Faculty Bibliography

Background: Genetic risk factors of human cancer emerge as promising markers of clinical outcome. The recent melanoma genome-wide scans (GWAS) have identified loci associated with the disease risk, nevi or UV/pigmentation, but the prognostic potential of these variants is yet to be determined. In this study, we performed the first-to-date systematic evaluation of the association between established melanoma risk loci and melanoma progression. Methods: 891 melanoma patients prospectively accrued and followed up at NYU Medical Center were studied. We examined the association of 108 melanoma susceptibility single nucleotide polymorphisms (SNPs), selected or imputed from recent GWASs on melanoma, nevi or pigmentation, with recurrence-free survival (RFS) and overall survival (OS). The genotyping was performed using Sequenom I-plex. Cox PH model was used to test the association between each SNP and RFS and OS adjusted by age at diagnosis, gender, tumor stage and histological subtype. ROC curves were used to measure predictive utility of SNPs in predicting 3-year recurrence. Results: The strong association was observed for rs7538876 (RCC2) with RFS (HR=2.445, 95% CI 1.57 - 3.8, p=0.0006) and rs9960018 (DLGAP1) with both RFS and OS (HR=4.7, 95% CI=2.11-10.43, p=0.0061, HR=1.55, 95% CI=1.11-2.17, p=0.0094, respectively) using adjusted multivariate analysis. In addition, we identified the classifier with rs7538876 and rs9960018, stage and histological type at primary tumor diagnosis, achieving a higher area under the ROC curve (AUC=84%) compared to the baseline (AUC=78%) in predicting 3-year recurrence. Univariate survival analyses have identified associations of several SNPs with ulceration and/or tumor thickness. Conclusions: Our data revealed an association between specific melanoma susceptibility variants and worse clinicopathological variables at the time of diagnosis as well as worse disease outcome. The strength of associations observed for rs7538876 and rs9960018 suggest biological implication of!

Background: Increased tumor infiltrating lymphocytes (TILs) in primary (P) and locoregional melanoma tissue correlate with improved clinical outcome. Our recent data have suggested that matrix metalloproteinase 23 (MMP 23) expression (exp) in P result in lower prevalence of TILs and correlate with poor clinical outcome. On this basis, we examined P and metastatic (M) melanoma tissues to assess for concordance between the presence of TILs, MMP 23 protein levels and clinical response(resp) to anti-cytotoxic T-lymphocyte antigen 4 (CTLA4) therapy (tx). Methods: 21 melanoma patients (pts) with M specimens were analyzed. 17 matched P specimens were also evaluated. Immunohistochemical (IHC) staining for TILs of the pre-anti-CTLA4 specimens were conducted and confirmed by 2 pathologists. IHC TILs were graded- 2+: >10% TILs present in multiple foci in both peri- and through the tumor; 1+: 1-10% TILs present in one or more foci in the tumor and predominantly peri-tumor; 0: no TILs were present or if the lymphocytes did not infiltrate the tumor. TILs in P and M were analyzed for concordance and potential for predictability of resp to anti-CTLA4 tx. Staining to identify lymphocyte subtypes and MMP 23 exp in M is being completed. Results: 20 pts received anti-CTLA4 tx. M analysis- 6 pts with 0 TILs in M (5 no response [NR], 1 partial response[PR]); 8 pts with 1-2+ TILs in M (1 complete response [CR], 5 PR, 2 progressive disease [PD]); 6 pts with 2+ TILs in M ( 3 CR, 2 PR, 1PD). 1 pt with 2+ TILs in M resected, no tx and 4 years disease free. TILs present in 13 P, absent in 4 P and not evaluable in 4 pts with unknown P melanoma. MMP 23 protein scores in P (range 2-4) correlated with melanoma recurrence. MMP 23 exp in M will be reported. Conclusions: TILs in P do not appear to correlate with TILs in M or predict for resp to anti-CTLA4 tx. TILs in M may be an indicator of responsiveness to anti-CTLA4 tx. Identification of the type of M TIL subsets may further refine tx recommendations

Background: We hypothesize that BRAF mutations result in microRNA (miRNA) alterations which contribute to orchestrating the mutant BRAF's oncogenic effects in melanoma. Our study is the first to examine the association between the BRAF mutation status in primary melanomas and the expression of miRNAs that target known tumor suppressors. Methods: 84 prospectively accrued melanoma patients at New York University Langone Medical Center were studied. DNA and total RNA were extracted from consecutive sections of formalin-fixed paraffin-embedded primary tissues. BRAF mutation status was determined by DNA sequencing. RNA was hybridized to miRCURY miRNA microarrays containing 1314 probes. Normalized miRNA data were analyzed using the t-test (p<0.05) to identify differentially expressed miRNAs between BRAFmut vs. BRAFwt cases. Those with an average fold change (FC) > 2 were selected for predicted (TargetScan, PicTar) and validated (miRWalk) gene target analysis, and overlapping genes targeted by 2 miRNAs were analyzed using pathway-mapping algorithms (KEGG, BioCarta, PANTHER). Results: 48 (57%) primaries were BRAFwt and 36 (43%) were BRAFmut (26 V600E, 4 V600K, 1 V600R, 1 V600D, 4 other). 30 miRNAs met the criteria for statistically significant differential expression and FC thresholding: let-7i, miR-23c, -26a/b, -27b, -34a, -98, -126*, -141, -148a, -181b, -195, -199a-3p, -199a/b-5p, -200a/b/c, -203, -205, -455-3p, -491-3p, -606, -641, -646, -1297, -4301; miRPlus-C1070, -C1110, -G1246-3p (average FC: 2.3-3.5, all increased in BRAFmut vs. BRAFwt). Predicted and validated target gene analysis revealed 317 genes, of which 110 (35%) were convergent targets of 2 miRNAs. Pathway analyses of the predicted, validated, and convergent target genes pointed to the potential impact of BRAFmut-associated miRNAs on known tumor suppressors FAS, PTEN, and TNF and the p53 pathway. Conclusions: Differentially expressed miRNAs in BRAFmut vs. BRAFwt primaries target genes with known roles in melanoma biology and/or treatmen!

Combined BRAF and MEK inhibition can delay the onset of resistance compared with BRAF inhibitor alone in preclinical models. Safety/tolerability of vem + GDC-0973 was evaluated in a phase Ib trial. Eligible pts had BRAFV600-mutated unresectable or metastatic melanoma by cobas BRAF test, ECOG PS 0/1 and were either naive to vem or had disease progression on vem. Pts received vem 720 or 960 mg BID continuously. GDC-0973 was dosed at 60, 80 or 100 mg QD 14 days (d) on/14 d off (14/14); 21 d on/7 d off (21/7); or continuously (28/0) in 10 cohorts. Primary endpoints were maximum tolerated dose (MTD), dose-limiting toxicity (DLT) and safety. Of the 70 pts treated as of July 6, 2012, 70% were male, median age 57.5 year (range 19-76), 74.3% M1c, and 54.3% had progressed on prior vem therapy. The median no. of cycles to date was 3. DLTs were observed in 3 pts, as of September 18, 2012: Grade (G) 3 QT prolongation (1 pt) in vem 960 mg BID + GDC-0973 60 mg QD 21/7 cohort; G3 mucositis (1 pt) and G3 arthralgia (1 pt), both in vem 960 mg BID + GDC-0973 60 mg QD 28/0 cohort. Most common adverse events (AEs) regardless of attribution were diarrhea (54.3%), non-acneiform rash (54.3%), fatigue/asthenia (38.6%), nausea (35.7%), photosensitivity/ sunburn (31.4%) and liver function test (LFT) abnormality (25.7%). Most frequent treatment-related G > 3 AEs were rash (7.1%), diarrhea (5.7%) and LFT abnormality (4.3%). One pt developed skin SCC. Dose reduction for AE was required for vem in 3 pts and GDC-0973 in 2 pts. Preliminary efficacy in 25 evaluable vem-naive pts showed that all 25 pts had tumor reduction. GDC-0973+ vem can be combined safely at the respective single-agent MTDs of vem (960 mg BID) and GDC-0973 (60 mg 21/7). This dose level was chosen for further clinical testing in an upcoming phase III study

The oral BRAF inhibitor vemurafenib (VEM) has shown improved overall survival (OS) and high response rates in patients (pts) with BRAFV600-mutant metastatic melanoma with median durations of VEM treatment of up to 5.7 months. Updated data are available from a phase 2 trial (BRIM-2) of VEM in 132 previously treated pts with BRAFV600-mutant metastatic melanoma (median follow-up: 13.4 months, clinical cut-off: February 1, 2012). Confirmed best overall response rate BORR (by IRC) was 53.0% (95% CI 44.2-61.8%). Median OS was 15.9 months and median PFS was 6.8 months. Long-term follow-up of trials with BRAF inhibitors is needed to assess the potential for these agents to induce secondary malignancies. Here we report long-term safety data from BRIM- 2. Safety assessments included incidence of adverse events (AEs), the most common of which were grade 1/2 arthralgia (n = 81; 61.3%), rash (n = 61; 46.2%), photosensitivity (n = 67; 50.8%), fatigue (n = 73; 55.3%), and alopecia (n = 53; 40.1%). Four pts experienced AEs leading to discontinuation of study drug. One drug-related death due to acute renal failure was reported. Secondary cutaneous squamous cell carcinomas (cuSCCs) usually appeared in the first few weeks of treatment and were seen in 36 (27.3%) pts. AEs also observed included two new primary melanomas, but there were no non-cutaneous SCCs or other malignancies and no cases of colonic polyps were reported. Cardiac events occurred in <1% of pts. Other common AEs were similar to those reported previously. Sixty pts required dose reduction below 960 mg BID; nine returned to full dose. After long-term follow-up (median 13.4 months), VEM remains well tolerated, with the majority of AEs being non-severe and manageable. No non-cutaneous malignancy has been observed