New strategies in melanoma care

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Published: 10 Sep 2017
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Dr Alexander van Akkooi - Netherlands Cancer Institute, Amsterdam, Netherlands

Dr van Akkooi speaks with ecancer at the ESMO 2017 Congress about ongoing and upcoming trials in melanoma, including these are neo-adjuvant therapy and combined immunotherapies.

He goes on to discuss the role of surgery in index node biopsy, and ongoing trials of advanced disease.

ecancer's filming has been kindly supported by Amgen through the ECMS Foundation. ecancer is editorially independent and there is no influence over content.

What we have been doing in Amsterdam are two studies, one with targeted therapy up front in the neoadjuvant setting and one with a combination of immunotherapy with ipi and nivo. Certainly the latter one has very exciting results to mention already because we’re seeing a high response rate of 80% in those cases where the combination for stage 4 has a response rate of about 50-60%. But also now, intriguingly, we’re seeing long term benefit of this combination where you would expect these high risk stage 3 patients to relapse quite quickly, within one or two years, about half to 70% of cases. Certainly for the complete responders we have seen zero relapses but also for the partial responders the chance of relapse seems to be very much reduced and we’re very hopeful that we’re increasing the cure rates now with this new approach.

I suppose if there is, like you say, this tremendous response and long term benefit, how much room does that leave any surgical intervention as a follow up or if it’s even necessary?

That’s a very intriguing question which we’re also examining now because we’re still doing the full lymph node surgery on these cases is if that is really necessary or if there are other ways to measure the response. So we’re using the CT scans now with the RECIST criteria to look at those responses but they’re not correlating with the pathologic response yet. So we’re moving towards other ways of assessing this and one thing we’ve been doing in breast cancer at my institution is taking out the index node and examining that index node. If that index node is then clear of disease it correlates really well with the rest of the lymph nodes and you can save the patient unnecessary extensive surgery in those cases. So we’re now doing that with a magnetic marker which is also not a radioactive marker which we were using in breast cancer which also takes away the risk of radiation which might not be applicable to all institutes.

Let’s have a look at what’s happened so far at ESMO, something that’s come out. Anything that’s caught your attention over the last two days?

Yes, for the stage 4 disease there was on Saturday some nice presentations on, for instance, a new combination of epacadostat with pembrolizumab for stage 4 patients which showed a very nice response rate but also a very good safety profile with less adverse events than the combination of ipi/nivo. So that’s something really to look forward to the phase III data which will eventually come out of that study.

For the upcoming data from the Monday trials and your own research, should we keep an eye out for those in the near future for any skin cancer congress? I think the next one is in Australia.

The next one will be, indeed, in Brisbane. I don’t think there will be any landmark new things coming there but certainly in the first or second quarter of 2018 the pembrolizumab study will also be released and there’s an ongoing study now with the combination ipi/nivo in the adjuvant setting which is still accruing so that will take some time still.

I think that covers what’s been and what’s coming up. Is there anything else that we didn’t get to mention?

Another interesting thing for surgical oncology in melanoma is the ongoing study of the combination of TVEC, which is an oncolytic virus, with pembrolizumab. That study is expected to complete the accrual by the first quarter of 2018. So certainly for me as a surgeon for patients with intransient lesions that is something I’m very much looking forward to and already from the phase I presented at ASCO this year there were some nice signs of a beneficial impact of the combination. Also just last week Tony Ribas published in Cell a nice paper on this.