur in sun-protected areas and share several biological features. Both the melanomas harbor KIT mutation in approximately 15% of the cases; BRAF or NRAS mutation is found in approximately 10-15% of acral melanoma, but these mutations are less frequent in mucosal melanoma. Combined use of BRAF and MEK inhibitors is one of the standards of care for patients with advanced BRAF-mutant melanoma. In patients with melanoma harboring KIT mutation in exon 11 or 13, KIT inhibitors can be a treatment option; however, none of them have been approved in Japan. Immune-checkpoint inhibitors are expected to be less effective against acral and mucosal melanomas because their somatic mutation burden is lower than those in non-acral cutaneous melanomas. A recently completed phase II trial of nivolumab and ipilimumab combination therapy in 30 Japanese patients with melanoma, including seven with acral and 12 with mucosal melanoma, demonstrated an objective response rate of 43%. Regarding oncolytic viruses, canerpaturev (C-REV, also known as HF10) and talimogene laherparepvec (T-VEC) are currently under review in early phase trials. In the adjuvant setting, dabrafenib plus trametinb combination, nivolumab monotherapy, and pembrolizumab monotherapy were approved in July, August, and December 2018 in Japan, respectively. However, most of the adjuvant phase III trials excluded patients with mucosal melanoma. A phase III trial of adjuvant therapy with locoregional interferon (IFN)-β versus surgery alone is ongoing in Japan (JCOG1309, J-FERON), in which IFN-β is injected directly into the site of the primary tumor postoperatively, so that it would be drained through the untreated lymphatic route to the regional node basin. After the recent approval of these new agents, the JCOG1309 trial will be revised to focus on patients with stage II disease. In conclusion, acral and mucosal melanomas have been treated based on the available medical evidence for the treatment of non-acral cutaneous melanomas. Considering the differences in genetic backgrounds and therapeutic efficacy of immunotherapy, specialized therapeutic strategies for these subtypes of melanoma should be established in the future.

Project description:Very late antigen-4 (VLA-4; also known as integrin α4β1) is expressed at high levels in aggressive and metastatic melanoma tumors and may provide an ideal target for imaging and targeted radiotherapy. 177Lu-DOTA-PEG4-LLP2A (177Lu-LLP2A) shows high affinity for VLA-4 and had high uptake in B16F10 mouse melanoma tumors in vivo. Here, we report efficacy studies of 177Lu-LLP2A, alone and combined with immune checkpoint inhibitors (ICI) in B16F10 tumor-bearing mice. Methods: B16F10 tumor cells (1 x 106) were implanted subcutaneously in C57BL/6 mice. After 8-10 days, the mice were randomized into eight groups (n = 8). 177Lu-LLP2A was injected i.v. on day 8 or 9 (single dose), and ICI antibodies were administered i.p. in 3 doses. Tumor growth was monitored over time via calipers. TUNEL staining for apoptosis was performed on fixed tumors. In a separate study, Cy3-LLP2A or Cy3-scramble LLP2A were injected in tumor-bearing mice, tumors were collected after 4 h post-injection, and then analyzed by flow cytometry and immunofluorescence microscopy using different immune cell markers. Results:177Lu-LLP2A alone showed comparable efficacy to combination anti-PD-1/PD-L1 + anti-CTLA-4 antibody treatment, while 177Lu-LLP2A together with combination ICI significantly enhanced survival. TUNEL staining showed the highest levels of apoptosis were found in the 177Lu-LLP2A + ICI groups. In addition to targeting tumor cells, 177Lu-LLP2A also binds immune cells in the B16F10 tumor microenvironment. Based on flow cytometry data, the tumor consists of ~77 % tumor cells/fibroblasts (CD45-CD49d+) and ~23 % immune cells (CD45+CD49d+), and immune cells express higher levels of VLA-4. Cy3-LLP2A and CD49d colocalized with macrophages (CD68), T cells (CD8, CD4), and B cells (CD19). Immunohistochemical analysis identified a significant colocalization of Cy3-LLP2A and CD68. Conclusion: Combination treatment of 177Lu-LLP2A and ICI targets both tumor cells and immune cells and has potential as a therapeutic agent in patients with metastatic melanoma.

Dataset Information

Treatment of melanoma of unknown primary in the era of immunotherapy and targeted therapy: A Dutch population-based study.

Publications

Treatment of melanoma of unknown primary in the era of immunotherapy and targeted therapy: A Dutch population-based study.

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