Cancer Treatment Today » Melanoma

Zelboraf for other mutations that BRAF-E

M Levin, MD — Fri, 08 Feb 2013 15:49:48 +0000

Zelboraf(vemurafenib) is anti BRAF kinase inhibitor. ZELBORAF™ is indicated for the treatment of patients with unresectable or metastatic melanoma with BRAFV600E mutation as detected by an FDA-approved test.

More than 30 mutations of the BRAF gene associated with human cancers have been identified. However, most of them work thorugh pathways and in a similar way to the BRAF-E. With this in mind, other BRAF mutations than E should also respond to Zelboraf. In the Chapman study, on which the FDA approval was based, there were ten patients with BRAF-K mutation and they showed some response. Ten patients in the vemurafenib group were later found to have BRAF V600K mutations; of these patients, 4 had a partial response (40%). Being that there are so many different BRAF mutations, it is not reasonable to require large studies performed for each mutation subtype.

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Melanoma: Retreating with Yervoy

M Levin, MD — Sun, 23 Dec 2012 19:57:23 +0000

Yervoy is recently approved drug that induces an ummune response against melanoma cells. )Some patients have only a partial response or progress afer responding, and owing to there not being many other good options, many doctors would retreat in such a situation. However, Yervoy is a toxic drug and the decision to use it again is not a trivial one. It is , unfortunately, not known whether retreatment is beneficial. There is a study looking at this question: Study to Compare the Effect of Ipilimumab Retreatment With Chemotherapy in Advanced Melanoma, NCT01709162. The purpose of the study is to determine whether additional doses of Ipilimumab have a positive effect on survival in the treatment of advanced melanoma that has progressed after successful initial treatment with Ipilimumab. In the meantime, NCCN supports retratment providing that there had been a response after first use and no toxicity and that 3 months have passed.

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Imaging after treatment for melanoma

M Levin, MD — Sun, 02 Dec 2012 16:44:24 +0000

Melanoma after treatment needs to be followed either by doctor exams, imaging or both. As better treatments appear, there is a growing realization that more and more patients have no evidence of disease for longer periods of time, but some of them will relapse, so how should they be followed?

The role of PET in melanoma is not fully defined. The most recent review by Petrella and others concluded: “PET scanning facilitates the appropriate management of high-risk melanoma patients being considered for operative intervention. PET imaging in addition to CT scanning should be strongly considered before operation in patients at high risk for occult metastatic disease.” It also says that a recommendation cannot be made for or against the use of PET for routine surveillance due to insufficient evidence.

2012 NCCN recommends reimaging of stage I and IIA with CT or PET/CT only for specific signs or symptoms. For stage IIB-IV disese it recommends: “consider chest-X-ray, CT or PET/CT every 6-12 months to screen for recurrent or metastatic disease, for up to 5 years.” Francken et al (2008)proposed a follow-up schedule in stage I annually, stage IIA 6-monthly for 2 years and then annually, stage IIB-IIC 4-monthly for 2 years, 6-monthly in the third year and annually thereafter.

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Spitz tumors and melanoma

M Levin, MD — Fri, 24 Aug 2012 18:08:47 +0000

Spitz nevus is a benign tumor that can be distinguished from melanoma in most instances. However, as stated by Allen and Spitz in 1953, in some circumstances, unequivocal distinction between Spitz nevus and melanoma is practically impossible. Some cases are difficult to distinguish from melanoma. Other cases turn out to be of higher risk and don’t behave like Spitz tumors. I consider a decision appropriate to treat it as melanoma after a consideration of all factors and discussion between physician and patient appropriate given the uncertainty of pathologic diagnosis in many cases.

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