Neoadjuvant Nivolumab and Ipilimumab in Resectable Stage III Melanoma

doi:10.1056/NEJMoa2402604

Clinical Trial

. 2024 Nov 7;391(18):1696-1708.

doi: 10.1056/NEJMoa2402604. Epub 2024 Jun 2.

Neoadjuvant Nivolumab and Ipilimumab in Resectable Stage III Melanoma

Christian U Blank¹, Minke W Lucas¹, Richard A Scolyer¹, Bart A van de Wiel¹, Alexander M Menzies¹, Marta Lopez-Yurda¹, Lotte L Hoeijmakers¹, Robyn P M Saw¹, Judith M Lijnsvelt¹, Nigel G Maher¹, Saskia M Pulleman¹, Maria Gonzalez¹, Alejandro Torres Acosta¹, Winan J van Houdt¹, Serigne N Lo¹, Anke M J Kuijpers¹, Andrew Spillane¹, W Martin C Klop¹, Thomas E Pennington¹, Charlotte L Zuur¹, Kerwin F Shannon¹, Beatrijs A Seinstra¹, Robert V Rawson¹, John B A G Haanen¹, Sydney Ch'ng¹, Kishan A T Naipal¹, Jonathan Stretch¹, Johannes V van Thienen¹, Michael A Rtshiladze¹, Sofie Wilgenhof¹, Rony Kapoor¹, Aafke Meerveld-Eggink¹, Lindsay G Grijpink-Ongering¹, Alexander C J van Akkooi¹, Irene L M Reijers¹, David E Gyorki¹, Dirk J Grünhagen¹, Frank M Speetjens¹, Sonja B Vliek¹, Joanna Placzke¹, Lavinia Spain¹, Robert C Stassen¹, Mona Amini-Adle¹, Céleste Lebbé¹, Mark B Faries¹, Caroline Robert¹, Paolo A Ascierto¹, Rozemarijn van Rijn¹, Franchette W P J van den Berkmortel¹, Djura Piersma¹, Andre van der Westhuizen¹, Gerard Vreugdenhil¹, Maureen J B Aarts¹, Marion A M Stevense-den Boer¹, Victoria Atkinson¹, Muhammad Khattak¹, Miles C Andrews¹, Alfons J M van den Eertwegh¹, Marye J Boers-Sonderen¹, Geke A P Hospers¹, Matteo S Carlino¹, Jan-Willem B de Groot¹, Ellen Kapiteijn¹, Karijn P M Suijkerbuijk¹, Piotr Rutkowski¹, Shahneen Sandhu¹, Astrid A M van der Veldt¹, Georgina V Long¹

Affiliations

Affiliation

¹ From the Departments of Medical Oncology (C.U.B., M.W.L., L.L.H., J.M.L., S.M.P., J.B.A.G.H., K.A.T.N., J.V.T., S.W., A.M.-E., I.L.M.R.), Pathology (B.A.W.), Biometrics (M.L.-Y., A.T.A., L.G.G.-O.), Surgical Oncology (W.J.H., A.M.J.K., A.C.J.A.), Head and Neck Surgery (W.M.C.K., C.L.Z.), Radiology (B.A.S.), and Molecular Oncology and Immunology (J.B.A.G.H.), Netherlands Cancer Institute, and the Department of Medical Oncology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Cancer Center Amsterdam (A.J.M.E.), Amsterdam, the Departments of Medical Oncology (C.U.B., J.B.A.G.H., F.M.S., E.K.) and Otorhinolaryngology Head and Neck Surgery (C.L.Z.), Leiden University Medical Center, Leiden, the Departments of Medical Oncology (K.A.T.N., R.C.S., A.A.M.V.), Surgical Oncology (D.J.G., R.C.S.), and Radiology and Nuclear Medicine (A.A.M.V.), Erasmus Medical Center, Rotterdam, the Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht (S.B.V., K.P.M.S.), the Department of Medical Oncology, Medical Center Leeuwarden, Leeuwarden (R.R.), the Department of Medical Oncology, Zuyderland Medical Center, Sittard-Geleen (F.W.P.J.B.), the Department of Medical Oncology, Medisch Spectrum Twente, Enschede (D.P.), the Department of Medical Oncology, Maxima Medical Center, Veldhoven (G.V.), the Department of Medical Oncology, Maastricht University Medical Center, GROW School for Oncology and Developmental Biology, Maastricht (M.J.B.A.), the Department of Medical Oncology, Amphia Hospital, Breda (M.A.M.S.B.), the Department of Medical Oncology, Radboud University Medical Center, Nijmegen (M.J.B.-S.), the Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen (G.A.P.H.), and Isala Oncology Center, Isala Hospital, Zwolle (J.-W.B.G.) - all in the Netherlands; the Department of Hematology and Medical Oncology, University Clinic Regensburg, Regensburg, Germany (C.U.B.); Melanoma Institute Australia (R.A.S., A.M.M., R.P.M.S., N.G.M., M.G., S.N.L., A.S., T.E.P., K.F.S., R.V.R., S.C., J.S., M.A.R., A.C.J.A., M.S.C., G.V.L.), the Faculty of Medicine and Health (R.A.S., A.M.M., R.P.M.S., N.G.M., S.N.L., A.S., T.E.P., K.F.S., S.C., J.S., M.A.R., A.C.J.A., G.V.L.), and Charles Perkins Centre (R.A.S., G.V.L.), University of Sydney, the Departments of Tissue Pathology and Diagnostic Oncology (R.A.S., R.V.R.) and Melanoma and Surgical Oncology (R.P.M.S., T.E.P., K.F.S., S.C., J.S., M.A.R., A.C.J.A.), Royal Prince Alfred Hospital, NSW Health Pathology (R.A.S., R.V.R.), the Departments of Medical Oncology (A.M.M., G.V.L.) and Breast and Melanoma Surgery (A.S.), Royal North Shore and Mater Hospitals, and the Department of Radiology, Mater Hospital (R.K.), Sydney, Royal Prince Alfred Hospital, Institute of Academic Surgery, Camperdown, NSW (A.C.J.A.), the Division of Cancer Surgery, Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC (D.E.G.), the Department of Medical Oncology, Peter MacCallum Cancer Centre, East Melbourne, VIC (L.S., S.S.), Lake Macquarie Oncology, Lake Macquarie Private Hospital, the Department of Medical Oncology, Calvary Mater Hospital, and the Department of Medicine, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW (A.W.), the Department of Medical Oncology, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), the Department of Medical Oncology, Fiona Stanley Hospital, Perth, WA (M.K.), the Department of Medical Oncology, Alfred Health, Melbourne, and the Department of Medicine, School of Translational Medicine, Monash University, Melbourne, VIC (M.C.A.), and the Department of Medical Oncology, Westmead Hospital and Blacktown, Sydney (M.S.C.) - all in Australia; the Melanoma Clinic, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (J.B.A.G.H.); the Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland (J.P., P.R.); the Department of Medical Oncology, Centre Léon Bérard, Lyon (M.A.-A.), Université Paris Cité, Assistance Publique-Hôpitaux de Paris (AP-HP) Dermato-Oncology and Clinical Investigation Center, Cancer Institute AP-HP, Nord Paris Cité, INSERM Unité 976, Saint Louis Hospital, Paris (C.L.), and the Department of Medical Oncology, Gustave Roussy and Paris-Saclay University, Villejuif (C.R.) - all in France; the Department of Surgical Oncology, Angeles Clinic and Research Institute, Los Angeles (M.B.F.); and the Melanoma Cancer Immunotherapy and Innovative Therapy Unit, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Naples, Italy (P.A.A.).

PMID: 38828984
DOI: 10.1056/NEJMoa2402604

Clinical Trial

Neoadjuvant Nivolumab and Ipilimumab in Resectable Stage III Melanoma

Christian U Blank et al. N Engl J Med. 2024.

. 2024 Nov 7;391(18):1696-1708.

doi: 10.1056/NEJMoa2402604. Epub 2024 Jun 2.

Authors

Affiliation

¹ From the Departments of Medical Oncology (C.U.B., M.W.L., L.L.H., J.M.L., S.M.P., J.B.A.G.H., K.A.T.N., J.V.T., S.W., A.M.-E., I.L.M.R.), Pathology (B.A.W.), Biometrics (M.L.-Y., A.T.A., L.G.G.-O.), Surgical Oncology (W.J.H., A.M.J.K., A.C.J.A.), Head and Neck Surgery (W.M.C.K., C.L.Z.), Radiology (B.A.S.), and Molecular Oncology and Immunology (J.B.A.G.H.), Netherlands Cancer Institute, and the Department of Medical Oncology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Cancer Center Amsterdam (A.J.M.E.), Amsterdam, the Departments of Medical Oncology (C.U.B., J.B.A.G.H., F.M.S., E.K.) and Otorhinolaryngology Head and Neck Surgery (C.L.Z.), Leiden University Medical Center, Leiden, the Departments of Medical Oncology (K.A.T.N., R.C.S., A.A.M.V.), Surgical Oncology (D.J.G., R.C.S.), and Radiology and Nuclear Medicine (A.A.M.V.), Erasmus Medical Center, Rotterdam, the Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht (S.B.V., K.P.M.S.), the Department of Medical Oncology, Medical Center Leeuwarden, Leeuwarden (R.R.), the Department of Medical Oncology, Zuyderland Medical Center, Sittard-Geleen (F.W.P.J.B.), the Department of Medical Oncology, Medisch Spectrum Twente, Enschede (D.P.), the Department of Medical Oncology, Maxima Medical Center, Veldhoven (G.V.), the Department of Medical Oncology, Maastricht University Medical Center, GROW School for Oncology and Developmental Biology, Maastricht (M.J.B.A.), the Department of Medical Oncology, Amphia Hospital, Breda (M.A.M.S.B.), the Department of Medical Oncology, Radboud University Medical Center, Nijmegen (M.J.B.-S.), the Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen (G.A.P.H.), and Isala Oncology Center, Isala Hospital, Zwolle (J.-W.B.G.) - all in the Netherlands; the Department of Hematology and Medical Oncology, University Clinic Regensburg, Regensburg, Germany (C.U.B.); Melanoma Institute Australia (R.A.S., A.M.M., R.P.M.S., N.G.M., M.G., S.N.L., A.S., T.E.P., K.F.S., R.V.R., S.C., J.S., M.A.R., A.C.J.A., M.S.C., G.V.L.), the Faculty of Medicine and Health (R.A.S., A.M.M., R.P.M.S., N.G.M., S.N.L., A.S., T.E.P., K.F.S., S.C., J.S., M.A.R., A.C.J.A., G.V.L.), and Charles Perkins Centre (R.A.S., G.V.L.), University of Sydney, the Departments of Tissue Pathology and Diagnostic Oncology (R.A.S., R.V.R.) and Melanoma and Surgical Oncology (R.P.M.S., T.E.P., K.F.S., S.C., J.S., M.A.R., A.C.J.A.), Royal Prince Alfred Hospital, NSW Health Pathology (R.A.S., R.V.R.), the Departments of Medical Oncology (A.M.M., G.V.L.) and Breast and Melanoma Surgery (A.S.), Royal North Shore and Mater Hospitals, and the Department of Radiology, Mater Hospital (R.K.), Sydney, Royal Prince Alfred Hospital, Institute of Academic Surgery, Camperdown, NSW (A.C.J.A.), the Division of Cancer Surgery, Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC (D.E.G.), the Department of Medical Oncology, Peter MacCallum Cancer Centre, East Melbourne, VIC (L.S., S.S.), Lake Macquarie Oncology, Lake Macquarie Private Hospital, the Department of Medical Oncology, Calvary Mater Hospital, and the Department of Medicine, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW (A.W.), the Department of Medical Oncology, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), the Department of Medical Oncology, Fiona Stanley Hospital, Perth, WA (M.K.), the Department of Medical Oncology, Alfred Health, Melbourne, and the Department of Medicine, School of Translational Medicine, Monash University, Melbourne, VIC (M.C.A.), and the Department of Medical Oncology, Westmead Hospital and Blacktown, Sydney (M.S.C.) - all in Australia; the Melanoma Clinic, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (J.B.A.G.H.); the Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland (J.P., P.R.); the Department of Medical Oncology, Centre Léon Bérard, Lyon (M.A.-A.), Université Paris Cité, Assistance Publique-Hôpitaux de Paris (AP-HP) Dermato-Oncology and Clinical Investigation Center, Cancer Institute AP-HP, Nord Paris Cité, INSERM Unité 976, Saint Louis Hospital, Paris (C.L.), and the Department of Medical Oncology, Gustave Roussy and Paris-Saclay University, Villejuif (C.R.) - all in France; the Department of Surgical Oncology, Angeles Clinic and Research Institute, Los Angeles (M.B.F.); and the Melanoma Cancer Immunotherapy and Innovative Therapy Unit, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Naples, Italy (P.A.A.).

PMID: 38828984
DOI: 10.1056/NEJMoa2402604

Abstract

Background: In phase 1-2 trials in patients with resectable, macroscopic stage III melanoma, neoadjuvant immunotherapy was more efficacious than adjuvant immunotherapy.

Methods: In this phase 3 trial, we randomly assigned patients with resectable, macroscopic stage III melanoma to two cycles of neoadjuvant ipilimumab plus nivolumab followed by surgery or surgery followed by 12 cycles of adjuvant nivolumab. Only patients in the neoadjuvant group with a partial response or nonresponse received adjuvant treatment. The primary end point was event-free survival.

Results: A total of 423 patients underwent randomization. At a median follow-up of 9.9 months, the estimated 12-month event-free survival was 83.7% (99.9% confidence interval [CI], 73.8 to 94.8) in the neoadjuvant group and 57.2% (99.9% CI, 45.1 to 72.7) in the adjuvant group. The difference in restricted mean survival time was 8.00 months (99.9% CI, 4.94 to 11.05; P<0.001; hazard ratio for progression, recurrence, or death, 0.32; 99.9% CI, 0.15 to 0.66). In the neoadjuvant group, 59.0% of patients had a major pathological response, 8.0% had a partial response, 26.4% had a nonresponse (>50% residual viable tumor), and 2.4% had progression; in 4.2%, surgery had not yet been performed or was omitted. The estimated 12-month recurrence-free survival was 95.1% in patients in the neoadjuvant group who had a major pathological response, 76.1% among those with a partial response, and 57.0% among those with a nonresponse. Adverse events of grade 3 or higher that were related to systemic treatment occurred in 29.7% of patients in the neoadjuvant group and in 14.7% in the adjuvant group.

Conclusions: Among patients with resectable, macroscopic stage III melanoma, neoadjuvant ipilimumab plus nivolumab followed by surgery and response-driven adjuvant therapy resulted in longer event-free survival than surgery followed by adjuvant nivolumab. (Funded by Bristol Myers Squibb and others; NADINA ClinicalTrials.gov number, NCT04949113.).

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Neoadjuvant Nivolumab and Ipilimumab in Resectable Stage III Melanoma

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Neoadjuvant Nivolumab and Ipilimumab in Resectable Stage III Melanoma

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