Journal Article

Neoadjuvant versus adjuvant ipilimumab plus nivolumab in macroscopic stage III melanoma

Peeper, Daniel S., Rozeman, Elisa A., Krijgsman, Oscar, Mallo, Henk A., Adriaansz, Sandra, Pronk, Loes M., Kvistborg, Pia, Haanen, John B. A. G., van Thienen, Johannes V., Schumacher, Ton N., Fanchi, Lorenzo F., van de Wiel, Bart, Warren, Sarah, van Akkooi, Alexander C. J., Broeks, Annegien, van Tinteren, Harm, van den Braber, Marlous, Bruining, Annemarie, Sikorska, Karolina, Gittelman, Rachel M., Blank, Christian U., ter Meulen, Sylvia, Grijpink-Ongering, Lindsay G., Philips, Daisy

2018

Overview

Adjuvant ipilimumab (anti-CTLA-4) and nivolumab (anti-PD-1) both improve relapse-free survival of stage III melanoma patients 1 , 2 . In stage IV disease, the combination of ipilimumab + nivolumab is superior to ipilimumab alone and also appears to be more effective than nivolumab monotherapy 3 . Preclinical work suggests that neoadjuvant application of checkpoint inhibitors may be superior to adjuvant therapy 4 . To address this question and to test feasibility, 20 patients with palpable stage III melanoma were 1:1 randomized to receive ipilimumab 3 mg kg −1 and nivolumab 1 mg kg −1 , as either four courses after surgery (adjuvant arm) or two courses before surgery and two courses postsurgery (neoadjuvant arm). Neoadjuvant therapy was feasible, with all patients undergoing surgery at the preplanned time point. However in both arms, 9/10 patients experienced one or more grade 3/4 adverse events. Pathological responses were achieved in 7/9 (78%) patients treated in the neoadjuvant arm. None of these patients have relapsed so far (median follow-up, 25.6 months). We found that neoadjuvant ipilimumab + nivolumab expand more tumor-resident T cell clones than adjuvant application. While neoadjuvant therapy appears promising, with the current regimen it induced high toxicity rates; therefore, it needs further investigation to preserve efficacy but reduce toxicity. Neoadjuvant combination immunotherapy in patients with advanced melanoma shows favorable activity over adjuvant treatment and warrants future evaluation with modified dosing schedules to reduce treatment-related adverse events.

• Publisher: Nature Publishing Group US,Nature Publishing Group
• Subject: 631/250/251 / 692/308/2779/109/1940 / 692/308/2779/777 / 692/699/67/1813/1634 / Adjuvant chemotherapy / Adult / Aged / Antibodies, Monoclonal - administration & dosage / Antibodies, Monoclonal - adverse effects / Antineoplastic Combined Chemotherapy Protocols - administration & dosage / Antineoplastic Combined Chemotherapy Protocols - adverse effects / Biomedical and Life Sciences / Biomedicine / Biopsy / Cancer Research / Chemotherapy, Adjuvant - adverse effects / Chemotherapy, Adjuvant - methods / Comparative analysis / CTLA-4 Antigen - antagonists & inhibitors / CTLA-4 Antigen - immunology / CTLA-4 protein / Disease-Free Survival / Dosage and administration / Drug therapy / Feasibility / Humans / Immune checkpoint / Immunotherapy / Infectious Diseases / Ipilimumab / Ipilimumab - administration & dosage / Ipilimumab - adverse effects / Letter / Lymphocytes / Lymphocytes T / Male / Melanoma / Melanoma - drug therapy / Melanoma - pathology / Melanoma - surgery / Metabolic Diseases / Middle Aged / Molecular Medicine / Monoclonal antibodies / Neoadjuvant therapy / Neoadjuvant Therapy - adverse effects / Neoplasm Staging / Neurosciences / Nivolumab / Nivolumab - administration & dosage / Nivolumab - adverse effects / Patient outcomes / Patients / PD-1 protein / Surgery / T cells / Targeted cancer therapy / Therapy / Toxicity / Tumors