EORTC Melanoma Group

Transcription

1 EORTC Melanoma Group : Prospective registry of Sentinel Node (SN) positive melanoma patients with minimal SN tumor burden who undergo Completion Lymph Node Dissection (CLND) or Nodal Observation. EORTC protocol 1208-MG (NCT ) Study Coordinator: Alexander van Akkooi Protocol Date of PRC Amendment reference version approval/notification N Classification Outline January 30, September 09, Version 1.0 / September 09, 2013 Copyright EORTC 2013

2 Contact addresses Writing Committee: Study Steering Committee: Study Coordinator: Clinical Research Physician: Project Manager: Data Manager: Statistician: A. van Akkooi, Erasmus MC - Daniel den Hoed Cancer Center, Rotterdam, The Netherlands EORTC Headquarters Team, Brussels, Belgium. A. van Akkooi, Rotterdam, The Netherlands A. Testori, Milan, Italy A. Eggermont, Paris, France M. Cook, Guildford, UK L. van Kempen, Montreal, Canada S. Suciu, EORTC Headquarters R. Karra, EORTC Headquarters Alexander van Akkooi Phone: a.vanakkooi@erasmusmc.nl Ravi Karra Phone: ravi.karra@eortc.be Gaetan de Schaetzen Phone: gaetan.deschaetzen@eortc.be Simon Vanderschaeghe Phone: simon.vanderschaeghe@eortc.be Stefan Suciu Phone: stefan.suciu@eortc.be Version / 44 September 09, 2013

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4 Table of contents: Protocol summary 7 1 Background and introduction Disease background information Rationale of the study 11 2 Objectives of the study General objectives End-points Primary endpoint Secondary endpoints 13 3 Patient eligibility criteria 14 4 Trial Design 15 5 Therapeutic regimens, expected toxicity, dose modifications 16 6 Clinical evaluation, laboratory tests and follow-up At enrollment During the study period Summary table 18 7 Criteria of evaluation Definitions of Sentinel Node Positivity Definitions of relapses Definitions of endpoints Methods of assessment of endpoints Evaluation of morbidity Reporting procedures 21 8 Statistical considerations Statistical design Sample size Registration Statistical analysis plan Primary and secondary endpoints Distant Metastasis Free Interval (primary endpoint) Regional Control Rate (secondary endpoint) Relapse Free Interval (secondary endpoint) 22 Version / 44 September 09, 2013

5 Melanoma Specific Survival (secondary endpoint) Overall Survival (secondary endpoint) Analysis populations Statistical methods Efficacy Morbidity Pre-planned sensitivity or exploratory analyses Prognostic factor analyses Data recoding and display Interim analyses End of study 25 9 Data Monitoring Translational research Objectives Translational research projects Translational Research Project 1: Regulation of DNA replication Rationale Objective Material Translational Research Project 2: Ki-67 expression Rationale Objective Material Translational Research Project 3: Circulating Tumor Cells (CTC) Rationale Objective Material Storage, Handling and Transportation Summary of samples collection and routing Laboratory processing Statistical Analysis Data storage and technical appendices General principles for human biological material (HBM) collection Investigator authorization procedure 30 Version / 44 September 09, 2013

6 12 Patient registration procedure Forms and procedures for collecting data Case report forms and schedule for completion Data flow Quality assurance Control of data consistency Audits External review of histology Ethical considerations Patient protection Subject identification Informed consent Administrative responsibilities The study coordinator The EORTC Headquarters The EORTC group Trial sponsorship Trial insurance Publication policy 38 Table of appendices: Appendix A: References 39 Appendix B: Abbreviations 42 Appendix C: Sentinel Node Surgical and Pathological Procedure 44 Version / 44 September 09, 2013

7 Protocol summary Title of the Study Objective(s) Methodology : Prospective registry of Sentinel Node (SN) positive melanoma patients with minimal SN tumor burden who undergo Completion Lymph Node Dissection (CLND) or Nodal Observation With this prospective registry we aim to evaluate the outcome of patients with a T2-T3 primary melanoma and minimal SN tumor burden, treated by CLND or nodal observation: The main objective is to determine if T2-T3 melanoma patients with minimal SN tumor burden and managed by nodal observation have a 5- year DMFI comparable to similar patients (T2-T3 melanoma patients with minimal SN tumor burden) treated by CLND based on historical data from the literature. We will compare this with SN-negative patients, based on historical data as well. We will also determine the actual proportion of patients and their characteristics, who opt to undergo a CLND compared to those, who opt to undergo nodal observation. This is a prospective registry of all melanoma patients with minimal SN tumor burden attending the participating sites, aiming to evaluate whether management of these patients with serial nodal observation only provides an equal outcome than immediate CLND. Since the focus of this study is represented by patients with minimal SN burden and melanoma of intermediate Breslow thickness, the primary aim population will be composed of T2-T3 (Breslow thickness mm) patients with minimal SN tumor burden. However, T1 and T4 patients with minimal SN tumor burden will be allowed to enter the registry for descriptive analyses. This is not a randomized trial. At each site melanoma patients with minimal SN tumor burden will be managed with CLND or serial nodal observation only according to patient decision, and will be offered the possibility to be included in the registry. Participating patients will be registered after signing the informed consent form and after eligibility criteria have been assessed. Data and blood samples for TR will be collected. Accrual will last approximately 5 years. Patients will be followed up for 10 years. Version / 44 September 09, 2013

8 Number of patients Number planed (Statistical design) Number analyzed Diagnosis and main criteria for inclusion The determination of the sample size was based on results from a more recent evaluation, where patients with melanoma of intermediate Breslow thickness, namely T2-T3 (Breslow thickness mm) (N=110), and minimal SN burden had a 5- and 10-year Melanoma Specific Survival rate of 87% and 80%. As generally, the majority of patients who have distant metastasis die within 1-2 years, one may estimate that the 5-year Distant Metastasis Free Interval (DMFI) rate of this group of patients is probably close to 87%. So, for a comparable group of patients, who would not undertake a CLND, an observed loss in the 5-year DMFI rate of approximately 3% would be considered as acceptable; a higher observed loss of the DMFI rate, compatible with a true 5-yr DMFI rate of 80 % or lower would be considered to be inacceptable. It is expected that 243 patients with an T2-T3 primary tumor and minimal SN tumor burden choosing a serial nodal observation will be registered in 5 years. If out of these 243 patients, in 38 (15.7%) patients or less a Distant Metastasis is reported within 5 years from their study enrollment, so 205 (84.3%) patients or more are DM-Free at 5-years, then one may reject the null hypothesis (the loss in 5-year DMFI rate is >= 7 %, i.e. 5-year DMFI rate is <= 80%) in favor of the alternative (5-year DMFI rate is 87%) with a statistical power of 90% (1-sided alpha=0.05 and beta=0.10, A'Hern design). As a drop-out of 7% is expected, the total number of T2-T3 patients to be registered will be increased to 260 patients. T1 and T4 patients will be excluded from the primary aim population, but allowed to enter the registry for descriptive analyses. Histological evidence of primary cutaneous melanoma Metastases solely confined within the SN: in the sub-capsular space (with no parenchymal infiltration) and with a maximum diameter of the largest metastasis not greater than 0.4 mm or regardless of the site, any sub-micrometastasis with a maximum diameter not greater than 0.1 mm If there is more than 1 metastatic SN, the patient will be still eligible provided that all involved SN have minimal tumor burden, regardless of the amount of positive SNs and the basin of interest Absence of clinically apparent metastatic disease at the time of or before undergoing a SN procedure No previous SN procedure for locally recurrent melanoma or uncertain malignant disease, such as atypical Spitz tumor/naevi Age 18 years No history of a previous melanoma (preceding the melanoma which prompted the SN biopsy) No history of any other malignancy within the past 5 years, except for Version / 44 September 09, 2013

9 Treatment Test product, dose and mode of administration Duration of treatment Reference therapy, dose and mode of administration Criteria for evaluation Efficacy non-melanoma skin cancer (Basal Cell Carcinomas or Squamous Cell Carcinomas) and in situ cervical cancer Absence of any psychological, familial, sociological or geographical condition potentially hampering compliance with the study protocol and follow-up schedule; those conditions should be discussed with the patient before registration in the trial Before patient registration, written informed consent must be given according to ICH/GCP, and national/local regulations NA NA NA Important note: All eligibility criteria must be adhered to, in case of deviation discussion with Headquarters and study coordinator is mandatory. Primary endpoint Distant Metastasis Free Interval (DMFI), defined as the time from SN positive biopsy until distant metastasis or death due to melanoma, whichever comes first. Secondary endpoints Regional Control Rate (secondary endpoint): Regional Metastasis Free Interval (RMFI): time from SN positive biopsy (date of surgical procedure) until regional relapse, on the same basin as the SN was previously removed. Regional Control Rate (RCR): rate of lymph node relapse (date of delayed CLND) in the same basin as the SN was previously removed. Regional relapse does not include any local or in-transit recurrences. Relapse Free Interval (RFI), defined as the time from SN positive biopsy until first relapse regional or distant metastasis or death due to melanoma. Melanoma Specific Survival (MSS), defined as the time from SN positive biopsy until death due to melanoma. Overall Survival (OS), defined as the time from SN positive biopsy until death due to any cause. Version / 44 September 09, 2013

10 Safety Statistical methods Translational research Quality of Life PK PD Morbidity: rates of wound infections, lymphedema and neurological damage, based on the clinical judgment of the local physician. All the main analyses of the efficacy endpoints will be performed on the intent-to-treat (ITT) population using the ITT principle The Kaplan-Meier technique will be used to obtain estimates of the survival-type distributions and the standard error of the estimates will be computed using the Greenwood formula. Medians - if reached - will be presented with a 2-sided (1-alpha)% confidence interval based on the non-parametric method All the analyses of the morbidities of interest will be performed on the safety population. Morbidities (frequency and percentage, unless otherwise noted) will be reported by arm. To prospectively collect biological material (whole blood, plasma, serum and tissue) for optional translational research projects to gain insight into tumor biology, especially in this study, which targets a specific population of melanoma patients with minimal SN tumor burden. The objective of the optional translational research studies associated with this prospective registry is to answer the following questions: Are micro-metastases within the minimal tumor burden positive SN capable of proliferation and migration? Are any markers of disease dissemination detectable in peripheral blood? Are there any markers, which can predict disease recurrence or disease outcome? In order to explore these questions, this protocol includes a prospective collection of biological material (whole blood, plasma, serum and tissue) from patients who have consented to take part in this research. NA NA Version / 44 September 09, 2013

11 1 Background and introduction 1.1 Disease background information Over the past two decades, the Sentinel Node (SN) biopsy (SNB) procedure has become a standard staging procedure for stage I/II melanoma patients worldwide. It is widely accepted that the SN status is the most important prognostic factor for disease outcome in AJCC stage I/II melanoma patients (Ref. 1, Ref. 2, Ref. 3, Ref. 4). The therapeutic value of the SN procedure followed by early Completion Lymph Node Dissection (CLND) is still widely debated (Ref. 5, Ref. 6, Ref. 7, Ref. 8, Ref. 9, Ref. 10, Ref. 11, Ref. 12, Ref. 13, Ref. 14, Ref. 15, Ref. 16). If a patient has a positive SN, this patient will usually be offered a completion lymph node dissection to remove all lymph nodes from that same nodal basin. However, only approximately 15-20% of all SN positive patients have further lymph node metastases detected in that basin at this time (Ref. 1, Ref. 4, Ref. 17, Ref. 18, Ref. 19). Therefore approximately 80-85% of SN positive patients may undergo unnecessary surgery. Any possible reduction of unnecessary CLND procedures would have an obvious benefit for those patients. Moreover, it remains unclear if the minority (15-20%) of patients with additional nodal involvement at CLND is the subgroup which has a survival benefit by undergoing an early CLND (Ref. 3, Ref. 15, Ref. 16). Over recent years many research groups have looked at different types of micro-staging of the tumor burden within the SN, as indicator or prognostic factor for additional nodal positivity in the CLND specimen, but also for disease-free (DFS), disease/melanoma specific (DSS/MSS) and overall survival (OS). Starz et al. (Ref. 20, Ref. 21) developed a classification for tumor burden by measuring the distance from the capsule to the most interior margin of the metastasis. This was prognostic for the probability of non-sn metastases. Cochran et al. (Ref. 22) calculated the surface area involved by the metastasis and demonstrated its prognostic significance. Dewar et al. (Ref. 23) developed a classification system based on the location of the metastasis within the SN. Subcapsular metastases were accompanied with no additional spread to other lymph nodes in the same lymph node basin. At the same time many studies have identified only very rough cut-off values for SN tumor burden, such as >2 or <2 mm in maximum diameter of the metastasis (Ref. 19, Ref. 24, Ref. 25, Ref. 26, Ref. 27). This was only useful for prognostic purposes, but not for the clinical decision making process. 1.2 Rationale of the study The principle of SUB-micrometastases has been described earlier in breast cancer (Ref. 28, Ref. 29) as metastases <0.2 mm in maximum diameter. It has been demonstrated in breast cancer patients that minimal tumor burden in the SN can be safely managed without performing a CLND (Ref. 28, Ref. 29). However, the question remains if the same situation exists in melanoma. This is an important reason to conduct the present trial. The principle of SUB-micrometastases was defined by van Akkooi et al. (Ref. 4) in melanoma as <0.1 mm in maximum diameter of the largest lesion, regardless of the site within the SN. Patients with SUBmicrometastases in their SN did not have further involvement of their lymph node basin and had excellent prognosis for long-term survival. These results were validated by an EORTC multicenter retrospective study, conducted in 388 patients from Berlin, Rotterdam and Warsaw (Ref. 30). Similarly, a study from Canada by Govindarajan et al. showed that none of the patients with metastases <0.2 mm had additional non-sn metastases in the CLND specimen (Ref. 31). These results were confirmed by the most recent studies, which have also investigated minimal SN tumor burden (Ref. 32, Ref. 33, Ref. 34). Version / 44 September 09, 2013

12 More recently, a large EORTC retrospective analysis by van der Ploeg et al. in 1080 SN positive patients from 9 centers, demonstrated that patients with metastases <0.1 mm in maximum diameter according to the Rotterdam classification for SN tumor burden had a 5-year 91% MSS, which is virtually identical to SN negative patients (Ref. 35). The CLND positivity rate was 9% in these cases. Rotterdam-Dewar Combined (RDC) classification further isolated excellent prognosis patients; in those with <0.1 mm subcapsular metastases had a 2% CLND positivity rate and a 95% 5-year MSS (Ref. 35). In a more recent evaluation (van der Ploeg & van Akkooi, personal communication), the Breslow thickness was confirmed to be an independent prognostic factor. Indeed, the 5-year MSS rate of those SNpositive patients with T1 (Breslow thickness <1 mm) and minimal SN tumor burden (defined as Rotterdam criteria 0.1 mm, or those with a subcapsular infiltration up to 0.4 mm) who received CLND (N=9) was 100%, whereas the 5- and 10-year MSS rate was 67% and 45% for patients with thick melanoma (T4, Breslow thickness > 4 mm) and minimal SN burden (N=21). Meanwhile, patients with melanoma of intermediate Breslow thickness, namely T2-T3 (Breslow thickness mm) (N=110), and minimal SN burden had a 5- and 10-year MSS rate of 87% and 80%. Based on preliminary data (van der Ploeg & van Akkooi, personal communication), the incidence of patients with T1 and T4 tumors presenting with minimal SN tumor burden is nearly non-existent. T1 tumors have very few metastases at all (<5% SN positive), while T4 tumors usually have advanced SN metastases, infrequent cases of minimal SN tumor burden which develop distant metastases within a very short timeframe exist. In addition, as the Breslow thickness remains of high prognostic importance, MSS rates are very high for T1 patients and low for T4 patients, as compared to MSS rates in T2-T3 patients. Hence, T1 and T4 patients represent two population groups with distinct prognostic and clinical characteristics compared to T2-T3 patients. For this reason, T2-T3 patients will be the focus of this study, as it is currently unknown if this patient population really benefits from immediate CLND or not. Patients with T1 and T4 melanomas will be excluded from the primary aim study population, but allowed to enter the registry for descriptive analyses. All these studies suggest that certain patterns or sizes of metastatic spread are not associated with further metastases in other lymph nodes of the same lymph node basin. At the moment the standard practice in most countries (Europe, U.S.A & Australia), as defined in the national guidelines, is that patients with a positive SN, regardless of amount, pattern or size, undergo completion lymph node dissection. This is a second operation for all these patients, which is accompanied with all the risks of a surgical procedure, but is also associated with significant post-operative morbidity, such as wound infections and chronic limb lymphedema (Ref. 36, Ref. 37, Ref. 38, Ref. 39). Although most countries suggest CLND as standard treatment for a positive SN in melanoma, there are large differences in local application of this guideline. A study by Bilimoria et al. demonstrated that only 50% of SN positive patients undergo a CLND in the U.S.A., regardless of SN tumor burden (Ref. 40). Likewise, the treatment of SN positive patients is quite heterogeneous across Europe (Ref. 41). Both CLND and nodal observation (with or without regional nodal ultrasound) are being performed. Based on the previous studies regarding SN tumor burden, some major melanoma centers have adjusted their protocol/standard of care in these cases with minimal SN tumor burden. Moreover, the MSLT-1 study has not yet been able to identify a survival benefit for SN followed by early CLND compared to nodal observation (Ref. 3, Ref. 15, Ref. 16). Therefore, the choice for nodal observation can be justified. Currently, there is one prospective randomized trial worldwide, the MSLT-2, which randomizes SN positive melanoma patients between CLND and nodal observation, regardless of SN tumor burden (Ref. 42). All these previous SN tumor burden studies in melanoma have been retrospective and the majority of included patients have undergone a CLND. Version / 44 September 09, 2013

13 Obviously, a prospective randomized controlled trial of minimal SN tumor burden melanoma patients randomizing between CLND and nodal observation would be the best possible trial design to address this question. However, this is practically impossible, as it would require a large number of patients to test this hypothesis. Therefore, the second best option would be to analyze a prospective registry of minimal SN tumor burden patients managed without CLND to historical data from the retrospective series, as described above, and to SN negative melanoma patient cohorts. In view of the discrepancy in the management of SN positive melanoma patients and in light of the previous retrospective analyses regarding SN tumor burden, any change from the standard of offering a CLND or nodal observation to minimal tumor burden SN positive patients would require an EORTC prospective trial to support this new standard of care and therefore this EORTC prospective registry will be the first to address this question, specifically in targeting minimal SN tumor burden melanoma patients. 2 Objectives of the study 2.1 General objectives With this prospective registry we aim to evaluate the outcome of patients with a T2-T3 primary melanoma and minimal SN tumor burden, treated by CLND or nodal observation: The main objective is to determine if T2-T3 melanoma patients with minimal SN tumor burden and managed by nodal observation have a 5-year DMFI comparable to similar patients (T2-T3 melanoma patients with minimal SN tumor burden) treated by CLND based on historical data from the literature. We will compare this with SN-negative patients, based on historical data as well. We will also determine the actual proportion of patients and their characteristics, who opt to undergo a CLND compared to those, who opt to undergo nodal observation. Answering these questions will be crucial to establish an accepted standard of care (CLND or not) for melanoma patients with minimal SN tumor burden. 2.2 End-points Primary endpoint Distant Metastasis Free Interval (DMFI): time from SN positive biopsy (date of surgical procedure) until distant metastasis or death due to melanoma, whichever comes first Secondary endpoints Regional Control Rate (RCR) is the resultant of two sub-endpoints: Regional Metastasis Free Interval (RMFI), defined as the time from SN positive biopsy (date of surgical procedure) until regional relapse in the same basin as the one from which the SN was previously removed. Regional Control Rate (RCR), defined as the rate of lymph node relapse (date of delayed CLND) in the same basin as the one from which the SN was previously removed. Regional relapse does not include any local or in-transit recurrences. Relapse Free Interval (RFI): time from SN positive biopsy (date of surgical procedure) until first relapse regional or distant metastasis or death due to melanoma. Version / 44 September 09, 2013

14 Melanoma Specific Survival (MSS): time from SN positive biopsy (date of surgical procedure) until death due to melanoma. Overall Survival (OS): time from SN positive biopsy (date of surgical procedure) until death due to any cause. Morbidity: rates of wound infections, lymphedema and neurological damage, based on the clinical judgment of the local physician. 3 Patient eligibility criteria Histological evidence of primary cutaneous melanoma Metastases solely confined within the SN: in the sub-capsular space (with no parenchymal infiltration) and with a maximum diameter of the largest metastasis not greater than 0.4 mm or regardless of the site, any sub-micrometastasis with a maximum diameter not greater than 0.1 mm If there is more than 1 metastatic SN, the patient will be still eligible provided that all involved SN have minimal tumor burden, regardless of the amount of positive SNs and the basin of interest Absence of clinically apparent metastatic disease at the time of or before undergoing a SN procedure No previous SN procedure for locally recurrent melanoma or uncertain malignant disease, such as atypical Spitz tumor/naevi Age 18 years No history of a previous melanoma (preceding the melanoma which prompted the SN biopsy) No history of any other malignancy within the past 5 years, except for non-melanoma skin cancer (Basal Cell Carcinomas or Squamous Cell Carcinomas) and in situ cervical cancer Absence of any psychological, familial, sociological or geographical condition potentially hampering compliance with the study protocol and follow-up schedule; those conditions should be discussed with the patient before registration in the trial Before patient registration, written informed consent must be given according to ICH/GCP, and national/local regulations. Important note: All eligibility criteria must be adhered to, in case of deviation discussion with Headquarters and study coordinator is mandatory. Version / 44 September 09, 2013

15 4 Trial Design This is a prospective registry of all melanoma patients with minimal SN tumor burden attending the participating sites, aiming to evaluate whether management of these patients with serial nodal observation only provides an equal outcome than immediate CLND. Since the focus of this study is represented by patients with minimal SN burden and melanoma of intermediate Breslow thickness, the primary aim population will be composed of T2-T3 (Breslow thickness mm) patients with minimal SN tumor burden. However, T1 and T4 patients with minimal SN tumor burden will be allowed to enter the registry for descriptive analyses. This is not a randomized trial (Figure 1). At each site melanoma patients with minimal SN tumor burden will be managed with CLND or serial nodal observation only according to patient decision, and will be offered the possibility to be included in the registry. Participating patients will be registered after signing the informed consent form and after eligibility criteria have been assessed. Data and blood samples for TR will be collected. Accrual will last approximately 5 years. Patients will be followed up for 10 years after registration. Version / 44 September 09, 2013

16 Figure 1. Flow chart showing the study design. SN, sentinel node; CLND, completion lymph node dissection; TR, translational research 5 Therapeutic regimens, expected toxicity, dose modifications Not applicable. Version / 44 September 09, 2013

17 6 Clinical evaluation, laboratory tests and follow-up 6.1 At enrollment A screening log needs to be completed by the investigator to assess potential selection bias. Availability of all required material for the Pathology Review committee within 3 months after entry into the registry. Please refer to Pathology Guidelines for further elaborated information. Medical history and physical examination. Morbidity: rates of wound infections, lymphedema and neurological damage, based on the clinical judgment of the local physician. Minimal staging assessment (chest X-ray and Ultrasound of the liver). Ultrasound of lymph nodes is not requested but result data will be collected for centers performing it routinely. Tissue from SN for Central Pathology review and TR purposes. For optional TR purposes, 3 x 5 ml of whole blood, 1 x 10 ml of serum and 1 x 10 ml tube of plasma (total of 35 ml). Whole blood should be collected in EDTA tubes and stored at -80 degrees Celsius. Serum should be collected in 10 ml tubes to be divided in aliquots of 1 ml and stored at -80 degrees Celsius. Plasma should be collected in heparin tubes, to be divided in 10 x 1 ml aliquots and stored at - 80 degrees Celsius. 6.2 During the study period Recent medical history and physical examination 4-monthly for years 1-2, 6-monthly for years 3-5, once a year for years Ultrasound of lymph nodes 4-monthly for years 1-2, 6-monthly for years 3-5, once a year for years Ultrasound of lymph nodes is not requested but result data will be collected for centers performing it routinely. Chest X-ray once a year for 10 years. Ultrasound of the liver, if clinically indicated. CT-thorax/abdomen, CT/MRI brain, PET-scan if clinically indicated Morbidity: rates of wound infections, lymphedema and neurological damage, based on the clinical judgment of the local physician. For optional TR purposes, 1 x 10 ml of serum and 1 x 10 ml of plasma (total 2 x 10 ml) once a year for 5 years. Further anti-tumor therapy. Survival status. Version / 44 September 09, 2013

18 6.3 Summary table Assessment Screening Log Enrollment X Years 1-2 Years 3-5 Years 6-10 Month Month Once a year History & Physical X X X X X X X X X X X X X X Morbidity X X X X X X X X X X X X X X Chest X-ray X X X X X X X Ultrasound Liver X * * * * * * * * * * * * * Ultrasound of Lymph Nodes CT-thorax/ abdomen, CT/MRI brain, PET-scan Tissue for Pathology Review & optional TR Whole blood for optional TR studies Serum for optional TR studies Plasma for optional TR studies Further anti-tumor therapy C C C C C C C C C C C C C C X X * * * * * * * * * * * * * X X X X X X X X X X X X X X X X X X X X X X X X X Survival status X X X X X X X X X X X X X * If clinically indicated C Only for Centers performing regular lymph node ultrasound examinations All centers must make the primary lesion available in the form of the block and send the original diagnostic slides of the primary melanoma along with all slides stained and unstained from all positive SNs. Additional stained slides from any negative sentinel node(s) removed at the same procedure may be requested for analysis by the Pathology Review committee later. Version / 44 September 09, 2013

19 7 Criteria of evaluation 7.1 Definitions of Sentinel Node Positivity Please refer to Appendix C for the sentinel node surgical and pathological procedure. 7.2 Definitions of relapses Relapse: Appearance of one or more new melanoma lesions: local, regional or distant. Local cutaneous relapse: Local relapse/recurrence is a lesion clearly occurring in continuity within the excision scar of the primary melanoma. Regional lymphatic and nodal relapses: The neoplastic nature of the regional relapses should be attempted to be confirmed by histology/cytology. In Transit Metastases: In transit metastasis represents the clinical manifestation of small tumor emboli trapped within the dermal and subdermal lymphatics between the site of the primary tumor and the regional lymph node drainage basin(s). In extremities in transit metastases can also occur distal to the site of the primary lesion as a result of reversed lymphatic flow. In transit metastases occur in 10% to 15% in patients with stage III disease. Although previous staging systems distinguished between the small satellitosis (within 2 cm of the primary tumor) and in transit metastases (more than 2 cm from the primary tumor), pathophysiologically these two events represent different points on a continuum of the same biologic process. When present, in transit metastases are usually multiple, evolve over time, and, as previously stated, are often the harbinger of subsequent systemic disease (AJCC 2002). Microscopic satellites are defined as any discontinuous nest of metastatic cells more than 0.05 mm in diameter that are clearly separated by normal dermis from the main invasive component of melanoma by a distance of at least 0.3 mm. As per AJCC 2010, satellites and intransit metastases are classified together. Regional Nodal Relapses: Regional nodal failure in a previously dissected basin is usually found at the periphery of the prior surgical procedure. Distant metastases: Melanoma is well known for its ability to metastasize to virtually any organ or tissue. The most common initial sites of distant metastases are the non visceral, such as the skin, subcutaneous tissue, and lymph nodes, which are relapse sites for 42% to 59% of patients in various studies. Visceral locations are the lung, brain, liver, gastrointestinal tract, and bone which are the initial sites of relapse in approximately 25% of all melanoma patients who experienced relapse. Note: Cutaneous relapses occurring beyond the periphery of the previous surgical bed of a lymph nodal dissection scar (i.e. over 2 cm) are considered distant metastases. Node relapses occurring beyond the anatomical compartment of the dissected basins are considered distant metastases. Version / 44 September 09, 2013

20 Node relapses in nodal basins situated in a different anatomical compartment or beyond the previously dissected basin or in two nodal basins (even if contiguous; i.e. 2 pelvic nodal basins, 2 mediastinal nodal basins) are considered distant metastases unless the primary was located within 2 cm from the midline and the nodes are in the same district as the initial nodal involvement. 7.3 Definitions of endpoints Distant Metastasis Free Interval (DMFI) has been defined as the time from SN positive biopsy (date of surgical procedure) until distant metastasis or death due to melanoma, whichever comes first. In case no events occurred, patients will be censored at the last follow-up date. Regional Control Rate (RCR) has been defined as the result of two sub-endpoints: Regional Metastasis Free Interval (RMFI), defined as the time from SN positive biopsy (date of surgical procedure) until regional relapse in the same basin as the one from which the SN was previously removed. Regional Control Rate (RCR), defined as the rate of lymph node relapse (date of delayed CLND) in the same basin as the one from which the SN was previously removed. Regional relapse does not include any local or in-transit recurrences. Relapse Free Interval (RFI) has been defined as the time from SN positive biopsy (date of surgical procedure) until first relapse regional or distant metastasis or death due to melanoma Melanoma Specific Survival (MSS) has been defined as the time from SN positive biopsy (date of surgical procedure) until death due to melanoma Overall Survival (OS) has been defined as the time from SN positive biopsy (date of surgical procedure) until death due to any cause Morbidity has been defined as the rates of wound infections, lymphedema and neurological damage, based on the clinical judgment of the local physician. 7.4 Methods of assessment of endpoints The following methodologies are recommended to assess endpoints Lymph Node Recurrence: cytology or histology. Lung: X-thorax or CT-thorax. Liver: Ultrasound, CT or MRI of the liver. Central Nervous System: brain CT-scan or MRI. (Sub)Cutaneous Recurrence: cytology or histology. Other Organs: CT-scan or MRI-scan or PET-scan; contrast GI series or ultrasound, or cytology or histology. Time points are specified in the table at chapter 6.3. Version / 44 September 09, 2013

21 7.5 Evaluation of morbidity The following morbidities are of interest for this study and will be assessed as present or absent by the local physician: wound infection rates lymphedema rates neurological damage 7.6 Reporting procedures Any confirmed morbidity, distant metastases, regional lymph node relapses, deaths due to melanoma should be reported immediately. Investigators will receive routine requests to enter follow-up data (also for those patients without events) 4-monthly for years 1-2, 6-monthly for years 3-5, once a year for years Statistical considerations 8.1 Statistical design Sample size The primary objective of this study is to determine whether melanoma patients with a T2-T3 primary tumor and minimal SN tumor burden managed only by serial nodal observation have a 5-year Distant Metastasis Free Interval (DMFI) comparable to melanoma patients with minimal SN tumor burden who had CLND and to melanoma patients with a negative SN biopsy, both based on historical data from the literature. The determination of the sample was based on results from a more recent evaluation (van der Ploeg & van Akkooi, personal communication), where patients with melanoma of intermediate Breslow thickness, namely T2-T3 (Breslow thickness mm) (N=110), and minimal SN burden had a 5- and 10-year MSS rate of 87% and 80%. As generally, the majority of patients who have distant metastasis die within 1-2 years, one may estimate that the 5-year DMFI rate of this group of patients is probably close to 87%. So, for a comparable group of patients, who would not undertake a CLND, an observed loss in the 5-year DMFI rate of approximately 3% would be considered as acceptable; a higher observed loss of the DMFI rate, compatible with a true 5-yr DMFI rate of 80 % or lower would be considered to be inacceptable. It is expected that 243 patients with a T2-T3 primary tumor and minimal SN tumor burden choosing a serial nodal observation will be registered in 5 years. If out of these 243 patients, in 38 (15.7%) patients or less a Distant Metastasis is reported within 5 years from their study enrollment, so 205 (84.3%) patients or more are DM-Free at 5-years, then one may reject the null hypothesis (the loss in 5-year DMFI rate is >= 7 %, i.e. 5-year DMFI rate is <= 80%) in favor of the alternative (5-year DMFI rate is 87%) with a statistical power of 90% (1-sided alpha=0.05 and beta=0.10, A'Hern design). As a drop-out of 7% is expected, the total number of T2-T3 patients to be registered will be increased to 260 patients. Patients with T1 or T4 primary tumors will be excluded from the primary aim population, but allowed to enter the registry for descriptive analyses. Version / 44 September 09, 2013

22 8.1.2 Registration Patients will be centrally registered (for practical details, see chapter on registration procedure). 8.2 Statistical analysis plan Primary and secondary endpoints Distant Metastasis Free Interval (primary endpoint) Distant Metastasis Free Interval (DMFI) is defined as the time from SN positive biopsy until distant metastasis or death due to melanoma, whichever comes first. A DMFI event observed up to 4 months after 5 years from SN positive biopsy, will be considered as DMFI events just before 5 years (e.g. at 4.9 yrs). The follow-up of patients without a DMFI-event will be censored at the time of last disease evaluation or at time of death due to other cause than melanoma Regional Control Rate (secondary endpoint) Regional Metastasis Free Interval (RMFI), defined as the time from SN positive biopsy until regional relapse, in the same basin as the SN was previously removed. The follow-up of patients without a RMFIevent will be censored at the time of last disease evaluation or at time of death. Regional Control Rate (RCR) is defined as the rate of lymph node relapse (date of CLND) in the same basin as the SN was previously removed Relapse Free Interval (secondary endpoint) Relapse Free Interval (RFI) is defined as the time from SN positive biopsy until first relapse regional or distant metastasis or death due to melanoma. The follow-up of patients without a RFI-event will be censored at the time of last disease evaluation or at time of death due to other cause than melanoma Melanoma Specific Survival (secondary endpoint) Melanoma Specific Survival (MSS) is defined as the time from SN positive biopsy until death due to melanoma. The follow-up of patients still alive will be censored at the time of last follow-up contact or at time of death due to other cause than melanoma Overall Survival (secondary endpoint) The overall survival (OS) is defined as the time from SN positive biopsy until death due to any cause. The follow-up of patients still alive will be censored at the time of last follow-up contact Analysis populations Intention-to-treat population (ITT): All patients registered in the study Per protocol population: All eligible patients registered in the study Safety population: All patients who have started their chosen treatment (observation or CLND) A patient will be considered to be eligible if he/she did not have any deviation from the patient entry criteria listed in chapter 3 of the protocol. Potential eligibility problems will be assessed by the Clinical Research Physician at time of medical review. Version / 44 September 09, 2013

23 These definitions will be used for the 2 patient populations: those with T2-T3 primary tumors (primary aim study population), and those with T1 or T4 primary melanomas Statistical methods Efficacy All the main analyses of the efficacy endpoints will be performed on the intent-to-treat (ITT) population using the ITT principle: patients will be considered in the arm group they entered at registration, regardless cause of going off-protocol, possible start of treatment before the 1st relapse, etc. In order to have a conservative approach for the 5-yr DMFI rate, we will consider a 4-month time window, so all distant metastases which were observed up to 4 months after 5 years from SN positive biopsy, will be considered as DMFI events just before 5 years (e.g. at 4.9 yrs). The Kaplan-Meier technique will be used to obtain estimates of the survival-type distributions and the standard error of the estimates will be computed using the Greenwood formula. Medians - if reached - will be presented with a 2-sided (1-alpha)% confidence interval based on the nonparametric method (Ref. 30). Patients with T1 or T4 primary tumors, as well as patients that chose CLND at study entry, will be considered separately, using descriptive analyses only, i.e. no inferential analyses will be done for this subpopulation vs the primary aim study population (patients with T2-T3 primary tumor, who did not undergo initial CLND) Morbidity All the analyses of the morbidities (see below) will be performed on the safety population, by chosen arm, in the overall population and in patients with T2-T3 primary tumor only. The safety analyses will be presented at baseline, during the study period as defined below: The baseline period will include all information recorded up to the registration date The study period will start on the first day after the registration and will end when the patient relapses or start further anti-tumor therapy (except local surgery). The following analyses of morbidities (frequency and percentage, unless otherwise noted) will be reported by each arm: wound infection rates (%) lymphedema rates (%) neurological damage (%) Pre-planned sensitivity or exploratory analyses For all endpoints sensitivity analyses will be performed: using the per protocol population In addition, in order to avoid the possible impact of CLND on the study endpoints (efficacy, morbidity) in patients who initially chose not to have CLND performed, the follow-up of patients in the observation arm who received CLND without a proof of relapse, will be censored at the date of CLND. Version / 44 September 09, 2013

24 8.2.5 Prognostic factor analyses Regarding each endpoint, for univariate analysis, a Cox proportional hazards model will be fitted including each of the potential prognostic factors mentioned in the literature: Minimal Tumor Burden (<= 0.1 mm any location vs <=0.2 mm subcapsular vs <=0.3 mm subcapsular vs <=0.4 mm subcapsular) Breslow thickness of the primary (<= 1.0 mm vs mm vs mm vs. > 4.0 mm) Ulceration (yes vs no vs unknown) Site of the primary (central (head, neck or trunk) vs. extremities) Sex (Male vs. Female) Age (<65 vs vs 70 years) Adjuvant treatment is foreseen to start after SNB (no vs IFN vs other) This list is not exhaustive: other variables might also be assessed based on new information that may become available during the course of the study. In order to avoid a possible treatment influence on the prognostic importance of such factors, only patients registered in the serial nodal observation arm will be included. Due to this restriction (implying a loss in the statistical power in detection of prognostic factors), a 2-sided relaxed alpha level (for instance, 20%) will be considered in univariate analyses Data recoding and display Frequency tables will be tabulated (by treatment group or otherwise) for all categorical variables by the levels of the variables as they appear on the CRF (with %). Categories with a text field specification will be tabulated as categories and then supplemented by a listing with the following information for the patients fulfilling the condition for the specification (SeqID, institution, treatment group, value of the item and text field contents). Dates relating to events prior to entry will be presented as the delay in days (or weeks, months, or years) between the past event and the date of entry (date of registration date of past event + 1) and presented using the median and range. Other delays are presented as continuous variables using the median and range. Continuous variables for which a coding system exists will be recoded into categories. Other continuous variables (for example age, ) are presented using the median and range (minimum, maximum). If appropriate, continuous data may also be presented in categories (for example, age may also be grouped in decades). 8.3 Interim analyses No interim analysis is foreseen for any of the endpoints defined in Version / 44 September 09, 2013

25 8.4 End of study End of study occurs when all of the following criteria have been satisfied: 1. Thirty days after all patients have stopped their follow-up up to 10 years from registration as per protocol 2. The trial is mature for the analysis of the primary endpoint as defined in the protocol 3. The database has been fully cleaned and frozen for this analysis 9 Data Monitoring Safety data are reviewed within the EORTC Headquarters on a regular basis as part of the Medical Review process. Problems which are identified will be discussed with the Study Coordinators who will take appropriate measures. Safety information will also be included in trial status reports which serve as a basis of discussion during EORTC Group meetings. These reports will be made available to investigators participating in the study. The EORTC Independent Data Monitoring Committee (IDMC) will review all safety problems identified by the EORTC Headquarters for which an advice is sought. Experts on the IDMC performing this review will be selected to have the relevant early trials/drug development expertise and will provide a review process independent of that of the Medical Review. In principle, no access to outcome data is necessary for safety reviews. However, the IDMC may also advise if they think a full review of all study data and endpoints is needed. 10 Translational research 10.1 Objectives The basic rationale to conduct Translational Research (TR) within a prospective registry is to gain insight into tumor biology, especially in this study, which targets a specific population of melanoma patients with minimal SN tumor burden. The objective of the optional translational research studies associated with this prospective registry is to answer the following questions: Are micro-metastases within the minimal tumor burden positive SN capable of proliferation and migration? Are any markers of disease dissemination detectable in peripheral blood? Are there any markers of prognostic importance regarding the outcome (regional relapse rate, RFI, DMFI, MSS)? In order to explore these questions, this protocol includes a prospective collection of biological material (whole blood, plasma, serum and tissue) from patients who have consented to take part in this research. Version / 44 September 09, 2013

26 10.2 Translational research projects Three optional TR projects, specifically designed at the onset of the study, are reported below. However, the TR to be performed within this prospective registry will not be necessarily restricted to these three correlative studies, as other projects might be defined in due course Translational Research Project 1: Regulation of DNA replication Rationale The Mini-Chromosome Maintenance (MCM) proteins 4 and 6 are two of 7 DNA helicases that form a multimeric protein complex that unwinds DNA during its replication. Their expression in primary tumors correlates with poor DMFS (Ref. 43). To gain a better understanding of the potential malignant power of minimal tumor burden SN lesions, immunohistochemistry of these lesions for MCM4 and MCM6 could teach us if they are truly active lesions or dormant lesions, which are only present as antigen presenters to the immune system for a host response against the cancer. PR70 is a regulatory subunit of the protein phosphatase 2A complex, which antagonizes CDK2/cyclinA mediated phosphorylation of cdc6. Cdc6 phosphorylation is a critical step in the initiation of DNA replication. PR70 is a novel tumor suppressor gene in melanoma and a critical regulator of initiation of DNA replication (van Kempen et al., manuscript in preparation) Objective To determine replication/proliferation capacity of tumor cells in minimum SN tumor burden lesions, the level of expression of MCM 4, MCM6 and PR70 will be determined and their prognostic importance regarding the outcome (regional relapse rate, RFI, DMFI, MSS) will be assessed Material The expression of MCM 4, MCM6 and PR70 will be measured by means of immunohistochemistry of unstained sections of the SN blocks Translational Research Project 2: Ki-67 expression Rationale Ki-67 is a proliferation marker of tumor cells. Since the malignant power of minimal SN tumor burden lesions is unclear, it is of interest to analyze the potential migration capacity of these highly proliferative tumor cells. The question to be answered is: can these cells migrate into the circulation and nest elsewhere in the body, thereby influencing the patient s outcome or are they merely dormant within the SN as antigen presenters for the host s immune response Objective To explore the biological significance of minimal SN tumor burden metastases on patient outcome and their potential role / behavior. The level of expression of Ki-67 and of new biomarkers (BRAF, CD133, Nestin, Integrin, JARID, S1000, Vimentin amongst others) will be determined and their prognostic value regarding the outcome (regional relapse rate, RFI, DMFI, MSS) will be assessed. Version / 44 September 09, 2013