School of Medicine, First Department of Medicine, National and Kapodistrian University of Athens, Laiko General Hospital, 75, Mikras Asias str., Goudi, 11527, Athens, Greece.
Am J Clin Dermatol. 2021 May;22(3):301-314. doi: 10.1007/s40257-021-00593-9. Epub 2021 Mar 25.
The management and prognosis of BRAF-mutant metastatic melanoma have changed drastically following the introduction of immune checkpoint inhibitors and molecularly targeted agents. These treatment options present different mechanisms of action and toxicities but also totally distinct kinetics of their response, including a "relatively" short-lasting benefit in subsets of patients treated with BRAF/MEK inhibitors and a lower response rate in patients treated with immune checkpoint inhibitors. BRAF/MEK inhibitors, when administered prior to or concurrently with immune checkpoint inhibitors, at least transiently alter some immunosuppressive parameters of the tumor microenvironment and theoretically improve sensitivity to immunotherapy. Preclinical data from mouse models with oncogene-addicted melanoma confirmed this beneficial immune/targeted synergy and supported the clinical testing of combinations of BRAF/MEK inhibitors and immune checkpoint inhibitors to improve the activity of upfront anti-melanoma therapies. The first positive phase III results were published in 2020, and triggered the discussion about the benefits, the limitations, as well as the possible implications of combining or sequencing targeted therapies with immune checkpoint inhibitors in everyday practice. Beginning from the interplay of immune/targeted agents within the melanoma microenvironment, this review outlines available information from the retrospective experience up to the late-stage randomized evidence on combinatorial treatments. Many clinical trials are currently underway exploring open questions about optimal timing, new immune biomarkers, and eligible patient subsets for these immune/targeted regimens. Awaiting these results, decision making in the first-line setting for BRAF-mutant melanoma is still guided by the patients' characteristics and the biological aspects of melanoma.
在引入免疫检查点抑制剂和分子靶向药物后,BRAF 突变型转移性黑色素瘤的管理和预后发生了巨大变化。这些治疗选择具有不同的作用机制和毒性,但它们的反应动力学也完全不同,包括 BRAF/MEK 抑制剂治疗的部分患者“相对”短暂受益,以及免疫检查点抑制剂治疗的患者反应率较低。BRAF/MEK 抑制剂在免疫检查点抑制剂之前或同时给药时,至少会暂时改变肿瘤微环境的一些免疫抑制参数,并从理论上提高对免疫治疗的敏感性。携带致癌基因依赖性黑色素瘤的小鼠模型的临床前数据证实了这种有益的免疫/靶向协同作用,并支持了 BRAF/MEK 抑制剂和免疫检查点抑制剂联合治疗的临床测试,以提高一线抗黑色素瘤治疗的活性。第一批阳性 III 期结果于 2020 年公布,引发了关于联合或序贯靶向治疗与免疫检查点抑制剂在日常实践中的获益、局限性以及可能影响的讨论。从免疫/靶向药物在黑色素瘤微环境中的相互作用开始,本综述概述了从回顾性经验到晚期随机证据的关于联合治疗的现有信息。目前许多临床试验正在探索关于这些免疫/靶向方案的最佳时机、新的免疫生物标志物和合格患者亚组的开放性问题。在等待这些结果的同时,BRAF 突变型黑色素瘤一线治疗的决策仍然取决于患者的特征和黑色素瘤的生物学方面。