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Acral melanoma tumors may require more aggressive surgical treatment

 

Gunmaste PV. J Clin Oncol. 32:5s, 2014. (suppl; abstr 9052).

 

June 11, 2014

 

 

Acral melanoma was found to have higher recurrence and lower survival rates than other types of melanoma and may require more aggressive surgical intervention, according to researchers.

 

    

The researchers selected patients from a prospectively enrolled cohort of primary melanoma patients at NYU Langone Medical Center; 61 patients with acral melanoma and 183 patients with non-acral melanoma were included. Median follow-up was 33 months in the acral melanoma cohort and 58 months in the non-acral melanoma cohort.

 

Compared with non-acral melanoma, the acral histologic subtype was found to be an independent negative predictor of recurrence-free survival (P < .001) and melanoma-specific survival (P = .001), according to the researchers.

 

Recurrence rates were significantly higher in patients with acral melanoma (49%) compared with patients who had non-acral melanoma (30%; P = .007).

 

The researchers also found that in tumors with a thickness of less than 2 mm, there was a significantly higher recurrence rate of acral melanoma at 28% compared with non-acral melanoma at 10% (P = .048). Additionally, the rate of loco-regional recurrence was nearly double among patients with acral melanoma (39%) compared with patients who had non-acral melanoma (19%; P = .001).

 

Disclosure: The study was supported by the Perlmutter NYU Cancer Institute NCI Cancer Center Support Grant (5 P30 CA 016087-2), and the Marc Jacobs Campaign to support melanoma research. Stein received support by the Irwin I. Lubowe Fellowship in Dermatology.

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DZnDef's picture
Replies 16
Last reply 6/12/2014 - 8:59pm
Replies by: DZnDef, Swanee, joelcairo, Sherron, Anonymous

Hi all,

I just had my follow up CT scan on June 9th with Dr. Steven O'Day at the Beverly Hills Cancer Center.  My previous  scan was February 7th.  I had met with Dr. O'Day a couple of months prior and had asked him if he thought I had time (given the status of my cancer) to first address my overall health before beginning treatment.  He thought that would be ok (though its not a request he hears often) as I had two small tumors in my lung (13mm and 9 mm) and no where else.  I am also BRAF V600E so if the tumors got out of control, he was confident he could shrink them with a BRAF inhibitor before putting me on Yervoy.  He also referred me to a Naturopath that he has worked closely with in the past.

I quit my job (too stressful and thankfully, we can live on one income), radically changed my diet and began supplementing (under my Naturopath's advice).  I had just over one month of that under my belt before the June 9th scans.

The full body CT scan showed no new tumors anywhere.  Other random pre-existing spots were unchanged (unknown if those are melanoma or not - likely not per the radiologist).  The two known melanomas in the lung each grew by 1 mm over the 4 month interval.

Dr. O'Day suggested that I keep doing what I'm doing if I'm comfortable with that and to scan again in 3 or 4 months.

I confess that I'm curious to see if I can favorably impact this disease using natural methods.  I'm willing to be my own guinea pig for this experiment as I feel comfortable that Dr. O'Day has my back if I fail and the melanoma decides to go wild.  I feel very fortunate to have an understanding doctor and the personal freedom to pursue my own health full time.  I was hoping for better news than I got, but it could have been a lot worse and I do have more things I'd like to try before resorting to chemicals if I have time.  Plus, I feel better than I have in years.  So, keeping my fingers crossed that it stays under control.

I hope you are all doing well,

Maggie

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Ginger8888's picture
Replies 11
Last reply 6/12/2014 - 8:39pm

Hi everybody, i'm starting Yervoy tomorrow for stage 111 C melanoma and was wondering if there anything i need to prepare for, for tomorrow besides something to read and stuff..Also was wondering how soon the side effects start? I'm really nervous and hope i can finish all the treatments and it works..I did the 30 high dose of interferon ( with only a little fatigue) about a months or so ago..Any help out there..??

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Julie in SoCal's picture
Replies 17
Last reply 6/12/2014 - 11:34am

Dear Friends,

Thank you so much for asking about my scan results.  Please celebrate with me! All is good!  My scan came back "perfect", no funk, no hot spots and nothing to watch and see!  It's all good.  In addition, Rock Star Doc thinks I'm a complete responder to Ipi!  The larger of my tumors is now pretty much down to nothing, and the  three smaller ones are now smaller than rice grain size.

We also talked about the lingering side effects from Ipi. Mostly this is a more active immune system, so I'm much more sensitive to everything, like bug bites, flu, bad food... But probably the most annoying of these is "arthritis like" symptoms in my hands, wrists and shoulders.  RS Doc said that this is from the IPI, and it should burn itself out in 6 months or so.  RS Doc said I could do a 5 day course of prednisone to take care of my hands and arms, but I'm not sure what is worse- 6 months of sore hands and arms or 5 days of steroids (they make me  crazy!!).  Don't get me wrong this is is no fun, but after hearing the "complete responder" news, I pretty much didn't care about my hands and would gladly power through stiff mornings with a hotter shower and ibuprofen for kicking Mel to the curb!

And to add good news to good news,  Rock Star Doc also said that I can be planning to go back to Asia!  So the plan is for me to get scans in 3 months and in 6 months, and anticipating that everything will be fine, return to Asia sometime in the new year.  Yea 2015!!

Some of the other things I learned from RS Doc: If you're an Ipi responder, you're probably not going to have a recurrence, but if you do, it's in the first two years. And if you're an ipi responder and get past 2 years with out a recurrence, he said he's never seen someone recur.  Essentially you're cured (ok he didn't use the "cured" word").  Life is good!

Thank you friends for your wisdom and support and standing beside me in this!!

Julie

 

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Anonymous's picture
Anonymous
Replies 1
Last reply 6/11/2014 - 9:12am
Replies by: Bubbles

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Anonymous's picture
Anonymous
Replies 6
Last reply 6/13/2014 - 8:09pm
Replies by: Anonymous, RJoeyB

Has anyone had cyber knife done on lung mets and a few lymph nodes. The disease load is low. We are out of other treatments.  Where would you go?

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melfighter's picture
Replies 4
Last reply 6/19/2014 - 12:02am

Hi, my husband started with stage 4 with tumors everywhere, liver, lungs, bones & brain (14 lesions), on the report, it says "innumerable" number of lesions throughout his body. He has been on Tafinlar/Mek combo for 16 weeks also WBR to his brain and radiation to his back due to severe lower back pain, due to L3 compression. First sets of scan after 12 weeks show a mixed bag. Tumors on soft tissues showed marked improvement with the bigger tumors shrinking and small ones disolving, but new lesions are showing up on the bone scans, so the combo has not worked on the bones. His brain also showed good results from the radiation.

Will the combo eventually work on the bone? I read from another post that it takes longer on the bone but the combo has shown to be effective on the bone?  The radiation on his lower back has resolved a lot of his pain but he now complains that his hip is in pain and that the pain moves around between his femur and hip?

 

 

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Anonymous's picture
Anonymous
Replies 6
Last reply 6/11/2014 - 8:56pm
Replies by: Anonymous, Swanee, BrianP, hbecker

I feel like I created quite a stir with my questions in my original post- cured.  It was not my intent to offend anyone- but just to get perspective.  I apologize if I did not comment on your thought and it offended anyone.  Again- thanks for all who shared.  Everyone one this board had their own battle to fight- and I am thankful for a place like here to express my thoughts! :). 

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Kenny's picture
Replies 7
Last reply 6/12/2014 - 7:13pm
Replies by: Kenny, BrianP, Kim K, Bubbles, G-Samsa

This is my first post, I have read a lot on this forum recently and have been very thankful for the content.  

I found out on March 25, 2014 that I have melanoma.  What started out as a very small spot on my upper left back about the size of a pencil tip has turned into stage 3a melanoma.  It was also found in one lymph node under my arm.  I had a axillary lymph node dissection on April 25th and no melanoma was found.  I had the melanoma tested for the BRAF mutation and I do.  I have been looking into treatment and have this as an option.

Does anyone have any experience with this trial?  I have a meeting on Monday June 16th to go over the details.

Thank you,

Ken

 

GSK BRF115532

A phase III randomized double blind study of dabrafenib (GSK2118436) in COMBInation with trametinib (GSK1120212) versus two placebos in the ADjuvant treatment of high-risk BRAF V600 mutation-positive melanoma after

Key Eligibility:

  • Completely resected histologically confirmed high-risk Stage IIIa, IIIb or IIIc

  • Must be surgically rendered free of disease no more than 12 weeks before randomization

  • BRAF V600E/K mutation positive

  • No prior systemic anti-cancer treatment (chemotherapy, immunotherapy, biologic therapy,

    vaccine therapy, or investigational treatment) or radiotherapy for melanoma allowed. For more information: NCT01682083 

 

Ken Sears

Stage 3a 

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Anonymous's picture
Replies 1
Last reply 6/10/2014 - 3:13pm
Replies by: BrianP

Hope your scans go well. Please keep us updated! Good Luck

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Patina's picture
Replies 2
Last reply 6/11/2014 - 9:29am
Replies by: Anonymous, jbronicki

I wanted to give everyone an update on my Mom who was diagnosed in November of last year with Stage IV melanoma.  

My Mom ended up having gamma knife radiation 26 days after diagnosis followed by Yervoy/ipi 4 days later.  (She is BRAF and PD1 positive.) - Since we knew she was BRAF positive and that the brain mets (8) were treated we elected to start with Yervoy/ipi, due to the positive retrospective analysis shown in patients with brain mets.

Within the first week of treatment the subcutaneous melanoma tumors found on her scalp and neck began changing and by the time she was to have her 3rd infusion most were either "gone" or much smaller.  She still had 6 tumors in her lungs, liver, kidney and adrenal glands that we didn't know what was happening with, but we could all see the changes on her scalp and neck, which gave us great hope. 

Unfortunately, my Mom did get colitis and was hospitalized a few times due to the severity of it.  Once the colitis was "under control" she had the 3rd treatment of Yervoy/ipi.  But she ended up getting colitis again.  She won't get her 4th infusion.

In April we ended up getting a second opinion on the MRI results for the brain mets and she had 16 more brain mets treated by gamma knife radiation. - These had developed since her ordinal gamma knife radiation treatment in December. -  Other than a bit of bruising and having a bit of hair fall out she's experienced no other issues with the treatment. (Cognitive or otherwise.)  

Last week she had her 60 day follow up for the gamma knife radiation and the end of her Yervoy/ipi treatment.  So far everything looks great. She has no new brain mets an those she had treated are stable or shrinking.  The other tumors are smaller  (in some cases stable) than what they were in 2/14 and 11/13.  There is also nothing new to report. - Those on her head and neck are virtually gone.

She's back to all of her normal activities and feels great.  She will have another checkup in 60 days and we all pray that the next MRI of her brain shows nothing new.  - She can't wait to drive her car again and she'll be quite upset if anything new is found... 

I hope this gives everyone hope whether you've just been diagnosed or considering treatment or new treatment. 

PS

As many of you know, she was misdiagnosed at first and I strongly recommend a second and even third opinion with someone who will look at all CT and MRI scans with you. - She ended up having brain mets and we would not have known this if we had not gone for the third opinion...

 

 

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kathy38's picture
Replies 6
Last reply 6/14/2014 - 10:57am

Hello, I was diagnosed on Friday, May 30th. The depth of my lesion was 4.2mm. I had a wide excision on my scalp and a sentinal lymph node biopsy done on Tues June 3rd followed by a PET scan on thur. The lymph node and PET both came back negative. Which is awsome! I am stage 2, and very confused and overwhelmed. I feel like I am a ticking time bomb, just waiting for it to show up somewhere else. Before I found the melanoma my husband and I were planning on moving to the south, Alabama/Georgia area. We live in WI now. I am hesitant to leave now, he thinks I am "cured" and we shouldn't change our plans for "what if" I also heard that health care isn't very good in the south, is there any truth to this?? I'm looking for advise on how to proceed with our future.

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braunerk's picture
Replies 3
Last reply 6/9/2014 - 5:15pm

So I had the testing and I am neg for BRAF NRAS and CKIt. I am starting ippi on Friday and hoping for an EAP for PD-1 to open soon. I am in Tucson AZ so does anyone know of an opening for PD-1 on the west coast I will travel if I can get into a trial. IL-2 is not really an option due to my asthma I am stage 4 so I am open to all suggestions. 

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Tim--MRF's picture
Replies 6
Last reply 6/10/2014 - 12:16pm

 

NOTES FROM ASCO 2014

I thought some on this board would like a report from the recent meeting of ASCO. This is a long post, but I have tried not to make it too technical.

Tim--MRF

Once melanoma spreads beyond the initial spot, or lesion, it has been notoriously difficult to treat. If it gets to other organs, the numbers have been appalling, with half of all patients dying of the cancer within about 10 months. Now that is changing.

The 50th meeting of the American Society for Clinical Oncology (ASCO) was held in Chicago May 30 through June 5. Some of the most exciting presentations of the weekend focused on melanoma. Here are a few highlights.

ipi + nivo:  In March, 2011 Yervoy (ipilimumab or “ipi”) became the first new drug to be approved for use in metastatic melanoma in 13 years. Ipi is a checkpoint inhibitor. In other words, it disables a natural braking mechanism—checkpoint—on the immune system that prevents the body from destroying cancer cells. An important component of our immune system is a group of cells called T-cells. If the T-cell count is low, as happens in HIV, the body is unable to fight off infection. If T-cells are too active they cause autoimmune diseases. The body regulates T-cells through a series of checkpoints, and melanoma cells seem particularly good at using these checkpoints to hide from T-cells.

The cancer research community is very excited about a new class of checkpoint inhibitors called anti-PD1, or simply PD-1 drugs. Several companies are working on these but BMS has combined their drug “ipi” with their PD-1 drug nivolumab, or “nivo”. The results are rather astonishing.

First the bad news. This was a somewhat small study, so numbers can change, and the combination is fairly toxic. In clinical trials doctors watch for adverse events, and they rank those events on a scale from 1 (mild) to 5 (death). In this combination study about 2/3 of patients had a grade 3 or grade 4 adverse events. That is a big number, though researchers report that many of these episodes were managed quickly and easily.

The good news, though, is the incredible response rate. Remember that the median survival time of metastatic melanoma is around 10 months. In this study, 82% of patients were still alive after a year, and after 2 years an impressive 75% of patients were still alive. The study looked at several doses, and some doses showed 1 and 2 year survival of 93% and 88%. No previous study in melanoma has come close to these results.

Anti-PD1:  Nivo was also studied by itself, in a group of about 100 patients who had gone through other melanoma treatment but had not had ipi. Just over a third of patients showed a response to nivo. Looking at the entire group, many of whom had gone through three or more prior therapies without success, 63% were still alive at 1 year, 48% at two years, and 41% at three years. Remember, these are patients who have already tried other drugs but those drugs didn’t work or stopped working. Presumably a group of patients who received nivo as a first treatment would do better.

Data from a study of Merck’s anti-PD1 drug, pembrolizumab (pembro or MK-3475) were also presented and generated a great deal of enthusiasm. The 18 month survival on a very large study was impressive, with about 2/3 of patients still alive. Side effects did not seem to be a major concern with this program; certainly no worse than other melanoma drugs. Response rates remain very high and much better than anything currently on the market.

Here are the numbers. The study looked at patients who had previously received ipi, and patients who had not received ipi. Presumably, those who had received ipi would be less responsive to another checkpoint inhibitor and that is how the data came out. About 40% of patients who had not received ipi responded to pembro; for patients who had previously been treated with ipi the number dropped to 28%. A sizeable group of patients had durable response, with 88% of that group still responding at the time the data was presented. About 12% of the more than 400 patients in this study had grade 3 or 4 adverse events.

T-VEC: A few companies are working on drugs that are injected into lesions on the skin or into cancerous lymph nodes. Amgen’s T-VEC seems to be the farthest along. This is a modified virus that has been designed only to infect tumor cells. When it infects the cell, the virus takes over the cell’s DNA and forces it to make more virus and also to make a compound that stimulates the immune system, GM-CSF. The altered DNA makes so many viruses they cause the cell to burst apart. This releases a lot of debris that can activate the immune response, along with GM-CSF that will ramp up that response.

T-VEC was compared to GM-CSF alone and definitely did better—though not as well as the checkpoint inhibitors. Median overall survival was 23.3 months, vs. 18.9 months on GM-CSF. The drug did not cause very many severe side effects.

Three or four years ago this information would have generated a lot of excitement. Now, however, the field has progressed so the numbers don’t look as strong as what is being seen in some of the studies mentioned earlier. A number of researchers are interested, however, in combining T-VEC with one of the checkpoint inhibitors or some other treatment.

BRAF and MEK: While therapies involving the immune system have received a lot of attention in the past couple of years, clinicians are still seeing positive results in treatments that go into tumor cells and shut down one or more of the mutations that is causing them to grow. Genentech’s Zelboraf (vemurafenib) was the first such drug to be approved; it blocks a compound called BRAF that is part of a series of steps transmitting signals from the cell surface to the nucleus of the cell. Two years later, GSK had their own BRAF drug, Tafinlar (trametinib), approved. They also had saw Mekinist (dabrafenib) approved; it blocks MEK, the next step after BRAF. More significantly, they showed that the BRAF and MEK inhibitors worked better when given together and now Genentech is actively studying their own MEK inhibitor to pair with Zelboraf.

Further data muddied the waters, unfortunately. These more comprehensive studies show little added benefit of giving trametinib and dabrafenib together over giving trametinib alone. The difference in time before relapse was only two weeks. The surprising part of the data is that patients on the combination did about the same as in earlier studies. The difference was that patients who only received trametinib did much better than has been seen in any previous study of a BRAF inhibitor. Some suggest that this is because doctors understand better how to give the drug than they did in the past. Others point to some odd statistical anomalies in the study. Several patients were dropped from the study very early on. Had they been included and recorded as having relapsed early, the numbers make much better sense.

Many doctors will prescribe the combination regardless of the data because patients experience fewer side effects on the combination than on either of the drugs alone.

Another study of the GSK combination looked at overall survival of patients receiving both drugs vs. those receiving only the BRAF inhibitor. The key data is to find how long it takes before half of the patients on each study arm to succumb to melanoma. Median overall survival for the monotherapy arm was about 20 months. When the data was reported the study was at almost 24 months and patients on the combination had not yet reached the median mark.

NRAS: Only those patients whose tumor has a BRAF mutation can take the BRAF inhibitors. This is about 40-50% of melanoma patients. Another 20% have a mutation upstream from BRAF, at a point called NRAS. These mutations have proven difficult to target. Researchers conducted a study in which they used a MEK inhibitor (two steps down from NRAS) and also blocked a different pathway that is impacted by NRAS. This second drug is called a CDK4 inhibitor.

This was a small study, involving only 14 patients, but the results were encouraging. The drugs led to tumor shrinkage in several patients. Six patients had an actual response and six others had stable disease, or no additional tumor growth. Clearly more work needs to be done in this area.

Adjuvant: The primary—and often only—treatment for early stage melanoma is surgery to remove the melanoma and, if necessary, one or more lymph nodes.  Once the surgery is done and all of the known cancer is removed, patients are said to be in the adjuvant setting. Despite the fact that some patients are known to be at elevated risk of recurrence, the standard of care is not to offer more treatment but, rather, to follow the patient with close observation. With some new drugs on the market for advanced melanoma, researchers have begun to study the effectiveness of these drugs on lowering the rate of recurrence in high-risk patients. Data was presented on the adjuvant study of ipi, and the results are mixed.

The good news is that ipi does work to lower the risk of melanoma recurrence. Nearly 1000 Stage III patients were split into two groups, one of which received ipi and the other of which received a placebo. (Adjuvant studies are one of the rare instances in which placebos are used in oncology.) After three years, 45.6% of patients on ipi were cancer free, vs. 34.8% in the placebo arm. This is a clear benefit for being on ipi.

The story is more complicated than this, unfortunately. The study was started when the best dose of ipi had not yet been determined. The dose in this study was more than three times as strong as what is given routinely to metastatic patients. This resulted in a high number of adverse events. More than half of the patients on the ipi arm of the study dropped out before the three year period because of side effects. Five of the patients on the arm died, possibly due to drug-related issues.

Another study is currently underway comparing ipi to Interferon, but using the lower dose of ipi. This may provide more clarity, but results from that study are not expected for a couple of years.

Miscellaneous: ASCO was awash in melanoma data, including many presentations that consisted simply of a large poster with data, graphs, and charts. Some key findings include:

·         Biologic tests show that patients with brain metastasis demonstrate significant levels of compounds related to immune response. This suggests that drugs such as ipi and the PD1 drugs would be effective in treating these tumors.

·         Ipi is just as effective in acral melanoma as in other cutaneous melanomas.

·         The level of Vitamin D in patients at the time of their diagnosis has no impact on their ultimate outcomes.

·         Uveal melanoma patients with liver metastases responded better to treatment using microbeads infused with a chemotherapy agent than did patients receiving other therapies, with about a six month survival advantage.

·         Pregnancy may impact melanoma. Melanoma cells grown in the lab grow faster in the presence of sera from pregnant women or in the presence of specific pregnancy-related hormones.

·         Tumor cells isolated from a simple blood sample can be tested for BRAF mutation. The presence or absence of such cells can be an indicator of whether or not the patient is responding to a BRAF inhibitor.

·         Stage IV patients with uveal melanoma have similar survival rates as Stage IV cutaneous melanoma patients. Stage IV mucosal melanoma patients, however, tend to do worse.

This is only a fraction of what came out of the conference. The melanoma field is more robust and promising than it has ever been in the past, with no sign that the current rate of progress is slowing.

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