Monday, May 25, 2015

ASCO 2015: Nivo plus ipi vs ipi alone. Results of the CheckMate 069 melanoma study.

Clinical response, progression-free survival, and safety in patients with advanced melanoma receiving nivolumab combined with ipilimumab vs ipi monotherapy in CheckMate 069 study.  ASCO J Clin Oncol 33, 2015.  Hodi, Postow, Chesney, Pavlick, Robert, Wolchok, et al.

Combined blockade of T cell checkpoints by Nivo and Ipi demonstrate a high objective response rate, promising overall survival, and manageable safety profile in a phase 1 study, based on which an appropriate dose was selected for registrational trials.  142 patients with metastatic and unresectable melanoma, including patients with poor prognostic factors were randomized 2:1 to receive IPI 3 mg/kg combined with either Nivo 1mg/kg or placebo every 3 weeks X 4, followed by Nivo 3mg/kg or placebo every 2 wks until disease progression or unacceptable toxicity.  Results:  In BRAF wild type (n=109) overall response rate was 60% (43/72) for Nivo plus ipi; 11% (4/37) for ipi alone. Complete responses were reported in 12 (17%) for the combo and 0 for ipi alone.  Higher overall response rate was observed for nivo plus ipi vs ipi in predefined subgroups such as:  elevated baseline LDH (53 vs 0%) M1c stage disease (62 vs 25%).  Similar results were found in 33 BRAF mutation positive patients.  Grade 3/4 AE's were reported in 51% of patients given the Nivo/ipi combo vs 20% for ipi alone and was similar across all groups.  Most resolved with immunosuppressive meds (more than 83%) with the exception of endocrinopathies.

Not really news at this point.  The ipi/nivo combo provides better results than ipi alone.  The combo causes more adverse reactions as well....  What'cha gonna do???  Hang in there, ratties!!! - c

Saturday, May 23, 2015

ASCO 2015: Nivo and Pembro after failing ipi. Ipi after failing anti-PD1.

Survival, biomarker, and toxicity analysis of Nivolumab (NIVO) in patients that progressed on ipi.  ASCO J Clin Oncol 33, 2015. Weber, Gibney, Yu, et al.

PD-1 antibody, nivolumab was administered to 126 patients with unresectable melanoma that failed at least one regimen and were ipi naive (34) or progressed on ipi (92).  Patients refractory to ipi were given Nivo at 3 mg/kg. 2 cohorts were HLA 0201 positive: N = 10 had grade 2 or less ipi related AE's.  N = 21 had dose limiting grade 3/4 ipi related AE's.  A third cohort (N = 61) was not HLA restricted and had experienced grade 2 or less ipi related AE's.  RESULTS:  Median f/u for ipi refractory pts was 18.7 months. Response rate was 29%.  44% had clinical benefit with confirmed partial and complete response or stable disease at 24 weeks.  Median duration of response was 14.3 months.  Median progression free survival was 5.4 months and median overall survival was 20.1 months with 1 and 2 year OS of 69.2% and 39.1%.  Of 14 patients that have completed all therapy or stopped due to toxicity while stable or in response, all remain in remission. Of 21 patients with prior ipi induced grade 3/4 AE's, only 2 had subsequent dose limiting (and different) AE's with nivo, with 8 PR and 5 SD seen.  All 8 PR and 3 SD are without progression.  Biomarker studies showed that circulating MDSC (myeloid derived suppressor cells) were associated with progression and worse OS.  CONCLUSION:  Prior ipi related AE's were not replicated by NIVO.

Safety of pembrolizumab in patients who stopped ipilimumab due to immune-related adverse events.  ASCO J Clin Oncol 33, 2015.  Shoushtari, Postow, Horvat, Chapman, et al.

Pembro which blocks programmed death-1 was recently FDA approved (as was Nivo) for the treatment of patients with advanced melanoma after progression on ipi.  Ipi is associated with immune mediated adverse events which can lead to treatment cessation.  Researchers collected date on patients with melanoma who received pembro at Sloan Kettering and had received less that 4 doses of ipi due to AE's grade 2 or higher requiring steroids.  RESULTS:  N= 10.  12 AE's contributed to ipi cessation:  colitis, neuropathy, ALT elevation (increased liver enzymes), rash.  All were given steroids and 3 required infliximab.  Median pembro doses given = 5.  7/10 patients are still getting treatment.  2/10 had treatment with pembro interrupted due to AE's that required steroids.  Neither were the AE seen when on ipi.  CONCLUSION:  Patients who stop ipi due to AE's may have different AE's on pembro.  Severe AE's on ipi does not preclude a patient from taking pembro.

Efficacy and toxicity of treatment with the anti-CTLA4 antibody Ipilimumab in patients with metastatic melanoma who have progressed on anti-PD1 therapy.  ASCO J Clin Oncol 33, 2015.  Prithviraj, McArthur, Atkinson, et al.

Immunotherapy with anti-CTLA4 (ipi) and anti-PD1 antibodies has demonstrated overall survival benefits in patients with metastatic melanoma compared to standard therapy.  Early clinical trails suggests that combination therapy with ipi and anti-PD1 increases the response rate sompared to single agent treatment however is associated with increased toxicity.  Anti-PD1 therapy demonstrated equal efficacy and toxicity in patients that progressed on or were naive to treatment with the anti-CTLA-4 antibody Ipilimumab.  So far, only very limited evidence exists regarding efficacy and toxicity of ipi in pateints that have progressed on treatment with an anti-PD1 agent.  Study:  N= 10 patients who had received Nivo/Pembro in a clinical trial and were subsequently treated with ipi.  Ipi was given at 3mg/kg every 3 wks for 4 cycles and response was assesses by CT scan 4-6 wks after last dose.  Results:  Median time between last dose of anti-PD1 and ipi was 7 months.  4/10 patients had increased LDH on commencement of ipi therapy.  1/10 patients achieved a partial remission as their best response to anti-PD1 therapy with an additional 5/10 having stable disease. 4/10 were given all 4 doses of ipi.  F/U after last dose of ipi has been more than 3 months.  1/10 patients achieved a response to ipi with another 1/10 having prolonged stable disease.  3/10 experienced grade 3/4 immune related AE.  Conclusion: Ipi can induce responses in patients who have failed anti-PD1.  The response rate appears similar compared to patients who have not received prior anti-PD1 therapy.  AE's were observed.  Significance of these observation remains to be seen.

The first two reports are not really news.  Patients who had to stop taking ipi due to side effects can take anti-PD1 (Nivo OR Pembro) without being cursed with their prior side effects from ipi and gain a response.  Additionally, and this is newer as fewer patients have reached this position, you can get a response from ipi after having taken anti-PD1. And ~ myeloid derived suppressor cells need to get out of our way!!! Hang in there ratties.  Sometimes it's a long ride! - c

Friday, May 22, 2015


Alisa Linton - RIP

Bleeding hearts

There are no words.  C

Thursday, May 21, 2015

ASCO 2015 - intralesional therapy for melanoma

I've been reviewing articles that have come out of ASCO the past couple of weeks.  Here is my round up of those related to intralesional therapy.

A multicenter, open-label trial of talimogene laherparepvec (T-VEC) plus pembrolizumab vs pembrolizumab monotherapy in previously untreated, unresected, stage IIIB-IV melanoma.  ASCO - J Clin Oncol 33, 2015.  Ribas, Puzanov, Gajewski, et al.

T-VEC is a herpes simplex virus-1-based oncolytic immunotherapy designed to preferentially replicate tumors, produce GM-CSF and stimulate an anti-tumor immune response.  {Remember this definition from a prior post:  GM-CSF can be given to premature babies and leukemia patients with low white cell counts to help build them back up....and reverse immune suppression.}  OPTiM, a phase III trial of T-VEC vs GM-CSF in unresected stage IIIB-IV melanoma (n=436), ....had improved durable response rate in the T-VEC arm (16 vs 2%).  Pembrolizumab is a human programmed death receptor-1 (PD-1) blocking antibody [anti-PD1 product, Keytruda] FDA approved in US for patients with unresectable or metastatic melanoma [after failing ipi and if BRAF V600 positive, BRAF inhibitors as well].  
     In this study, started Dec 2014, T-VEC is injected into cutaneous, subcutaneous or nodal lesions at up to 4 ml on day 1, then up to 4 ml on day 22 and every 2 weeks  (phases 1B and 2).  Pembro is given at 200 mg IV every 2 weeks from day 36 in phase 1B (n=20) and day 1 in phase 2 (n=90).  Treatment with both therapies will be given (whichever comes first) until: complete response or progression of disease, intolerance, for up to 2 years.  T-VEC injections stop when there are no longer injectable lesions. Patients in Phase 2 will be randomized 1:1 to T-VEC and pembro vs pembro alone.

Tumor size and clinical outcomes in melanoma patients treated with T-VEC. ASCO - J Clin Oncol 33. Kaufman, Amatruda, Nemunaitis, et al.

436 patients.  Previously treated and untreated.  Stage IIIB-IV mel in OPTiM, randomized 2:1 phase 3 trial of IT T-VEC vs subq GM-CSF.  288 T-VEC and 126 GM-CSF patients.  Median calculation for size of tumor at baseline was 14.8cm squared for T-VEC and 14.1 for GM-CSF.  Median size was higher with advanced stage.  Results for this study:  T-VEC patients, patients with lower than median sized tumors and lower stage were associated with better overall survival.

Survival, safety, and response patterns in a phase 1b multicenter trial of talimogene laherparepvec (T-VEC) and ipi in previously untreated, unresected stage IIIB-IV melanoma.  ASCO - J Clin Oncol 33, 2015.  Puzanoz, Milhem, Hamid, Kaufman, et al.

History on T-VEC as noted above.  Requirements:  Stage IIIB-IV melanoma patients with no prior systemic treatment, measurable disease and at least 1 injectable cutaneous, sub q, or nodal lesion.  T-VEC was given IT at week 1, week 4, and every 2 weeks until injectable tumor was gone or disease progression.  Ipi was given at 3mg/kg every 3 wks for 4 infusions starting week 6.  RESULTS:  At cutoff, all patients were 17 months from start of treatment.  18 patients were treated.  Grade 3/4 AE's occurred in 32% and grade 3/4 immune related AE's occurred in 2 patients with no treatment-related deaths.  Overall response rate was 56% (33% complete response) and DRR was 44%.  Median time to response was 5.3 months.  Median progression free survival was 10.6 months.  Median overall survival was not reached.  12 month and 18 month survival were 72% and 67%.  On a lesion level, 24 and 11 of 35 indexed lesions and 8 and 5 of 16 uninjected lesions regressed at least 50%  and 100%, respectively.  Conclusion:  At more than 17 months out, T-VEC + ipi continued to demonstrate durable response with 2/3 patients alive at 18 months and no new safety signals.

A phase 1 study of intratumoral injection of ipilimumab and interleukin-2 in patients with unresectable stage III-IV melanoma.  ASCO - J Clin Oncol 33, 2015.  Bowen, Meek, Williams, Grossman, et al.

Intratumoral IL-2 is highly effective and well tolerated, but does not generate systemic immunity or response in untreated lesions.  IV ipi lowers the threshold for T cell activation leading to a durable clinical response in a minority of melanoma patients, but is associated with potentially severe toxicities.  Since IV ipi doesn't have tissue distribution, circulating anti-tumor T cells activated by the drug may differ greatly from tumor infiltrating lymphocytes activated by INTRATUMORAL ipi in terms of quantity and quality.  Therefore, we hypothesized that a combination of IT IL-2 and IT ipi would effectively hyperactivate and expand TILs to engender systemic immunity with minimal toxicity.   This phase 1 dose escalation trial for ipi and fixed dose IL-2 involved patients with unresectable stage III/IV melanoma and at least one injectable lesions.  A single lesion in each patient was treated with IL-2 IT TIW for 2 wks, then BIW for 6 wks, with escalating doses of ipi IT weekly for 8 weeks.  RESULTS:  12 patients were treated with 3 ipi dose levels.  Treatments were well tolerated.  The only grade 3 toxicity was injection site/tumor necrosis, not dose limiting.  Other toxicities were grade 1.  An abscopal effect (response in a least 1 NON-injected lesion) was seen in 9/12 patients (75%).  10 patients were evaluable for immune response:  4 with partial regression (40%) and 6 had progressive disease, though later one PD was later found to be a complete response by resection.  The 2 nonevaluable patients had regression of multiple skin lesions.  An increase in the frequency of IFN producing CD8+ T cell was detected in 6/8 abscopal responders.  Tbet+ and granzyme B+ CD8+ T cells were observed in 4/5 and 3/5 responders tested, respectively.  Researchers plan to conduct a phase II trial using IT Ipi/IL-2 in conjunction with systemic immunotherapy.

Final data from CALM: A phase II study of Coxsackievirus A21 (CVA21) oncolytic virus immunotherapy in patients with advanced melanoma.  ASCO - J Clin Oncol 33, 2015.  Andtbacka, Curti, Kaufman, Daniels, et al.

CVA21 is a novel bio-selected oncolytic and immunotherapeutic strain of Coxsackievirus A21.  Intratumal injection initiates preferential tumor cell infection, cell lysis [death] and enhancement of a systemic anti-tumor immune response.  The CALM study looked at 57 patients with treated or untreated, unresectable Stage IIIC-IV melanoma.  Patients were given injections on study days 1, 3, 5, 8, and 22, then every 3 weeks for a further 6 injections.  Patients showing immune-related progression-free survival or better at 6 months were eligible for 9 additional injections.  RESULTS:  21 of 57 (38%) patients displayed progression free survival at 6 months with median PFS of 4.2 months.  Overall response rate was 28% (16 of 57) with a more than 6 month durable response rate of 19% (11 of 57).  Median time to response was 2.8 months, 1 year survival rate was 75% (43 of 57 patients).  At more than 16 months, median duration of response in responders and median overall survival for all patients was not yet reached.  Most common side effects = Grade 1 fatigue, chills, local injection site reaction, and fever.  No grade 3 or 4 reactions.  Further studies with CVA21 in combination with other immunotherapies are in process.

Another recent intralesional therapy report, but NOT from ASCO:

Intralesional administration of L19-IL2/L19-TNF in stage III or stage IV  melanoma patients:  results of a phase II study.  Cancer Immu Imm. 2015 May 14. Danielli, Patuzzo, Di Giaomo, et al.

IT injection of IL2 has shown promise for cutaneous melanoma patients.  We recently reported that the IT injection of L19-IL2, an immunocytokine combining IL2 and the human monoclonal antibody fragment L19, resulted in efficient regional control of disease progression, increased time to distant metastasis and evidence of effect on circulating immune cell populations.  Results of phase II clinical trial with intralesional administration of L19-IL2 and L19-TNF in patients with stage IIIC and IVM1 metastatic melanoma, who were not surgical candidates.  In 20 patients, 32 melanoma lesions exhibited complete responses after IT administration of the two products.  Side effects were mainly injection site reactions.  We observed complete responses in 7/13 (53%) NONINJECTED lesions (4 cutaneous and 3 lymph nodes), indicating a systemic activity of the IT therapy.  This therapy represents a simple and effective method for the local control of inoperable melanoma lesions, with a potential to eradicate them or make them suitable for a facile surgical removal of the residual mass.

Obviously, there are no results from the first study report as yet.  Logically, smaller tumors seem to respond better.  But, I find these intralesional therapies promising. With the possibility of eradication of the injected tumor, potential for abscopal responses, and if only for the reduction of tumor size so that it can then be resected surgically with a very benign side effect sounds good to me.  The combination of IT injections with systemic immune therapies just makes sense to me.  Of course, time will tell.  But, I think I'd certainly try it if I had the need.  Wishing all my fellow ratties well. - c

Saturday, May 16, 2015

New Immunotherapy Trial with NBS20 for Stage III recurrent/IV metastatic melanoma

Not much coming out of ASCO yet....but will keep looking.  However, my resident researcher did come across this:  (Click on link for entire article, pertinent excerpts below!)

New Immunotherapy Phase 3 trial for melanoma

'New York, April 29, 2015 — NeoStem, Inc. (Nasdaq:NBS), a biopharmaceutical company developing novel cell-based individualized medicine therapies, announced today the randomization of the first patient in the Intus Phase 3 clinical trial investigating the efficacy of the Company’s patient-specific targeted cancer immunotherapy candidate NBS20 (USAN = eltrapuldencel-T) in patients with stage III recurrent or stage IV metastatic melanoma. 

The Intus trial is based on consistent, compelling results from two Phase 2 trials in identical patient populations evaluating the therapeutic vaccine that has become NBS20. The more recent of the two trials was a randomized trial comparing NBS20 to injections of autologous irradiated (inactivated) tumor cells in 42 patients. At two years, survival was 72% compared to 31% for control patients (p=0.007), which was consistent with the previous Phase 2 trial’s findings in which NBS20 demonstrated 73% two-year survival in 54 patients, with a median survival of five years. Toxicity was minimal and consisted of mild to moderate local injection site reactions of the type normally associated with injections of GM-CSF (a protein secreted by immune cells that helps stimulate other immune cells to promote immune defenses against disease).

“The randomization of the first patient in the pivotal Phase 3 trial for NBS20 represents the achievement of a significant milestone for NeoStem, marking our transformation into a Phase 3 immuno-oncology company. We are now part of a select group of immunotherapy companies at such an advanced clinical development stage,” said Dr. David J. Mazzo, Chief Executive Officer of NeoStem.

The Intus study is a multi-national, randomized, double-blind, placebo-controlled Phase 3 clinical trial in which stage III recurrent or stage IV metastatic melanoma patients will be randomized in a 2:1 ratio to receive either NBS20 (autologous dendritic cells loaded with antigen from self-renewing, proliferating autologous tumor cells in GM-CSF) or a control treatment (peripheral blood mononuclear cells obtained from apheresis product in GM-CSF). The study is expected to randomize 250 eligible patients across approximately 50 sites internationally (US, Canada, Australia, New Zealand and, potentially, select countries of the EU); each patient will receive subcutaneous injections once weekly for three consecutive weeks, and then once monthly for five months.

In addition to metastatic melanoma, the platform technology on which NBS20 is based is potentially applicable across multiple solid tumor types, including advanced lung, colon, kidney, ovarian and hepatocellular carcinomas, and glioblastoma multiforme—indications that collectively lead to more than 200,000 deaths in the United States each year.'

I have some reticence about things announced by the pharmaceutical company itself....but looks like this might be worth investigation for some, especially for patients who have tried multiple therapies and are still in need of additional treatment options.
Here's the link on - Autologous dendritic cell-tumor cell immunotherapy for metastatic melanoma
It is currently recruiting.  Sites:  CA, Indiana, Kentucky, Louisiana, Maryland, Ohio, New Jersey, PA, Texas, TN.  Patients must have measurable disease and at least one tumor that can be resected. The "cell line can be initiated with either a specimen of fresh tumor or tumor that has been previously cryopreserved."  Patient must have already been treated with IL2, Ipi, vemurafenib (if BRAF+) OR dacarbazine.  These may have been given in combination or individually.  Must be 4 weeks post systemic therapy and more than 3 weeks post radiation.

NOTE:  The inclusion/exclusion section doesn't seem to address the status of patients who have had anti-PD1.  So I'm not sure about that.  As for all trials, if you are interested....CALL!  Ask any questions of the trial coordinator and make the best decision you can for YOU!!!

Wishing you my best - c

Wednesday, May 13, 2015

Melanoma kills...

...the best people.  Not my usual upbeat bullshit is it?  I believe in hope.  I believe in new treatments that have extended, saved and maybe...just maybe...cured some from the scourge that is melanoma.  But, I also KNOW that if you turn your back on melanoma, if you decide your are immune and don't have to trouble yourself with being vigilant, under the care of a melanoma specialist, NO MATTER what stage of melanoma you find yourself diagnosed are going to be in world of hurt my friend.  Hell, you can end up in a world of hurt no matter what you do.  If you care about somebody with melanoma, you might want to see some of these posts, from some of the most generous you know what you could be in for, how quickly your world can change, how fleeting life can be.  Really....if you care about ANYBODY....   You might want to make sure they know that.  We don't get a re-do, no matter how much we might like one.

Alisa, loving wife and mother of 4 boys

A small peek of Alisa's life, loves, and one of many treatments

An amazing couple get the news....Jeanne and 9TS

9TS - as should be


Patti - pehaps the most amazing woman I will never meet

Patricia Garcia-Prieto, her leap

Hard Talks - Meagan and her Cabana Boy

Nurses teach the Cabana Boy

Meagan - her words

Beautiful Kathy - her light and loves

Eric and Jill - The hard reality  They caught a lot of flack for this graphic video of Eric's tumors.  Don't look if you are not up to it.  However, I think they were the bravest couple.  He was perhaps the world's sweetest man.  graphic video of melanoma tumors

Eric's beautiful life....

For all of you, past and present....  For those of you who have loved well and work to carry on....

"I hope the days come easy and the moments pass slow,
And each road leads you where you wanna go,
And if you're faced with a choice, and you have to choose,
I hope you choose the one that means the most to you.
And if one door opens to another door closed,
I hope you keep on walkin' till you find the window,
If it's cold outside, show the world the warmth of your smile.

I hope you never look back, but you never forget,
All the ones who love you, in the place you live,
I hope you always forgive, and you never regret,
And you help somebody every chance you get,
Oh, you find God's grace, in every mistake,
And always give more than you take.
But more than anything, yeah, more than anything
My wish, for you, is that this life becomes all that you want it to,
Your dreams stay big, your worries stay small,
You never need to carry more than you can hold,
And while you're out there getting where you're getting to,
I hope you know somebody loves you, and wants the same things too,
Yeah, this, is my wish."
                          ~ STEELE/ROBSON and Rascal Flatts

...I hope to live as bravely, as fully, and with as much grace...  
"When you live in the hearts of those you love, remember then - you never die."  ~ Meagan McPhee
I will hold you all in my heart, forever. - c

Sunday, May 10, 2015

Happy Mother's Day!!!! From another kind of mother!

Being a mother...hmmm....  Not sure of all the things that motherhood means, or should mean, or most often does....  Not sure how good this movie will be.  But, it seems to hit some serious high notes:

Trailer for Ricki and The Flash with Meryl Streep

This certainly sums up my view on motherhood...  "It really doesn't matter if the kids love you or not.  It's not their job to love you.  It's YOUR job to love THEM!"

As for my kids...they would probably tell you this is similar to the typical words of wisdom they have been given from THEIR mother...  "Lots of things are going to change in your life.  One day you're going to wake up and find a grey hair....  And I don't mean on your head!!!"

Sorry punkins!  Lots of mistakes have been made.  You have had to endure all kinds of crazy.  But... I KNOW, YOU KNOW.....I love you. - mommy