Disclosures None 1 NOT THE REAL QUESTION Did you get it all? Did - - PDF document

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Disclosures None 1 NOT THE REAL QUESTION Did you get it all? Did - - PDF document

Nov 18, 2022 32 likes •142 views

Winship Cancer Institute of Emory University Is there a role for surgical resection for stage IV melanoma anymore? Debates and Didactics in Hematology Oncology Sea Island, GA August 9, 2014 Disclosures None 1 NOT THE REAL QUESTION Did

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1 Winship Cancer Institute of Emory University

Is there a role for surgical resection for stage IV melanoma anymore?

Debates and Didactics in Hematology‐Oncology Sea Island, GA August 9, 2014

Disclosures

  • None
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NOT THE REAL QUESTION

  • Did you get it all?
  • Did my cancer come back?
  • Do I need a scan?
  • Am I cured?

Single-agent therapy for melanoma

Class Examples Response Rates Notes Alkylating agents Dacarbazine 10-20% Soft tissue, lung Nitrosoureas BCNU, CCNU, fotemustine 10-20% Brain Platinum compounds Cisplatin, carboplatin 10-20% Biochemotherapy Taxanes Paclitaxel, docetaxel 10-20% Imidazotetrazine Temozolomide 10-20% Brain Biologics IFN-, IL-2 10-20% Hormonal Tamoxifen 4-6% Dartmouth

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Name/Acronym Agents Response Rates Notes CVD Cisplatin, vinblastine, DTIC 24-45% Soft tissue, lung BOLD Bleomycin, Oncovin, lomustine, DTIC 4-40% Recent response rates 4-20% Dartmouth Cisplatin, BCNU, DTIC, tamoxifen 20-40% Tamoxifen probably does not enhance efficacy IFN-+IL-2 IFN-+IL-2 20-40% No clear improved efficacy over IL-2 alone IL-2+TIL IL-2+tumor infiltrating lymphocytes 20-38% Conditioning chemotherapy improves engraftment Bone marrow transplant Varies 20-81% Low CR rates, short duration of responses Alternating biochemotherapy CVD+IL-2+IFN- (BIO) alternated every 6 weeks 33% Similar response rate to CVD alone Sequential biochemotherapy CVD+BIO immediately following 47-73% CVD->BIO appeared better than BIO->CVD Concurrent biochemotherapy CVD+BIO given together 63% Reduced treatment duration, more convenient, less toxic

Combination therapy for melanoma

Canvaxin™ Trial

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Surgery

  • Only therapy with predictable 100% response

rate

  • Duration of response is variable
  • Selection is key

Stage IV trial

  • Morton and colleagues
  • Surgery vs Best known medical therapy
  • Failed to accrue
  • Closed prematurely

– Why?

  • Medical oncologists had preconceived notions about

patients undergoing surgery

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MSLT‐1: Surgery +/‐ Systemic Rx

Breakdown by “M” Stage

Surgery vs Systemic Therapy

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Interferon Ipilimumab

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Trametinib (MEK Inhibition) Dabrafenib

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Vemurafenib

Antitumor Activity of Lambrolizumab.

Anti‐PD 1 Therapy

Hamid, et al. NEJM 2014

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T‐Vec

Stage IIIB/C Stage IV M1a/b

Profiling (the good kind…)

n=112 p<0.0001 Class 1 Class 2

10‐yr MFS Class 1 = 84% Class 2 = 13% ROC = 0.8778 Accuracy = 79% Sensitivity = 85%

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Personalized Medicine

  • There are seven different drugs discussed in

this presentation

  • All have shown some (questionable) benefit in

the management of melanoma

  • It is a unique time in the care of these patients
  • There is no better time to pursue combination

therapy than now

Simple question:

If you were a 47 year old patient with no significant medical comorbidities and two isolated small bowel metastases, what would you want? That remains the answer.

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11 Winship Cancer Institute of Emory University

Is there a role for surgical resection for stage IV melanoma anymore?