Faculty Bibliography

BACKGROUND:The EORTC 18071 phase 3 trial compared adjuvant ipilimumab with placebo in patients with stage III melanoma. The primary endpoint, recurrence-free survival, was significantly longer in the ipilimumab group than in the placebo group. Investigator-reported toxic effects of ipilimumab consisted mainly of skin, gastrointestinal, endocrine, and hepatic immune-related adverse events. Adjuvant treatment with ipilimumab in this setting was approved in October, 2014, by the US Food and Drug Administration based on the results of the primary outcome of this trial. Here, we report the results of the secondary endpoint, health-related quality of life (HRQoL), of this trial. METHODS:EORTC 18071 was a multinational, double-blind, randomised, phase 3 trial in patients with stage III cutaneous melanoma (excluding lymph node metastasis ≤1 mm or in-transit metastasis) in 19 countries worldwide. Participants were randomly assigned (1:1) centrally by an interactive voice response system, to receive either ipilimumab 10 mg/kg or placebo every 3 weeks for four doses, then every 3 months for up to 3 years. Using a minimisation technique, randomisation was stratified by disease stage and geographical region. HRQoL was assessed with the EORTC QLQ-C30 quality-of-life instrument at baseline, weeks 4, 7, 10, and 24, and every 12 weeks thereafter up to 2 years, irrespective of disease progression. Results were summarised by timepoint and in a longitudinal manner in the intention-to-treat population. Two summary scores were calculated for each HRQoL scale: the average score reported during induction (ipilimumab or placebo at a dose of 10 mg/kg, administered as one single dose at the start of days 1, 22, 43, and 64-ie, four doses in 3 weeks), and the average score reported after induction. A predefined threshold of a 10 point difference between arms was considered clinically relevant. The primary HRQoL endpoint was the global health scale, with the predefined hypothesis of no clinically relevant differences after induction between groups. This trial is registered with EudraCT, number 2007-001974-10, and ClinicalTrials.gov, number NCT00636168. FINDINGS/RESULTS:Between July 10, 2008, and Aug 1, 2011, 951 patients were randomly assigned to treatment: 475 in the ipilimumab group and 476 in the placebo group. Compliance with completing the HRQoL questionnaire was 893 (94%) of 951 patients at baseline, 693 (75%) of 924 at week 24, and 354 (51%) of 697 at week 108. Patient mean global health scores during (77·32 [SD 17·36] vs 72·96 [17·82]; p=0·00011) and after induction (76·48 [17·52] vs 72·32 [18·60]; p=0·00067) were statistically significantly different between groups but were not clinically relevant. Mean global health scores differed most between the groups at week 7 (77 [SD 19] in the placebo group vs 72 [22] in the ipilimumab group) and week 10 (77 [20] vs 70 [23]). Mean HRQoL scores differed by more than 10 points at week 10 between treatment groups for diarrhoea (7·67 [SD 17·05] for placebo vs 18·17 [28·35] for ipilimumab) and insomnia (15·17 [22·53] vs 25·60 [29·19]). INTERPRETATION/CONCLUSIONS:Despite increased toxicity, which led to treatment discontinuation for most patients during the induction phase of ipilimumab administration, overall HRQoL, as measured by the EORTC QLQ-C30, was similar between groups, as no clinically relevant differences (10 points or more) in global health status scores were observed during or after induction. Clinically relevant deterioration for some symptoms was observed at week 10, but after induction, no clinically relevant differences remained. Together with the primary analysis, results from this trial show that treatment with ipilimumab results in longer recurrence-free survival compared with that for treatment with placebo, with little impairment in HRQoL despite grade 3-4 investigator-reported adverse events. FUNDING/BACKGROUND:Bristol-Myers Squibb.

Background: We previously confirmed the feasibility of adoptive cell therapy (ACT) with tumor infiltrating lymphocytes (TIL) for patients with advanced melanoma. Patients successfully treated had a 38% response rate, but patient attrition due to progression before ACT (21 %) resulted in a response rate of only 26% based on intent to treat (IIT) analysis. We hypothesized that combination immunotherapy would decrease attrition due to progression. Here we present the final report of a pilot trial combining ipilimumab (IPI) and ACT.
Method(s): Thirteen patients with metastatic melanoma were accrued to an IRB-approved trial. All had >1 cm³ of soft tissue/nodal metastases amenable to resection leaving residual disease. Patients received 3 mg/kg of IPI two weeks prior to tumor resection for TIL generation. One week following resection, a second dose of IPI was administered. ACT included pre-conditioning chemotherapy and TIL infusion followed by IL-2. Two additional doses of IPI were given 2 and 5 weeks after ACT. Feasibility was a primary endpoint and considered achieved if > 2 doses of IPI and TIL were infused to at least 60% of all patients. The clinical responses were assessed by RECIST 1.1 criteria at 12 weeks following TIL transfer.
Result(s): All patients received at least 2 doses of IPI, and 12 of the 13 patients (92%) received TIL One patient (7%) dropped out due to progression before TIL infusion. TIL were expanded from 47.2% of tumor fragments and 58.7% of these fragments generated TIL reactive to autologous tumor. Median number of infused TIL was 6.5e10 (2.29e10-1.04e11) and median 85% were CD8+ (27-99). At 12 weeks following infusion, of the 13 patients enrolled, there were 6 responders (46%). Median progression-free survival was 7.4 months (1.4-42.2). Grade >3 immune-related adverse events included colitis (1), uveitis (1), and hypothyroidism (1).
Conclusion(s): IPI combined with ACT with TILs for patients with advanced melanoma is feasible with decreased attrition due to progression and is associated with promising clinical results based upon ITT analysis. This combination approach of TIL cell therapy and co-inhibitory blockade serves as a model for future efforts to improve the efficacy of immunotherapy for patients with cancer

The recent demonstration of the antitumor efficacy of checkpoint protein inhibition has resulted in the approval of blocking antibodies against the programmed cell death 1 (PD-1)/programmed cell death ligand 1 (PD-L1) pathway in multiple different histologic findings. Therapeutic successes with PD-1/PD-L1 antibodies in melanoma and lung cancer have been followed by approvals in bladder, renal, and head and neck cancers and Hodgkin lymphoma, with others undoubtedly to come. However, PD-1 is only one of many checkpoints and agonistic regulatory molecules expressed on T cells by which maintenance of the balance between costimulatory and coinhibitory signaling pathways is perturbed in cancer. The manipulation of many of these molecules in cancer patients might be associated with clinical benefit. The majority of the T-cell cosignaling receptors belong to either the immunoglobulin superfamily or the tumor necrosis factor receptor superfamily. A total of 29 immunoglobulin superfamily and 26 tumor necrosis factor receptor superfamily cosignaling receptors have been identified that are expressed on T cells, providing fertile ground for development of inhibitory or agonistic antibodies and small molecules as cancer therapeutics. In the current work, we focus on some of the most promising new checkpoints and agonistic or cosignaling molecules that are in early clinical development as single agents or in combinations with PD-1/PD-L1, cytotoxic T-lymphocyte-associated protein 4 blockade, or chemotherapy with an emphasis on those that have reached the clinic and on important targets that are in late preclinical development.

In CheckMate 037, patients (pts; n = 405) with MEL who progressed on/after anti-CTLA-4 therapy (plus a BRAF inhibitor if BRAF V600 positive), were randomized 2:1 to NIVO 3 mg/kg IV Q2W or ICC (dacarbazine 1000 mg/m² Q3W or carboplatin AUC6+ paclitaxel 175 mg/m² Q3W). At the first analysis, objective response rate (ORR) for NIVO was 32% versus 11% for ICC. Here we report for the first time the co-primary endpoint of overall survival (OS), updated ORR, and the secondary endpoint of progression-free survival (PFS) assessed by independent radiology review. Of 272 pts randomized to NIVO and 133 to ICC, 99 and 77%, respectively, received study treatment. A larger proportion of NIVO versus ICC pts had brain metastases (20 versus 14%) and increased lactate dehydrogenase levels (52 versus 38%) at baseline. At ~2 years' minimum follow-up, ORR (27 versus 10%) and median duration of response (32 versus 13 months) were notably higher for NIVO versus ICC. Median OS was 16 versus 14 months (NIVO versus ICC) in all randomized pts (HR: 0.95 [95.5% CI: 0.73, 1.24]) and 16 versus 12 months (0.81 [95% CI: 0.59, 1.1]) in all treated pts censored at the start of subsequent PD-1/PD-L1 therapy, as 41% of ICC pts (11% NIVO) received subsequent anti-PD1 agents. Median PFS (NIVO versus ICC) was 3.1 versus 3.7 months (1.0 [95% CI: 0.78, 1.4]). Fewer grade 3/4 treatment-related AEs were observed in NIVO pts (14 versus 34%) and most NIVO-related AEs were low grade and manageable. In summary, in pts with MEL who progressed after IPI, NIVO demonstrated higher, more durable responses and did not show statistical significance in survival difference versus ICC. OS should be interpreted with caution because of the open-label study design and increased dropout rate prior to treatment initiation, subsequent ICC arm anti-PD-1 therapy, and increased proportion of pts with poor prognostic factors in the NIVO arm

Immune checkpoint blockade has revolutionized the care of patients (pts) with melanoma; however, treatment guidelines lack specific recommendations on the use of these agents for individual pt cases. We developed an interactive, online treatment (Tx) decision tool to assess whether expert Tx recommendations based on specific disease and pt characteristics would affect the planned Tx decisions of community practitioners. In January 2016, 5 experts provided Tx recommendations for 90 case variations based on key factors they considered important to guide Tx choice and then an online tool was developed to provide this guidance to clinicians. To use the tool, specific pt and disease characteristics along with the intended Tx for that pt were entered. Then Tx recommendations from 5 experts for that scenario were provided and users were prompted to indicate whether this online consultation would change their Tx plan. An analysis of 432 cases entered into the tool found variation between the intended use of immunotherapy among tool users versus Tx recommendations from the experts. For example, compared with the experts who all chose immune checkpoint blockade as frontline Tx for BRAF wild-type disease, 44% of tool users planned to use a different Tx or were unsure. For BRAF^V600-mutant disease with a good PS and normal LDH, all of the experts recommended frontline immunotherapy whereas 55% of users selected combination BRAF/MEK therapy for this scenario. In total, 59% of tool users whose planned Tx differed from the experts indicated that the expert recommendations from the tool would subsequently change their Tx plan. An analysis of specific first- and second-line agent and combination choice along with Tx variance in other case scenarios will be presented

The identification of predictive biomarkers for the benefit of cancer immunotherapy is the holy grail of the burgeoning immunotherapy field. Recent work has shown that there are a core of concepts that establish the presence of an immune cell-infiltrate, an inflammatory signature of the tumor microenvironment, and the availability of target antigens defined by mutated neoantigens, as critical for the success of the checkpoint blockade. Genetic analyses have shown that resistance to PD-1 blockade, either innate or adaptive, may be due to existing or de novo mutations in signaling pathways critical for T-cell function in a modest proportion of cases. Major hurdles in the field that remain to be overcome are the difficulty of obtaining tumor biopsies for biomarker assessment, the heterogeneity of biomarker expression within tumors and within different tumors from the same patient, and the inducibility of some biomarkers by disease-related processes. Although assessment of peripheral blood or serum biomarkers would be ideal, few data suggest that they would reliably predict outcome with checkpoint blockade. Ultimately, some amalgamated biomarker that includes tumor and host factors will be required to predict which patients are likely to benefit from, or be resistant to, the effects of checkpoint inhibition.

Background: Immune checkpoint inhibitors directed against programmed death-1 (PD-1) and cytotoxic T lymphocyte antigen-4 (CTLA-4) can provide long term benefit to a subset of cancer patients. Optimal patient selection remains challenging. Using serum mass spectrometry, we have developed a predictive test associated with prolonged survival of patients on anti-PD-1 therapy. Refinement of the test defined a subgroup of patients with particularly poor survival. Analysis of protein set enrichment analysis (PSEA) generated several hypotheses about the biological processes associated with the tests. Materials and Methods: MALDI mass spectra were generated from pretreatment serum samples from 119 patients with metastatic melanoma (MM) treated with nivolumab at the Moffitt Cancer Center. A classifier development platform optimized for creation of multivariate molecular diagnostic tests which can generalize well to independent datasets was employed to create a test that identified patients with prolonged overall survival. This test classified samples into two groups: group 1 with prolonged survival and group 2 with short survival. The classifier was validated using two independent cohorts of MM patients receiving anti-PD-1 agents: 30 patients from Yale University (YU) and 25 patients, most treated with pembrolizumab, from Massachusetts General Hospital (MGH). The test was also applied to pretreatment sera collected from 21 patients from Yale that received combination PD-1/CTLA-4 blockade. The difference in outcomes between patients in group 1 and group 2 were assessed using log-rank p values and Cox proportional hazard ratios (HRs). Results: Of the 119 patients used in the test set, 34 (29%) were classified as group 1. Group 1 had longer overall survival (OS) and progression-free survival (p = 0.002, p = 0.014 respectively), with twoyear survival of 67%. Thirteen patients (43%) from the Yale cohort and eleven patients (44%) from the MGH cohort were classified as Group 1. In the combined analysis of validation sera sets from patients receiving anti-PD-1 agents, patients classified as Group 1 had better OS than Group 2 (p < 0.0001, HR = 0.162); their two-year survival was 86%. Within the cohort of patients receiving combination PD-1/CTLA-4 blockade, 13 (62%) were classified as Group 1. Two-year survival was 83% in Group 1 and 63% in Group 2. Further refinement of the test identified patients who had either better and worse outcome among those classified as Group 2. The difference appears to be related to proteins associated with Th1 versus Th2 mediated immunity in these patients. Conclusions: A serum proteomic test identified a subgroup of patients with prolonged survival with anti-PD-1 therapy. High two-year survival in the Group 1 cohort may indicate that the test has potential utility in identifying patients who derive significant benefit from anti-PD-1 monotherapy and might gain little benefit from the addition of an anti-CTLA-4 agent. Further stratification of patients classified as Group 2 identified patients who can benefit from treatment from PD-1 monotherapy. Follow-up was 2 years for OS, and the numbers in the validation set are small, indicating that further validation is necessary. Detection of biological differences in sensitivity and resistance using PSEA methods applied to mass spectral data suggest potentially important lines of further investigation

BACKGROUND: Antibodies inhibiting the programmed death receptor 1 (PD-1) have demonstrated significant activity in the treatment of advanced cutaneous melanoma. The efficacy and safety of PD-1 blockade in patients with uveal melanoma has not been well characterized. METHODS: Fifty-eight patients with stage IV uveal melanoma received PD-1 or PD-1 ligand (PD-L1) antibodies between 2009 and 2015 at 9 academic centers. Patients who were evaluable for response were eligible for the analysis. Imaging was performed every 12 weeks and at the investigators' discretion. Safety and clinical efficacy outcomes, including the best overall response, progression-free survival (PFS), and overall survival (OS), were retrospectively determined. RESULTS: Of 56 eligible patients, 48 (86%) had received prior therapy, and 35 (63%) had received treatment with ipilimumab. Three patients had an objective response to ipilimumab, and 8 had stable disease as their best response. Thirty-eight patients (68%) received pembrolizumab, 16 (29%) received nivolumab, and 2 (4%) received atezolizumab. Objective tumor responses were observed in 2 patients for an overall response rate of 3.6% (95% confidence interval [CI], 1.8%-22.5%). Stable disease (>/=6 months) was observed in 5 patients (9%). The median PFS was 2.6 months (95% CI, 2.4-2.8 months), and the median OS was 7.6 months (95% CI, 0.7-14.6 months). There was no association between prior treatment with ipilimumab or liver-directed therapy and PFS or OS. Treatment was well tolerated, and only 1 patient discontinued treatment because of toxicity. CONCLUSIONS: PD-1 and PD-L1 antibodies rarely confer durable remissions in patients with metastatic uveal melanoma. Clinical trial enrollment should be prioritized in this population. Cancer 2016. (c) 2016 American Cancer Society.

The prognosis of patients with gastrointestinal (GI) melanoma metastases is poor. Surgery renders select patients disease free and/or palliates symptoms. We reviewed our single-institution experience of resection with GI melanoma metastases. A retrospective review was performed on patients who underwent surgery for GI melanoma metastases from 2007 to 2013. Fifty-four patients were identified and separated based on completeness of resection into curative 13 (24%) and palliative 41 (75.9%) groups. Thiry-six (63.2%) were symptomatic preoperatively with bleeding and/or obstruction/pain with 91.7 per cent achieving objective symptom relief. Thirty-day operative mortality was 0 per cent. The most common complication was wound infection (n = 5); major complications like anastomotic leak (n = 1) were uncommon. With a median follow-up of 9.5 months (range 0.2-75.8), median overall survival was not reached (curative) versus 9.53 months (palliative group). Median recurrence-free and progression-free survival after resection were 18.89 and 1.97 months in the curative versus palliative groups, respectively. On multivariate analysis, resection to no clinical evidence of disease (P = 0.012) and presence of single metastases (P = 0.031) were associated with improved overall survival. Surgery for GI metastases from melanoma provides symptomatic relief without major morbidity. Fewer metastases and curative resection were associated with improved survival.