Authors: Christian U. Blank, Irene L.M. Reijers, Thomas Pennington, Judith M. Versluis, Robyn PM Saw, Elisa A. Rozeman, Ellen Kapiteijn, Astrid Aplonia Maria Van Der Veldt, Karijn Suijkerbuijk, Geke Hospers, W. Martin. C. Klop, Karolina Sikorska, Jos A. Van Der Hage, Dirk J. Grunhagen, Andrew Spillane, Robert V Rawson, Bart A. Van De Wiel, Alexander M. Menzies, Alexander Christopher Jonathan Van Akkooi, Georgina V. Long; Netherlands Cancer Institute, Amsterdam, Netherlands; Melanoma Institute Australia, Sydney, Australia; Melanoma Institute Australia, The University of Sydney, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Leiden University Medical Center, Leiden, Netherlands; Departments of Medical Oncology and Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, Netherlands; UMCU, Utrecht, Netherlands; University of Groningen, University Medical Center Groningen, Department of Medical Oncology, Groningen, Netherlands; Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands; Department of Statistics, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands; Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, Netherlands; Melanoma Institute Australia, Royal Prince Alfred Hospital, Sydney, Australia; Melanoma Institute Australia, University of Sydney, Royal North Shore Hospital, Sydney, Australia; Melanoma Institute Australia, The University of Sydney, Royal North Shore Hospital, Mater Hospital, Sydney, Australia
Research Funding: BMS
Background: OpACIN-neo tested 3 dosing schemes of neoadjuvant (neoadj) IPI+NIVO and identified 2 cycles of IPI 1mg/kg + NIVO 3mg/kg (I1N3) as the most favorable with a pathologic (path) response rate (pRR) of 77% and 20% grade 3-4 irAEs. After 17.6 months median FU, 1/64 (2%) patients (pts) with path response vs 13/21 (62%) of the non-responders ( > 50% viable tumor cells; pNR) had relapsed. We hypothesized that therapeutic lymph node dissection (TLND) could be omitted in pts achieving a complete or near-complete path response (≤10% viable tumor cells; major path response, MPR) in the index node (largest LN metastasis: ILN), whereas additional adjuvant (adj) therapy might improve the outcome of pNR pts.
Methods: PRADO is an extension cohort of the multi-center phase 2 OpACIN-neo study that aims to confirm the pRR and safety of neoadj I1N3 and to test response-driven subsequent therapy. Pts with RECIST 1.1 measurable clinical stage III melanoma were included to receive 2 cycles of neoadj I1N3 after marker placement in the ILN. ILN resection was planned at wk 6. Pts that achieved MPR in the ILN did not undergo TLND; pts with pPR ( > 10 –≤50% viable tumor cells) underwent TLND; and pts with pNR underwent TLND and received adj NIVO or targeted therapy (TT) for 52 wks +/- radiotherapy (RT). Primary endpoints were pRR in the ILN and 24-month RFS. Estimated toxicity rates at wk 12 were calculated using a Kaplan Meier based method.
Results: Between Nov 16, 2018 and Jan 3, 2020, 99 of 114 screened pts were eligible and enrolled. So far, 86 pts had ≥12 wks FU. 70/99 pts achieved a path response in the ILN (pRR 71%, 95% CI 61% – 79%); 60 (61%) had MPR. TLND was omitted in 58 (97%) of the MPR pts. There were 28 non-responders; 7 developed distant metastasis before ILN resection. To date, 8 of the 21 pNR pts had adj NIVO, 7 had adj TT and 7 had adj RT. The estimated grade 3-4 irAE rate at wk 12 was 24%. Due to toxicity, 10 pts (10%) received only 1 cycle I1N3 and in 3 pts ILN resection was not performed: 2 of these pts underwent TLND at wk 9 and one pt was not evaluated for path response. At data cutoff, the surgery-related grade 1,2 and 3 AE rates were 29%, 10% and 0% in pts who underwent ILN resection only vs 21%, 30% and 9% in pts who underwent subsequent TLND (p = 0.004). At ASCO 2020 all pts will have reached ≥12 wks FU.
Conclusions: Neoadj I1N3 treatment induced a high pRR with tolerable toxicity. TLND was omitted in a major subset of pts, reducing surgical morbidity. Longer FU is needed to report safety and RFS when TLND is omitted in MPR pts. Clinical trial information: NCT02977052