Neoadjuvant Treatment of Regional Stage IIIB Melanoma

VOLUME
24
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NUMBER
19
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JULY
1
2006
JOURNAL OF CLINICAL ONCOLOGY
O R I G I N A L
R E P O R T
Neoadjuvant Treatment of Regional Stage IIIB Melanoma
With High-Dose Interferon Alfa-2b Induces Objective
Tumor Regression in Association With Modulation of
Tumor Infiltrating Host Cellular Immune Responses
Stergios J. Moschos, Howard D. Edington, Stephanie R. Land, Uma N. Rao, Drazen Jukic, Janice Shipe-Spotloe,
and John M. Kirkwood
From the Melanoma and Skin Cancer
Program; Division of Medical Oncology,
Department of Medicine; Department
of Surgery, Division of Surgical Oncology; Department of Biostatistics, Graduate School of Public Health;
Department of Pathology; and the
Department of Dermatology, Division
of Dermatopathology, University of
Pittsburgh School of Medicine,
Pittsburgh, PA.
Submitted January 6, 2006; accepted
April 24, 2006.
Supported by a research scholarship
from the Robert Johnson Foundation
for Melanoma Research and the Grant
Channel Memorial Melanoma Research
Fund (S.J.M.), and by National Institutes of Health National Cancer Institute Grant No. P30 CA4790413 (J.M.K.
and S.R.L.). Costs for radiographic and
laboratory analyses were funded in part
by a research grant from ScheringPlough Research Institute to the
University of Pittsburgh.
Presented in part at the 41st Annual
Meeting of the American Society of
Clinical Oncology, Orlando, FL,
May 13-17, 2005.
Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this
article.
Address reprint requests to John M.
Kirkwood, MD, Department of Medicine, University of Pittsburgh Cancer
Institute, Hillman Cancer Center,
Research Pavilion, Suite 1.32, 5117
Centre Avenue, Pittsburgh, PA 152132584; e-mail: kirkwoodjm@upmc.edu.
© 2006 by American Society of Clinical
Oncology
0732-183X/06/2419-3164/$20.00
DOI: 10.1200/JCO.2005.05.2498
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Purpose
Adjuvant high-dose interferon-alfa-2b (HDI) improves disease-free and overall survival in patients
with high-risk melanoma. However, its mechanism of action is largely unknown. Therefore, HDI
was investigated in the neoadjuvant setting to assess clinical and pathologic responses after 4
weeks of HDI and to perform immunohistochemical evaluation of immune cell subsets and
melanoma-associated antigens.
Patients and Methods
Patients with palpable regional lymph node metastases from melanoma (American Joint Committee on Cancer stage IIIB-C) underwent surgical biopsy at study entry and then received standard
intravenous HDI (20 million units/m2, 5 days per week) for 4 weeks followed by complete
lymphadenectomy and standard maintenance subcutaneous HDI (10 million units/m2 3 times per
week) for 48 weeks. Biopsy samples were obtained before and after intravenous HDI and
subjected to immunohistochemical analysis as well as routine pathologic study.
Results
Twenty patients were enrolled, and biopsy samples were informative for 17. Eleven patients
(55%) demonstrated objective clinical response, and 3 patients (15%) had complete pathologic
response. At a median follow-up of 18.5 months (range, 7 months to 50 months) 10 patients had
no evidence of recurrent disease. Clinical responders had significantly greater increases in
endotumoral CD11c⫹ and CD3⫹ cells and significantly greater decreases in endotumoral CD83⫹
cells compared with nonresponders. No changes in the expression of melanoma-associated
lineage antigens, tumor cell proliferation, angiogenesis, or apoptosis were evident.
Conclusion
Neoadjuvant HDI is highly effective for the treatment of palpable stage IIIB-C melanoma, and the
findings of this study implicate an indirect immunomodulatory mechanism rather than a direct
antitumor mechanism.
J Clin Oncol 24:3164-3171. © 2006 by American Society of Clinical Oncology
INTRODUCTION
The risk of relapse and death for patients with
clinically palpable regional lymph node metastases (American Joint Committee on Cancer
[AJCC] stage IIIB-C cutaneous melanoma) is
high and approaches 70% at 5 years.1-3 Surgery is
the cornerstone of treatment at this stage of disease, and only high-dose interferon alfa-2b (HDI)
has ever shown a consistent, significant, and durable relapse-free survival benefit when given as
adjuvant therapy in multicenter randomized controlled trials of the US Cooperative Groups.4-6
Two of these trials demonstrated that HDI significantly prolonged overall survival, the first of
which led to US Food and Drug Administration
approval of HDI in 1996. This clinical benefit of
HDI has been reaffirmed in several regulatory
reviews over the past 9 years, but its acceptance in
the medical community has not been uniform.
Despite 20 years of clinical research, the antitumor mechanism of action for interferon alfa-2b
(IFN-␣2b) therapy in patients with melanoma
has not been universal. A better understanding
of the antitumor mechanism of action would
enable more selective application of this therapy to those patients who are most likely to
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Neoadjuvant High-Dose IFN-␣2b for Melanoma
benefit and may improve the therapeutic index and cost effectiveness of HDI.
Murine models and clinical correlative studies of IFN-␣2b therapy have suggested that the indirect immunomodulatory activity of
IFN-␣2b may be more important than direct cytotoxic, proapoptotic,
or antiangiogenic effects.7-10 Unfortunately, no strong link has been
established between the clinical antitumor effects of HDI in patients
with metastatic melanoma and any of the immunomodulatory,
antiproliferative, or antiangiogenic effects that are otherwise welldocumented for IFN-␣. This is in part attributable to the low frequency of antitumor response in patients with advanced unresectable
metastatic disease.9 Unfortunately, the mechanism cannot be studied
in tumor tissue for postoperative adjuvant settings where HDI therapy
has been most extensively investigated.
Neoadjuvant therapy has potential advantages over standard
adjuvant therapy in patients with locally advanced disease.11 For example, in breast, bladder, and esophageal cancer, neoadjuvant chemotherapy improves survival outcomes compared with surgery
alone12-14 and may be as good or even better than the same therapy
given postoperatively.
We, therefore, investigated the efficacy of neoadjuvant HDI in
melanoma patients with palpable regional lymph node metastases
either presenting with clinical AJCC stage IIIB-C (TanyN2,3) disease or
with recurrent regional lymphadenopathy. Our goals were to evaluate
the clinical and pathologic response to neoadjuvant HDI and to identify immunologic and histologic correlates of tumor response.
PATIENTS AND METHODS
Patients
Eligible patients had histopathologically confirmed, palpable, regional
lymph node metastatic melanoma (AJCC stage IIIB-C; N1b-3) either at initial
presentation or at regional lymph node recurrence. Other eligibility criteria
included normal findings from routine radiographic studies (computed tomography [CT] scans of the chest, abdomen and pelvis, and brain magnetic
resonance imaging), unimpaired performance status (Eastern Cooperative
Oncology Group 0 or 1), adequate hematologic, hepatic, and renal function.
Patients were excluded if they had in-transit disease or matting of nodal tissue
that might compromise complete lymphadenectomy, or had received prior
radiotherapy, chemotherapy, or immunotherapy. Other exclusion criteria
were active ischemic cardiac or cerebrovascular disease, infections requiring
antibiotics, autoimmune disease or other disorders requiring immunosuppressive therapy, psychiatric illnesses requiring therapy, or lack of effective
contraception for women of childbearing potential and sexually active males.
All patients signed informed consent to obtain both pre- and post-treatment
biopsies, and the study was approved by the University of Pittsburgh (Pittsburgh, PA) institutional review board.
Treatment Plan
The treatment plan is illustrated in Figure 1. A surgical lymph node
biopsy (sample 1) was performed within 14 days of study entry to confirm the
presence of melanoma. Subsequently, patients received standard outpatient
induction HDI (IFN-␣2b 20 million units/m2 per day intravenously [IV], 5
days per week, Monday to Friday) for 4 weeks. During the induction period,
patients underwent physical examination every week for 4 weeks to assess
toxicity and clinical response of palpable tumor. After completion of the
4-week induction phase, patients underwent radical lymph node dissection
(sample 2). Surgical procedures were performed by the same surgeon
(H.D.E.). Therefore, differences in surgical management and technique are
unlikely to account for differences in patient outcome. Pathology material was
assessed for evidence of residual disease and apportioned by the reference
Fig 1. Treatment schema. Tumor biopsies are obtained before and immediately
after the induction phase of high-dose interferon alfa-2b (HDI). IV, intravenous;
IFN, interferon alfa; TIW, three times per week.
surgical pathologist (U.N.R.) for additional immunohistochemical (IHC)
studies. After recovery from surgery and wound healing, standard outpatient
maintenance IFN-␣2b therapy (10 million units/m2, subcutaneously [SC], 3
times per week) was administered for 48 weeks. Patients were observed over
time (monthly for the first 3 months and then every 3 months) for treatmentrelated toxicity and melanoma recurrence.
Immunoperoxidase Staining
Lymph node samples were fresh-frozen and stored at ⫺70°C. Cryostatcut sections (4 ␮m thick) were fixed in cold acetone (4°C) and stained using
routine hematoxylin and eosin and IHC procedures (Vectastain ABC kit,
Vector Laboratories, Burlingame, CA), as recommended by the manufacturer.
Monoclonal mouse antihuman antibodies were used to identify mononuclear
cell subsets in the initial biopsy and subsequent lymphadenectomy specimens,
including CD3⫹ T lymphocytes and their subsets (CD4⫹ and CD8⫹; Becton
Dickinson, San Jose, CA), CD11c⫹ mononuclear cells (AMC Inc, Westbrook,
ME), CD56⫹ natural killer cells (Neomarkers, Fremont, CA), and CD123⫹
cells (Becton Dickinson-Pharmingen). Mature CD83⫹ (Beckman Coulter,
Immunotech, Somerset, NJ) and activated CD86⫹ (DAKO, Carpinteria, CA)
dendritic cells were also identified.
Histologic Evaluation
All tissue sections were scored at ⫻20 magnification by independent
observers, including a surgical pathologist (U.N.R.), a dermatopathologist
(D.J.), a medical oncologist specialized in melanoma (J.M.K.), and a fellow in
medical oncology (S.J.M.). All four observers were blinded to the patient and
treatment status (both pre- and post-treatment) when they examined tissue
samples. Given the variation in the amount of tissue available for IHC stains, as
well as the amount of viable tumor present in a given section, a single field with
the maximum viable tumor density was selected by the surgical pathologist for
scoring. The total numbers of endotumoral, peritumoral, and perivascular
mononuclear cell infiltrates (CD3⫹, CD4⫹, CD8⫹, CD11c⫹, CD56⫹, CD83⫹,
CD86⫹, and CD123⫹) were scored.
Clinical Response
Response was assessed both clinically and histologically after completion
of the 4-week induction phase of HDI. After 14 patients were enrolled, radiological assessment was also performed by coregistered positron emission tomography (PET)/CT scans, but the predetermined primary end point was the
clinicopathologic response, not the radiographic response. Clinical complete
response (CR) was defined as the disappearance of all clinical evidence of
tumor, whereas clinical partial response (PR) was defined as 50% or more
decrease in the product of the greatest perpendicular diameters of nodal
disease (WHO).15 No clinical response was defined as no change, reduction of
less than 50% in the product of the greatest perpendicular diameter of nodal
disease, or unequivocal increase in size of measurable lesions.15
Statistical Methods
The median follow-up was estimated with reverse censoring using the
Kaplan-Meier method. Associations of clinical response (responders v nonresponders) with changes in IHC measurements of cell surface antigens
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Moschos et al
present in pretreatment and post-treatment tissue samples were assessed using
the Wilcoxon rank sum test. The effect of treatment was assessed for the whole
group using the Wilcoxon signed-rank test. The log-rank test was used to
compare the survival outcome by clinical response in an intention-to-treat
analysis. For grading of adverse effects, the National Cancer Institute Common
Terminology Criteria for Adverse Events version 3.0 was used. Given the
exploratory nature of the study, corrections for multiple testing were not
performed, and statistical tests were considered significant at P ⫽ .05 and
suggestive at P ⫽ .10. Analyses of IHC data were performed for patients with
assessable IHC data. Survival and clinical response analyses were performed
for all patients with confirmed melanoma pretreatment. Safety analyses were
performed for all enrolled patients.
RESULTS
Patients
Twenty patients were enrolled between January 2001 and February 2005, and their baseline characteristics are shown in Table 1. The
median age of the cohort entering the study was 59 years (range, 40
years to 78 years), and 13 patients were male. Clinically palpable
regional lymphadenopathy was recurrent in 11 patients (55%), and
these patients had experienced recurrence at a median of 27 months
(range, 7 months to 150 months) after the original diagnosis of melanoma. One patient was deemed ineligible because the pretreatment
biopsy did not show evidence of melanoma (patient 2; Table 1).
Fifteen patients completed 4 weeks of induction HDI therapy.
Clinicopathologic Responses
At weekly clinical assessments during administration of IV HDI,
regression of palpable lymphadenopathy was noted in 11 patients
(Table 1). One patient had regression of all palpable lymphadenopathy (ie, clinical CR) after 4 weeks of HDI treatment, and 10 patients
had clinical PR. Examination of post-treatment lymph node tissue
revealed pathologic CR (pN0) in three patients (two patients with a
clinical PR and one patient with no evidence of a clinical response) and
residual microscopic disease (pN1a) in a single lymph node in two patients (10%) who had either clinical CR or PR (Table 1). The remaining
13 assessable patients had pathologic evidence of macroscopic residual
nodal disease (pN1b or pN3) after induction HDI. Two patients were
not assessable because their enrollment biopsy specimen either did not
show melanoma or demonstrated nonviable necrotic tumor.
At a median follow-up of 18.5 months (range, 7 months to 50
months), 10 patients had no evidence of disease, seven patients died
from metastatic disease, and three patients were alive with metastatic
disease. Figure 2 shows the Kaplan-Meier estimates of disease-free and
overall survival for clinical responders versus nonresponders for the 19
eligible patients. This analysis excludes patient 2, whose pretreatment
biopsy did not show evidence of melanoma; therefore, clinical response could not be defined. Disease-free and overall survival are
longer among patients with clinical response compared with nonresponders, although the results did not reach statistical significance
(log-rank P ⫽ .15; P ⫽ .17, respectively). For disease-free survival, the
median survival times were 32 months for responders versus 10
months for nonresponders.
Toxicity
One grade 4 toxicity requiring inpatient psychiatric hospitalization occurred in the fourth week of IV HDI treatment, and 1 week of
treatment was held followed by a 33% dose reduction in four patients
Table 1. Patient Baseline Characteristics and Clinical Outcome After 4 Weeks of HDI Therapy
Age
(years)
Sex
50
66
42
65
M
M
F
F
41
56
66
76
56
60
72
76
44
57
41
70
62
74
50
53
M
M
F
M
F
M
F
M
M
F
M
M
M
F
M
M
Primary
Site
Trunk
Arm
Scalp
Minor
labia
Trunk
Scalp
Arm
Face
Leg
Trunk
Leg
Neck
Face
Unknown
Trunk
Face
Unknown
Unknown
Unknown
Trunk
Disease
Status
Disease Stage
at Original
Diagnosis
Pathologic
Duration of Patients
Being Free of
Disease (months)
Current
Status
Response
HDI
Completed
Clinical
I
R
I
R
T4aN2b(cl)
T1aN0(cl)
T4bNx
T3aN0(s)
1/3 DR
1/3 DR
Yes
Yes
CR
NR
NR
NR
RMiD
N/A
RMaD
RMaD
32
N/A
6
1
Deceased
NED
Deceased
Deceased
R
R
R
R
I
I
R
R
R
I
R
R
IP
IP
IP
IP
T1bN0(cl)
T3a(al)N0(cl)
T3bN0(s)
T2a(al)N0(s)
T4bN3(cl)
T4bN2b(cl)
T3aN0(cl)
TxN0(s)
T2aN0(s)
TxN3(cl)
T2aN0(cl)
T2aN0(cl)
TxN3(cl)
TxN2(cl)
TxN3(cl)
T2aN3(cl)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
1/3 DR
Yes
Yes
1/3 DR
Yes
Yes
1/3 DR
PR
NR
NR
PR
NR
NR
PR
PR
PR
PR
PR
NR
PR
PR
NR
PR
RMiD
CR
RMaD
CR
RMaD
RMaD
RMaD
RMaD
RMaD
RMaD
CR
RMaD
RMaD
N/A
RMaD
RMaD
49
34
32
12
6
6
30
15
18
4
14
12
10
7
9
7
NED
MET
NED
Deceased
Deceased
Deceased
NED
MET
NED
Deceased
NED
MET
NED
NED
NED
NED
Abbreviations; HDI, high-dose interferon alfa-2b; M, male; I, initial presentation; cl, nodal staging based on clinical exam; DR, dose reduction; CR, complete
response; RMiD, residual microscopic disease; R, regional lymph node recurrence; NR, no response; N/A, not applicable (no viable melanoma cells); NED, no
evidence of disease; F, female; RMaD, residual macroscopic disease; s, nodal staging based on sentinel lymph node mapping and pathologic interpretation; PR,
partial response; al, at least; MET, metastatic disease; Tx, unknown primary; IP, isolated palpable nodal metastases arising from an unknown primary.
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Neoadjuvant High-Dose IFN-␣2b for Melanoma
Fig 2. Kaplan-Meier estimates of (A) disease-free survival and (B) overall survival for clinical responders (dashed lines) versus nonresponders (solid lines) in all eligible
patients (N ⫽ 19).
due to grade 3 hematologic (n ⫽ 1), hepatic (n ⫽ 1), or musculoskeletal (n ⫽ 2) toxicity. Five patients (two clinical responders and three
nonresponders) never entered the SC phase due to refusal (n ⫽ 2),
grade 4 adverse event (n ⫽ 2), or disease progression (n ⫽ 1).
IHC Analysis
IHC analysis of pre- and post-treatment tissue biopsies was informative in 17 patients (nine responders and eight nonresponders)
and demonstrated a number of changes in the mononuclear cell
populations infiltrating the tumor (Figs 3 and 4). At 4 weeks of IV HDI
treatment, a significant increase in the number of CD11c⫹ and
CD86⫹ cells infiltrating the tumor (P ⫽ .047; P ⫽ .074, respectively)
was observed, whereas the number of CD83⫹ cells decreased slightly,
but the result did not reach statistical significance (P ⫽ .107). An
increase of the peritumoral CD4⫹ cell infiltrate (P ⫽ .143) was also
noted. Clinical responders compared with nonresponders exhibited a
trend toward greater increase in the number of endotumoral CD11c⫹
and CD3⫹ cells (P ⫽ .094 and P ⫽ .094, respectively; Figs 3 and 4) and
a trend toward greater reduction in endotumoral CD83⫹ cells
(P ⫽ .060). Clinical responders compared with nonresponders also
had an increase in endotumoral CD56⫹ cells that did not achieve
significance, but it is of interest in view of the other changes observed
(P ⫽ .138). HDI did not differentially alter the immune cell infiltrates
in the peritumoral and perivascular cell compartments of clinical
responders versus nonresponders, and there were no similar trends
toward differences between clinical responders and nonresponders in
the phenotype of melanoma cells, as assessed by several lineage markers (data not shown). Finally, HDI did not appear to alter angiogenesis, HLA expression (either among melanoma or mononuclear cells),
or proliferation and/or apoptosis (of melanoma cells) based on IHC
studies with antibodies against von Willebrand factor, HLA-ABC,
HLA-DR, Ki67, and Apoptag (data not shown).
DISCUSSION
This is the first reported evaluation of HDI given as single-agent
neoadjuvant therapy for the treatment of melanoma. IFN-␣ has previously been administered preoperatively at low doses as part of combined modality biochemotherapy regimens for upper aerodigestive
cancer and other malignancies with variable results.16-19 IFN-␣ has
also been investigated at lower dosages as part of neoadjuvant biochemotherapy regimens for patients with stage III melanoma with clinical
response in approximately 40% of patients and pathologic response in
10% of patients.20,21 In contrast to these earlier studies employing
lower dosages of IFN-␣, HDI was administered here in the US Food
and Drug Administration-approved adjuvant dosage regimen. This
regimen avoids the issues of interaction that confound studies of
combinations of IFN-␣ with chemotherapeutic agents, some of which
have been shown to be immunosuppressive,22 that may potentially
antagonize or alter the therapeutic effects of IFN-␣.
Despite the small size of this study, the 55% clinical and 15%
pathologic response rates observed are notable for several reasons.
First, patients with stage IIIB-C melanoma have the highest risk for
relapse and mortality of all the risk groups included in prior adjuvant
trials conducted by the cooperative groups.1 Second, most patients
enrolled in this study had regional lymph node recurrence after initial
therapy for melanoma rather than synchronous nodal disease at initial
diagnosis. Recurrent disease has a worse prognosis than disease initially presenting in stage III, as documented in multiple trials of the US
Cooperative Groups (E1684 and E1690).4,5 Third, the high clinical
response rate with neoadjuvant HDI therapy observed in this study is
to be contrasted to the response rates observed in clinical assessment
during earlier phase I/II studies of HDI for stage IV melanoma. In the
setting of advanced stage IV disease, response rates of less than 20%
were achieved, although a number of patients had durable responses
ranging from 26 to more than 30 months.23 Finally, although this
study was not designed to study the effect of neoadjuvant IFN on
surgical outcome, it did not appear to compromise surgical management and the reduction of tumor burden may favorably influence the
management of patients with clinical response to HDI.24
Pathologic and clinical response were not perfectly correlated,
and pathologic response was also imperfectly correlated with radiographic assessment of response for PET-CT, where two of five patients
evaluated by coregistered PET/CT scan had no evidence of radiographic response while pathology demonstrated response (data not
shown). These discrepancies may be attributed to at least two confounding factors. First, patients vary in terms of extent of disease and
the likely kinetics of tumor and host response; the single point of
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Fig 3. Numbers of (A) CD3⫹, (B) CD4⫹,
(C) CD11c⫹, (D) CD56⫹, (E) CD83⫹, and (F)
CD86⫹ cells present in lymph node tumor
tissue per high power field pre- (x-axis) and
post-treatment with high-dose interferon
alfa-2b (HDI) for 4 weeks (y-axis) for responders (black diamonds) versus nonresponders (gray circles).
clinical, radiological, and pathologic evaluation at day 29 in this study
may not have accurately represented the dynamic process of tumor
regression, which may take longer intervals in patients with high initial
tumor volume or slower tumor response kinetics. Second, the influx
of immune cells infiltrating the tumor may lead to inflammatory
swelling, confounding the assessment of clinical response at day 29, as
in patient 6 of our study. In support of this interpretation we observed
several different phases of the immune response process in evaluating
the post-treatment samples: these ranged from perivascular immune
cell infiltrates to the appearance of melanophages, and the appearance
of later phases of fibrosis/necrosis (data not shown).
This trial was not powered to detect increases in disease-free and
overall survival among clinical responders compared with nonresponders. The prolongation of disease-free survival, while not sta3168
tistically significant for patients responding to IFN at 4 weeks
assessment in this trial, is supported by several large phase III trial
experiences in the United States. The consistent and highly significant
disease-free survival benefit observed in three previous Eastern Cooperative Oncology Group/Intergroup adjuvant trials of HDI for melanoma was in fact part of the rationale for our pursuit of this
investigation. The results of this study suggest two hypotheses. First,
assessment of response to HDI at 4 weeks may predict the ultimate
impact of HDI on disease. If so, this decision, made early in treatment
might allow us to avoid the toxicity of therapy in patients who are not
destined to derive benefit from additional treatment with the remaining 11 months of therapy. Second, the study suggests that the benefit of
IFN may derive from the 4 weeks of IV induction HDI, without
requirement of maintenance therapy for an additional 11 months.
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Neoadjuvant High-Dose IFN-␣2b for Melanoma
Fig 4. Immunohistochemical staining for
CD3 (A, B) and CD11c (C, D) in melanomainfiltrated lymph nodes from a clinical responder before (A, C) and after (B, D)
treatment with high-dose interferon alfa-2b
for 4 weeks. Peritumoral (pt) and endotumoral (et) compartments are shown.
This has important implications for the intergroup E1697 international trial of 4 weeks of induction IV HDI currently under way. While
this trial of neoadjuvant therapy was underpowered to define the role
of response at 4 weeks in terms of overall survival benefit, the E1697
trial targeting 1,490 patients will have ample power to detect relapsefree benefits of as little as 7.5%. While clinical and radiological response of disease at 4 weeks may not correspond perfectly with
histopathologic responses in the setting of bulky regional lymph node
metastasis (stage IIIB), the clinical, radiological, and pathologic findings we have reported here will be relevant to the Intergroup study
E1697, where 4 weeks of induction IV HDI is being tested in comparison to observation for patients with earlier stages of deeper primary
(stage IIA-B) and microscopic nodal disease (stage IIIA).
The neoadjuvant study design adopted for this trial allowed us to
study the effects of HDI on tumor tissue and to examine immunologic
and molecular biomarkers in tumor tissue as potential correlates of
tumor response. IHC analysis of tumor tissue revealed that HDI did
not appear to influence the tumor cell phenotype, proliferation rate, or
apoptotic fraction of cells in tumor biopsies, and did not significantly
affect tumor vasculature, irrespective of clinical response. In contrast,
IHC analysis of immunologic markers including T lymphocytes
(CD3, CD4, and CD8), natural killer cells (CD56), and dendritic cells
(CD11c, CD83, and CD86) showed that clinical response to HDI was
consistently associated with augmented numbers of mononuclear
immune cells infiltrating the tumor, but not those in the peritumoral
or perivascular cellular compartments. These changes exhibited
strong trends approaching nominal significance in regard to CD3, and
CD11c, as well as CD83/86 positive populations.
IHC analysis did not demonstrate significant alterations of the
numbers of mononuclear cells infiltrating the tumor in general, but
rather showed changes in the endotumoral compartment that we and
others have previously shown to be most closely correlated to the
impact of earlier immunotherapeutic agents25-27; the findings of this
study do not suggest any change in the expression of lineage or other
antigens of melanoma with IFN. This suggests that the primary antitumor mechanism of HDI is an indirect immunomodulatory mechanism rather than a direct and/or cytotoxic mechanism. Specifically,
clinical response to HDI was associated with a consistent trend toward
significantly greater numbers of CD3⫹ and CD11c⫹ cells infiltrating
the tumor. The changes observed in tumor-infiltrating CD11c⫹ and
CD83⫹ cells likely represent monocyte-derived dendritic cell subpopulations and are in agreement with the differential expression of CD83 and
CD86 in monocyte-derived dendritic cells from healthy donors in vitro.28
In summary, neoadjuvant HDI therapy for high-risk melanoma
patients with bulky regional stage IIIB-C lymphadenopathy results in
high clinical and pathologic response rates without increased morbidity. In fact, neoadjuvant treatment of patients studied in this series may
have improved the surgical outcomes and facilitated rather than impeded surgery. The present results suggest that neoadjuvant HDI
therapy exerts its effects through immunomodulatory rather than
direct cytotoxic mechanisms in patients with stage IIIB-C melanoma,
and has antitumor effects in a greater proportion of patients with
regionally advanced disease than previously noted in studies of distant
metastatic disease we and others have conducted over the past 20
years. These results suggest that the beneficial effects of HDI in the
adjuvant setting for high-risk resected melanoma are also likely to
derive from immunomodulatory effects, which now deserve a more
careful prospective evaluation in the context of additional studies of
stage IIIB or resectable stage IV (eg, M1a or M1b) disease. They have
implications for the current intergroup trial E1697, targeting earlier
stages of disease in which the microscopic tumor burden will not
permit similar biopsy studies of mechanism, but the relevance of
changes induced by 4 weeks of IV HDI will be definitively tested in
terms of impact on disease-free survival.
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■ ■ ■
Acknowledgment
We thank Ruth Mascari, Cindy Sander, and Megan Renstrom for their excellent technical assistance.
Authors’ Disclosures of Potential Conflicts of Interest
Although all authors completed the disclosure declaration, the following authors or their immediate family members indicated a financial interest. No conflict exists for
drugs or devices used in a study if they are not being evaluated as part of the investigation. For a detailed description of the disclosure categories, or for more information
about ASCO’s conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for
Contributors.
Authors
Employment
Leadership
Consultant
Stock
Honoraria
Howard D. Edington
Janice Shipe-Spotloe
Schering Plough (A)
John M. Kirkwood
Testimony
Other
Schering Plough (A)
Schering Plough (A)
Dollar Amount Codes
3170
Research Funds
Schering Plough (B)
(A) ⬍ $10,000
(B) $10,000-99,999
(C) ⱖ $100,000
Schering Plough (B)
(N/R) Not Required
JOURNAL OF CLINICAL ONCOLOGY
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Neoadjuvant High-Dose IFN-␣2b for Melanoma
Author Contributions
Administrative support: Stergios J. Moschos, Howard D. Edington, Uma N. Rao, Drazen Jukic, Janice Shipe-Spotloe, John M. Kirkwood
Provision of study materials or patients: Stergios J. Moschos, Howard D. Edington, Uma N. Rao, Drazen Jukic, Janice Shipe-Spotloe, John M. Kirkwood
Collection and assembly of data: Stergios J. Moschos, Howard D. Edington, Stephanie R. Land, Uma N. Rao, Drazen Jukic, Janice Shipe-Spotloe,
John M. Kirkwood
Data analysis and interpretation: Stergios J. Moschos, Stephanie R. Land, Uma N. Rao, Drazen Jukic, Janice Shipe-Spotloe, John M. Kirkwood
Manuscript writing: Stergios J. Moschos, Stephanie R. Land, John M. Kirkwood
Final approval of manuscript: Stergios J. Moschos, Howard D. Edington, Stephanie R. Land, Uma N. Rao, Drazen Jukic, Janice Shipe-Spotloe,
John M. Kirkwood
3171
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