Keywords
malignant melanoma - BRAF mutation - dabrafenib - trametinib
Bivas Biswas
Sandip Ganguly
Introduction
Malignant melanoma (MM) arises from the melanocytes. The incidence of MM has a wide
geographical variation with the highest incidence being reported from Australia and
the lowest from South-Central Asia.[1] Metastatic MM (MMM) is associated with a poor response with standard conventional
chemotherapy leading to poor outcome. However, recently the advent of newer therapies
like immunotherapy and tyrosine kinase inhibitors (TKIs) has improved the response
rate and survival outcome compared with historic data.[2] Targeted therapy is directed toward the dual inhibition of BRAF and MEK pathway
inhibition. The incidence of BRAF mutation is very high in patients with MMM.[3] Initially only BRAF inhibition was targeted with BRAF inhibitors like dabrafenib[4] and vemurafenib[5] but due to cross-activation of the MAPK pathway, it led to resistance to therapy
with a shorter duration of disease control.[6] Additionally, the activation of the MAPK pathway led to the development of secondary
cutaneous malignancies and also reactivation of RAS mutant tumors.[7] Further research led to the development of MEK inhibitors like trametinib and cobimetinib,
and it showed there is improvement in overall survival in patients with BRAF mutant
MMM with no paradoxical activation.[8]
[9] Combination of these two groups of the drug has synergistic activity leading to
improvement in overall survival in patients with MMM in the metastatic setting. Similar
improved results have been seen in patients with resected node-positive disease.[10] Real-world data on the usage of this drug is scarce in the available literature
especially from a resource-poor country like India. Here we report our early experience
with the usage of these inhibitors in patients with advanced MM. Initially, the drug
was not available in India and we received the drug from Novartis Pharmaceuticals
through a compassionate access program.
Materials and Methods
This is a single institutional data assessment of patients with BRAF-mutated MM registered
and treated with BRAF–MEK inhibitors in the Department of Medical Oncology at Tata
Medical Center, Kolkata. Clinico-pathological features and treatment details were
reviewed for all patients. Ethical clearance was taken from the institutional review
board.
Diagnosis and Workup
All patients underwent tissue diagnosis by biopsy with appropriate immunohistochemistry
markers (S100, HMB 45, and Melan-A.) Metastatic workup was done with either whole-body
18-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) or
CT of thorax and abdomen with/without 99technetium bone scintigraphy whenever indicated. Magnetic resonance imaging of the
brain was done in patients with symptomatic neurological symptoms. BRAF mutation was
analyzed by next-generation sequencing (NGS) using ion torrent platform with cancer
hotspot V2 panel.
Treatment and Response Evaluation
Patients who were found to have BRAF mutation by the NGS technique were given a combination
of capsule dabrafenib (150 mg twice daily) and tablet trametinib (2 mg once daily)
both in empty stomach with normal organ functions. Toxicities were graded as per the
Common Terminology Criteria for Adverse Events version 4.[11] Patients were assessed periodically for response assessment. Complete response (CR),
partial response (PR), stable disease (SD), and progressive disease (PD) were defined
according to the Response Evaluation Criteria in Solid Tumors (RECIST v1.1) criteria
wherever applicable.[12] Overall response rate (ORR) was defined as the sum of CR + PR. Clinical benefit
rate (CBR) was defined as the sum of CR + PR + SD. Descriptive statistics were used
for demographic and clinical characteristics. Progression-free survival (PFS) was
calculated from the date of diagnosis to the date of clinical and/or radiological
disease progression or death from any cause.
Results
The total number of MMM treated at our department from January 2013 to December 2020
was 122, and out of them, 50 patients underwent BRAF testing. Out of these, eight
patients were found to have BRAF mutation on NGS testing and seven patients took treatment.
The median age of the study cohort was 66.5 years (range: 49–72 years) with a male:female
ratio being 3:4. Among them, six (85.7%) had metastatic disease. Five patients had
BRAF V600E mutation while two patients had BRAF V600R mutation. Five patients received
upfront systemic therapy with the combination TKI, one received the same in the adjuvant
setting (stage III disease), and one received the treatment in second-line setting
after the failure of taxane-based chemotherapy. The baseline characteristics of the
patients are shown in [Table 1].
Table 1
Clinicopathologic characteristics and treatment outcome
|
Age
|
Sex
|
Primary site
|
Sites of metastases
|
Which line?
|
Type of BRAF mutation
|
Line of treatment
|
Response assessment
|
|
Abbreviations: CR, complete response; PD, progressive disease; PR, partial response;
SD, stable disease.
|
|
72
|
Female
|
Arm
|
Bone, skin
|
First
|
V600R
|
First
|
PR
|
|
44
|
Female
|
Scalp
|
Lung
|
First
|
V600E
|
First
|
CR
|
|
65
|
Male
|
Upper limb
|
Brain, soft tissue, nodes
|
First
|
V600E
|
First
|
PD
|
|
49
|
Male
|
Anal canal
|
Lung, nodes
|
Second
|
V600R
|
Second
|
CR
|
|
56
|
Female
|
Inguinal nodes
|
Nil
|
Adjuvant
|
V600E
|
Adjuvant
|
|
|
63
|
Male
|
Pericardium
|
Nodes
|
First
|
V600E
|
First
|
SD
|
|
61
|
female
|
Breast
|
Skin, nodes
|
First
|
V600E
|
First
|
PR
|
Response Assessment and Outcome
All six patients with metastatic disease had their initial response assessment. It
was CR in 2 (33%), PR in 2 (33%), SD in 1 (17%), and PD in 1 (17%) patient with an
ORR of 60% and a CBR of 83%. At a median follow-up of 23 (95% confidence interval
[CI]: 6 to NR [not reached]) months, the median PFS was 9.3 (95% CI: 1.3 to not reached)
months as shown in [Fig. 1].
Fig. 1 Kaplan–Meier curve showing the median progression-free survival of patients who were
treated with the drug combination.
Discussion
MM is a rare cancer in India constituting 0.3% of all new cases as per the latest
GLOBOCAN data.[13] Very limited literature is available from India.[14]
[15] None of the studies does not discuss the outcome with recently approved targeted
therapies and this is the first study from India which deals with an early experience
of using targeted therapies in patients with MM.
The median age of the study population was 66.5 years, which was higher than that
reported in the available literature.[14]
[15]
[16]
[17] In total, 80% of our patient population had two or less than two sites of metastasis
in comparison to 52% in the landmark trial.[16] The response rate of our study population was 66%, which was almost similar to 67%
in clinical trial settings[16] and 72% from the Japanese study.[17]
At a median follow-up of 23 months, the median PFS of the cohort of our patients was
9.3 months. It is almost similar to the updated analysis of the pivotal landmark trial
where it was 11.1 months.[18] Pyrexia is the most commonly reported adverse effect of this combination therapy.
Only two (33.3%) patients had fever as a side effect, which was easily managed with
dose interruption and in some cases, prophylaxis with paracetamol was used.
One of the limitations of our study is that we have not stratified our patients based
on the lactate dehydrogenase level and another limitation being the small number of
patients in our cohort.
However, our study does have some strong points. This is the first study from India
where we are reporting our experience with the usage of dabrafenib and trametinib
in patients with MM. Another interesting point is that though the drug has been approved
for use in patients with V600E/K mutation only, we have used this therapy in patients
with BRAF V600R mutation and they have also responded to the therapy. Further studies
are required to see the efficacy of this combination therapy in patients with nonapproved
BRAF mutation.
