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Personalized response-directed surgery and adjuvant therapy after neoadjuvant ipilimumab and nivolumab in high-risk stage III melanoma: the PRADO trial

Abstract

Neoadjuvant ipilimumab and nivolumab induces high pathologic response rates (pRRs) in clinical stage III nodal melanoma, and pathologic response is strongly associated with prolonged relapse-free survival (RFS). The PRADO extension cohort of the OpACIN-neo trial (NCT02977052) addressed the feasibility and effect on clinical outcome of using pathologic response after neoadjuvant ipilimumab and nivolumab as a criterion for further treatment personalization. In total, 99 patients with clinical stage IIIb–d nodal melanoma were included and treated with 6 weeks of neoadjuvant ipilimumab 1 mg kg−1 and nivolumab 3 mg kg−1. In patients achieving major pathologic response (MPR, ≤10% viable tumor) in their index lymph node (ILN, the largest lymph node metastasis at baseline), therapeutic lymph node dissection (TLND) and adjuvant therapy were omitted. Patients with pathologic partial response (pPR; >10 to ≤50% viable tumor) underwent TLND only, whereas patients with pathologic non-response (pNR; >50% viable tumor) underwent TLND and adjuvant systemic therapy ± synchronous radiotherapy. Primary objectives were confirmation of pRR (ILN, at week 6) of the winner neoadjuvant combination scheme identified in OpACIN-neo; to investigate whether TLND can be safely omitted in patients achieving MPR; and to investigate whether RFS at 24 months can be improved for patients achieving pNR. ILN resection and ILN-response-tailored treatment were feasible. The pRR was 72%, including 61% MPR. Grade 3–4 toxicity within the first 12 weeks was observed in 22 (22%) patients. TLND was omitted in 59 of 60 patients with MPR, resulting in significantly lower surgical morbidity and better quality of life. The 24-month relapse-free survival and distant metastasis-free survival rates were 93% and 98% in patients with MPR, 64% and 64% in patients with pPR, and 71% and 76% in patients with pNR, respectively. These findings provide a strong rationale for randomized clinical trials testing response-directed treatment personalization after neoadjuvant ipilimumab and nivolumab.

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Fig. 1: Study scheme and flowchart of PRADO.
Fig. 2: Radiologic and pathologic response.
Fig. 3: Effect of ILN procedure on surgical morbidity and HRQoL.
Fig. 4: Survival outcomes.

Data availability

To minimize the risk of patient re-identification, de-identified individual patient-level clinical data are available under restricted access. Upon a scientifically sound request, data access can be obtained via the NKI’s scientific repository at repository@nki.nl, which will contact the corresponding author (C.U.B.). Data requests will be reviewed by the institutional review board of the Netherlands Cancer Institute (NKI) and will require the requesting researcher to sign a data access agreement with the NKI.

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Acknowledgements

We thank all patients and their families for participation in the trial and the participating study teams. We gratefully acknowledge the support of all colleagues from Melanoma Institute Australia, Royal Prince Alfred Hospital, Royal North Shore and Mater Hospital, University Medical Center Utrecht, Erasmus Medical Center, Leiden University Medical Center, University Medical Center Groningen and the Netherlands Cancer Institute; B. Schermers from Sirius Medical for providing magnetic seeds and a magnetic seed detector; S. Vanhoutvin for financial management; R. Zucker, M. J. Gregorio, K. de Joode, A. M. van Eggermond, E. H. J. Tonk and J. Kingma-Veenstra for administrative support and data management; and A. Evans and B. Stegenga from Bristol Myers Squibb for scientific input and long-term support of our neoadjuvant immunotherapy efforts. A.M.M. is supported by a National Health and Medical Research Council (NHMRC) Investigator Grant, Melanoma Institute Australia and Nicholas and Helen Moore. R.P.M.S. is supported by Melanoma Institute Australia. R.V.R. is supported by a Clinical Research Scholarship from Sydney Research. R.A.S. is supported by an NHMRC Program Grant and Practitioner Fellowship. G.V.L. is supported by an NHMRC Investigator Grant and the University of Sydney Medical Foundation. Financial support for the trial was provided by Bristol Myers Squibb.

Author information

Authors and Affiliations

Authors

Contributions

C.U.B. designed the trial and wrote the trial protocol. E.A.R. provided additional input and wrote the amendment for the PRADO extension cohort during the 20th Workshop on ‘Methods in Clinical Cancer Research’ (Zeist, Netherlands). G.V.L. and A.v.A. reviewed the protocol. A.H.B. wrote the HRQoL part of the protocol. I.L.M.R., A.M.M., J.M.V., R.P.M.S., T.P., E.A.R., E.K., A.A.M.v.d.V., K.P.M.S., G.A.P.H., W.M.C.K., W.J.v.H., J.A.v.d.H., D.J.G., M.W.W., A.J.W., C.L.Z., J.M.L., K.F.S., S.C., J.S., A.S., A.v.A., G.V.L. and C.U.B. recruited and treated patients and collected data. A.J.C., R.V.R., R.A.S. and B.A.v.d.W. reviewed and scored the pathology of all cases. N.M.J.v.d.H., I.L.M.R., M.G., L.V.v.d.P.-F., A.H.B. and C.U.B. collected and interpreted data on HRQoL. K. Sikorska and I.L.M.R. performed statistical analysis of the clinical data. A.H.B. and K.J. performed the HRQoL statistical analyses. A.T.A. and L.G.G.-O. contributed to central and local data management. R.Z. and M.G. were clinical project managers of the trial. I.L.M.R., A.H.B. and C.U.B. wrote the first draft of the manuscript. All authors interpreted the data, reviewed the manuscript and approved the final version.

Corresponding author

Correspondence to Christian U. Blank.

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Competing interests

No author has received financial support for the work on this manuscript, and no medical writer was involved at any stage of the preparation of this manuscript. A.M.M. has served on advisory boards for Bristol Myers Squibb (BMS), Merck Sharp & Dohme (MSD), Novartis, Roche, Pierre Fabre and QBiotics. R.P.M.S. has received honoraria for advisory board participation from MSD, Novartis and Qbiotics and speaking honoraria from BMS and Novartis. E.K. received honoraria for consultancy/advisory relationships (all paid to the institute) from BMS, Novartis, Merck and Pierre Fabre and received research grants not related to this paper from BMS. A.A.M.v.d.V. received compensation for advisory roles and honoraria (all paid to the institute) from BMS, MSD, Merck, Roche, Eisai, Pfizer, Sanofi, Novartis, Pierre Fabre and Ipsen. K.P.M.S. received compensation for advisory roles and honoraria (all paid to the institute) from BMS, MSD, Roche, Novartis, Pierre Fabre and Abbvie and received research funding from Novartis, TigaTx and BMS. G.A.P.H. received compensation for consulting and advisory roles (all paid to the institute) from Amgen, Roche, MSD, BMS, Pfizer, Novartis and Pierre Fabre and received research grants (paid to the institute) from BMS and Seerave. W.J.v.H. received compensation for advisory roles (all paid to the institute) from BMS, Amgen and Sanofi. D.J.G. received compensation for advisory roles (all paid to the institute) from Amgen and Novartis. M.W.W. received compensation for advisory roles (all paid to the institute) from Novartis. A.J.S. has served on an advisory board for QBiotics and received fees for professional services from Eli Lily Australia. J.B.A.G.H. received compensation (all paid to the institute) for advisory roles from AIMM, Amgen, BioNTech, BMS, GlaxoSmithKline, Ipsen, MSD, Merck Serono, Molecular Partners, Neogene Therapeutics, Novartis, Pfizer, Roche/Genentech, Sanofi, Seattle Genetics, Third Rock Ventures and Vaximm; stock option ownership of Neogene Therapeutics; and institutional research funding from Amgen, BioNTech, BMS, MSD and Novartis. B.A.v.d.W. has served on the advisory board for BMS. A.v.A. had served on advisory boards and received consultancy honoraria (all paid to the institute) for Amgen, BMS, Novartis, MSD, Merck-Pfizer, Pierre Fabre, Sanofi, Sirius Medical and 4SC and received research grants (all paid to the institute) from Amgen and Merck-Pfizer. R.A.S. has received fees for professional services from F. Hoffmann-La Roche, Evaxion, Provectus Biopharmaceuticals Australia, Qbiotics, Novartis, MSD, NeraCare, Amgen, BMS, Myriad Genetics and GlaxoSmithKline. A.H.B. has received a research grant from BMS. G.V.L. is consultant advisor for Aduro, Amgen, Array Biopharma, Boehringer Ingelheim, BMS, Evaxion, Hexal AG (Sandoz Company), Highlight Therapeutics, MSD, Novartis, Oncosec, Pierre Fabre, Provectus, QBiotics and Regeneron Pharmaceuticals. C.U.B. reports receiving compensation for advisory roles from BMS, MSD, Roche, Novartis, GlaxoSmithKline, AstraZeneca, Pfizer, Eli Lilly, GenMab, Pierre Fabre and Third Rock Ventures and receiving research funding from BMS, MSD, Novartis, 4SC and NanoString. Furthermore, C.U.B. reports to be co-founder of Immagene BV. All compensations and funding for C.U.B. were paid to the institute, except for Third Rock Ventures and Immagene. The other authors declare no conflicts of interest.

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Extended data

Extended Data Fig. 1 Marker placement in the ILN.

Schematic overview of magnetic seed placement in the ILN and retrieval of the ILN during the ILN procedure. (1) Magnetic seed, (2) Ultrasound image of positioning of the needle tip (red arrow) in the ILN (green arrow) before implantation of the magnetic seed, (3) Two cycles of ipilimumab plus nivolumab are given after the magnetic seed is implanted, (4) Magnetic detector (Endomag Sentimag®) used during surgery for seed detection, (5) Postoperative specimen X‐ray with magnetic seed (red arrow) in situ. This image has been adapted from Schermers B, Br J Surg, 201919.

Extended Data Fig. 2 Objective radiologic response underestimates pathologic response.

Waterfall plot of the radiologic change in target lesions (in %) between baseline and week 6 of all PRADO patients with evaluable CT-scan (n = 96). Colours indicate the responses as pCR (dark green), near-pCR (light green), pPR (yellow), pNR (red) and distant metastases (grey). The dotted line indicates the cutoff for RECIST version 1.1 radiologic response.

Extended Data Fig. 3 Flowchart for patient inclusion for surgical morbidity and HRQoL analyses.

a, Flow chart of patient inclusion for surgical morbidity analyses. For information regarding the execution of the ILN resection and TLND, see also Supplementary Table 2. b, HRQoL analyses of the PRADO trial.

Extended Data Fig. 4 Effect of pathological response and treatment on HRQoL outcomes.

Curves showing the unadjusted mean HRQoL scores of patients with MPR (n = 60, green line) versus patients without MPR (n = 31, orange line). Error bars indicate the 95% CI. The differences in mean HRQoL scores between patients with MPR and non-MPR (see also Supplementary Table 5) were adjusted for age, gender, adjuvant treatment and relapse status (no/yes). The adjusted score differences were interpreted in terms of statistical significance using a linear mixed effect model with a two tailed P value (P < 0.05), and by clinical relevance according to the guideline of Cocks et al32. Statistically significant adjusted differences were marked with * and clinically relevant differences were marked with # (Supplementary Table 5). Results were considered clinically relevant if the adjusted difference in mean scores between the two groups was at least ‘medium’ and clinically irrelevant if differences in mean scores were ‘trivial or small’. Questionnaire compliance rates in the MPR and non-MPR group were 87% vs 97% at baseline, 98% vs 94% at week 6, 90% vs 81% at week 12, 88% vs 81% at week 24, 92% vs 84% at week 36, 85% vs 68% at week 48, 80% vs 77% at week 60 and 87% vs 61% at week 104 (year 2).

Extended Data Fig. 5 HRQoL comparison between patients with MPR, pPR and pNR.

Curves showing the unadjusted HRQoL scores between patients with MPR (n = 60, green line), pPR (n = 11, yellow line) and pNR (n = 20, red line). Error bars indicate the 95% CI. The differences in mean HRQoL scores between patients with MPR versus pPR and MPR versus pNR were adjusted for age, gender, adjuvant treatment and relapse status (no/yes). The adjusted score differences were interpreted in terms of statistical significance using a linear mixed effect model with a two tailed P value (P < 0.05), and by clinical relevance according to the guideline of Cocks et al32. Statistically significant adjusted differences were marked with * and clinically relevant differences were marked with #. Results were considered clinically relevant if the adjusted difference in mean scores between the two groups was at least ‘medium’ and clinically irrelevant if differences in mean scores were ‘trivial or small’.

Extended Data Fig. 6 RFS by adjuvant treatment.

RFS of patients with pNR from the PRADO trial by adjuvant therapy. Patients were treated with adjuvant nivolumab (n = 7, light blue line), adjuvant BRAF/MEK inhibition (n = 10, orange line) or no adjuvant therapy (n = 3, dark blue line). The patient who was lost to follow-up was excluded.

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Supplementary Tables 1–11, references HRQoL questionnaire information and study protocol.

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Reijers, I.L.M., Menzies, A.M., van Akkooi, A.C.J. et al. Personalized response-directed surgery and adjuvant therapy after neoadjuvant ipilimumab and nivolumab in high-risk stage III melanoma: the PRADO trial. Nat Med 28, 1178–1188 (2022). https://doi.org/10.1038/s41591-022-01851-x

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