The new paradigm of systemic therapies for metastatic melanoma

REVIEW

The new paradigm of systemic therapies for metastatic melanoma Virginia O. Volpe, MD,a Daniel M. Klufas, BS,b Upendra Hegde, MD,a and Jane M. Grant-Kels, MDb Farmington, Connecticut New treatments for metastatic melanoma work through distinct mechanisms: enhancing the immune response and blocking cellular proliferation. Agents that enhance the immune response include ipilimumab, pembrolizumb, and nivolumab; agents that block cellular proliferation include vemurafenib, dabrafenib, trametinib, cobimetinib, binimetinib, and selumetinib. The translational impact of laboratory discoveries has revolutionized management of metastatic melanoma and enhanced the prognosis of affected patients. ( J Am Acad Dermatol 2017;77:356-68.) Key words: immune therapy; metastatic melanoma; targeted therapy.

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lucidation of the mechanisms that contributed to the inefficacies of previous melanoma therapies led to the discovery of molecules (referred to as checkpoints) expressed by activated T cells. These molecules mediated the inhibition of T cells so that immune homeostasis was preserved and the harm caused to the body by uncontrolled inflammation prevented. The characterization of these checkpoints and their blockade by monoclonal antibodies resulted in the evolution of immune checkpoint inhibitor treatments of metastatic melanoma (MM) (Fig 1). Cytotoxic T-lymphocyteeassociated antigen 4 (CTLA-4) and programmed cell death 1 (PD-1) receptor represent 2 inhibitory molecules expressed on activated T cells that regulate their growth, proliferation, and survival and potentially compromise melanoma immunity.

Abbreviations used: APC: BRAF: CRR: CTLA-4: irAEs: KA: LDH: MAPK: MHC: MM: OS: PD-1: PFS: PI3K: SCC:

antigen presenting cells v-RAF murine sarcoma viral oncogene complete response rate cytotoxic T-lymphocyteeassociated antigen 4 immune related adverse events keratoacanthoma lactate dehydrogenase mitogen-activated protein kinase means of antigen presenting metastatic melanoma overall survival programmed cell death 1 progression-free survival phosphatidylinosital-3-kinase squamous cell carcinoma

A melanoma-specific immune response is generated when melanoma antigen on the major histocompatibility complexes of antigen-presenting cells (APCs) is presented to the T-cell receptors of T cells. The antigen-primed T cell becomes activated by engagement of its CD28 molecule with the costimulatory molecules CD80 and CD86 present on APCs

(Fig 2). The resulting tight synapse between the T cell and APC leads to proliferation and survival of T cells that help eliminate tumor cells.1 The CTLA-4 pathway regulates this reaction through rapid expression of CTLA-4 antigens on activated na€ıve and memory T cells. By virtue of their superior affinity for the costimulatory molecules on the APC, CTLA-4 antigens outcompete the CD28 molecule for binding and thereby abrogate T-cell antitumor activity.2

From the Department of Internal Medicine, Division of Oncology’s Neag Cancer Center, University of Connecticut Health Center, Farmingtona; and the Department of Dermatology, University of Connecticut Health Center, Farmington.b Dr Volpe and Mr Klufas contributed to this work equally. Drs Hegde and Grant-Kels contributed to this work equally. Funding sources: Supported by Jane and Richard Lublin. Conflicts of interest: None declared.

Accepted for publication April 25, 2017. Reprints not available from the authors. Correspondence to: Jane M. Grant-Kels, MD, UConn Health Department of Dermatology, 21 South Rd, Suite 200, Farmington, CT 06030-6231. E-mail: [email protected]. 0190-9622/$36.00 Ó 2017 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2017.04.1126

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AntieCTLA-4 antibody ipilimumab monoclonal antibodies against PD-1 receptor or Ipilimumab is a human monoclonal antibody of PDL1 leading to blockade of T-cell inhibition and IgG1 type developed to inhibit CTLA-4 activity and to activation of antimelanoma immune responses in allow for T-cell activation and proliferation (Fig 3). animal studies. Pembrolizumab and nivolumab are 2 Phase 1 and 2 clinical trials demonstrated antitumor humanized monoclonal antibodies of the IgG4 subactivity leading to durable responses in patients types that are FDA approved to treat unresectable including those with unfavorable characteristics stage III or IV disease. (M1c melanoma subclass Nivolumab. Nivolumab and elevated lactate dehyis a fully human monoclonal CAPSULE SUMMARY drogenase [LDH]) but also IgG4 antibody against PD-1. revealed autoimmune side A pilot study on nivolumab Metastatic melanoma historically has effects.3-6 In a large prospecin patients with treatmentbeen associated with a poor prognosis. tive multicenter randomized refractory solid tumors Emerging treatments have resulted from phase 3 clinical trial, patients demonstrated a promising knowledge of mechanisms to enhance diagnosed with unresectable safety profile and evidence the immune response against tumors stage III or IV melanoma of antitumor activity.10 A and molecular characterization of failing previous treatments larger phase 1 study reinmutated gene products important for were randomly assigned in forced this finding showing cellular proliferation. 3:1:1 ratio to receive ipilimua durable objective response mab plus gp100 (vaccine (28%) with nivolumab.11 The new treatments discussed herein derived from melanosomal Further studies were unhave revolutionized management of glycoprotein 100), ipilimudertaken in previously metastatic melanoma. mab alone, or gp100 alone treated advanced melanoma at a dose of 3 mg/kg body patients who had not weight every 3 weeks for #4 treatments. The results received CTLA-4 antibody treatment. An overall showed similar median survival of 10 months among response rate of 30.8% was obtained across all doses patients in the ipilimumab groups compared with of nivolumab, with median progression-free survival 6.4 months in patients receiving gp100 alone. Grade (PFS) of 3.7 months, median overall survival (OS) of III/IV toxicities occurred in 10%-15% of the patients 16.8 months, and an OS of 62% and 43% at 1 and receiving ipilimumab, and 14 deaths occurred 2 years, respectively.12 This led to 2 large, randomincluding 7 deaths from autoimmune side effects. ized, open-label, phase 3 clinical trials. One trial Overall survival for ipilimumab plus gp100, ipilimucompared nivolumab versus dacarbazine in treatmab alone, and gp100 alone at 12 months was 43.6%, ment-na€ıve, BRAF (v-RAF murine sarcoma viral 45.6%, and 25.3%, respectively; at 18 months it was oncogene) wild-type tumors; this trial demonstrated 30.0%, 33.2% and 16.3%, respectively; and at 2 years a higher OS with the nivolumab treatment than with was 21.6%, 23.5%, and 13.7%, respectively.7 In a the dacarbazine treatment (73% vs 42%) at 1 year. Other studies showed a similar benefit regardless of pooled analysis, overall survival for patients who BRAF mutation status. The survival benefit associreceived ipilimumab appeared to plateau after ated with nivolumab was also noted irrespective of 3 years. This analysis, however, reflects the survival PDL1 status; in those negative for PDL1, survival was status, not the disease status, of survivors.8 improved in the nivolumab group in comparison with the dacarbazine group.13 AntiePD-1 antibody pembrolizumab and Another study compared nivolumab versus nivolumab investigator-choice chemotherapy in previously PD-1, like CTLA-4, is an immune checkpoint treated MM patients who progressed after treatment receptor that regulates a different point in the with CTLA-4 or BRAF inhibitor. Objective responses immune response and can be found on activated were 31.7% with the CTLA-4 inhibitor and 10.6% with effector T cells in tumor microenvironments (Fig 2). the BRAF inhibitor, suggesting ipilimumab is an The 2 ligands, PDL1 (B7H1) and PDL2 (B7DC), are efficacious treatment option after progression.14 found on a variety of cells including APCs and tumor Pembrolizumab. Pembrolizumab (initially tissues. This bond results in downregulation of the called labrolizumab) is another highly selective immune response that protects the host against humanized monoclonal antibody of the IgG4 isoautoimmunity.9 This mechanism can be used by type that was designed to block PD-1 receptor tumors to circumvent antitumor immunity and expressed on activated effector T lymphocytes. In develop immune tolerance. Interruption of the PDa phase 1 study, patients with MM previously 1ePDL1/2 axis is accomplished by generating d

d

d

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Fig 1. Molecular targets of melanoma chemotherapeutic agents. Drugs in yellow text are currently FDA approved and used in clinical practice.

refractory to other immune therapy, such as highdose interleukin 2, ipilimumab, or BRAF inhibitory agents, were treated with pembrolizumab at 10 mg/ kg every 2 weeks.15 Median PFS was 7 months and median OS was not reached after 11 months of follow-up. Subsequent studies confirmed the efficacy of pembrolizumab in large, randomized phase 3 studies of treatment-na€ıve or previously ipilimumab-treated patients. The 1-year OS was 67% (63% for the ipilimumab treated and 71% for ipilimumab na€ıve); the survival at 2 years was 50% (46% for the ipilimumab treated and 53% for the ipilimumab na€ıve).15,16 Pembrolizumab was also compared with ipilimumab in patients with advanced disease who had had no more than 1 prior systemic treatment; pembrolizumab resulted in significantly longer PFS and OS.17

ADVERSE EVENTS SECONDARY TO IMMUNE CHECKPOINT INHIBITION The common side effects are nonspecific and include fatigue, diarrhea, rash, and nausea. Immunerelated adverse events (irAEs) have been commonly seen and involve a number of organ systems, including the gastrointestinal tract (colitis, hepatitis), skin (dermatitis), lung (pneumonitis), endocrine

glands (hypophysitis, thyroid dysfunction), nervous system, and eyes (Table I).3-8,10-15,17-28 Dermatologic complications usually occur earliest, sometimes after the first infusion, and irAEs usually appear within the first 12 weeks of therapy, with rare reports of events seen months after the last therapy dose.18,29,30 Although side effects are generally moderate in severity, irAEs can be severe or life threatening. Therefore, clinical monitoring and early interventions are warranted. Algorithms for management of the irAEs incorporate temporary or permanent discontinuation of these medications with the possible use of immunosuppressive agents, typically including steroids.31 Patients refractory to steroid treatment might require alternative immunosuppressive therapies. Usually toxicities resolve in 2-4 weeks; however, endocrinopathies are slower to resolve and might be permanent.29 Concomitant use of vemurafenib with ipilimumab has resulted in grade III transaminitis. Also, the combination of antieCTLA-4 and antiePD-1 has resulted in increased grade III-IV toxicities in some patients, and nivolumab alone showed reduced toxicity when compared with combination therapy and ipilimumab alone. Finally, autoimmune myocarditis has been reported with fulminant myocarditis, which can be fatal. Although myocarditis is thought to be rare, the true incidence

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Fig 2. Mechanism of action of PD-1 and PD-1 inhibitors. MHC, Major histocompatibility complex; PD-1, programmed cell death 1; PDL1, programmed cell death 1 ligand; TCR, T-cell receptor.

Fig 3. Mechanism of action of ipilimumab. APC, Antigen-presenting cell; CTLA-4, cytotoxic T-lymphocyteeassociated antigen; MHC, major histocompatibility complex; TCR, T-cell receptor.

Adverse events and toxicities* Drug

Skin

Immunotherapies Ipilimumab3-8

GI

Liver

Endocrine

Rash, pruritus

Diarrhea, nausea, colitis

Hepatotoxicity

Endocrinopathies

Nivolumab10-14,18

Rash, pruritus

Diarrhea, nausea, colitis

Hepatotoxicity

Endocrinopathies

Pembrolizumab15-17

Rash, pruritus

Diarrhea, nausea, colitis

Hepatotoxicity, hepatitis

Hypothyroid, type 1 diabetes, hypophysitis

Rash, photosensitivity, SCC, keratoacanthoma, papilloma, new primary melanoma, alopecia, hyperkeratosis, pruritus, seborrheic keratosis

Diarrhea, nausea, decreased appetite, vomiting, constipation

Increased LFTs

Hyperkeratosis, SCC, keratoacanthoma

Nausea, vomiting

Rash, acneiform dermatitis, alopecia Rash, alopecia, hyperkeratosis, photosensitivity, SCC, keratoacanthoma

Nausea, vomiting, diarrhea, constipation Diarrhea, nausea, vomiting

Targeted therapies BRAF inhibitors Vemurafenib20

Dabrafenib21

MEK inhibitors Trametinib22 Cobimetinib27,28

Other

Asthenia, arthralgia, fatigue, pneumonitis, myocarditis, nephritis, thrombocytopenia, neutropenia, uveitis Fatigue, pneumonitis, myocarditis, nephritis, thrombocytopenia, neutropenia, uveitis Pyrexia, fatigue, myocarditis, pneumonitis, nephritis, thrombocytopenia, neutropenia, uveitis

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Table I. Adverse events and toxicities associated with melanoma treatment3-8,10-15,17-28

Arthralgia, fatigue, neutropenia, headache, weight loss, pyrexia, prolonged QT interval, myalgias, musculoskeletal pain, peripheral edema, HTN, cough, dysgeusia, anemia Neutropenia, thrombocytopenia, arthralgia, fatigue, pyrexia, asthenia, headache Fatigue, peripheral edema, HTN

Increased LFTs, increased GTT

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Arthralgia, fatigue, pyrexia, serous retinopathy, increased CPK, decreased EF, QT prolongation, decreased appetite

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Diarrhea, nausea, vomiting, constipation Acneiform dermatitis Selumetinib19,25,26

ARDS, Acute respiratory distress syndrome; CPK, creatine phosphokinase; CTCAE, Common Terminology Criteria for Adverse Events; EF, ejection fraction; GI, gastrointestinal; GTT, glucose tolerance test; HTN, hypertension; LFT, liver function test; SCC, squamous cell carcinoma. *All adverse events are graded based on CTCAE guidelines from the National Cancer Institute. Grade III and IV adverse events might require discontinuation of the therapy. (National Cancer Institute. Common Terminology Criteria for Adverse Events v4.0. NCI, NIH, DHHS. NIH publication #09-7473. Bethesda, MD: National Cancer Institute at the National Institutes of Health; 2009.)

Diarrhea, nausea, vomiting Rash, acneiform dermatitis, pruritus Binimetinib23,24

Fatigue, edema (facial, periorbital, peripheral), increased CPK, dysgeusia, central serous retinopathylike events, small bowel perforation (NRAS patients), malaise and general health deterioration (BRAF patients) Fatigue, peripheral edema, headache, pyrexia

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is unknown and studies are underway to identify predisposing factors.29,20,32

COMBINED IMMUNE CHECKPOINT INHIBITION: PRINCIPLE Knowledge that blocking either of the 2 T-cell inhibitory checkpoints by monoclonal antibodies improved survival in MM patients and that these checkpoints are nonredundant led to the hypothesis that further improvement in survival might be achieved by combined blockade. Validated in preclinical studies, the first phase 1 study combined (concurrently or sequentially) ipilimumab and nivolumab treatments in unresectable stage III or IV melanoma. The results confirmed improved outcomes following combined blockade of CTLA-4 and PD-1 compared with single immune checkpoint blockade, but higher incidences of autoimmune toxicities were noted. Objective responses were reported in 53% of patients, with complete responses reported in nearly 20%. Grade III/IV autoimmune side effects were seen in about 53% of patients. Most responses recorded at the time of tumor assessment (12 weeks) were substantial ([80% shrinkage of the tumor) and were ongoing even after discontinuation of treatment. Treatment-related toxicity led to discontinuation of treatment in 21% of patients. Ipilimumab was dosed at 3 mg/kg and nivolumab at 1 mg/kg for concurrent administration; toxicity was manageable with prompt intervention with steroids upon recognition of symptoms of toxicities. Subsequently, 2 large randomized clinical trials comparing combined immune checkpoint blockade versus ipilimumab or nivolumab alone confirmed results of the phase 1 studies and indicated that the clinical responses occurred irrespective of serum LDH and PD-1 ligand expression status.32,33 On the basis of this data, the FDA approved combined use of ipilimumab and nivolumab for the treatment of stage IV melanoma. Recent combinations of ipilimumab and nivolumab in patients with untreated MM have shown improved survival when compared with ipilimumab alone regardless of BRAF status.32

TARGETED THERAPIES Genetic components of multiple cellular signaling pathways critical to maintaining cellular homeostasis by controlling key cellular functions of growth, proliferation, and cell death by apoptosis have been discovered. Mutations of genes encoding proteins of such pathways foster carcinogenesis by conferring uncontrolled cellular signaling for growth and proliferation. Targeted therapy involves control of tumor growth with small molecules designed to

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block the aberrant proteins of these signaling pathways. Rat sarcoma (RAS) signaling regulates cell growth, survival, and invasion via the RAS/mitogen-activated protein kinase (MAPK) and the RAS-phosphatidylinosital-3-kinase (PI3K) signaling streams. The best studied oncogenic mutation in melanoma is the BRAF that encodes a serine/threonine protein kinase, which acts in the RAS-RAF-MEK-ERK MAPK pathway.34 MAPK signaling involves activation of RAS GTPase, which allows RAS to bind and activate RAF by a complex sequence of events. The signaling cascade culminates in MEK phosphorylating and activating the ERK1 and ERK2 MAPKs, which then translocate to the nucleus and regulate transcription factors.35-37 Consequently, cell proliferation is promoted by gene expression patterns induced by upregulated expression of nuclear transcription factors.35-37 Oncogenic RAS activates MAPK and the PI3K-AKT signaling pathway, which leads to activation of AKT and its downstream targets. Although both pathways cause cell proliferation, dissemination, and survival, the PI3K-AKT signaling pathway also promotes anabolism; the RAS-RAF-MEK-ERK pathway is more active in proliferation and invasion.37,38 Mutations in BRAF occur in over 50% of melanomas with the most common mutations leading to a substitution of glutamic acid for valine at amino acid position 600 (p.V600E).39,40 Although the wild-type BRAF is typically activated by KRAS, the p.V600E mutation confers BRAF with unregulated kinase activity leading to constitutive activation of MEK that drives the growth-promoting extracellular signal-regulated kinase (ERK) pathway.41 In addition, activating BRAF mutations are frequently found in acquired and dysplastic melanocytic nevi. The activation of BRAF leads to nevus development through a process known as oncogene-induced senescence.41 However, these nevi do not undergo malignant transformation because cell cycle arrest is induced via the expression of the key cyclindependent kinase inhibitor, p16INK4A.42 Similarly, BRAF mutation alone does not cause melanoma; additional genetic alterations in BRAF-mutant cells are required to elicit a fully cancerous phenotype.43 The V600E mutation is not a classic ultraviolet B signature change and has been shown to occur most commonly in tumors arising in areas intermittently exposed to sun and not in chronically exposed, sundamaged or unexposed skin (acral or mucosal melanomas).44 This suggests that complex genetic interactions promote BRAF mutations rather than physical or chemical mechanisms45 and that most BRAF mutations are lethal unless the correct genetic

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and biochemical environment exists to allow cell survival and proliferation.35 Alterations in proto-oncogene, KIT, have been found in acral, mucosal, and cutaneous melanomas. Like gastrointestinal stromal tumors, tumors with KIT mutations have also been targeted for treatment in melanoma. In a phase 2 study, patients with MM who harbored KIT mutations were recruited and treated with imatinib, a tyrosine kinase inhibitor. Results showed clinical response in a subset of patients with overall durable response rate of 16%, a median time to progression of 12 weeks, and a median OS of 46.3 weeks.46 Other studies, however, did not show clinical benefit of KIT inhibition.47,48 Nevertheless, further research discovered that patients with KIT amplification without mutation benefited less from treatment with imatinib than did those with KIT mutations. It was also noted that KIT mutations were found on exons 11 and 13. Given the differences in responses to treatment among persons with melanoma with KIT mutations and amplifications and persons with gastrointestinal stromal tumors with KIT mutations, variability in the biology of KIT is suggested.49 Despite durable responses observed in these patients, disease progression for most is inevitable. Nilotinib, another tyrosine kinase inhibitor, has been studied as a second-line treatment after disease progression on imatinib. In a certain subset of patients, clinical benefit might result; however, further studies are needed.50 BRAF inhibitors: Monotherapies BRAF mutation was identified to be the most common mutated gene in melanoma,39 which launched an era of therapeutics aimed at targeting this mutation. Vemurafenib and dabrafenib are the 2 main inhibitors of BRAF used, and they have demonstrated dramatic antitumor activity in patients with advanced disease expressing the BRAF mutation in phase 3 trials. Vemurafenib. Vemurafenib is a potent kinase inhibitor of the mutant BRAF molecule that specifically targets its antitumor effects on cells featuring the BRAFV600E mutation rather than on wild-type BRAF.51-53 The phase 3 BRIM-3 trial assessed OS and PFS in patients with unresectable stage IIIC or stage IV melanoma harboring BRAFV600E mutations; these patients were randomly assigned to receive either vemurafenib or dacarbazine.54 Of the 675 patients, 598 had a BRAFV600E mutation. At the median followup (12.5 months for patients treated with vemurafenib and 9.5 months for those given dacarbazine), the median OS was longer for patients on vemurafenib (13.6 months) than it was for those on dacarbazine (9.7 months). Additionally, the median PFS was also

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significantly longer in the vemurafenib group (6.9 months) than it was in the dacarbazine group (1.6 months). For patients with BRAFV600K (57 of 675), median OS and median PFS for those on vemurafenib were 14.5 months and 5.9 months, respectively, and the median OS and medium PFS for those on dacarbazine were 7.6 months and 1.7 months, respectively.55 These results highlight the efficacy of vemurafenib in melanoma patients with BRAF mutations. Important adverse events and toxicities were noted with this medication. The most common were cutaneous squamous cell carcinomas (SCCs) and keratoacanthomas (KAs), increased liver function tests, rash, and arthralgia. Grade IV or worse adverse events occurred in 29 (8%) patients in the vemurafenib group and treatment was discontinued because of adverse events in 24 (7%) of patients on vemurafenib.55 Molecular studies suggest that BRAF inhibition leads to a paradoxic activation of the MAPK pathway in BRAF wild-type cells of the cutaneous epithelium in a manner that bypasses BRAF, which might explain the occurrence of cutaneous adverse events.20 Dabrafenib. Dabrafenib, another BRAF inhibitor, was approved by the FDA for patients with V600E positive advanced melanoma.56 In an openlabel, phase 3 trial, 250 patients with stage IV or unresectable stage III MM featuring a BRAFV600E mutation were randomly assigned to either dabrafenib or dacarbazine and their PFS was assessed. The dabrafenib-treated group showed significantly increased PFS compared with the dacarbazine group (5.1 months versus 2.7 months, respectively).21 Fifty-three percent of patients receiving dabrafenib experienced a grade II or higher adverse event. These were mostly cutaneous (hyperkeratosis, papillomas, palmar-plantar erythrodysesthesia), but also included pyrexia, fatigue, headache, and arthralgia.21 MEK inhibitors Activated BRAF phosphorylates and activates downstream MEK 1/2 proteins, resulting in increased phosphorylation of the ERK1 and ERK2 MAPKs and transcription of genes responsible for cellular growth and proliferation. Trametinib. Orally administered trametinib selectively inhibits MEK1 and MEK2.57 The drug originally showed promise in BRAFV600E mutations transplanted into mice and in phase 1 and 2 trials, which showed tumor regression and disease stabilization in melanoma patients with BRAF mutations.58,59 A phase 3 trial composed of patients with MM with BRAFV600E or BRAFV600K mutations received in a 2:1 ratio oral trametinib or intravenous

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chemotherapy consisting of dacarbazine or paclitaxel.22 For the trametinib group, median PFS was 4.8 months, and for the chemotherapy group, it was 1.5 months. The OS at 6 months was 81% in the trametinib group and 67% in the chemotherapy group.22 The most common adverse events reported in the trametinib group included skin rash, diarrhea, peripheral edema, fatigue, and an acneiform eruption. In addition, decreased ejection fraction or ventricular dysfunction and grade III drug-related cardiac events were observed. Ocular events (blurry vision and reversible chorioretinopathy) were reported. Unlike BRAF inhibitors, there was an absence of cutaneous toxicities, such as SCCs or hyperproliferative skin lesions.22 Binimetinib (in development). Binimetinib (MEK162) is a selective, non-ATP-competitive allosteric inhibitor of MEK1 and MEK2. Preclinical studies revealed that it inhibited growth of NRASmutated and BRAFV600E-mutated melanoma in in vitro and in vivo models.23,24 NRAS mutations are associated with thicker primary tumors, tumors in older individuals, and melanomas presenting in chronically exposed sun-damaged skin.60-62 In addition, the NRAS mutation is associated with aggressive disease with an increased incidence of brain metastasis.40 In a nonrandomized, open-label phase 2 study, 71 patients with unresectable, locally advanced or metastatic, stage IIIB-IV cutaneous melanoma with NRAS or BRAFV600 mutations were treated with MEK162 forty-five milligrams twice daily to determine objective response and PFS. The results showed that 8 of 41 cases with the BRAF mutation and 6 of 30 patients with the NRAS mutation had a partial response at the 3-month follow-up. The most common adverse events were peripheral edema, gastrointestinal symptoms (diarrhea, nausea, vomiting), skin-related symptoms (rash, acneiform eruption, pruritus), and increased blood creatinine phosphokinase concentrations. Overall, 15 patients discontinued treatment due to adverse events. Binimetinib remains a promising targeted therapy, particularly for patients with NRAS mutations.23 Selumetinib (in development). Selumetinib, another MEK inhibitor, was studied in a phase 2, open-label randomized trial that evaluated 200 patients with unresectable, stage III and IV melanoma. The patients were randomly assigned to treatment with oral selumetinib (100 mg) or oral temozolomide (200 mg/m2/day for 5 days). The results showed no significant difference in PFS, making selumetinib a less-promising monotherapy.19 In another study, selumetinib, when combined with dacarbazine,

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improved PFS but not OS.25 In another combination trial with docetaxel, selumetinib showed increased objective response rates but did not show a significant difference in progression-free disease or OS.26

COMBINATION THERAPIES BRAF inhibitors in combination with MEK inhibitors Though BRAF inhibitors have high disease control rates, treatment failures following BRAF inhibitor monotherapy are common, with most patients developing tumor progression within 6-7 months. The tumor developing resistance to the BRAF inhibitor therapy is the main cause of treatment failure and is multifactorial.21,54 Recent data shows that approximately two thirds of cases are caused by reactivation of oncogenic signaling via the MAPK pathway and the remainder by an MAPK-independent pathway.63-65 Because MEK is downstream of BRAF, simultaneous blockade of both BRAF and MEK might reduce the possibility of resistance to treatment. Recent trials have studied the impact of a multitargeted approach to combat acquired resistance. Vemurafenib in combination with cobimetinib In a randomized phase 3 study, 495 patients with previously untreated, unresectable, locally advanced or metastatic, BRAFV600 mutationepositive melanoma were treated with both vemurafenib (960 mg twice daily) and cobimetinib (60 mg once daily for 21 days, followed by 7 days off) or vemurafenib and placebo (control group) to assess PFS. The results showed a median PFS of 9.9 months for the combination therapy group versus 6.2 months for the control group. Completed or partial response was 68% in the combination group versus 45% in the control group.27 An updated analysis of PFS and response data showed that the median OS was 22.3 months for the combination group versus 17.4 months for the control group. Median PFS was 12.3 months versus 7.2 months in the combination and control groups, respectively.28 The toxicity of combined BRAF and MEK inhibitor treatment included a higher incidence of central serous retinopathy, gastrointestinal symptoms (diarrhea, nausea, vomiting), photosensitivity, elevated aminotransferase levels, and increased creatinine kinase (as opposed to the control group). However, KAs, cutaneous SCCs, alopecia, and arthralgia were less frequent in the combination group compared with the control. Treatment was discontinued due to adverse events in 13% of

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patients in the combination group and 12% in the control group.27 Dabrafenib in combination with trametinib Two phase 3 trials have been performed to assess the efficacy and safety of dabrafenib used in combination with trametinib. In 1 study, 423 previously untreated BRAFV600E and BRAFV600K mutationepositive MM patients were assigned to either dabrafenib plus trametinib or dabrafenib plus placebo (control group). Median survival was 25.1 months for the combination therapy group and 18.7 months for the control group. OS at 1 and 2 years was 74% and 51%, for the combination group, as opposed to 68% and 42%, respectively, for the control group.66 Eighty-seven percent of patients in the combination group experienced adverse events compared with 90% of patients in the control group, with the most common events including pyrexia, chills, fatigue, rash, and nausea. Fewer patients in the combination group experienced cutaneous SCCs, hyperkeratosis, skin papillomas, and alopecia than those in the control group. However, treatment discontinuation was more frequent in the combination group than in the control group (11% vs 7%), mostly due to pyrexia and chills.66 The other phase 3 clinical trial featured patients with MM with BRAFV600 mutation positivity who received dabrafenib plus trametinib or vemurafenib alone. At 12 months, the OS rate in the combination group was 72% versus 65% in the vemurafenib-only control group. Median PFS was 11.4 months in the combination group versus 7.3 months in the control group.67 Adverse events in the combination group included pyrexia, nausea, diarrhea, chills, fatigue, headache, and vomiting. Only 1% of patients in the combination group experienced cutaneous SCCs and KAs compared with 18% of the control group.67 In summary, combined inhibition of BRAF and MEK in MM patients with BRAF mutations delays the development of resistance reflected by improved PFS and OS compared with BRAF inhibitor alone (Table II).7,8,12-14,15-17,19,21,23,28,32,33,54-56,66 MEK inhibition also appears to reduce the incidence of cutaneous side effects like cutaneous SCCs and KAs, which commonly plague patients on BRAF inhibitor monotherapy, while a higher incidence of fever is seen in patients receiving dabrafenib and trametinib combination therapy.

TREATMENT DECISION OF A PATIENT DIAGNOSED WITH UNRESECTABLE STAGE III OR IV MELANOMA The treatment options for patients with unresectable stage III or stage IV melanoma are expanding

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Table II. Efficacy of melanoma treatments7,8,12-14,15-17,19,21,23,28,32,33,54-56,66 Drug

Immunotherapies Ipilimumab7,8 Nivolumab12-14 Pembrolizumab15-17 Ipilimumab 1 nivolumab32,33 Targeted therapies BRAF inhibitors Vemurafenib54,55 Dabrafenib21,56 MEK inhibitors Binimetinib23 Selumetinib19 BRAF 1 MEK inhibitors Vemurafenib 1 cobimetinib28 Dabrafenib 1 trametinib66

Complete response

Partial response

Median PFS, months

Median OS, months

1-year survival

2- to 3-year survival

11.4% 8.9% NR 11.5%

NR NR NR 46.2%

2.9 3.7 7.0 11.5

10.1 16.8 NR NR

45.6% 62.0% 67.0% NR

23.5% 43.0% 50.0% NR

NR 3.0%

NR 47.0%

6.9 5.1

16.9 NR

NR NR

NR NR

NR

NR

NR

NR

NR

0%

19.5% (BRAF mutation) 20.0% (NRAS mutation) 5.8%

NR

NR

NR

NR

15.7%

53.8%

12.3

22.3

NR

NR

15.6%

52.6%

11.0

25.1

74.0%

51.0%

BRAF, v-RAF murine sarcoma viral oncogene; NR, not reported; OS, overall survival; PFS, progression free survival.

(Fig 4). A number of patient specific and disease factors are required to determine the best treatment option. These factors include treatment na€ıve status, previous use of immune therapy in the adjuvant setting, sites of metastasis, rate of tumor growth, tumor bulk, comorbidities including autoimmune diseases and their severities, performance status, age, serum LDH levels, and tumor PDL1 status. Immune-based treatment strategies led by immune checkpoint blockade (antiePD-1 and antieCTLA-4) are the preferred choice of treatment because of the durability of their responses and potential for long term survival, but the potential autoimmune side effects are concerning. Single agent as well as combination checkpoint inhibitor therapies are approved by the FDA and include 2 antiePD-1 blockade agents (pembrolizumab or nivolumab), an antieCTLA-4 blockade agent (ipilimumab), and combination of antieCTLA-4 and antiePD-1 (ipilimumab plus nivolumab). Single agent antiePD-1 has a superior therapeutic index compared with single agent antieCTLA-4 treatment but has to be administered for a longer time compared with the relatively shorter duration of antieCTLA-4 treatment. AntiePD-1 agents are typically preferred to antieCTLA-4 agents. Although a combined checkpoint blockade generally results in higher and more durable responses, severe toxicity might limit its use in patients at risk of toxicity or with underlying comorbidities (Fig 4). The potential severity of toxicity requires experienced providers. This strategy also is not appropriate for patients whose compliance and

reliability to report autoimmune side effects might be impaired by social and personal factors, elderly patients with limited social resources, patients with severe comorbidities, and patients with active autoimmune diseases who might be at higher risk of bad outcomes from autoimmune toxicity. AntiePD-1 agents have higher response rates and lower incidence of autoimmune toxicities compared with the antieCTLA-4 agent. Patients with normal LDH, na€ıve treatment status, and PDL1-expressing melanoma demonstrated high response rates akin to combined antieCTLA-4 and antiePD-1 treatment without severe toxicity. Combined treatment might be superior to single-agent checkpoint, inhibitor treatment if the patient has rapid tumor growth, elevated LDH, high tumor burden, and PDL1nonexpressing tumors. Targeting the MAPK pathway through combined BRAF and MEK inhibition is possible in patients exhibiting BRAF mutated tumors. The targeted therapy provides prompt onset of response and effectiveness in a proportion of melanoma patients exhibiting BRAF mutations. This treatment might be preferred as frontline treatment if rapid tumor growth requires a quick response to stabilize the patient or the patient is not a safe candidate for immunecheckpoint inhibitor therapy. Uninterrupted use of this treatment is important to prevent acquired drug resistance and maintain tumor control. The disadvantages include side effects that at times are severe enough to require dose reduction or discontinuation. Particular attention is necessary to avoid drug interaction by the P450 cytochrome system that might

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Fig 4. Flow chart of therapy recommendations. BRAF, v-RAF murine sarcoma viral oncogene; CTLA-4, cytotoxic T-lymphocyteeassociated antigen; LDH, lactate dehydrogenase; PD-1, programmed cell death 1; PDL1, programmed cell death 1 ligand.

reduce efficacy or increase toxicity. A recent followup study suggested potential durable survival might be seen with targeted therapy in patients with favorable tumor characteristics, such as low tumor bulk, few sites and numbers of metastases, and low serum LDH levels.68 How to sequence treatment in BRAF mutated melanoma patients is less clear and awaits larger studies. Available data suggest previous immune therapy treatments do not negatively impact subsequent targeted therapy treatments. Whether a negative effect is present with the reverse order of treatment is not clear; some evidence suggests that the response to immune therapy is deficient when following failure of targeted therapies.

CONCLUSION Immune-based treatments and targeted therapies for MM have yielded promising results. Challenges still exist due to the toxicities that might limit

treatment options in subsets of patients. While durable remissions are more likely with immunebased treatments, combined BRAF and MEK blockade can delay development of resistance and improve treatment outcomes. The authors would like to acknowledge the generosity of Jane and Richard Lublin. Their financial support as well as encouragement has enabled the University of Connecticut Melanoma Center to thrive. REFERENCES 1. Grosso JF, Jure-Kunkel MN. CTLA-4 blockade in tumor models: an overview of preclinical and translational research. Cancer Immun. 2013;13:5. 2. Abbas AK, Lichtman AH. Basic immunology: functions and disorders of the immune system. 3rd ed. Philadelphia: Sanders Elsevier; 2009. 3. Weber JS, O’Day S, Urba W, et al. Phase I/II study of ipilimumab for patients with metastatic melanoma. J Clin Oncol. 2008;26:5950-5956. 4. Weber J, Thompson JA, Hamid O, et al. A randomized, double-blind, placebo-controlled, phase II study comparing

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