17 december 2020: The Lancet

Immuuntherapie met het anti-PD medicijn nivolumab plus ipilimumab na operatie van een melanoom stadium IV waarbij geen aantoonbare ziekte meer aanwezig was na de operatie gaf veel betere recidiefvrije overleving in vergelijking met of nivolumab als monotherapie of een placebo. Deze studie (gepresenteerd op ASCO 2020 en gepubliceerd in The Lancet) liet dus duidelijk betere resultaten zien voor aanvullend ipilimumab (IPI) + Nivolumab (NIVO) ten opzichte van aanvullend alleen nivolumab, waarbij de patiënten die een een placebo kregen het slechtst eraf kwamen. 

2-jaars recidiefvrije overleving was voor de combinatiegroep 70 procent (range 55·1%–81·0 %) terwijl voor nivolumab alleen de recidiefvrije overleving 42 procent was (range 28·6%–54·5 %). Voor de placebogroep was de recidiefvrije overleving nog een stuk lager 14 procent (range 5·9%–25·7%). 

Dat blijkt uit een fase II studie met drie groepen. In de IMMUNED fase II-studie werden 167 patiënten met operabel stadium IV melanoom gerandomiseerd ingedeeld naar een van de drie groepen: adjuvante nivolumab (NIVO) (N = 59), adjuvante combinatie ipilimumab + nivolumab (IPI + NIVO) (N = 56)  of een placebo (N = 52).

Deze studie staat geregistreerd bij ClinicalTrials.govNCT02523313, en loopt nog steeds. 

Het volledige studierapport is tegen betaling in te zien. Hier het abstract van de studie zoals gepubliceerd in The Lancet:

Adjuvant nivolumab plus ipilimumab or nivolumab monotherapy versus placebo in patients with resected stage IV melanoma with no evidence of disease (IMMUNED): a randomised, double-blind, placebo-controlled, phase 2 trial

Summary

Background

Nivolumab and ipilimumab, alone or in combination, are widely used immunotherapeutic treatment options for patients with advanced—ie, unresectable or metastatic—melanoma. This criterion, however, excludes patients with stage IV melanoma with no evidence of disease. We therefore aimed to evaluate the safety and efficacy of adjuvant nivolumab plus ipilimumab or nivolumab monotherapy versus a placebo in this patient population.

Methods

We did a randomised, double-blind, placebo-controlled, phase 2 trial in 20 German academic medical centres. Eligible patients were aged 18–80 years with stage IV melanoma with no evidence of disease after surgery or radiotherapy. Key exclusion criteria included uveal or mucosal melanoma, previous therapy with checkpoint inhibitors, and any previous immunosuppressive therapy within the 30 days before study drug administration. Eligible patients were randomly assigned (1:1:1), using a central, interactive, online system, to the nivolumab plus ipilimumab group (1 mg/kg of intravenous nivolumab every 3 weeks plus 3 mg/kg of intravenous ipilimumab every 3 weeks for four doses, followed by 3 mg/kg of nivolumab every 2 weeks), nivolumab monotherapy group (3 mg/kg of intravenous nivolumab every 2 weeks plus ipilimumab-matching placebo during weeks 1–12), or double-matching placebo group. The primary endpoint was the recurrence-free survival in the intention-to-treat population. The results presented in this report reflect the prespecified interim analysis of recurrence-free survival after 90 events had been reported. This study is registered with ClinicalTrials.govNCT02523313, and is ongoing.

Findings

Between Sept 2, 2015, and Nov 20, 2018, 167 patients were randomly assigned to receive nivolumab plus ipilimumab (n=56), nivolumab (n=59), or placebo (n=52). As of July 2, 2019, at a median follow-up of 28·4 months (IQR 17·7–36·8), median recurrence-free survival was not reached in the nivolumab plus ipilimumab group, whereas median recurrence-free survival was 12·4 months (95% CI 5·3–33·3) in the nivolumab group and 6·4 months (3·3–9·6) in the placebo group. The hazard ratio for recurrence for the nivolumab plus ipilimumab group versus placebo group was 0·23 (97·5% CI 0·12–0·45; p<0·0001), and for the nivolumab group versus placebo group was 0·56 (0·33–0·94; p=0·011). In the nivolumab plus ipilimumab group, recurrence-free survival at 1 year was 75% (95% CI 61·0–84·9) and at 2 years was 70% (55·1–81·0); in the nivolumab group, 1-year recurrence-free survival was 52% (38·1–63·9) and at 2 years was 42% (28·6–54·5); and in the placebo group, this rate was 32% (19·8–45·3) at 1 year and 14% (5·9–25·7) at 2 years. Treatment-related grade 3–4 adverse events were reported in 71% (95% CI 57–82) of patients in the nivolumab plus ipilimumab group and in 27% (16–40) of those in the nivolumab group. Treatment-related adverse events of any grade led to treatment discontinuation in 34 (62%) of 55 patients in the nivolumab plus ipilimumab group and seven (13%) of 56 in the nivolumab group. Three deaths from adverse events were reported but were considered unrelated to the study treatment.

Interpretation

Adjuvant therapy with nivolumab alone or in combination with ipilimumab increased recurrence-free survival significantly compared with placebo in patients with stage IV melanoma with no evidence of disease. The rates of grade 3–4 treatment-related adverse events in both active treatment groups were higher than the rates reported in previous pivotal trials done in advanced melanoma with measurable disease.

Funding

Bristol-Myers Squibb.
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