Check out the link below for a webinar with slides presented by Jeffrey S. Weber, MD, PhD now of the Laura and Isaac Perlmutter Cancer Center at NYU. Just click the 'view activity' button at the bottom. I have included some info off the slides as well as my report of Dr. Weber's applicable comments in red below. (Sorry for the strange lay out...best I could do without retyping everything!)
What’s New in Melanoma 2016?
Combination immunotherapies and targeted therapies
Overcoming BRAF resistance
New immune agonistic molecules
Novel cytokines and fusion molecules
Chemokine antibodies
Bispecific T-cell engaging molecules
Adoptive cell therapy
Targeted therapy and immunotherapy
Masked antibodies
Vemurafenib Plus Atezolizumab in BRAF-Mutant
Melanoma—Trial Design
Patients with untreated BRAFV600-mutant
unresectable or metastatic melanoma (N = 17)
Cohorts: 1- atezo and vemurafenib together 2- vemurafenib X 56 days followed by atezo
3- vemurafenib X 28 days followed by Atezo. Atezolizumab (an anti PD-L1 anti-body) was given IV q 3 wk at 20 or 15 mg/kg and Vemurafenib was BID at 960 mg during run in, then decreased to 720mg bid.
Confirmed overall response rate: Cohort 1 - 33%, Cohort 2 - 75 %, Cohort 3 - 100%. Overall 76% response rate. Median of 12.2 months. AE's were manageable with no grade 4. Additive activity with excellent level of response. You will hear much more about this combo in the future.
MASTERKEY-265: A Phase Ib/III Study of T-VEC + Pembrolizumab (NCT02263508)
Cohorts: 1- atezo and vemurafenib together 2- vemurafenib X 56 days followed by atezo
3- vemurafenib X 28 days followed by Atezo. Atezolizumab (an anti PD-L1 anti-body) was given IV q 3 wk at 20 or 15 mg/kg and Vemurafenib was BID at 960 mg during run in, then decreased to 720mg bid.
Confirmed overall response rate: Cohort 1 - 33%, Cohort 2 - 75 %, Cohort 3 - 100%. Overall 76% response rate. Median of 12.2 months. AE's were manageable with no grade 4. Additive activity with excellent level of response. You will hear much more about this combo in the future.
MASTERKEY-265: A Phase Ib/III Study of T-VEC + Pembrolizumab (NCT02263508)
Phase
Ib:Enrollment from December 2014 to March 2015 (n = 21 ) N = 21
patients, Unresectable stage III or IV melanoma, treatment naive, injectable lesions, no clinically active brain mets, no active herpetic skin lesions or prior complications from herpetic infection. TVEC intralesional 4ml/treatment was given with pembro 200 mg IV q2wk. Mild side effects.
Complete response - 12.5%, Partial response - 43.8%. ORR - 56.3%. Additive effects, may even be better. Phase 3 study is ongoing.
Epacadostat (an IDO inhibitor) +
Pembrolizumab:Preliminary Results
61 patients were enrolled by September 2, 2015 Safety data on
46 patients (19 melanoma, 7 RCC, 7 NSCLC, 5 transitional cell carcinoma, 4
endometrial adenocarcinoma). Most common
all-grade treatment-related AEs were rash (22%), fatigue (17%), nausea (11%),
and pruritus (11%).
Grade 3/4
treatment-related AEs occurred in 13% of patients (rash, 7%). One patient
discontinued for a treatment-related AE. IDO inhibitor did not seem to increase side effects. Melanoma patients only (n - 18) - 56% ORR. Melanoma treatment naive patients (n - 16) - 63% ORR. Weber found these results very promising and comparable to the ipi/nivo combo in regard to response rates but with much milder side effects!!!
KEYNOTE-029: Pembrolizumab + Low-Dose
Ipilimumab for Advanced Melanoma
Pembrolizumab 2 mg/kg + ipilimumab 1 mg/kg. 72% received all 4 ipilimumab doses. 36% incidence of grade 3-4 treatment-related AEs. 54% incidence of immune-mediated AEs (17% grade 3/4). Pembrolizumab 2 mg/kg + ipilimumab 1 mg/kg provided an ORR of 56%, comparable to that previously reported for nivo 1 mg/kg + ipilimumab 3 mg/kg. Efficacy, safety, and biomarkers to be further analyzed in the full expansion cohort of 153 patients. So far, the side effects appear to be decreased by decreasing the ipi dose...while response rates remain good.
Pembrolizumab 2 mg/kg + ipilimumab 1 mg/kg. 72% received all 4 ipilimumab doses. 36% incidence of grade 3-4 treatment-related AEs. 54% incidence of immune-mediated AEs (17% grade 3/4). Pembrolizumab 2 mg/kg + ipilimumab 1 mg/kg provided an ORR of 56%, comparable to that previously reported for nivo 1 mg/kg + ipilimumab 3 mg/kg. Efficacy, safety, and biomarkers to be further analyzed in the full expansion cohort of 153 patients. So far, the side effects appear to be decreased by decreasing the ipi dose...while response rates remain good.
CheckMate
064: Study Design: Cohort A - nivo 3mg/kg q2wk X6, then ipi 3mg/kg 1 3wk X4. Cohort B - ipi 3mg/kg 1 3wk X4, then nivo 3mg/kg q2wk X6. Both cohorts were followed with nivo, 3mg/kg q2wk until progression, toxicity, or withdrawal of consent. Toxicities were no different between arms. Significant difference in response rates due to sequence of drugs. Nivo followed by ipi gave better results. "A real surprise."
I already had a rant on this one: Sequential nivo then ipi orr of 41%!
I already had a rant on this one: Sequential nivo then ipi orr of 41%!
Efficacy
Summary Week 13
|
Week 25
|
||||||
NIVOàIPI
(n = 68)
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IPIàNIVO
(n = 770)
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NIVOàIPI
(n = 68)
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IPIàNIVO
(n = 70)
|
||||
Confirmed ORR, %
|
--
|
--
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41.2
|
20.0
|
|||
Complete response, n
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0
|
0
|
0
|
0
|
|||
Partial response, n
|
24
|
7
|
28
|
14
|
|||
Conventional ORR, %
|
35.3
|
10.0
|
47.7
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22.6
|
|||
Progression rate, %
|
38.2 (26.7–50.8)
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61.4 (49.0–72.8)
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38.2 (26.7–50.8)
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60.0 (47.6–71.5)
|
|||
Intralesional Immunotherapy With
Oncolytic Coxsackievirus A21 (CVA21)
Final response and safety data of the open-label, multicenter phaseII CALM (CAVATAK in Late-stageMelanoma) study of intratumoral CVA21 in 57 patients with unresectable stage IIIC/IV melanoma. The study met its primary endpoint. 22 of 57 (38.6%) evaluable patients with PFS at 6 months. Median PFS of 4.2 mos. ORR 28.1%; median TTR 2.8 mos. 1-year survival rate 75.4%. Median OS and median DOR not reached (16.5 mos follow-up). Most common AEs were grade 1 fatigue, chills, fever, and injection site reactions; no grade 3/4 AEs observed. Looks like another promising intralesional therapy. Will soon have phase 3 study.
Final response and safety data of the open-label, multicenter phaseII CALM (CAVATAK in Late-stageMelanoma) study of intratumoral CVA21 in 57 patients with unresectable stage IIIC/IV melanoma. The study met its primary endpoint. 22 of 57 (38.6%) evaluable patients with PFS at 6 months. Median PFS of 4.2 mos. ORR 28.1%; median TTR 2.8 mos. 1-year survival rate 75.4%. Median OS and median DOR not reached (16.5 mos follow-up). Most common AEs were grade 1 fatigue, chills, fever, and injection site reactions; no grade 3/4 AEs observed. Looks like another promising intralesional therapy. Will soon have phase 3 study.
Radiotherapy in Combination With
Anti-PD-1 Antibodies: Safety and Efficacy
Retroactively evaluated all patients at Melanoma
Institute Australia and Westmead Hospital who had received either pembrolizumab
or nivolumab for unresectable stage III/IV melanoma who had sequential or
concurrent radiotherapy. In 32 evaluable patients, 9 (28%) PR and 5 (16%)
stable disease. In 25 patients who had progressed on PD-1 at the start
of RT, 7 (28%) subsequent PRs and 3 (12%) CRs, while 5 (20%) continued
progressing.
Survival Brain
metastases: PFS 2.5 mos, OS 6.8 mos. Which I think is excellent.
No brain
metastases: PFS 4.1 mos, OS 16.4 mos.
No excess RT toxicity observed except cerebral
radionecrosis in 1 patient 3 months after SRS; potential delayed neurotoxicity
in 1 patient with multiple small asymptomatic BMs; disproportionate cerebral
edema in 1 patient with rapidly progressive BMs. So, yes, you can deliver radiation to the brain, or elsewhere, safely...there is no excess toxicity if radiation is given with either nivo or pembro.
Clinical Activity To Date: BRAF + MEK
+ PD-L1 ab MEDI 4736
Response-evaluable
population includes all patients dosed ≥16 weeks prior to the cut-off date with
measurable disease at baseline and ≥1 f/u scan (or discontinuation due to death
or PD prior to 1st scan). Dabrafenib (BRAFi) and Trametinib (MEKi) and MEDI 4736 (PD-L1 antibody) were given in various regimens.
Median
duration of response has not yet been reached for Cohorts A and B.
*Shorter
follow up in Cohort C, with 5 additional patients ongoing with best response of
unconfirmed PR.
Clinical activity
|
Cohort A(n = 26)
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Cohort B(n = 19)
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Cohort C*(n = 15)
|
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D + T + M
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T + M
|
T /M (sequential)
|
||||
ORR, n (%)
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18 (69)
|
4 (21)
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2a(13)
|
|||
DCR (CR + PR + SD), n (%)
|
26 (100)
|
15 (79)
|
12 (80)
|
|||
SD ≥12 weeks, n (%)b
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4 (15)
|
10 (53)
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6 (40)
|
|||
Ongoing responders, n/N
(%)
|
16/18 (89%)
|
4/4 (100%)
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1/2 (50%)
|
|||
Range of duration of
ongoing response, wks
|
7.7+ –50.6+
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7.9+ –24.7+
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7.0+
|
|||
Very interesting study. I like this a lot. Large influx of T-cells with the trio, converting a cold tumor to a hot tumor, leading to an augmentation of T-cell function. The trio with its 69% response rate, at least gave additive efficacy, if not synergistic, without increased side effects.
Innovative Ideas: Targeted Therapies
Innovative Ideas: Targeted Therapies
Immunotherapy with targeted therapies:
BRAF + MEK + pembro, atezo, IPI + HDAC inhibitor, Ipi + nivo + HDAC inhibitor
Overcoming BRAF resistance by combining with:
Hsp90 inhibitors, HDAC inhibitors, PI3 kinase/AKT inhibitors, ERK inhibitors, ERBb3 inhibitors
Hsp90 inhibitors, HDAC inhibitors, PI3 kinase/AKT inhibitors, ERK inhibitors, ERBb3 inhibitors
Innovative Ideas: Immunotherapy
“Masked antibodies” have a peptide linker that “masks”
the antigen-binding region of antibodies unless it is cleaved by proteases
within the tumor (This is the same as the ADC's - antibody drug conjugates. Post here: Another antibody drug conjugate)
IL-12 has been linked to a tumor-targeting antibody
IL-15/IL-15 receptor alpha fusion proteins to augment
binding to effector T cells but not T regulatory cells
TGF-beta receptor antibody has been linked to a PD-L1
antibody
Neoantigen-specific T cells can be expanded from
tumor-infiltrating lymphocytes and adoptively transferred
Bispecific T-cell engagers link CD3 and
tumor-associated antigens
Prime Points: Melanoma Immunotherapy
IDO plus pembro trial will have mature data at ASCO
Survival f/u from sequential BMS-064 trial of nivo then ipi vs nivo then ipi
Nivo + CD137 antibody phase I-II trialIDO plus pembro trial will have mature data at ASCO
Survival f/u from sequential BMS-064 trial of nivo then ipi vs nivo then ipi
LAG-3 antibody + nivo phase I-II trial
OX- 40 antibody phase I trial
IL-15/IL-15 receptor complex phase I trial
Coxsackievirus + pembro phase I-II trial
Ipi + high dose IL=2
Synopsis of final thoughts by Dr. Weber:
More to come it seems!!! Thanks, ratties. - c
I want to thank you for all your comments, You have been my go to since my son was diagnosed in June. When it all becomes to much I read your words and become inspired again.So, thanks you are making a difference.
ReplyDeleteYou are so sweet to share that with me. Sometimes I fear I sound more like Debbie Downer than anyone else and that is not who I feel I am or wish to be. Mostly I just try to be real and put out information I fear some folks may not have access to in an understandable way. I am very glad to have been of some help to you and wish you and your son my very best.
ReplyDeleteThanks for the good info.
ReplyDeleteAllyson