8551 Background: Patients with regionally disseminated malignant cutaneous melanoma, stage III, have a variable prognosis with reported 5-year survival of 24-67%, depending on subcategory. There is a subgroup of patients with a better long-term survival, even when known adverse pathological risk factors, such as macro-metastasis, number of lymph node metastases and ulceration are taken into consideration. Identification of a molecular profile may predict subgroups of patients with prognostic benefits of adjuvant treatments in stage III disease. Methods: A RNA oligonucleotide microarray study was performed on lymph node metastases from 42 patients with stage III melanoma: 19 patients with short survival (≤ 14 months) and 23 with long survival (≥ 60 months). Candidate genes were validated by qRT-PCR and IHC. Results: Categorization according to the biological functions revealed gene ontology (GO) clusters that are highly significantly differentially expressed between the prognosis groups. Two of the top categories were glycolysis (GO: 0006096) (p<0.001) and pigment biosynthetic process (GO: 0046148) (p<0.001). No single gene was significantly differentially expressed between the groups. Four genes from the two top GO categories, GAPDHS, GAPDH, PKM2 and TYRP1, were selected for validation. Best result is found for GAPDHS in both qRT-PCR (p=0.11) and IHC (p=0.012). The median relative quantity values for all mRNAs are lower for those with good outcome compared to those with poor outcome. When combining the results from IHC a significant finding was observed. High expression of at least two of these four gene products was found to be an independent adverse prognostic factor for overall survival in a multivariate analysis (p=0.037). Conclusions: We have identified a prognostic panel of four gene products associated with clinical outcome in stage III melanoma.
e14048 Background: DNA-PK, with its protein subunits, Ku70 and Ku80, regulates one of the major pathways responsible for repair of double-strand breaks in DNA that are induced by radiotherapy (RT) and some chemotherapeutic agents (CT). Therefore, the combined strategy of RT with a DNA-PKi is promising. The purpose of this phase I trial is to explore the safety, tolerability, pharmacokinetic (PK) profile, and clinical activity of M3814 administered together with RT and chemo-RT (CRT). Methods: Patients (pts) with tumors or metastasis in the head and neck region or thorax in need of palliative RT (10 x 3 Gy) are eligible for the dose escalation part Ia, with a starting dose of 100 mg once daily. Dose escalation decisions are aided by the Bayesian logistic regression model with overdose control. Dose-limiting toxicity (DLT) is evaluated up to 3 weeks after RT. Rich PK sampling is taken during treatment. Tumor evaluation is performed every 6 weeks up to 6 months and every third month thereafter. Results: As of January 2017, 7 pts had been enrolled into the part Ia dose escalation arm and treated with 100 mg daily. The most frequent adverse events (AEs) were fatigue, constipation, decreased appetite, dry mouth, dysphagia, headache, oral pain, radiation skin injury, and mucositis in more than 1 pt (20%). No pts discontinued due to AE. Two episodes of grade 3 mucositis lasting > 7 days were reported; one of these was classified as a DLT, and both pts recovered without sequelae. Two of 7 pts enrolled had local tumor control at +300 days. PK analysis demonstrated high exposure variability. Conclusions: M3814 at the 100 mg daily dose was tolerable as palliative treatment and dose escalation is currently at 200 mg. In part Ib of the study, two separate dose escalation arms will enroll pts with either head and neck squamous cell carcinoma (SCCHN; US only) or non-small cell lung cancer (EU and US) to receive CRT 2 Gy x 30-35 over 6-7 weeks with curative intent; the SCCHN cohort is now open for enrollment. For these two cohorts, the DLT window will be 12 weeks. Clinical trial information: NCT02516813.
Ulceration is an independent adverse prognostic factor in cutaneous malignant melanoma (CMM). There is, however, a need for additional prognostic markers to identify patients with ulcerated stage I-II CMM who have a high-risk for recurrence. The aim of this study was to examine the prognostic impact of BRAF mutation, proliferation and presence of tumour infiltrating lymphocytes (TILs) in primary ulcerated CMM.We have used a consecutive cohort consisting of 71 primary ulcerated CMM (T1b-T4b). BRAF mutation was detected using Cobas test and pyrosequencing. Protein expression of the proliferation marker Ki67 was analysed using immunohistochemistry. Presence of TILs was evaluated in representative hematoxylin-eosin stained formalin-fixed paraffin-embedded tumour sections.Proportion of BRAF mutated alleles, proliferation and presence of TILs all had a statistically significant impact on recurrence free survival in univariate analyses (HR 2.44, 95% CI 1.23-4.84, p = 0.011; HR 2.66, 95% CI 1.32-5.35, p = 0.006 respectively HR 0.48, 95% CI 0.24-0.98, p = 0.045). A trend test found a statistically significant decrease in the proportion of recurrence by including the three favourable factors (BRAF wildtype/low proportion of BRAF mutated alleles, low proliferation and high presence of TILs) (p = 0.0004). When at least two out of three factors were present there was a statistically significant association with longer recurrence free survival in the multivariate analysis (HR 0.30, 95% CI 0.15-0.61, p = 0.001) when adjusted for Breslow thickness, an established independent prognostic marker for CMM.Thus, this panel of markers could be an interesting novel concept for predicting the clinical outcome in patients with high-risk stage I-II ulcerated CMM.
Precision radiation of immune checkpoint therapy resistant melanoma metastases (PROMMEL study): study protocol for a phase II open-label multicenter trial
There are insufficient numbers of prognostic factors available for prediction of clinical outcome in patients with stage III malignant cutaneous melanoma, even when known adverse pathological risk factors, such as macrometastasis, number of lymph node metastases, and ulceration are taken into consideration. The aim of this study was therefore to identify additional prognostic factors to better predict patients with a high risk of relapse, thus enabling us to better determine the need for adjuvant treatment in stage III disease. An RNA oligonucleotide microarray study was performed on first regional lymph node metastases in 42 patients with stage III melanoma: 23 patients with short-term survival (≤ 13 months) and 19 with long-term survival (≥ 60 months), to identify genes associated with clinical outcome. Candidate genes were validated by real-time PCR and immunohistochemical analysis. Several gene ontology (GO) categories were highly significantly differentially expressed including glycolysis (GO: 0006096; P<0.001) and the pigment biosynthetic process (GO: 0046148; P<0.001), in which overexpression was associated with short-disease-specific survival. Three overexpressed glycolytic genes, GAPDHS, GAPDH, and PKM2, and two pigment-related genes, TYRP1 and OCA2, were selected for validation. A significant difference in GAPDHS protein expression between short- and long-term survivors (P=0.021) and a trend for PKM2 (P=0.093) was observed in univariate analysis. Positive expression of at least two of four proteins (GAPDHS, GAPDH, PKM2, TYRP1) in immunohistochemical analysis was found to be an independent adverse prognostic factor for disease-specific survival (P=0.011). Our results indicate that this prognostic panel in combination with established risk factors may contribute to an improved prediction of patients with a high risk of relapse.
The variable prognosis in stage III cutaneous melanoma is partially due to unknown prognostic factors. Improved prognostic tools are required to define patients with an increased risk of developing metastatic disease who might benefit from adjuvant therapies. The aim was to examine if cellular immune markers in association with tumor proliferation rate and BRAF mutation status have an impact on prognosis in stage III melanoma. We have used two sets of case series with stage III disease: 23 patients with short survival (≤ 13 months) and 19 patients with long survival (≥ 60 months). Lymph node metastases were analyzed for Ki67, CD8 and FOXP3 protein expression using immunohistochemistry. BRAF mutation status was analyzed in a previous study on the same samples. Low tumor proliferation rate was significantly associated with a better prognosis (p = 0.013). Presence of FOXP3+ T cells was not correlated to adverse clinical outcome. A highly significant trend for a longer survival was found in the presence of an increasing number of markers; CD8+ and FOXP3+ T cells, low tumor proliferation and BRAF wildtype status (p = 0.003). Presence of at least three of these four markers was found to be an independent favorable prognostic factor (OR 19.4, 95% CI 1.9-197, p = 0.012), when adjusting for ulceration and number of lymph node metastases. Proliferation alone remained significant in multivariate analyses (OR 26.1, 95% CI 2.0-344, p = 0.013) but with a wider confidence interval. This panel still remained independent when also adjusting for a previously identified prognostic glycolytic-pigment panel. We have demonstrated that presence of immune cells in association with tumor proliferation and BRAF mutation status may further contribute to identify stage III melanoma patients with high risk of relapse.
2518 Background: DNA-dependent protein kinase (DNA-PK), regulates one of the major pathways responsible for repair of DNA double-strand breaks. The combination of RT and DNA-PK inhibition (DNA-PKi) has been shown to be synergistic in preclinical studies. The purpose of this phase I trial is to explore the safety, tolerability, pharmacokinetic (PK) profile, and clinical activity of M3814 administered together with RT (Arm A) and chemo-RT (CRT; Arm B). Results for Arm A are reported. Methods: Pts with tumors or metastases in the head and neck region or thorax in need of palliative RT (30 Gy in 10 factions) are enrolled in the dose escalation part Ia of Arm A to receive M3814, starting dose 100 mg. Dose escalation is aided by a Bayesian logistic regression model. Dose-limiting toxicity (DLT) is evaluated up to 3 weeks after RT. Rich PK sampling is taken during treatment. Tumor evaluation is performed every 6 weeks up to 6 months and every third month thereafter. Results: 16 pts had been enrolled, 100 mg (N = 7), 200 mg (3) and 400 mg (6). The most frequent adverse events (AEs) were fatigue (n = 12), nausea (8), constipation, decreased appetite, dysphagia, mucosal inflammation/stomatitis (6), vomiting (5), back pain, chest pain, diarrhea, radiation skin injury, and weight decreased (4). All pts completed treatment ( > 80% of specified dose) and no pts discontinued due to DLTs. Four DLTs were reported: grade 3 mucositis lasting > 7 days in 3 pts (100 and 400 mg) and odynophagia in one pt (400 mg). All pts with DLTs recovered without sequelae. One fatal suspected unexpected serious AE considered as radiation pneumonitis occurred. Preliminary efficacy: in field response: one pt had pCR, 4 PR, 7 SD, and 3 have not yet been evaluated one pt was not evaluable. PK was like an earlier first-in-man study, including high inter-subject variability. Conclusions: M3814 is well tolerated at doses of 100 and 200 mg QD as part of a palliative treatment combination with RT. Since 2 DLTs were seen at 400 mg QD, the therapeutic window will be further evaluated based on toxicity profile and PD data. Currently, M3814 300 mg QD is being explored. Updated safety and efficacy data will be presented Clinical trial information: NCT02516813.
DNA-dependent protein kinase (DNA-PK) plays a key role in the repair of DNA double strand breaks via nonhomologous end joining. Inhibition of DNA-PK can enhance the effect of DNA double strand break inducing anticancer therapies. Peposertib (formerly "M3814") is an orally administered, potent, and selective small molecule DNA-PK inhibitor that has demonstrated radiosensitizing and antitumor activity in xenograft models and was well-tolerated in monotherapy. This phase 1 trial (National Clinical Trial 02516813) investigated the maximum tolerated dose, recommended phase 2 dose (RP2D), safety, and tolerability of peposertib in combination with palliative radiation therapy (RT) in patients with thoracic or head and neck tumors (arm A) and of peposertib in combination with cisplatin and curative-intent RT in patients with squamous cell carcinoma of the head and neck (arm B).
