THE FUTURE OF MELANOMA MANAGEMENT

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1 THE FUTURE OF MELANOMA MANAGEMENT CHARLES M. BALCH, MD, FACS PROFESSOR OF SURGERY UNIV. OF TEXAS MD ANDERSON CANCER CENTER HOUSTON, TEXAS UNIV. OF TEXAS SOUTHWESTERN MEDICAL CENTER DALLAS, TEXAS Editor-in-Chief, Annals of Surgical Oncology Editor-in-Chief, Patient Resource Cancer Guides Past Executive VP and Chief Executive Officer, ASCO

3 Molecular Subtypes Clinical Implications BRAF 47% RAS 29% NF1 9% Triple wild-type 15% C-KIT/RTK inhibitors MDM2/TP53 inhibitors CDK4 inhibitors

4 BRAF and NRAS-mutant Melanomas Jakob, et al. Cancer 2011

Vemurafenib ERK Cellular proliferation Vemurafenib

5 The target: BRAF kinase An important mediator of cellular proliferation RTK RAS ATP ATP BRAF V600E Raf MEK Vemurafenib ERK Cellular proliferation Vemurafenib co-structure with the kinase domain of BRAF V600E (Bollag, et al. Nature 2010)

6 Metabolic response to Roche/PLX4032 BRAF inhibitor, V600E+ melanoma Day 1 Day 15 Image courtesy of Grant McArthur, Peter MacCallum Cancer Institute, Melbourne

7 Progression-free survival (%) Vemurafenib Progression-free Survival Median 1.6 mos Dacarbazine (N=274) Vemurafenib (N=275) Median 5.3 mos Hazard Ratio 0.26 (95% CI; ) Log-rank P< No. of patients in follow up Months Dacarbazine Vemurafenib Chapman PB, et al. N Engl J Med. 2011;364:

9 Proportion Alive COMBI-d: Overall Survival Dabrafenib + Trametinib Died: 99 (47%) Med OS = 25 1 mo (95% CI:19.2-NR) Dabrafenib Died: 123 (58%) Median OS = 18.7 mo (95% CI: ) Number at risk Dabrafenib + trametinib Dabrafenib + placebo 0 HR 0.71 (95% CI: 0.55, 0.92) P = Time (months) Dabrafenib+Trametinib med follow up 20 mo (range 0-30 mo); Dabrafenib med follow up 16 mo (range 0-32 mo). Long GV, et al. Lancet. 2015;386:

10 Proportion Alive COMBI-d: Overall Survival yr OS = 74% Dabrafenib + Trametinib Died: 99 (47%) Med OS = 25 1 mo (95% CI:19.2-NR) Dabrafenib Died: 123 (58%) Median OS = 18.7 mo (95% CI: ) 1-yr OS = 68% Number at risk Dabrafenib + trametinib Dabrafenib + placebo 0 HR 0.71 (95% CI: 0.55, 0.92) P = Time (months) Dabrafenib+Trametinib med follow up 20 mo (range 0-30 mo); Dabrafenib med follow up 16 mo (range 0-32 mo). Long GV, et al. Lancet. 2015;386:

11 Proportion Alive COMBI-d: Overall Survival yr OS = 74% Dabrafenib + Trametinib Died: 99 (47%) Med OS = 25 1 mo (95% CI:19.2-NR) yr OS 51% Dabrafenib Died: 123 (58%) Median OS = 18.7 mo (95% CI: ) 1-yr OS = 68% 2-yr OS 42% Number at risk Dabrafenib + trametinib Dabrafenib + placebo 0 HR 0.71 (95% CI: 0.55, 0.92) P = Time (months) Dabrafenib+Trametinib med follow up 20 mo (range 0-30 mo); Dabrafenib med follow up 16 mo (range 0-32 mo). Long GV, et al. Lancet. 2015;386:

12 APPROVAL OF GSK DRUGS

14 Checkpoint Inhibitors: Anti-CTLA4 (ipilimumab; BMS) ORR 15% Anti-PD1 (lambrolizumab; Merck) ORR 38% 52% at max dose (10% CR) Anti-PD1 (nivolimab; BMS) ORR 19% With ipilimimab, ORR 40% Anti-PDL1(Roche/Genentech): ORR 29% plus 29% stable disease Presented by: Charles Balch, MD

15 CTLA-4 and PD-1/PDL1 Mostly CENTRAL in LNN Mostly PERIPHERAL Tumor Microenvironment Activation (cytokines, lysis, proliferation, migration to tumor) Dendritic cell MHC B7 TCR CD B7 CTLA CTLA-4 Blockade (ipilimumab tremelimumab) anti-ctla-4 T cell T cell TCR PD-1 MHC PD-L1 anti-pd-1 PD-1 PD-L2 anti-pd-1 PD-1 Blockade (nivolumab, lambrolizumab) Tumor cell

16 Signal 1 Signal 2 MHC TCR B7 CD28 T cell endritic cell Inhibitor of signal 2 Lymph node TCR MHC Cancer PD-1 PD-L1

PD-1 blockade induces responses by inhibiting adaptive immune resistance Response Progression Melanoma cell or tumor macrophage Interferons Hypothesis formulated based on

17 PD-1 blockade induces responses by inhibiting adaptive immune resistance Response Progression Melanoma cell or tumor macrophage Interferons Hypothesis formulated based on quantitative IHC analyses of 46 cases from UCLA Melanoma cell or tumor macrophage Paul C. Tumeh, Christina L. Harview, I. Peter Shintaku, Emma J. M. Taylor, Jennifer H. Yearley, Robert H. Pierce

18 Proportion alive Potential for long-term survival with IT: ipilimumab example Primary analysis of pooled overall survival data for patients (N=1861) with melanoma across trials of ipilimumab Median overall survival: 11.4 months (95% CI: ) Ipilimumab CENSORED 3-year overall survival: 22% (95% CI: 20 24) Months Patients at risk Ipilimumab Adapted from Schadendorf D, et al. Oral presentation at ESMO 2013: abstract 24LBA.

19 Proportion alive Potential for long-term survival with IT: ipilimumab example Primary analysis of pooled overall survival data for patients (N=1861) with melanoma across trials of ipilimumab Median overall survival: 11.4 months (95% CI: ) Ipilimumab CENSORED 3-year overall survival: 22% (95% CI: 20 24) Months Patients at risk Ipilimumab Adapted from Schadendorf D, et al. Oral presentation at ESMO 2013: abstract 24LBA.

20 Proportion alive Potential for long-term survival with IT: ipilimumab example Primary analysis of pooled overall survival data for patients (N=1861) with melanoma across trials of ipilimumab Median overall survival: 11.4 months (95% CI: ) Ipilimumab CENSORED 3-year overall survival: 22% (95% CI: 20 24) Months Patients at risk Ipilimumab Adapted from Schadendorf D, et al. Oral presentation at ESMO 2013: abstract 24LBA.

Overall survival (%) Potential for long-term survival with IT: ipilimumab example Primary analysis of pooled overall survival data for patients (N=4846) with melanoma across trials of ipilimumab 100

21 Overall survival (%) Potential for long-term survival with IT: ipilimumab example Primary analysis of pooled overall survival data for patients (N=4846) with melanoma across trials of ipilimumab patients (clinical trials and EAPs) Median OS: 9.5 months (95% CI: ) 3-year OS rate: (95% 21% (95% CI): 21% CI: (20 22%) Time (years) Adapted from Schadendorf D, et al. J Clin Oncol. 2015;33(17):

with advanced melanoma PRE-RX POST-RX Dermatitis Colitis

22 CTLA-4 blockade induces objective tumor responses in 12.5%, and severe autoimmune toxicities in 23% of patients with advanced melanoma PRE-RX POST-RX Dermatitis Colitis Hepatitis Phan, et al. PNAS 2003; Attia, et al. JCO 2005

23 Ipilimumab Pattern of Response: Responses After the Appearance and Subsequent Disappearance of New Lesions Pre-treatment July 2006 Week 12: Progression 3 mg/kg ipilimumab Q3W X 4 New lesions 2008 ASCO Abstract #3020 Wolchok.

24 Ipilimumab Pattern of Response: Responses After the Appearance and Subsequent Disappearance of New Lesions Pre-treatment July 2006 Week 12: Progression 3 mg/kg ipilimumab Q3W X 4 New lesions Week 20: Regression Week 36: Still Regressing 2008 ASCO Abstract #3020 Wolchok.

27 JOURNAL OF CLINICAL ONCOLOGY, MARCH 3,2014

28 135 patients Phase II trial ORR 38 % PFS > 7 mo. N Engl J Med 2013

29 Lambrolizumab Now named pembrolizumab N Engl J Med 2013

30 Response of a Large Chest-Wall Melanoma Metastasis to One Dose of Ipilimumab plus Nivolumab Chapman PB, et al. N Engl J Med 2015;372:

31 Clinical activity of pembrolizumab (anti-pd-1) in a patient progressing to 3 prior lines of therapy Baseline: April 13, 2012 April 9, year-old male with symptomatic progression after bio-chemotherapy, HD IL-2, and ipilimumab

32 Clinical activity of pembrolizumab (anti-pd-1) in a patient progressing to 3 prior lines of therapy Baseline: April 13, 2012 April 9, 2013 Used with permission. 72-year-old male with symptomatic progression after bio-chemotherapy, HD IL-2, and ipilimumab

33 Clinical activity of pembrolizumab (anti-pd-1) in a patient progressing to 3 prior lines of therapy Baseline: April 13, 2012 April 9, 2013 Used with permission. 72-year-old male with symptomatic progression after bio-chemotherapy, HD IL-2, and ipilimumab

34 Anti PD1 (nivolumab) in BRAFwt stage IV Robert C, et al. N Engl J Med. 2015;372:

35 PFS, % PFS and OS Based on Tumor PD-L1 Expression 100 Progression-Free Survival PD-L PD-L1 P = Time, weeks PD-L1 positivity defined as staining in 1% of tumor cells. Analysis cut-off date: 18 October Daud A et al. Presented at: 2014 Annual AACR Meeting; April 5-9, 2014; San Diego, CA. Presented by: Richard Kefford

36 PFS, % OS, % PFS and OS Based on Tumor PD-L1 Expression Progression-Free Survival Overall Survival PD-L PD-L PD-L PD-L1 P = P = Time, weeks Time, weeks PD-L1 positivity defined as staining in 1% of tumor cells. Analysis cut-off date: 18 October Daud A et al. Presented at: 2014 Annual AACR Meeting; April 5-9, 2014; San Diego, CA. Presented by: Richard Kefford

37 Patients Surviving (%) Nivo Improved OS vs Dacarbazine Regardless of PD-L1 status Nivolumab, PD-L1 Postive (N = 74) Nivolumab, PD-L1 Negative (N = 128) Dacarbazine PD-L1 Positive (N = 74) Dacarbazine PD-L1 Negative (N = 126) Months Median OS: Not reached Median OS: Not reached Median OS: 12.4 mo Median OS: 10.2 mo Robert C, et al. N Engl J Med. 2015;372:

38 Pembrolizumab: OS by PDL1 expression and line of therapy Garon, EB et al. N Engl J Med. 2015;372:

39 Slide 26 Pembrolizumab versus Ipilimumab In Advanced Melanoma Robert, et al. NEJM. 2015;372: patients randomized to received Pembro q2 weeks, Pembro q3 weeks or Ipi Presented By Suzanne Topalian at 2015 ASCO Annual Meeting

40 Efficacy and Safety Results From a Phase III Trial of Nivolumab Alone or Combined With Ipilimumab vs. Ipilimumab Alone in Treatment-naïve Patients With Advanced Melanoma (CheckMate 067) Jedd D. Wolchok, 1 Vanna Chiarion-Sileni, 2 Rene Gonzalez, 3 Piotr Rutkowski, 4 Jean-Jacques Grob, 5 C. Lance Cowey, 6 Christopher D. Lao, 7 Dirk Schadendorf, 8 Pier Francesco Ferrucci, 9 Michael Smylie, 10 Reinhard Dummer, 11 Andrew Hill, 12 John Haanen, 13 Michele Maio, 14 Grant McArthur, 15 Arvin Yang, 16 Linda Rollin, 17 Christine Horak, 16 James Larkin, 18,* F. Stephen Hodi 19,* 1 Memorial Sloan Kettering Cancer Center, Ludwig Institute for Cancer Research and Weill Cornell Medical College, New York, NY, USA; 2 Oncology Institute of Veneto IRCCS, Padua, Italy; 3 University of Colorado Cancer Center, Denver, CO, USA; 4 Maria Sklodowska-Curie Memorial Cancer Center & Institute of Oncology, Warsaw, Poland; 5 Aix-Marseille Université and APHM Timone Marseille, Marseille, France; 6 Texas Oncology-Baylor Charles A. Sammons Cancer Center, US Oncology Research, Dallas, TX, USA; 7 University of Michigan, Ann Arbor, MI, USA; 8 Department of Dermatology, University of Essen, Essen, Germany; 9 European Institute of Oncology, Milan, Italy; 10 Cross Cancer Institute, Edmonton, Alberta, Canada; 11 Universitäts Spital, Zurich, Switzerland; 12 Tasman Oncology Research, QLD, Australia; 13 Netherlands Cancer Institute, Amsterdam, The Netherlands; 14 University Hospital of Siena, Siena, Italy; 15 Peter MacCallum Cancer Centre, Victoria, Australia; 16 Bristol-Myers Squibb, Princeton, NJ, USA; 17 Bristol-Myers Squibb, Wallingford, CT, USA; 18 Royal *Equal Marsden contributors. Hospital, London, UK; 19 Dana-Farber Cancer Institute, Boston, MA, USA. Abstract #LBA1

41 CA : Study Design Randomized, double-blind, phase III study to compare NIVO + IPI or NIVO alone to IPI alone N=314 NIVO 1 mg/kg + IPI 3 mg/kg Q3W for 4 doses then NIVO 3 mg/kg Q2W Unresectable or Metatastic Melanoma Previously untreated 945 patients Randomize 1:1:1 Stratify by: PD-L1 expression* BRAF status AJCC M stage N=316 NIVO 3 mg/kg Q2W + IPI-matched placebo Treat until progression** or unacceptable toxicity *Verified PD-L1 assay with 5% expression level was used for the stratification of patients; validated PD-L1 assay was used for efficacy analyses. N=315 IPI 3 mg/kg Q3W for 4 doses + NIVO-matched placebo **Patients could have been treated beyond progression under protocol-defined circumstances.

42 Proportion alive and progression-free PFS (Intent-to-Treat) Median PFS, months (95% CI) NIVO + IPI (N=314) 11.5 ( ) NIVO (N=316) 6.9 ( ) IPI (N=315) 2.9 ( ) 0.8 HR (99.5% CI) vs. IPI 0.42 ( )* 0.57 ( )* HR (95% CI) vs. NIVO 0.74 ( )** *Stratified log-rank P< vs. IPI **Exploratory endpoint NIVO + IPI NIVO IPI 0.0 No. at Risk Months NIVO + IPI NIVO IPI

43 Proportion alive and progression-free Proportion alive and progression-free PFS by PD-L1 Expression Level (5%) PD-L1 5%* PD-L1 <5%* 1.0 mpfs HR NIVO + IPI mpfs HR NIVO + IPI NIVO IPI NIVO IPI NIVO + IPI NIVO IPI NIVO + IPI NIVO IPI No. at Risk Months No. at Risk Months NIVO + IPI NIVO IPI NIVO + IPI NIVO IPI

44 Management of melanoma in the post-anti-pd-1/l1 era

45 Management of melanoma in the post-anti-pd-1/l1 era Anti-PD-1/anti-PD-L1

46 Management of melanoma in the post-anti-pd-1/l1 era Anti-PD-1/anti-PD-L1 Bring T cells into tumors: + anti-ctla4 + immune activating antibodies or cytokines + TLR agonists or oncolytic viruses + IDO or macrophage inhibitors + targeted therapies Generate T cells: Vaccines TCR engineered ACT CAR engineered ACT

47 Advances in the treatment of metastatic melanoma McArthur & Ribas, J Clinical Oncology 2013

48 Advances in the treatment of metastatic melanoma McArthur & Ribas, J Clinical Oncology 2013

49 Advances in the treatment of metastatic melanoma Checkpoint inhibitors Checkpoint inhibitors McArthur & Ribas, J Clinical Oncology 2013

50 Balancing T cell activation: ACTIVATE THE ACTIVATORS; INHIBIT THE INHIBITORS!! Activating receptors CD28 OX40 CD137 Agonistic antibodies T-cell stimulation Inhibitory receptors CTLA-4 PD-1 TIM-3 LAG-3 Blocking antibodies PD-1 and CTLA4 play distinct roles in regulating T cell immunity. CTLA4 modulates early phases of T cell priming (naïve and memory T cells) PD-1 is expressed on antigen-experienced T cells (TILs and Tregs) Specific response to tumour, regardless of its characteristics, including mutation status Adapted from Mellman, et al. Nature. 2011;480(7378): ; Pardoll DM. Nat Rev Cancer. 2012;12: PD-1/PDL-1 interaction downregulates overt inflammation in lesions.

T-VEC: An HSV-1 Derived Oncolytic Immunotherapy Designed to Produce Both Local and Systemic Effects Local Effect: Tumor Cell Lysis Systemic Effect: Tumor-Specific Immune Response Selective viral

51 T-VEC: An HSV-1 Derived Oncolytic Immunotherapy Designed to Produce Both Local and Systemic Effects Local Effect: Tumor Cell Lysis Systemic Effect: Tumor-Specific Immune Response Selective viral replication in tumor tissue Tumor cells rupture for an oncolytic effect Systemic tumor-specific immune response Death of distant cancer cells T-VEC key genetic modifications: JS1/ICP34.5-/ICP47-/hGM-CSF ICP34.5 ICP34.5 ICP47 pa hgm-csf CMV CMV hgm-csf pa 1. Varghese S, et al. Cancer Gene Ther. 2002;9: Hawkins LK, et al. Lancet Oncol. 2002;3: Fukuhara H, et al. Curr Cancer Drug Targets. 2007;7: Sobol PT, et al. Mol Ther. 2011;19: Liu BL, et al. Gene Ther. 2003;10: Melcher A, et al. Mol Ther. 2011;19: Fagoaga OR In: McPherson RA, Pincus MR, eds. Henry s Clinical Diagnosis and Management by Laboratory Methods, 22nd ed. Philadelphia, PA: Elsevier; 2011: Dranoff G. Oncogene. 2003;22:

52 T-VEC Responses in Injected And Uninjected Lesions Cycle 1 Cycle 13

53 Time to Treatment Failure (%) Secondary Endpoint: Time to Treatment Failure 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% T-VEC (N = 295) GM-CSF (N = 141) Median (95% CI) 8.2 (6.5, 9.9) months 2.9 (2.8, 4.0) months Log Rank: P < * Hazard Ratio: 0.42 (0.32, 0.54) *P-value is descriptive only 0% Risk set, n Study Month T-VEC GM-CSF Time to treatment failure was defined as time from the first dose of study treatment until death or development of clinically significant progressive disease (PD) per investigator for which no objective response was subsequently achieved Patients who withdrew prior to development of clinically significant PD were censored at the time of the last assessment

54 Kaplan Meier percent Exploratory OS subgroup analysis by disease stage Stage IIIB/C, IV M1a 100 Log rank: P < (descriptive) 80 HR: 0.57 (95% CI: 0.40, 0.80) 100 Log rank: P = 0.71 (descriptive) 80 Stage IV M1b/c HR: 1.07 (95% CI: 0.75, 1.52) Risk set, n T-VEC GM-CSF Study month Events/n (%) median (95% CI), mo T-VEC 80/163 (49) 41.1 (30.6, NE) GM-CSF 57/86 (66) 21.5 (17.4, 29.6) Study month Risk set, n T-VEC GM-CSF Events/n (%) median (95% CI), mo T-VEC 109/131 (83) 13.4 (11.4, 16.2) GM-CSF 44 /55 (80) 15.9 (10.2,19.7) Mo, months. Kaufman H, et al. ASCO 2014: abstract 9008a.

56 Merck Enters Strategic Collaborations with Amgen, Incyte and Pfizer to Evaluate Novel Combination Anti-cancer Regimens with MK-3475 Merck Also to Initiate Phase I Signal Finding Study with MK-3475 in 20 New Cancers Wednesday, February 5, :40 am EST Dateline: WHITEHOUSE STATION, N.J. "These new collaborations with Amgen, Incyte and Pfizer underscore our shared determination to evaluate treatment regimens with the potential to provide meaningful benefits to patients suffering from cancer." WHITEHOUSE STATION, N.J.---Merck (NYSE:MRK), known as MSD outside the United States and Canada, announced today it has signed three separate clinical collaboration agreements, through subsidiaries, with Amgen Inc., Incyte Corporation and Pfizer Inc. to evaluate novel combination regimens with MK-3475, Merck s investigational anti-pd-1 immunotherapy. The financial terms of the agreements were not disclosed. Merck clinical scientists intend to explore the potential of our PD-1 inhibitor across a wide range of cancers, both as monotherapy and in combination, said Dr. Roger M. Perlmutter, president, Merck Research Laboratories. These new collaborations with Amgen, Incyte and Pfizer underscore our shared determination to evaluate treatment regimens with the potential to provide meaningful benefits to patients suffering from

58 EORTC 18071/CA : Study Design High-risk, stage III, completely resected melanoma N=951 R N=475 N=476 INDUCTION Ipi 10 mg/kg Q3W X4 INDUCTION Placebo (Pbo) Q3W X4 MAINTENANCE Ipi 10 mg/kg Q12W up to 3 years MAINTENANCE Placebo (Pbo) Q12W up to 3 years Week 1 Week 12 Week 24 Treatment up to a maximum 3 years, or until disease progression, intolerable toxicity, or withdrawal Stratification factors: Stage (IIIA vs IIIB vs IIIC 1-3 positive lymph nodes vs IIIC 4 positive lymph nodes) Regions (North America, European countries and Australia) Primary Endpoint: RFS Secondary endpoints: DMFS and OS

59 Patients Alive Without Recurrence (%) Primary Endpoint: Recurrence-free Survival (IRC) Median: 17.1 mo Ipi 10 mg/kg Pbo Median: 26.1 mo Ipi Pbo Events/patients 234/ /476 HR (95% CI)* 0.75 ( ) Log-rank P value* Year RFS rate (%) Year RFS rate (%)** *Stratified by stage. **Data are not yet mature Patients at Risk O N Months Ipi Pbo

60 Patient Disposition and Treatment Ipi (n=471) Pbo (n=474) Discontinuation, %* 91.7% 83.1% Reasons for discontinuation, % Normal completion* Disease progression AE related to study drug Other reasons** Median doses, per patient Mean doses, per patient % Receiving 1 maintenance dose % Receiving 7 doses (1 yr of therapy) *1.9% of patients in the Ipi group and 3.0% in the Pbo group had 16 cycles reported as per protocol without a documented reason for discontinuation. **Less than 1% difference between groups; includes AE unrelated to study drug, both (related and unrelated to study drug), patient request, poor/non-compliance, death, pregnancy, patient no longer eligible, other.

61 Patient Disposition and Treatment Ipi (n=471) Pbo (n=474) Discontinuation, %* 91.7% 83.1% Reasons for discontinuation, % Normal completion* Disease progression AE related to study drug Other reasons** Median doses, per patient Mean doses, per patient % Receiving 1 maintenance dose % Receiving 7 doses (1 yr of therapy) *1.9% of patients in the Ipi group and 3.0% in the Pbo group had 16 cycles reported as per protocol without a documented reason for discontinuation. **Less than 1% difference between groups; includes AE unrelated to study drug, both (related and unrelated to study drug), patient request, poor/non-compliance, death, pregnancy, patient no longer eligible, other.

62 Patient Disposition and Treatment Ipi (n=471) Pbo (n=474) Discontinuation, %* 91.7% 83.1% Reasons for discontinuation, % Normal completion* Disease progression AE related to study drug Other reasons** Median doses, per patient Mean doses, per patient % Receiving 1 maintenance dose % Receiving 7 doses (1 yr of therapy) *1.9% of patients in the Ipi group and 3.0% in the Pbo group had 16 cycles reported as per protocol without a documented reason for discontinuation. **Less than 1% difference between groups; includes AE unrelated to study drug, both (related and unrelated to study drug), patient request, poor/non-compliance, death, pregnancy, patient no longer eligible, other.

63 Patient Disposition and Treatment Ipi (n=471) Pbo (n=474) Discontinuation, %* 91.7% 83.1% Reasons for discontinuation, % Normal completion* Disease progression AE related to study drug Other reasons** Median doses, per patient Mean doses, per patient % Receiving 1 maintenance dose % Receiving 7 doses (1 yr of therapy) *1.9% of patients in the Ipi group and 3.0% in the Pbo group had 16 cycles reported as per protocol without a documented reason for discontinuation. **Less than 1% difference between groups; includes AE unrelated to study drug, both (related and unrelated to study drug), patient request, poor/non-compliance, death, pregnancy, patient no longer eligible, other.

64 AJCC Collaborative Melanoma Database 3424 Stage III Patients Survival Rate Stage n 5-year 10-year IIIA 1,262 78% 68% IIIB 1,418 60% 42% IIIC % 24% P < Balch, et al. JCO 2009

65 EORTC TRIAL: IPI VS PLACEBO All the DFS benefit in IIIB and IIIC patients, none in the 186 patients with Stage IIIA. Patients with microscopic N+ and ulcerative primaries melanoma did better Five (1%) participants died because of drugrelated adverse events in the ipilimumab group; three patients died because of colitis (two with gastrointestinal perforation), one patient because of myocarditis, and one patient because of multiorgan failure with Guillain- Barré syndrome

66 RATIONALE FOR NEOADJUVANT THERAPY FOR MELANOMA Can accurately assess pathological response to systemic therapy, especially with mixed response Can assess amount of viable residual tumor (with biomarker analysis as appropriate) Can assess the magnitude of inflammatory response (with analysis of lymphocyte subsets) Can adjust postoperative therapy according to the magnitude of response and molecular/genetic signature of residual cells) But is it a surrogate for drug efficacy in melanoma????

69 NeoALTTO Efficacy: pcr and tpcr Baselga J, et al. Lancet. 2012;379:

70 IMPROVED IMAGING=BETTER STAGING Vermeeren, J Surg Oncol 2010; 101:

71 Intraoperative Imaging: Sentinella

72 Sunil Singhal, M.D. Univ of Pennsylvania Dept Surgery Optical Biopsy diagnosis: LUNG ADENOCARCINOMA

73 Minimizing Morbidity from Lymphadenectomy With Videoscopic and Other Approaches Keith A. Delman, MD Emory Medical Center, USA

76 Overall survival by treatment: M1a (skin, subcutaneous melanoma metastases) p<0.0001, HR=0.357

77 Overall survival by treatment and site of recurrence: M1a (skin, subcutaneous melanoma metastases) p<0.0001, HR=0.357 Surgery +/- SMT Survival for MSLT-I patients treated surgically and medically for stage IV melanoma recurrence Morton DL, et al. Ann Surg Oncology Sept 2012

78 Overall survival by treatment and site of recurrence: M1b (Lung melanoma metastases) p=0.0003, HR=0.452 Surgery +/- SMT Survival for MSLT-I patients treated surgically and medically for stage IV melanoma recurrence Morton DL, et al. Ann Surg Oncology Sept 2012

CONCERNS/UNKNOWNS IN THE FUTURE: Can we validate an enormous number of combinations and sequences of innovative therapies in a timely, efficient, cost-effective fashion?

79 CONCERNS/UNKNOWNS IN THE FUTURE: Can we validate an enormous number of combinations and sequences of innovative therapies in a timely, efficient, cost-effective fashion? Can we afford these therapies, especially in combination Can we develop reliable surrogates for survival in clinical trials so new agents don t cost so much Will physicians be paid for writing prescriptions instead of doing procedures? Will patients be compliant with their therapy on a longterm basis

80 THE FUTURE OF MELANOMA MANAGEMENT: New technologies to better stage surgical patients and to conduct safer surgery Multidisciplinary treatments with combination and sequences calibrated according to the quantutrative estimate of subclinical metastatic disease Molecular and genetic markers used to select systemic treatments More adjuvant systemic therapy before and after surgery for high risk Stage II and III melanoma More adjuvant surgery for Stage IV melanoma after systemic treatment for pathological assessment of index metastases and molecular markers of resistant melanoma to alter treatment strategies after surgery

III Sessione I risultati clinici

10,30-13,15 III Sessione I risultati clinici Moderatori: Michele Maio - Valter Torri 10,30-10,45 Melanoma: anti CTLA-4 Vanna Chiarion Sileni Vanna Chiarion Sileni IOV-IRCCS,Padova Vanna.chiarion@ioveneto.it