Simple blood tests that tells us where we are with our melanoma....AGAIN (and again, and again, and again)!!!

I have been yelling about simple blood tests that give good information to melanoma patients for YEARS!!  I think my first post was in 2015.  Here is some of what I said and a link to that February post (with a zillion links within): "Yep.  It's me again, Margaret.  I'm still yelling about simple blood draws that can provide critical information related to the diagnosis of, feasibility of treatment for, response to treatment, and prognosis generally in melanoma patients!"  Simple blood tests that tell us how melanoma patients are responding to therapy and identify their disease in the first place....AGAIN!!!!

On a rather disheartening note ~ At a recent symposium for melanoma patients in Atlanta, facilitated by Northside and MRF, with "melanoma specialists" from Emory and Northside Hospital, I asked the panel what they were utilizing in regard to blood assays in diagnosing, monitoring, and implementing treatment for their patients.  They looked at me like deer in the headlights!!  One blathered on about it only being useful in regard to diagnosing BRAF status, not being "validated", blah, blah, blah. Seriously???  I call - B.S.!!!!  Some of these tests are not particularly special, like the NLR (neutrophil-to-lymphocyte ratio) for instance.  This is easily attained and computed via a simple CBC (complete blood count) drawn at every lab in this country a zillion times a day.  AND...we have looked at this data long enough to know that it is true!!!

Okay.  I'll quit yelling.  Now, there's this ~

Neutrophil-to-lymphocyte Ratio (NLR) as a predictor for recurrence in patients with stage III melanoma. Ma, Kuzman, Ray, et al.  Sci Rep. 2018 Mar 6. 

Neutrophil-to-lymphocyte ratio is a strong predictor for overall survival and disease free survival in many cancers. Our study is the first investigation aiming to determine the predictive value of neutrophil-to-lymphocyte ratio on prognosis of patients with stage III melanoma. This retrospective study utilized a cohort of 107 patients with stage III melanoma treated at Huntsman Cancer Institute, University of Utah, from May 2002 to March 2016. The optimal cutoff of neutrophil-to-lymphocyte ratio was determined by the significance of log-rank tests. A total of 97 log-rank tests were conducted to find the optimal cutoff. Disease free survival was assessed using the Kaplan-Meier method, and univariable and multivariable Cox models were applied to evaluate the predictive value of neutrophil-to-lymphocyte ratio. 2.5 was identified as the optimal cutoff. Kaplan-Meier curve showed that the disease free survival rate of the low value group was significantly higher compared to that of high value group. After adjusting for confounders and other prognostic factors, the neutrophil-to-lymphocyte ratio greater than or = to 2.5 remained a strong predictor for disease recurrence in patients with stage III melanoma.

Liquid biopsy to monitor melanoma patients. Gaiser, von Bunoff, Gebhardt, Utikal. J Dtsch Dermatol Ges. 2018 Mar 7.

During the last six years, several innovative, systemic therapies for the treatment of metastatic malignant melanoma (MM) have emerged. Conventional chemotherapy has been superseded by novel first-line therapies, including systemic immunotherapies (anti-CTLA4 and anti-PD1; authorization of anti-PDL1 is anticipated) and therapies targeting specific mutations (BRAF, NRAS, and c-KIT). Thus, treating physicians are confronted with new challenges, such as stratifying patients for appropriate treatments and monitoring long-term responders for progression. Consequently, reliable methods for monitoring disease progression or treatment resistance are necessary. Localized and advanced cancers may generate circulating tumor cells and circulating tumor DNA (ctDNA) that can be detected and quantified from peripheral blood samples (liquid biopsy). For melanoma patients, liquid biopsy results may be useful as novel predictive biomarkers to guide therapeutic decisions, particularly in the context of mutation-based targeted therapies. The challenges of using liquid biopsy include strict criteria for the phenotypic nature of circulating MM cells or their fragments and the instability of ctDNA in blood. The limitations of liquid biopsy in routine diagnostic testing are discussed in this review.

Liquid Profiling of Circulating Tumor DNA in Plasma of Melanoma Patients for Companion Diagnostics and Monitoring of BRAF Inhibitor Therapy. Haselmann, Gebhardt, Brechtel, et al.Clin Chem. 2018 Feb 26. 

The current standard for determining eligibility of patients with metastatic melanoma for BRAF-targeted therapy is tissue-based testing of BRAF mutations. As patients are rarely rebiopsied, detection in blood might be advantageous by enabling a comprehensive assessment of tumor mutational status in real time and thereby representing a noninvasive biomarker for monitoring BRAF therapy.

In all, 634 stage I to IV melanoma patients were enrolled at 2 centers, and 1406 plasma samples were prospectively collected. Patients were assigned to 3 separate study cohorts: study 1 for assessment of circulating tumor DNA (ctDNA) as part of companion diagnostics, study 2 for assessment of ctDNA for patients with low tumor burden and for follow-up, and study 3 for monitoring of resistance to BRAF inhibitor (BRAFi) or mitogen-activated protein kinase inhibitor therapy.

Overall, a high degree of concordance between plasma and tissue testing results was observed at 90.9% (study 1) and 90.1% (study 2), respectively. Interestingly, discrepant results were in some cases associated with nonresponse to BRAFi (n = 3) or a secondary BRAF-mutant malignancy (n = 5). Importantly, ctDNA results correlated with the clinical course of disease in 95.7% and with response to treatment. Significantly, the detection of BRAF mutant ctDNA preceded relapse assessed by Response Evaluation Criteria in Solid Tumors, and was more specific than serum S100 and lactate dehydrogenase.

Blood-based testing compares favorably with standard-of-care tissue-based BRAF mutation testing. Importantly, blood-based BRAF testing correlates with the clinical course, even for early-stage patients, and may be used to predict response to treatment, recurrence, and resistance before radioimaging under BRAFi therapy, thereby enabling considerable improvements in patient treatment.

Early evolution of BRAFV600 status in the blood of melanoma patients correlates with clinical outcome and identifies patients refractory to therapy. Gonzalez-Cao, Mayo de Las Casas, Jordana, et al. Melanoma Res. 2018 Feb 23.

Serial analysis of BRAF mutations in circulating-free DNA (cfDNA) could be of prognostic value in melanoma patients. We collected blood samples from 63 advanced BRAFV600E/K melanoma patients and determined BRAFV600E/K status in cfDNA using a quantitative 5'-nuclease PCR-based assay. Levels of BRAF mutation in pre-cfDNAs were associated significantly with tumour burden, progression-free survival and overall survival. Changes in BRAF status in cfDNA after initiation of treatment (early-cfDNA) had a significant correlation with outcome. In patients with persistent BRAF mutations (n=12), progression-free survival and overall survival were 3.5 months and 5.3 months compared with 16.6 months and 21.9 months in patients with BRAF negativization (n=16), and 15.1 months and NR in patients who maintained their initial negative status (n=12). The median duration of response in patients with radiological response, but persistence of BRAFV600 in early-cfDNA (n=5) was 4 months. Our study indicates that serial BRAF testing in the blood of advanced melanoma identifies patients refractory to therapy.

And these are just a handful of reports!!!   They don't even address other blood assays of which we know a great deal, including CD4+ T cells, microRNA, gene expressions, and circulating melanoma cells. I am just one little woman sitting in Chattanooga, TN!!  With melanoma.  Without a salary for this effort.  But with a computer and basic common sense!  You "melanoma experts" need to do better!!!  Get with the program.  These tests are available, have important implications for melanoma patients, and we need YOU to get on board and start incorporating them in your management of melanoma patients NOW!  Some folks don't have the luxury of waiting around for you to get off your hands!  Liquid blood assays WILL be utilized to diagnosis, monitor and evaluate melanoma patients for appropriate treatment choices!!  They are not likely to be the sole, end-all-be-all answer to all things melanoma, but will certainly be an essential component of basic care.  We need you peeps to make it so...SOONER...rather than later.  C'mon, man!!!!  (It's good that ratties have long tails!  We need them!) - c

Circulating tumor DNA to help differentiate true progression of melanoma vs pseudoprogression in patients treated with anti-PD-1

I've been yelling for some time about the need to develop, refine and put into practice valid, reliable blood assays....whether they are measuring circulating DNA, tumor cells, various other tumor makers, white blood cells, any other floating bits and bobs...in order to diagnosis melanoma, determine the most effective treatment, and recognize progression and/or effectiveness of that treatment.  Here is a link to a zillion of those reports/rants:  Blood assays, tumor markers, circulating DNA, you name it!!!! 

In fact, the report below is a follow-up report and specific look at pseudoprogression from this study:  2017: Circulating DNA predicts response to anti-PD1

Now, there's this -

Association Between Circulating Tumor DNA and Pseudoprogression in Patients With Metastatic Melanoma Treated With Anti-Programmed Cell Death 1 Antibodies.Lee, Long, Menzies, et al. JAMA Oncol. 2018 Feb 8.  

Longitudinal circulating tumor DNA (ctDNA) has been shown to predict response and survival in patients with metastatic melanoma treated with anti-programmed cell death 1 (PD-1) antibodies. Pseudoprogression, defined as radiologic finding of disease progression prior to response, has been a challenge to clinicians.

To establish whether ctDNA at baseline and up to week 12 of treatment can differentiate between the radiologic findings of pseudoprogression and true progression in patients with metastatic melanoma.

This explorative biomarker study examined circulating BRAF and NRAS mutations in a cohort of 125 patients with melanoma receiving PD-1 antibodies alone or in combination with ipilimumab between July 3, 2014, and May 24, 2016. Pseudoprogression was defined retrospectively as radiologic progression not confirmed as progressive disease at the next radiologic assessment. Plasma samples of ctDNA at baseline and while receiving treatment were taken for analysis prospectively over the first 12 weeks of treatment. Favorable ctDNA profile (undetectable ctDNA at baseline or detectable ctDNA at baseline followed by greater than 10-fold decrease) and unfavorable ctDNA profile (detectable ctDNA at baseline that remained stable or increased) were correlated with response and prognosis.

Early differentiation of pseudoprogression from true progression using longitudinal ctDNA profile.

According to guidelines by Response Evaluation Criteria in Solid Tumors (RECIST), progressive disease occurred in 29 of the 125 patients (23.2%). Of the 29 patients, 17 (59%) were 65 years or younger, 18 (62%) were men, 9 (31%) had pseudoprogression, and 20 (69%) had true progression. Of the 9 patients (7%) with confirmed pseudoprogression, all patients had a favorable ctDNA profile. At a median follow-up of 110 weeks, 7 of 9 patients (78%) were alive. All but 2 patients with true progression had an unfavorable ctDNA profile. Sensitivity of ctDNA for predicting pseudoprogression was 90% and specificity was 100%. The 1-year survival for patients with RECIST-defined progressive disease and favorable ctDNA was 82% vs 39% for unfavorable ctDNA. Overall survival was longer in patients with a partial response (54 of 125 patients [43%]) compared with patients with progressive disease and a favorable ctDNA profile (11 of 125 patients [9%]).

The results demonstrate that ctDNA profiles can accurately differentiate pseudoprogression from true progression of disease in patients with melanoma treated with PD-1 antibodies. Results of this blood test performed at regular intervals during systemic treatment reflect tumor biology and have potential as a powerful biomarker to predict long-term response and survival.

Here researchers looked at 125 melanoma patients with BRAF and NRAS mutations treated with anti-PD-1 alone or in combination with ipi between July 2014 and May 2016.  They drew their blood before and during the first 12 weeks of their treatment and correlated those findings with the patient's response and prognosis.  Per the RECIST scale, progressive disease occurred in 29 of the 125.  9 had pseudoprogression and 20 had real progression.  "All but 2 of the patients with true progression had an unfavorable ctDNA profile.  Sensitivity of ctDNA for predicting pseudoprogression was 90% and specificity was 100%."  The 1 year survival for the folks with RECIST defined progression but WITH the favorable blood test ctDNA was 82%, while for folks with an unfavorable ctDNA it was only 39%.  "The results demonstrate that ctDNA profiles can accurately differentiate pseudoprogression from true progression of disease in patients with melanoma treated with PD-1 antibodies."

I think we've yammered about this stuff enough.  Consistent, available, defined blood assays need to be made readily available for melanoma patients!!!! C'mon man!!!! - c

Simple blood tests that tell us how melanoma patients are responding to therapy and identify their disease in the first place....AGAIN!!!!

Yep.  It's me again, Margaret.  I'm still yelling about simple blood draws that can provide critical information related to the diagnosis of, feasibility of treatment for, response to treatment, and prognosis generally in melanoma patients!  Just last week I posted this:  More blood tests to determine prognosis as well as response to therapy in melanoma patients!!!

Now, there's this....

Clinical response to PD-1 blockade correlates with a sub-fraction of peripheral central memory CD4+ T cells in patients with malignant melanoma. Takeuchi, Tanemura, Tada, et al.  Int Immunol. 2017 Dec 23.

Cancer immunotherapy that blocks immune checkpoint molecules, such as PD-1/PD-L1, unleashes dysfunctional antitumor T-cell responses and has durable clinical benefits in various types of cancers. Yet its clinical efficacy is limited to a small proportion of patients, highlighting the need for identifying biomarkers that can predict the clinical response by exploring antitumor responses crucial for tumor regression. Here we explored T-cell responses associated with clinical benefits using peripheral blood mononuclear cells (PBMCs) from patients with malignant melanoma treated with anti-PD-1 monoclonal antibody (mAb). Pre- and post-treatment samples were collected from two different cohorts (discovery set and validation set) and subjected to mass cytometry assays that measured the expression levels of 35 proteins. Screening by high dimensional clustering in the discovery set identified increases in three micro-clusters of CD4+ T cells, a subset of central memory CD4+ T cells harboring CD27+FAS-CD45RA-CCR7+ phenotype, after treatment in long-term survivors, but not in non-responders. The same increase was also observed in clinical responders in the validation set. We propose that increases in this subset of central memory CD4+ T cells in peripheral blood can be potentially used as a predictor of clinical response to PD-1 blockade therapy in patients with malignant melanoma.

Here researchers looked at the blood of folks before and after patients with melanoma were treated with anti-PD-1.  They found that a particular type of CD4+ T cell increased in long term survivors and clinical responders...but NOT in non-responders.

That seems pretty straight forward to me!  But, there's more....

A high neutrophil to lymphocyte ratio prior to BRAF inhibitor treatment is a predictor of poor progression-free survival in patients with metastatic melanoma. Finon, Zaragoza, Maillard, et al. Eur J Dermatol. 2018 Jan 16.

Some studies have shown that a high neutrophil/lymphocyte ratio (NLR) greater than or = to 4 before initiating ipilimumab treatment is an independent prognostic indicator of poor survival in patients with metastatic melanoma (MM). To determine whether the NLR before starting BRAF inhibitor (BRAFi) treatment in patients with (MM) is associated with progression-free survival (PFS). This retrospective study included 49 patients consecutively receiving BRAFi for MM between July 2012 and December 2014. Cox proportional hazards regression was used to analyse the relationship between NLR and other factors, such as lactate dehydrogenase (LDH), performance status, BRAFi as first- or second-line therapy, and corticosteroid intake with PFS. The NLR before starting BRAFi was significantly associated with PFS based on univariate analysis and multivariate analysis adjusted for potential confounding factors, such as LDH activity, ulceration, performance status, first-line therapy, and corticosteroid intake. A high NLR (continuous variable) was associated with short PFS, and NLR greater than or = to 4 was associated with shorter PFS . Corticosteroid intake was not associated with short PFS based on multivariate analysis. An NLR greater than 4, before starting BRAFi treatment, is an independent prognostic indicator of poor progression-free survival.

SO.....again ~ folks with a high NLR (greater than or = to 4) did worse!!!  This is NOT news people.  I've been yelling about this since 2015!!!

That fact was valid when the NLR was tested in folks without metastatic disease ~  Neutrophil-to-lymphocyte ratios as a predictor of death from melanoma in patients with NONmetastatic disease
That fact was valid when the NLR was examined in regard to ipi (as noted in the above article) ~  Neutrophils as a prognostic predictor in patients trated with ipi/Yervoy
That fact was valid when first postulated in 2015 ~  Lab values that may predict response to Ipi/Yervoy????

Do we really need to examine that any further???  There is also this...

Development and validation of a plasma-based melanoma biomarker suitable for clinical use.  Van, Lincoln, Van Laar.  Br J Cancer. 2018 Jan 23.

In Australia, more money is spent on skin cancer than any other malignancy. Despite this, the mortality rate of melanoma, the deadliest form, has steadily increased over the past 50 years. Diagnostic imprecision and a lack of complimentary molecular biomarkers are partially responsible for this lack of progress.

Whole-microRNAome profiling was performed on plasma samples from 32 patients with histologically confirmed melanoma and 16 normal controls. A classification algorithm was trained on these data and independently validated on multiple previously published microRNA data sets, representing (i) melanoma patient- and normal-blood, (ii) melanoma and nevi biopsy tissue, and (iii) cell lines and purified exosomes.

38 circulating microRNAs had biologically and statistically significant differences between melanoma and normal plasma samples (MEL38). A support vector machine algorithm, trained on these markers, showed strong independent classification accuracy (AUC 0.79-0.94). A majority of MEL38 genes have been previously associated with melanoma and are known regulators of angiogenesis, metastasis, tumour suppression, and treatment resistance.

MEL38 exhibits disease state specificity and robustness to platform and specimen-type variation. It has potential to become an objective diagnostic biomarker and improve the precision and accuracy of melanoma detection and monitoring.

Here folks looked at blood samples for microRNA whose presence helped define the difference between melanoma and normal plasma.  

I have endless posts regarding the examination of tumor DNA in the blood of melanoma patients, allowing for the identification of disease, BRAF status, progression, response, etc.  Earlier this month, I posted this:  Circulating tumor DNA to help differentiate true progression of melanoma vs pseudoprogression in patients treated with anti-PD-1  Here are about a zillion additional posts:  Circulating melanoma DNA

Really people!  Can someone not do a definitive study on a larger scale...rather than piecemeal this and that....without sharing data...to come up with a valid and specific melanoma panel???  We have simple lipid panels that help guide heart health.  We have lab draws and tests that help diagnosis and monitor diabetes.  No set of labs is an absolute for ANYTHING.  BUT!!!!  They are incredibly important tools in diagnosing, treating and managing a wide variety of disease processes.  They can do that for melanoma, too!!!   We have learned that we can look at T cells, other basic blood cells, tumor DNA, RNA, all sorts of bits and bobs....floating in the blood of patients with melanoma, to provide meaningful information that could allow melanoma patients and their doctors a mechanism for making better choices in their treatment and care.

Radiologic scans expose us to radiation, "find" lots of red herrings, and are a huge financial burden.  They also have limits regarding what they can see.  Sub-centimeter tumors, not to mention little demon melanoma cells floating about, are not visualized.  Additionally, imaging studies are cumbersome and have a built in time lag that can delay needed therapy or a change in current therapy as patients wait for "their next scan" to be compared to a prior one in order to define disease status.  Determining pathology from tumor samples is often confusing.  I had to have my initial slides examined by 3 pathologists to gain consensus that I was in fact dealing with melanoma.  Folks need and deserve answers. A basic algorithim that incorporates all forms of investigation including blood markers, nuclear, radiographic, and tissue examination needs to be established for melanoma. NOW!!!

Seriously..NOW!!! - c

Biomarkers - blood components, circulating tumor cells AND of the tumor itself

Biomarkers.  Sounds important.  What are they?  What can they really tell us? 

Researchers have been seeking to find a connection between nonspecific biomarkers (things we ALL have circulating in our blood) like LDH, various white blood cells (neutrophils and monocytes - whether as an absolute count or as a neutrophil to lymphocyte ratio), myeloid-derived suppressor cells (MDSCs) and T-regs (See post with links about all that here:   Blood markers associated with clinical outcomes).  And while many meaningful correlations have been drawn between these components and response to treatment (or lack thereof); the fact that they are all affected by numerous circumstances other than melanoma and its treatment, create limitations in the clarity with which they can be used to PREDICT responses.

With recent scientific advances, PCR testing (Polymerase chain reaction) has become more efficient and cost-effective, allowing labs to copy or "amplify" small segments of DNA or RNA though screening blood or other biological specimens.  This ability allows the cellular identification of whatever may be floating in that blood sample....whether it is a virus or fungus, or actual bits and pieces of tumor cells themselves, to allow a determination of  disease burden, prognosis, and response to treatment.  Here is an earlier post:  Circulating tumor cells: how they may eventually impact melanoma diagnosis and evaluation of response

Now there are these reports:

Liquid biopsy utility for the surveillance of cutaneous malignant melanoma patients.  Haung and Hoon.  Mol Oncol. 2015 Dec 17.

Cutaneous melanoma is one of the highest incident-rate cancers with increasing prevalence in Western societies. Despite the advent of new approved therapeutics, the 5-year overall survival rate of stage IV melanoma patients remains below 15%. Current treatments for late stage disease have shown higher efficacy when treated at a lower disease burden. Thus, blood-based biomarkers capable of detecting melanoma prior to clinically evident distant metastasis, will improve the treatment and outcomes for melanoma patients. To that end, effective treatment of melanoma necessitates identification of patients at risk for developing distant metastases. Furthermore, employing blood biomarkers that monitor cancer progression over the course of treatment is a promising solution to post-treatment drug resistance often developed in melanoma patients. Non-invasive blood biomarker assays allow for regular dynamic monitoring of disease. "Liquid Biopsy" of blood, which exploits circulating tumor cells (CTCs), cell-free circulating tumor DNA (ctDNA) and cell-free circulating microRNA (cmiRNA), has been shown to detect prognostic factors for relapse in AJCC stage III and stage IV melanoma patients. Moreover, molecular characterization of CTC and analysis of various forms of ctDNA present promising potential in development of individualized therapy for melanoma patients. New approaches such as massive parallel sequencing (MPS) provide a comprehensive view of the disease progression, allowing for the selection of therapeutic options for individual patients. With advancements of improving molecular assays, liquid biopsy analysis as a powerful, routine clinical assay for melanoma patients, is highly promising prospective.

Circulating melanoma cells as a potential biomarker to detect metastasis and evaluate prognosis.  Hida, Yoneta, Wakamatsu, et al.  Australas J Dermatol. 2016 Mar 1.

TNM staging is mainly used to evaluate the prognosis of melanoma patients. Serum biomarkers such as 5-S-cysteinyldopa (5-S-CD) have occasionally been used but most do not respond until the tumour burden becomes high. Recently, circulating melanoma cells (CMC) have been reported as a possible new biomarker to detect metastasis, monitor treatment response and predict prognosis. The object of this exploratory study was to evaluate the efficacy of CMC to detect metastasis and predict prognosis by cross-sectional and prospective observational analyses, respectively. Altogether 15 patients with stages II-IV melanoma were enrolled and CMC were enumerated by CellSearch system with cut-off values of two cells/7.5 mL. Serum 5-S-CD and lactate dehydrogenase (LDH) were also measured. The sensitivity of CMC and 5-S-CD for the detection of metastasis was 33 and 50%, respectively. The combination of CMC and 5-S-CD showed a sensitivity of 67%, the best performance among CMC, 5-S-CD, LDH and any combination of two of the markers. Additionally, a 30-month prospective observation showed that CMC could segregate patients with poorer prognosis. The median survival time for the patients with less than 2 CMC and those with greater than or equal to 2 CMC was 19.5 and 4.5 months, respectively. The limitation of this study is the small sample size. These preliminary results indicate CMC may complement the efficacy of 5-S-CD to detect metastasis and can be a prognostic marker. Although there is still room for improvement to maximize the sensitivity, the CellSearch system is reproducible, standardized and suitable for multi-center studies.

Then, there's the examination of the properties of the tumor sample itself.  This article talks about looking at the tumor in regard to how well it is being recognized by the immune system....specifically t-cells:
 

Melanoma-specific MHC-II expression represents a tumour-autonomous phenotype and predicts response to anti-PD-1/PD-L1 therapy.  Johnson, Estrada, Salgado, Sosman, et al.  Nat Commun.  2016 Jan 29.

Anti-PD-1 therapy yields objective clinical responses in 30-40% of advanced melanoma patients. Since most patients do not respond, predictive biomarkers to guide treatment selection are needed. We hypothesize that MHC-I/II expression is required for tumour antigen presentation and may predict anti-PD-1 therapy response. In this study, across 60 melanoma cell lines, we find bimodal expression patterns of MHC-II, while MHC-I expression was ubiquitous. A unique subset of melanomas are capable of expressing MHC-II under basal or IFNγ-stimulated conditions. Using pathway analysis, we show that MHC-II(+) cell lines demonstrate signatures of 'PD-1 signalling', 'allograft rejection' and 'T-cell receptor signalling', among others. In two independent cohorts of anti-PD-1-treated melanoma patients, MHC-II positivity on tumour cells is associated with therapeutic response, progression-free and overall survival, as well as CD4(+) and CD8(+) tumour infiltrate. MHC-II(+) tumours can be identified by melanoma-specific immunohistochemistry using commercially available antibodies for HLA-DR to improve anti-PD-1 patient selection.

Here...the tumor is being characterized by surface molecules that are correlated with prognosis:

Molecular markers to complement sentinel node status in predicting survival in patients with high risk locally invasive melanoma.  Rowe, Tang, Hughes, et al.  Int J Cancer. 2016 Mar 14. 

Sentinel lymph node status is a major prognostic marker in locally invasive cutaneous melanoma. However this procedure is not always feasible, requires advanced logistics, and carries rare but significant morbidity. Previous studies have linked markers of tumour biology to patient survival. In this study we aimed to combine the predictive value of established biomarkers in addition to clinical parameters as indicators of survival in addition to or instead of sentinel node biopsy in a cohort of high risk melanoma patients. Patients with locally invasive melanomas undergoing sentinel lymph node biopsy were ascertained and prospectively followed. Information on mortality was validated through the National Death Index. Immunohistochemistry was used to analyse proteins previously reported to be associated with melanoma survival, namely Ki67, p16, and CD163. Evaluation and multivariate analyses according to REMARK criteria were used to generate models to predict disease-free and melanoma-specific survival. 189 patients with available archival material of their primary tumour were analysed. Our study sample was representative of the entire cohort (N=559). Average Breslow thickness was 2.5 mm. 32 (17%) patients in the study sample died from melanoma during the follow-up period. A prognostic score was developed and was strongly predictive of survival, independent of sentinel node status. The score allowed classification of risk of melanoma death in sentinel node negative patients. Combining clinicopathological factors and established biomarkers allows prediction of outcome in locally invasive melanoma and might be implemented in addition to or in cases when sentinel node biopsy cannot be performed.

Here the tumor is being analyzed for specific genetic variations:   

Genomic and Transcriptomic Features of Response to Anti-PD-1 Therapy in Metastatic Melanoma.  Hugo, Zaretsky, Sun, et al.  Cell. 2016 Mar 15. 

PD-1 immune checkpoint blockade provides significant clinical benefits for melanoma patients. We analyzed the somatic mutanomes and transcriptomes of pretreatment melanoma biopsies to identify factors that may influence innate sensitivity or resistance to anti-PD-1 therapy. We find that overall high mutational loads associate with improved survival, and tumors from responding patients are enriched for mutations in the DNA repair gene BRCA2. Innately resistant tumors display a transcriptional signature (referred to as the IPRES, or innate anti-PD-1 resistance), indicating concurrent up-expression of genes involved in the regulation of mesenchymal transition, cell adhesion, extracellular matrix remodeling, angiogenesis, and wound healing. Notably, mitogen-activated protein kinase (MAPK)-targeted therapy (MAPK inhibitor) induces similar signatures in melanoma, suggesting that a non-genomic form of MAPK inhibitor resistance mediates cross-resistance to anti-PD-1 therapy. Validation of the IPRES in other independent tumor cohorts defines a transcriptomic subset across distinct types of advanced cancer. These findings suggest that attenuating the biological processes that underlie IPRES may improve anti-PD-1 response in melanoma and other cancer types.

While none of these (other than those that are simple measures of recognized blood components) are validated and ready for daily screening of cancer patients across this country....every step is important in helping docs...eventually....determine the best treatment options for the individual and monitor their response to that treatment in ways that are specific, easily measured, and less invasive and damaging to that patient.  What a beautiful day that will be!!!  Minimized only by the day we figure out how to avoid cancer entirely!  Hey....might as well live large and dream big!!! - c

Circulating tumor DNA in melanoma - Yep. AGAIN!!!

If you've hung around this space for half a minute, you know that I've long been yelling about "liquid assays" (including ctDNA) that can diagnose, predict, and evaluate progression or response in melanoma patients.  Perhaps more importantly, despite the clear benefit of these tests, they remain pretty much unavailable to most melanoma patients.  Here are only a zillion reports: Melanoma and circulating tumor DNA

Now there are these:

Prediction and monitoring of relapse in stage III melanoma using circulating tumor DNA.  Tan, Sandhu, Lee, et al.  Ann Oncol.  2019 May 30.

The advent of effective adjuvant therapies for patients with resected melanoma has highlighted the need to stratify patients based on risk of relapse given the cost and toxicities associated with treatment. Here we assessed circulating tumor DNA (ctDNA) to predict and monitor relapse in resected stage III melanoma.

Somatic mutations were identified in 99/133 (74%) patients through tumor tissue sequencing. Personalized droplet digital PCR (ddPCR) assays were used to detect known mutations in 315 prospectively collected plasma samples from mutation-positive patients. External validation was performed in a prospective independent cohort (n=29).

ctDNA was detected in 37 of 99 (37%) individuals. In 81 patients who did not receive adjuvant therapy, 90% of patients with ctDNA detected at baseline and 100% of patients with ctDNA detected at the postoperative time point relapsed at a median follow up of 20 months. ctDNA detection predicted patients at high risk of relapse at baseline and postoperatively. ctDNA detection at baseline and postoperatively was also associated with inferior distant metastasis-free survival (DMFS). These findings were validated in the independent cohort. ctDNA detection remained an independent predictor of RFS and DMFS in multivariate analyses after adjustment for disease stage and BRAF mutation status.  Baseline and postoperative ctDNA detection in two independent prospective cohorts identified stage III melanoma patients at highest risk of relapse and has potential to inform adjuvant therapy decisions.

Circulating tumor cells and early relapse in node-positive melanoma.  Lucci, Hall, Patel, et al.  Clin Cancer Res. 2020 Feb 3. There is a need for sensitive, reproducible biomarkers for stage III melanoma patients to guide clinical decision making. Circulating tumor cells (CTCs) can be detected in melanoma patients; however, there is limited data regarding their significance in stage III disease. The aim of this study was to determine if CTCs are associated with early relapse in stage III melanoma. We prospectively assessed CTCs at first presentation in clinic (baseline) for 243 stage III melanoma patients. CTCs were measured using the CellSearch System. Relapse-free survival (RFS) was compared between patients with one or more baseline CTC versus those with no CTCs. Log-rank test and Cox regression analysis were applied to establish associations of CTCs with RFS. At least one baseline CTC was identified in 90/243 (37%) patients. Forty-five (19%), 67 (28%), 118 (49%), and 13 (5%) patients were stage IIIA, IIIB, IIIC, or IIID, respectively. CTC detection was not associated with sub stage, or primary tumor characteristics. Multivariable analysis demonstrated that the detection of greater than/= to 1 baseline CTC was significantly associated with decreased 6 month RFS and 54 month RFS. Greater than/= to 1 CTC was independently associated with melanoma relapse, suggesting that CTC assessment may be useful to identify patients at risk for relapse who could derive benefit from adjuvant therapy.

Circulating tumour cells as tumour biomarkers in melanoma: detection methods and clinical relevance.  Khola, Lorigan, Dive, et al.  Ann Oncol.  2019 Dec 4.

Circulating tumour cells (CTCs) are cells of solid tumour origin detectable in the peripheral blood. Their occurrence is considered a prerequisite step for establishing distant metastases. Metastatic melanoma was the first malignancy in which CTCs were detected and numerous studies have been published on CTC detection in melanoma at various stages of disease. In spite of this, there is no general consensus as to the clinical utility of CTCs in melanoma, largely due to conflicting results from heterogeneous studies and discrepancies in methods of detection between studies. In this review, we examine the possible clinical significance of CTCs in cutaneous, mucosal and ocular melanoma, focusing on detection methods and prognostic value of CTC detection.

Despite very convincing data and a desperate need in the patient population these tests remain unavailable to the average patient.  Will the desire of firms to make a buck, make a difference?

This report from CNBC tech, 2/2020 :  These start-ups are racing to help doctors detect cancer early with a simple blood test

Which states, in part:  "Getting a blood test to screen for cancer in the earliest stages might seem like a pipe dream. But a group of biotech entrepreneurs say they’re close to making it a reality. If Gabriel Otte’s start-up, Freenome, is successful, millions of people could get a blood test to screen for early-stage colorectal cancer. Freenome looks for two major biomarkers in the blood. It’s simultaneously hunting for tiny fragments of DNA that are shed into the bloodstream from a tumor, as well as early signals that the patient’s immune system is starting to respond.  The medical industry has known for years that that blood-based “liquid biopsies” can find signatures of cancer. But the tests on the market today focus on monitoring the progression of the disease once a patient has been diagnosed with cancer, including how it’s responding to treatment.  The next generation of companies want to detect cancer while it’s early and often easier to treat."

We know these tests work.  We know they could provide a great deal of helpful information for melanoma patients facing hard choices.  It is past time that they be made available.  For what it's worth. ~ c

Radiological evaluation of response to melanoma treatments

Another reason liquid assays (as discussed here last month:  Blood tests to diagnose, check response to therapy, and use as follow-up in melanoma! ) would be so helpful:

Patterns of response to anti-PD-1 treatment: an exploratory comparison of four radiological response criteria and associations with overall survival in metastatic melanoma patients.  Khoja, Kibiro, Metser, et al. Br J Cancer. 2016 Oct 4.  

Radiological assessment of response to checkpoint inhibitors remains imperfect. We evaluated individual lesion and inter-patient response by response evaluation (RECIST) 1.1, immune-related response criteria (irRC), CHOI and modified CHOI (mCHOI) and correlated response with overall survival (OS). Thirty-seven patients with 567 measurable lesions treated with pembrolizumab in the Keynote 001 trial were studied. Association of response with OS was determined.  Response varied according to site; lung lesions had the highest rate of complete response (69 out of 163 (42%) vs other sites 71 out of 404 (18%). Delayed response post first scan was seen in 2 out of 37 (5%) deemed progressive (PD) by RECIST and 2 out of 14 (14%) deemed PD by irRC. Modified CHOI criteria showed response of 38% (14 out of 37). Change in tumour size and density on first follow-up assessment was associated with OS with each 1000 mm² increase in tumour size from baseline increasing the hazard of dying by 25.9%.  Response defined by any criteria had superior OS. Response by any criterion was prognostic. Novel patterns of response and changes on treatment in tumour density suggest complex anti-tumour responses to immunotherapy.  

Then there is this report on using ultrasound to determine progression vs pseudo progression ~
 
Ultrasonographic findings can identify 'pseudoprogression' under nivolumab therapy.   Imafuku, Hata, Kitamura, et al.  Br J Dermatol. 2016 Nov 22. 

'Pseudoprogression' is often seen in patients with melanomas who are treated with immune-checkpoint inhibitors such as nivolumab or ipilimumab. We sometimes evaluate metastatic lesions by imaging tests such as CT or PET-CT. 'Pseudoprogression' usually occurs upon the initial administration, which may make it difficult for the physician to determine the disease condition. In our two cases of metastatic melanoma treated with nivolumab (anti-PD-1 antibody), we examined the ultrasonography (US) of target lesions that could be accessed from the body surface, such as those of the regional lymph node or subcutaneous metastasis. In both cases, the US revealed a lesion approximately 10% greater in size after 40-50 days of nivolumab administration, even though the blood flow inside the tumour was reduced by about 20% within 50 days. From about 100 days after blood flow reduction was detected by US, the tumours began to decrease in size. However, contrast CT was unable to detect the association between tumour size and tumour blood flow. The present cases suggest that US could be a powerful tool for differentiating between 'pseudoprogression' and real progressive disease in patients treated with cancer immunotherapies such as those involving immune-checkpoint inhibitors. The misdiagnosis of progressive disease can lead to unnecessary alternations in the current treatment. Therefore, the US findings in our study could be clinically useful and educational for physicians.  

Good data to know when depending on radiology studies as evaluation of status and progression.  But wouldn't it be nice to just do a blood draw????  At least some of the time???? - c

Blood tests to diagnose, check response to therapy, and use as follow-up in melanoma!

Also from the Boston Conference, Society for Melanoma Research -

And as I said earlier this year:   A valid and specific blood draw that could help diagnose, determine the presence of a response to therapy, and be used as follow-up (instead of scans!) would be sooooooooooo  awesome!!!!  Now there's this: 

Non-invasive monitoring of treatment response to immunotherapy in patients with metastatic melanoma.  Gray, Pereira, Calapre, et al.

Current methods for monitoring melanoma dynamics during treatment are limited to LDH levels and imaging to estimate tumour burden. In particular, responses to immune checkpoint inhibitors vary greatly in timing and extent, and may not be accurately reflected through radiological examination. The analysis of circulating tumour DNA (ctDNA) through sensitive methods can provide a rapid, accurate and quantitative method to determine therapeutic effect as early as possible. In this study mutation-specific droplet digital PCR was used to measure plasma concentrations of oncogenic BRAF, NRAS and TERT variants in 47 patients with advanced metastatic melanoma before commencing treatment with the immune checkpoint inhibitors pembrolizumab (N=30) or ipilimumab (N=17). Tumour-associated ctDNA was detected in 32/47 (68%) plasma prior to treatment, in 76% (N=17) of BRAF mutant and 100% (N=2) of NRAS mutant melanomas. In addition, TERT promoter mutations were detected in the plasma of 61% (N=28) of BRAF/NRAS wild-type cases. Monitoring of ctDNA levels in patients positive at baseline, showed a decrease in ctDNA in response to therapies prior to or concurrently with radiographic response. However, a delayed pattern of response was observed in comparison with our previous data in patients treated with MAPK inhibitors, and consistent with clinical measures of response in ipilimumab and pembrolizumab clinical trials. In conclusion, this study demonstrates the utility of ddPCR assays to monitor ctDNA in the plasma of melanoma patients undergoing immunotherapy.  
Yep!  Been yelling about this for some time:

Here's a post about BRAF testing via a blood draw with lots of previous links to liquid biopsy info:  BRAF testing via blood draw....and more

Here's another demonstrating the value of such non-invasive monitoring:  Melanoma antigens in blood are prognostic of OS and correlate with response to ipi

C'mom man!!!  Let's get this going....for everybody!!! -  c

Circulating DNA (ctDNA) Yes, again! A noninvasive method of diagnosing and monitoring melanoma patients

Yep.  Another thing I have been yelling about for years.  Circulating tumor DNA.  Something we can measure in the blood of melanoma patients.  Here are zillions of reports:  Important stuff floating in our blood - tumor DNA, micro RNA, cytokines - can determine tumor burden, predict response, and side effects for melanoma patients!!!  Now, there's this:

ctDNA as a noninvasive monitoring tool in metastatic melanoma.  2019 ASCO.  Varaljai, Wistuba-Hamprecht, Seremet, et al.  J Clin Oncology 37, 2019.

Background: The field of liquid biopsy provides a promising alternative to standard tissue biopsies. Previous work has shown that plasma circulating cell-free DNA (ctDNA) can reflect the heterogeneous spectrum of mutations in cancer including metastatic melanoma. Our project aimed to establish and statistically validate plasma-based assays for tumour load and therapy monitoring in melanoma. Methods: On a large cohort of stage III and stage IV melanoma patients (N = 96) who received signalling targeted or immune checkpoint inhibitors we showed that the most common oncogenic drivers of this disease such as the BRAFV600E, NRASQ61 and the TERTC250T and TERTC228T promoter mutations (termed TERTprom) can be analysed in ctDNA with highly sensitive droplet digital PCR technology (detection of mutant ctDNA down to 0.01% analytical sensitivity). Results: Our research has demonstrated that ctDNA (irrespective of the genotype) significantly correlates with tumour stage. Using receiver operating characteristics (ROC) analyses thresholds were established for risk stratification and response prediction. Elevated ctDNA at baseline was a significant predictor of disease progression compared to elevated LDH or S100 in multivariable cox proportional hazards model. During therapy, patients with low ctDNA load (below the ROC threshold) had significantly better radiological outcomes and prolonged progression free survival (PFS) compared to patients with high ctDNA load. Our findings were confirmed on an independent cohort of metastatic melanoma patients (N = 35) treated with immune checkpoint inhibitors, where also during therapy low ctDNA load correlated with prolonged PFS. An added benefit of ctDNA was demonstrated in about 80% of the patients, where ctDNA analyses preceded the radiological diagnosis of response or relapse. Progression was detected in plasma ctDNA in average 3.5 months earlier as compared to routine imaging techniques. Finally, we demonstrated that the occurrence of NRASQ61 mutation in BRAFV600-inhibitor treated patients at therapy baseline was associated with treatment failure. The sub-clonal NRASQ61 mutation at therapy baseline was an independent predictor of shorter PFS as compared to BRAFV600E patients without the NRASQ61 mutation at therapy baseline. Conclusions: In sum, our results support the value of ctDNA as a sensitive biomarker for real-time therapy monitoring and early detection of disease progression.

It works!  Doesn't require surgical biopsy.  Shows results months sooner than radiological imaging techniques and doesn't expose the patient to radiation.  What are we waiting on??????

There is also, this:

Circulating Cell-Free DNA-Diagnostic and Prognostic Applications in Personalized Cancer Therapy.  Oellerich, Schutz, Beck, Walson.  Ther Drug Monit. 2019 Apr.

Genomic analyses in oncologic care allow for the development of more precise clinical laboratory tests that will be critical for personalized pharmacotherapy. Traditional biopsy-based approaches are limited by the availability of sequential tissue specimens to detect resistance. Blood-based genomic profiling ("liquid biopsy") is useful for longitudinal monitoring of tumor genomes and can complement biopsies. Tumor-associated mutations can be identified in cell-free tumor DNA (ctDNA) from patient blood samples and used for monitoring disease activity. The US Food and Drug Administration approved a liquid biopsy test for EGFR-activating mutations in patients with non-small-cell lung cancer as a companion diagnostic for therapy selection. ctDNA also allows for the identification of mutations selected by treatment such as EGFR T790M in non-small-cell lung cancer. ctDNA can also detect mutations such as KRAS G12V in colorectal cancer and BRAF V600E/V600K in melanoma. Chromosomal aberration pattern analysis by low-coverage whole genome sequencing is a new, broader approach. Genomic imbalances detected in cell-free DNA (cfDNA) can be used to compute a copy number instability (CNI) score. In clinical studies, it was demonstrated that the change in CNI score can serve as an early predictor of therapeutic response to chemotherapy/immunotherapy of many cancer types. In multivariable models, it could be shown that the CNI score was superior to clinical parameters for prediction of overall survival in patients with head and neck cancer. There is emerging evidence for the clinical validity of ctDNA testing regarding identification of candidates for targeted therapies, prediction of therapeutic response, early detection of recurrence, resistance mutation detection, measuring genetic heterogeneity, tumor burden monitoring, and risk stratification. Improvement of sensitivity to detect tumors at very early stages is difficult due to insufficient mutant DNA fraction of less than/= to 0.01%. Further developments will include validation in prospective multicenter interventional outcome studies and the development of digital platforms to integrate diagnostic data.

The technology exists to make this simple test available - impacting melanoma patients in lots of ways!  Let's make it so!!!

And, yes.  There is still beauty -

 - despite the storm.  ~ les

Circulating tumor DNA (ctDNA) the little bits of tumor floating in our blood and how they can impact melanoma patients

In this post, replete with many links within - Circulating tumor DNA to monitor and predict response in melanoma patients - yes - AGAIN!!!!  - from earlier this year, I wrote:  "I first posted articles related to blood analysis to evaluate circulating tumor DNA in 2014.  It is a fairly non-invasive and relatively painless way to diagnose melanoma, measure tumor burden, and evaluate progression or response in melanoma patients.  It may even indicate those who are more likely to respond to a particular therapy.  Unfortunately, it is not commonly utilized."  Now there are these reports: 

Circulating tumour DNA in patients with advanced melanoma treated with dabrafenib or dabrafenib plus trametinib: a clinical validation study.  Syeda, Wiggins, Corless, et al.  Lancet Oncol.  Feb 2021.

Background: Melanoma lacks validated blood-based biomarkers for monitoring and predicting treatment efficacy. Cell-free circulating tumour DNA (ctDNA) is a promising biomarker; however, various detection methods have been used, and, to date, no large studies have examined the association between serial changes in ctDNA and survival after BRAF, MEK, or BRAF plus MEK inhibitor therapy. We aimed to evaluate whether baseline ctDNA concentrations and kinetics could predict survival outcomes.

Methods: In this clinical validation study, we used analytically validated droplet digital PCR assays to measure BRAFV600-mutant ctDNA in pretreatment and on-treatment plasma samples from patients aged 18 years or older enrolled in two clinical trials. COMBI-d (NCT01584648) was a double-blind, randomised phase 3 study of dabrafenib plus trametinib versus dabrafenib plus placebo in previously untreated patients with BRAFV600 mutation-positive unresectable or metastatic melanoma. Patients had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. COMBI-MB (NCT02039947) was an open-label, non-randomised, phase 2 study evaluating dabrafenib plus trametinib in patients with BRAFV600 mutation-positive metastatic melanoma and brain metastases. Patients in cohort A of COMBI-MB had asymptomatic brain metastases, no previous local brain-directed therapy, and an ECOG performance status of 0 or 1. Biomarker analysis was a prespecified exploratory endpoint in both trials and performed in the intention-to-treat populations in COMBI-d and COMBI-MB. We investigated the association between mutant copy number (baseline or week 4 or zero conversion status) and efficacy endpoints (progression-free survival, overall survival, and best overall response). We used Cox models, Kaplan-Meier plots, and log-rank tests to explore the association of pretreatment ctDNA concentrations with progression-free survival and overall survival. The effect of additional prognostic variables such as lactate dehydrogenase was also investigated in addition to the mutant copy number.

Findings: In COMBI-d, pretreatment plasma samples were available from 345 (82%) of 423 patients and on-treatment (week 4) plasma samples were available from 224 (53%) of 423 patients. In cohort A of COMBI-MB, pretreatment and on-treatment samples were available from 38 (50%) of 76 patients with intracranial and extracranial metastatic melanoma. ctDNA was detected in pretreatment samples from 320 (93%) of 345 patients (COMBI-d) and 34 (89%) of 38 patients (COMBI-MB). When assessed as a continuous variable, elevated baseline BRAFV600 mutation-positive ctDNA concentration was associated with worse overall survival outcome, independent of treatment group and baseline lactate dehydrogenase concentration, in COMBI-d. A ctDNA cutoff point of 64 copies per mL of plasma stratified patients enrolled in COMBI-d as high risk or low risk with respect to survival outcomes and was validated in the COMBI-MB cohort. In COMBI-d, undetectable ctDNA at week 4 was significantly associated with extended progression-free and overall survival, particularly in patients with elevated lactate dehydrogenase concentrations.

Interpretation: Pretreatment and on-treatment BRAFV600-mutant ctDNA measurements could serve as independent, predictive biomarkers of clinical outcome with targeted therapy.

Circulating tumour DNA and melanoma survival: A systematic literature review and meta-analysis.  Gandini, Zanna, De Angelis, et al.  Crit Rev Oncol Hematol.  Jan 2021.

We reviewed and meta-analysed the available evidence (until December 2019) about circulating tumour DNA (ctDNA) levels and melanoma patients survival. We included twenty-six studies (more than 2000 patients overall), which included mostly stage III-IV cutaneous melanoma patients and differed widely in terms of systemic therapy received and somatic mutations that were searched. Patients with detectable ctDNA before treatment had worse progression-free survival (PFS) and overall survival (OS), with no difference by tumour stage. ctDNA detectability during follow-up was associated with poorer PFS and OS; in the latter case, the association was stronger for stage IV vs. III melanomas. Between-estimates heterogeneity was low for all pooled estimates. ctDNA is a strong prognostic biomarker for advanced-stage melanoma patients, robust across tumour (e.g. genomic profile) and patients (e.g. systemic therapy) characteristics.

The Prognostic Impact of Circulating Tumour DNA in Melanoma Patients Treated with Systemic Therapies-Beyond BRAF Mutant Detection.  Marsavela, Johansson, Pereira, et al.  Cancers (Basel).  Dec 2020.

In this study, we evaluated the predictive value of circulating tumour DNA (ctDNA) to inform therapeutic outcomes in metastatic melanoma patients receiving systemic therapies. We analyzed 142 plasma samples from metastatic melanoma patients prior to commencement of systemic therapy: 70 were treated with BRAF/MEK inhibitors and 72 with immunotherapies. Patient-specific droplet digital polymerase chain reaction assays were designed for ctDNA detection. Plasma ctDNA was detected in 56% of patients prior to first-line anti-PD1 and/or anti-CTLA-4 treatment. The detection rate in the immunotherapy cohort was comparably lower than those with BRAF inhibitors (76%). Decreasing ctDNA levels within 12 weeks of treatment was strongly concordant with treatment response and predictive of longer progression free survival. Notably, a slower kinetic of ctDNA decline was observed in patients treated with immunotherapy compared to those on BRAF/MEK inhibitors. Whole exome sequencing of ctDNA was also conducted in 9 patients commencing anti-PD-1 therapy to derive tumour mutational burden (TMB) and neoepitope load measurements. The results showed a trend of high TMB and neoepitope load in responders compared to non-responders. Overall, our data suggest that changes in ctDNA can serve as an early indicator of outcomes in metastatic melanoma patients treated with systemic therapies and therefore may serve as a tool to guide treatment decisions.

Yep!  THAT LAST SENTENCE!!!

Prognostic Value of ctDNA Mutation in Melanoma: A Meta-Analysis.  Zheng, Sun, Cong, et al.  J Oncol.. May 2021.

Purpose: Melanoma is the most aggressive form of skin cancer. Circulating tumor DNA (ctDNA) is a diagnostic and prognostic marker of melanoma. However, whether ctDNA mutations can independently predict survival remains controversial. This meta-analysis assessed the prognostic value of the presence or change in ctDNA mutations in melanoma patients.

Methods: We identified studies from the PubMed, EMBASE, Web of Science, and Cochrane databases. We estimated the combined hazard ratios (HRs) for overall survival (OS) and progression-free survival (PFS) using either fixed-effect or random-effect models based on heterogeneity.

Results: Sixteen studies including 1,781 patients were included. Both baseline and posttreatment detectable ctDNA were associated with poor OS. For PFS, baseline detectable ctDNA may be associated with adverse PFS and baseline high ctDNA and increased ctDNA were significantly associated with adverse PFS. The baseline BRAFV600 ctDNA mutation-positive group was significantly associated with adverse OS compared with the baseline ctDNA-negative group. There were no significant differences in PFS between the baseline BRAFV600 ctDNA mutation-detectable group and the undetectable group.

Conclusion: The presence or elevation of ctDNA mutation or BRAFV600 ctDNA mutation was significantly associated with worse prognosis in melanoma patients.

Liquid biopsy and radiological response predict outcomes following discontinuation of targeted therapy in patients with BRAF mutated melanoma. Di Guardo, Randon, Corti, et al.  Oncologist. August 2021.

Background: Outcomes of patients with metastatic melanoma discontinuing BRAF-targeted therapy for cumulative toxicity after sustained response are unknown.

Patients and methods: This retrospective case series analysis conducted at a single Cancer Center in Italy included patients with BRAF mutated metastatic melanoma treated with a BRAF inhibitor as a single agent or in combination with a MEK inhibitor between June 1, 2011 and January 1, 2020 and interrupting treatment after achieving complete response (CR) or long-lasting partial response (PR - i.e. greater than 12 months) due to cumulative toxicity.

Results: We included 24 patients with a median treatment duration of 59.4 months. CR and PR were achieved in 71% and 29% of patients, respectively. At a median follow-up after treatment discontinuation of 37.8 months, 12-months progression free survival after discontinuation (dPFS) rate was 70.8% and 24-months dPFS rate was 58.3%. Baseline patients and tumor characteristics as well as treatment duration and best response did not significantly impact on dPFS. Patients with CR and negative circulating tumor DNA (ctDNA) at time of discontinuation had a significantly improved dPFS compared to patients with either radiological residual disease or ctDNA positivity. No patient in CR with undetectable ctDNA experienced progression.

Conclusion: The risk of progression is high even in patients with sustained sensitivity to BRAF/MEK inhibitors. Integration of liquid biopsy in clinical trials investigating optimal management of patients with sustained sensitivity to BRAF/MEK inhibitors is warranted.

Implications for practice: Outcomes of patients with metastatic melanoma discontinuing BRAF-targeted therapy for cumulative toxicity are unknown. We analyzed patients with sustained responses (median treatment duration 59.4 months). Twelve and 24-months progression free survival following discontinuation were 70.8% and 58.3% respectively. Complete response and negative ctDNA at time of discontinuation are promising prognostic biomarkers in this setting.

Detection of clinical progression through plasma ctDNA in metastatic melanoma patients: a comparison to radiological progression.  Marsavela, McEvoy, Pereira, et al.  Br J Cancer.  August 2021.

Background: The validity of circulating tumour DNA (ctDNA) as an indicator of disease progression compared to medical imaging in patients with metastatic melanoma requires detailed evaluation.

Methods: Here, we carried out a retrospective ctDNA analysis of 108 plasma samples collected at the time of disease progression. We also analysed a validation cohort of 66 metastatic melanoma patients monitored prospectively after response to systemic therapy.

Results: ctDNA was detected in 62% of patients at the time of disease progression. For 67 patients that responded to treatment, the mean ctDNA level at progressive disease was significantly higher than at the time of response. However, only 30 of these 67 (45%) patients had a statistically significant increase in ctDNA by Poisson test. A validation cohort of 66 metastatic melanoma patients monitored prospectively indicated a 56% detection rate of ctDNA at progression, with only two cases showing increased ctDNA prior to radiological progression. Finally, a correlation between ctDNA levels and metabolic tumour burden was only observed in treatment naïve patients but not at the time of progression in a subgroup of patients failing BRAF inhibition (N = 15).

Conclusions: These results highlight the low efficacy of ctDNA to detect disease progression in melanoma when compared mainly to standard positron emission tomography imaging.

I think the vast preponderance of the evidence shows that knowing the presence of and/or quantity of bits of melanoma floating in your blood stream gives the patient and their physician important information that can impact treatment choice.  That same data can help make decisions about whether or not to stop or change treatments.  Many studies have demonstrated that this simple blood draw can tell you your status weeks to months sooner than tumors can be seen on radiographic studies.  The last study above stands in contrast to that but I try to be complete.  I will say that it is important to note that the study above was a retrospective review of 108 blood samples collected at the time of disease progression vs 66 patients monitored after response to systemic therapy.  I don't think that is the best way to collect and compare data - maybe that's just me.  I leave you with this ~

The prognostic value of circulating tumor DNA in patients with melanoma: A systematic review and meta-analysis.  Feng, Cen, Tan, et al.  Transl Oncol.  June 2021.

Background: Circulating tumor DNA (ctDNA) has been investigated as a potential prognostic biomarker to evaluate the therapeutic efficacy and disease progression in melanoma patients, yet results remain inconclusive. The purpose of this study was to illustrate the prognostic value of ctDNA in melanoma.

Objectives: To describe the clinical prognostic value of ctDNA for melanoma patients.

Methods: Searched for eligible articles from Pubmed, Web of Science and Embase. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated to evaluate the association between ctDNA at baseline or during treatment and overall survival (OS) and progression-free survival (PFS).

Results: A total of 9 articles were obtained, involving 617 melanoma patients. The pooled HRs revealed that compared with baseline undetectable ctDNA patients, detectable ctDNA was highly correlated with poor OS and PFS. A meta-analysis of these adjusted HRs was performed and confirmed that ctDNA collected at baseline was associated with poorer OS/PFS. During treatment, a significant association was shown between ctDNA and poorer OS/PFS.

Conclusion: Investigation and application of ctDNA will improve "liquid biopsy" and play a role in early prediction, monitoring disease progression and precise adjusting treatment strategies in melanoma patients.

For me, I think ctDNA can provide valuable information that we can use when having to make the incredibly difficult decisions faced by cancer patients.  Coming soon - putting my money and my blood - where my mouth is. Hang tough. - c 

Ditzels!!! Ancillary findings on routine melanoma scans!

Yep.  Ditzels are a thing!!  Incidentals found during routine radiologic studies.  I've found gall stones, sparkly doo dads in my thyroid, and uterine fibroids...all of which were doing me NO HARM...in the process of years of scans and surveys to follow my melanoma.  Alternatively, a routine chest x-ray in 2010 (of all simple things) revealed a lesion within the right main bronchus of my lung that no one could believe was melanoma for months - until it was finally biopsied via a bronchoscopy.  Then there's the funny looking, "probably mucoid", appendix that showed up on my final melanoma scans in August that turned out to be ex-goblet cell carcinoma (GCC)!!!!  And I am not alone...

False-Positive Results and Incidental Findings with Annual CT or PET/CT Surveillance in Asymptomatic Patients with Resected Stage III Melanoma.  Nijhuis, Dieng, Khanna, et al.  Ann Surg Oncol. 2019 Mar 25. 

The aim of this study was to quantify false-positive and incidental findings from annual surveillance imaging in asymptomatic, American Joint Committee on Cancer stage III melanoma patients.

This was a cohort study of patients treated at Melanoma Institute Australia (2000-2015) with baseline computed tomography (CT) or positron emission tomography (PET)/CT imaging and at least two annual surveillance scans. False-positives were defined as findings suspicious for melanoma recurrence that were not melanoma, confirmed by histopathology, subsequent imaging, or clinical follow-up, while incidental findings were defined as non-melanoma-related findings requiring further action. Outcomes of incidental findings were classified as 'benign' if they resolved spontaneously or were not seriously harmful; 'malignant' if a second malignancy was identified; or 'other' if potentially harmful.

Among 154 patients, 1022 scans were performed (154 baseline staging, 868 surveillance) during a median follow-up of 85 months; 57 patients (37%) developed a recurrence. For baseline and surveillance imaging, 124 false-positive results and incidental findings were identified in 81 patients (53%). The frequency of these findings was 5-14% per year, and an additional 181 tests, procedures, and referrals were initiated to investigate these findings. The diagnosis was benign in 109 findings of 124 findings (88%). Fifteen patients with a benign finding underwent an unnecessary invasive procedure. Surveillance imaging identified distant metastases in 20 patients (13%).

False-positive results and incidental findings occur in at least half of all patients undergoing annual surveillance imaging, and the additional healthcare use is substantial. These findings persist over time. Clinicians need to be aware of these risks and discuss them with patients, alongside the expected benefits of surveillance imaging.

So, yeah.  Right now, with imaging being the preferred method of follow-up for melanoma peeps, at least half of us will experience findings that will have to be investigated (to some extent) that will NOT be melanoma!  DO NOT FREAK OUT!!!  Unfortunately, this is to be expected.  Still, we must be diligent and pursue needed answers when weird things show up.  All the more reason for putting blood assays that test for melanoma specifically and tangentially into practice sooner rather than later!!!  Here's the latest on that front (with a zillion links within) posted just last month:  Circulating tumor DNA (ctDNA)  

Hang tough melanoma peeps!  Ours is not an easy path.  But, it is one that we can not only walk down, but run through!!! - c