Abstract
Neoangiogenesis is a recognized hallmark of cancer, granting tumor cells to dispose of metabolic substrates through a newly created vascular supply. Neoangiogenesis was also confirmed in melanoma, where vascular proliferation is associated with increased aggressiveness and poorer prognosis. Furthermore, melanoma cells show the so-called vascular mimicry, consisting in the assumption of endothelial-like features inducing the expression of pro-angiogenic receptors and ligands, which take part in the interplay with extracellular matrix (ECM) components and are potentiated by the ECM remodeling and the barrier molecule junction alterations that characterize the metastatic phase. Although neoangiogenesis was biologically proven and clinically associated with worse outcomes in melanoma patients, in the past anti-angiogenic therapies were employed with poor improvement of the already unsatisfactory results associated with chemotherapic agents. Among the novel therapies of melanoma, immunotherapy has led to previously unexpected outcomes of treatment, yet there is a still strong need for potentiating the results, possibly by new regimens of combination therapies. Molecular models in many cancer types showed mutual influences between immune responses and vascular normalization. Recently, clinical trials are investigating the efficacy of the association between anti-angiogenetic agents and immune-checkpoint inhibitors to treat advanced stage melanoma. This paper reviews the biological bases of angiogenesis in melanoma and summarizes the currently available clinical data on the use of anti-angiogenetic compounds in melanoma.
Introduction
Melanoma is an aggressive cancer arising from melanocytic precursors, with high potential for locoregional and metastatic spread. As a common hallmark of cancers, when the dimensions of the primary tumoral mass of melanoma reach the threshold for nutrient diffusion, a cancer-specific net of blood vessels is fundamental to provide substrates for cancer cell survival and growth (1). The newborn neoplastic vasculature is aberrant and incomplete with distorted, dilated, and leaky vessels, insufficient pericyte coverage, abnormal endothelial cell proliferation, an uneven distribution within cancer tissues, and wide fenestrations that ultimately contribute to tumor cell sprouting through the vascular flow (2–5). The process of activation of quiescent vasculature by cancer cells is called “angiogenic switch” and is sustained by a disequilibrium between molecular activators and inhibitors of angiogenesis, in favor of angiogenesis (6). Angiogenesis is essential in growth and progression of cancers, including melanoma (7). Warren first described angiogenesis in a melanoma graft animal model, observing remarkable angiogenic capacity of melanoma tissue (8). Since then, angiogenesis in melanoma has been furtherly investigated to identify a possibly more complex and heterogeneous behavior in the handling of blood vessels by this neoplasm (9). First, melanoma cells induce the spread of new blood vessels by pre-existing ones; secondly, melanoma cells recruit bone marrow progenitors that reach hypoxic areas within the tumor microenvironment, where they can induce vascular formation; finally, melanoma cells themselves can acquire an endothelial-like phenotype in the so-called vascular mimicry phenomenon, directly taking part into the structure of blood vessels (9). So far, inhibitors of angiogenesis have been used in oncology in other cancers including renal, colorectal, and ovarian neoplasms, but data from clinical melanoma research are lacking. The current therapies for advanced stage disease in melanoma are based on the inhibition of either the aberrantly activated BRAF/MEK pathway, or the immune checkpoints PD1 and CTLA4. Despite obtaining previously unexpected outcomes in patients with advanced disease, leading to improved survival rates, these therapies still have potential for further improvements. This paper summarizes the biological bases of angiogenesis in melanoma matching to the most recent development of treatments, and reviews the currently available preclinical and clinical data on the use of anti-angiogenetic compounds in patients with melanoma.
Insights Concerning the Molecular Mechanisms of Angiogenesis
The recent evolution of melanoma treatment has led to a primary role of targeted and immune therapy both in the adjuvant and the metastatic setting. Interestingly, the molecular architecture of melanoma microenvironment is far more complex than previously thought, and a strong cross-talk has been clearly demonstrated between the angiogenic and the immune components of cancer stroma, with mutual influences in the molecular compartments that are involved in response to systemic treatments. Angiogenic factors are produced by tumor cells, stromal cells including cancer-associated fibroblasts (CAFs), and inflammatory cells like lymphocytes and macrophages. The hyperproduction of pro-angiogenetic factors is induced by several mechanisms, primarily the activation of the hypoxia-induced HIF1α pathway, the oncogene-induced transcription of Vascular Endothelial Growth Factor (VEGF), and the loss of oncosuppressor genes including p53, which both stimulates the production of antiangiogenic factors like thrombospondin-1 and inhibits the expression of proangiogenic factors (10, 11).
Vascular Endothelial Growth Factor (VEGF)
VEGF-A is the archetype and most biologically relevant among proangiogenic factors, with a strong effect on endothelial survival and migration (12), and on vasculogenic mimicking properties in melanoma cells (13). VEGF-A is upregulated by HIF-1α and oncogene signaling pathways (14–16). Remarkably, VEGF-A has also shown immunosuppressive capacity. In particular, the increased production of VEGF-A in cancer leads to inhibition of T cells in several ways: 1) reducing the activity of functional T cells both directly (17) and indirectly through the endothelial PGE2-mediated suppressive action on T cells (18); 2) decreasing neoantigen presentation to lymphocytes by inhibiting the maturation of dendritic cells (DCs) (19), mainly interfering with NF-kB activation (20); 3) recruiting immunosuppressive T regulatory cells (Tregs) into the tumor microenvironment (21, 22); 4) limiting endothelial cytokine response and adhesion molecule expression, hence affecting vascular functional permeability to leukocytes and their peripheral recruitment to cancer microenvironment (23, 24). Relevantly for immunotherapy, VEGF pathway activation also enhances T cell exhaustion mediated by immune checkpoints like PDL1, CTLA4, TIM3, and LAG3 (25). While lowering the immunogenic compartment of immunity, VEGF potentiates the counteracting immunopermissive microenvironment (26) both by recruiting immune-suppressive Tregs (27) and myeloid derived stromal cells (MDSCs) (28), and activating tumor-associated macrophages (TAMs) at the tumor site (29). To confirm this role of VEGF, the anti-VEGF antibody Bevacizumab induces DC maturation and a reduction in Tregs and MDSCs recruitment to cancer sites (22, 30, 31). VEGF can be produced by cancer cells and immune cells from tumor microenvironment, mostly from Tregs and in smaller proportions from TAMs, MDSCs and DCs (32), creating cellular communications that either directly or indirectly convey on the inhibition of cytotoxic T lymphocytes (33).
Angiopoietin-2 (ANG-2)
ANG-2 is an antagonist cytokine of the Angiopoietin-1/Tie2 pathway that acts as a facilitator of VEGF-dependent angiogenesis (34). ANG-2 has long been considered an exclusive product of endothelium, but more recently Pari and colleagues demonstrated that it can also be produced by melanoma (35). ANG-2 levels in sera are increased in stage III and IV melanoma patients, but not in stages I and II (36). Consistently with this evidence, ANG-2 is produced by melanoma cells themselves, especially by metastatic sites (35). Differently from the stromal-derived ANG-2, melanoma-derived ANG-2 was not shown to increase the microvessel density of melanoma microenvironment but rather showed a protection of tumor cells from oxidative stress and a role in reactive oxygen species associated metastatization to the lungs in a mouse model (35). High serum ANG-2 levels were correlated with worse overall response rate to immunotherapy in melanoma (37). ANG-2 contributes to immune microenvironment composition, by acting on the Tie-2 expressing subpopulation of circulating monocytes, that are recruited by ANG-2 and converted to M2-like macrophages (38) and secrete IL10, which is a known promoter of Treg expansion and inhibitor of effector T cell activity (39).
Toll-Like Receptors (TLRs)
TLRs are a family of pattern recognition receptors involved in antimicrobial immunity, apoptotic cell clearance, and cancer. Among all family members, TLR-4 is expressed in 90% of primary and 93% of metastatic melanomas, where it plays a role in the aggressive behavior of cancer cells (40). TLR-4 signaling involves the activation of signal transducer and activator of transcription 3 (STAT3), which on turn promotes melanoma growth and aggressiveness associated features including angiogenesis and epithelial to mesenchymal transition (41). During melanomagenesis, ultraviolet radiation recruits and activates neutrophils in a TLR4-mediated mechanism, inducing an inflammation that facilitates angiogenesis and favors melanoma angiotropism (40). Moreover, STAT3 has also been associated to immunosuppression in melanoma (42).
Immune Cells in Microenvironment and Angiogenesis
In cancer microenvironment, there is a constant dynamic cross-talk between all resident cells which is far beyond the mere activity of cancer cells alone: the dynamic interaction between all cell components is responsible for the biological behavior of cancer. Accordingly, angiogenesis in cancer is not only induced by cancer cells themselves: the immune cells in tumor microenvironment can sustain angiogenesis in cancer (43). Globally, tumor cells can influence immune infiltrates towards an immune permissive phenotype. VEGF, for example, is produced by TAMs, tumor-associated neutrophils, regulatory DCs, myeloid derived suppressor cells, NK cells, and γδT17 cells (43). VEGF-R1 and -2 are expressed on DCs, which can promote angiogenesis (44). Neutrophils and TAMs secrete proangiogenic factors including VEGF, TNFα, IL8, and chemokines (45), together with matrix metalloproteases, which are essential to remodel the extracellular matrix during angiogenesis and metastatization (46). In an analysis on mouse models of breast cancers, extended to some of TCGA databases excluding melanoma, Tian et al. (47) demonstrated that the activation of vessel normalization (pericyte coverage, reduced vascular leakage, improved blood perfusion) is one of the effects of immune checkpoint inhibitors (ICIs) mediated by the activation of CD4+ T lymphocytes, in particular IFNγ producing Th1 cells (47). In particular, the authors postulated the existence of a positive feedback loop, according to which Th1 cells localize proximal to tumoral vessels and change the local tumor microenvironment via CKs like IFNγ, which induces a reduction in VEGF-A production and an increase in Th1- and pericyte-recruiting chemokines CXCL9, CXCL10, CXCL11 (47). Such finding would confirm the evidence that inhibition of IFNγ signaling is associated to secondary resistance to immune checkpoint inhibitors (48). Furthermore, after interacting with DCs, T cells can acquire neurophilin-1 which is a ligand of VEGF-A that promotes angiogenesis (49). Endothelial cells, formerly considered passive lining cells of blood vessels, are actively responsible of the intense reciprocal cellular interaction consisting in the so-called angiocrine signaling that is essential in normal organ development (50) and can be exacerbated in cancer. Tumor cells can then induce endothelial activation mediated by CKs including Angiopoietin-2, which are responsible for the autocrine induction of STAT3 signaling in the endothelium, followed by the expression of chemokines (CCL2) and adhesion molecules (ICAM1) that recruit CCR2+ macrophages to the cancer site (37). Endothelial cells take part in granulocyte differentiations in physiology and pathology, given the common developmental origin between endothelial cells and hematopoietic cells (37): the endothelium secretes CKs (SCF, CXCL12) that contribute to the quiescence of hematopoietic cells in the bone marrow, but can also promote granulopoiesis in case of inflammation (51). The hypoxia-regulated Endothelin B receptor on tumor endothelium acts as an obstacle to T cell adhesion and has been identified in some cases of resistance to immune therapy (52).
Manipulation of Angiogenesis by Therapeutic Agents in Melanoma
Antiangiogenics are a class of kinase inhibitors that bind either angiogenic factors or their receptors. The first antiangiogenic agent to be developed was Bevacizumab, an anti-VEGF monoclonal antibody, which is still indicated in the treatment of cancers including colorectal, ovarian, or uterine carcinomas. Many other agents were synthesized furtherly, presenting a wider spectrum of pharmacodynamic targeting, including Sunitinib, Pazopanib, Ramucirumab, Regorafenib, Sorafenib, Aflibercept, being so far approved in daily practice either alone or in combination. Antiangiogenic agents model the irregular and leaky vessels of cancer to create an almost normalized intratumoral vascular network, at least transiently. Such improved vascular efficiency of cancer microcirculation is thus the main responsible for a more efficient transport of chemotherapic agents to cancer cells, and also the molecular background to the association of antiangiogenic therapies with traditional chemotherapies (53). Part of the effects of antiangiogenics in cancer may also be attributed to the modulation of immune cell composition in tumor microenvironment, triggered by the reduction in the tissue hypoxia that is associated with the immature cancer vasculature. The response to hypoxia favors the polarization of the tumor microenvironment towards an immune-suppressive phenotype in terms of increase in Tregs and M2-TAMs, reduction of DC activity, and increase in PDL1 expression on endothelial cells, TAMs, DCs, and cytotoxic lymphocytes (33). Antiangiogenics can then interfere with both CD8+ T cells trafficking and TAMs repolarization, inducing an immunostimulatory milieu (37). Anti-VEGF-A agents also improve immune responses (54). In a preclinical model of antiangiogenic-driven vascular normalization in melanoma and other primary cancers, Schmittnaegel et al. demonstrated that the administration of a bispecific anti-VEGF-ANG2 antibody was associated with increased recruitment and activation of CD4+ and CD8+ T cells at the areas with normalized vessels (55). In the cross-talk between adaptive and innate immunity, IFNγ from CD4+ and CD8+ T cells then stimulates M1-TAMs to angiostatic activity and antagonize endothelial cell proliferation (56). In a preclinic mouse model with multiple cancer cell lines including melanoma, DeAlmeida and Colleagues demonstrated that therapy with anti-VEGFA targeting agent induces the HIF1α-mediated activation of intratumoral CD8+ cells resulting in an increase in IFNγ and TNFα production (57). Unfortunately, the response is usually transient (58) and short in duration (59), due to mechanisms of escape that include the activation of metabolic stress responses in cancer cells; the activation of alternative angiogenic pathways like the ANG-2 pathway; the participation to new vessel growth according to the vascular co-option mechanism; the normalization of cancer vessels (56). In renal cell carcinoma, two different molecular subsets have been identified: the angiogenic subset, characterized by upregulation of angiogenesis-associated genes and responsiveness to antiangiogenic therapy, and the inflammatory subset, presenting an upregulation in immune-related genes and refractoriness to antiangiogenic therapy (60). In contrast, no similar dichotomy has been identified in melanoma, for which resistance to antiangiogenic therapies may be intrinsically associated to its biology: as evidenced by Donnem, melanoma primary and metastatic lesions strongly rely on vessel co-option for their vascular supply, as an alternative to angiogenesis (61). In melanoma, the mutation of the BRAF gene has primary importance, since mutations at the codon 600 are druggable and clinically associated with significant responses. The constitutive activation of BRAF kinase is not only a driver mutation in melanoma, but also has effects on melanoma microenvironment composition (62). In particular, BRAF mutations are associated with an increased density of Treg infiltrate (63), and a reduction in T cell activity by the indirect secretion of IL-1α and IL-1β from CAFs (64). PDL1 expression in immune infiltrate is also more prevalent in BRAF mutated tumor specimens (65). Finally, BRAF mutated cells also have angiogenic capacity (66), since they can induce other cancer cells and microenvironmental cells to secrete CXCL8 and CCL2, two pro-tumorigenic chemokines, leading to cancer cell proliferation and macrophage-mediated angiogenesis (62). Furthermore, the pathway of VEGFR-1 has recently been identified as an escape mechanism to the BRAF-inhibitor Vemurafenib (67). As evidenced by Aztori and colleagues, melanoma cell lines express higher VEGF-receptors when transformed into Vemurafenib-resistant, and silencing of such receptors can prolong the maintenance of sensitivity to Vemurafenib (67). Together with targeted therapy for BRAF mutated patients, the backbone of treatment in advanced melanoma is represented by the immune therapy with either anti-CTLA4 or anti-PD1 agents, that remove immune checkpoint inhibition to potentiate the immune response to melanoma. Despite an overall improvement in the outcomes of treatment, still immune therapy is often associated to secondary resistance and progression and, yet more rarely, to early resistance. Among the possible mechanisms underpinning these resistances, recent evidence also identified some vascular-related mechanisms. In particular, high serum ANG-2 levels correlated with worse overall response rate to ICI therapy in melanoma, possibly because ANG-2 can recruit monocytes and induce PDL1 expression in M2-macrophages (37). Wu and colleagues identified a subset of melanoma patients characterized by a significant tumor infiltration of CD68+ macrophages that particularly responded to treatment with Ipilimumab and Bevacizumab with a neat decrease in ANG-2 expression (68). Allen and colleagues demonstrated that the combination therapy of antiangiogenics and anti-PD1 agents induced an increase in intratumoral high endothelial venules responsible for selective leukocyte infiltration and for the switch of microenvironment towards immunosensitive features (69). A bispecific anti-VEGFA and anti-ANG2 was also shown to potentiate the efficacy of an anti-PD1 treatment (55).
Discussion: Evidence From Clinical Treatment Outcomes and Possible Perspectives
The first trials involving antiangiogenetic drugs in melanoma date back to early experiences two decades ago, when chemotherapy was the only available treatment for advanced stage disease, with palliative intent and dramatically poor outcomes. Most of these studies are phase 1 or 2 trials for stage III unresectable or stage IV melanoma, either in single or double arm of treatment, with small cohorts of recruited patients, usually 20–30 (Table 1). Despite preclinical data suggesting the advantage of a more regular vascular network in the distribution of chemotherapics to cancer cells, these trials did not provide satisfying results from the association of antiangiogenics with common chemotherapics, showing no statistically significant improvement in the outcomes of traditional chemotherapy schedules, therefore they have never been investigated in wider phase 3 clinical trials and have never been adopted in everyday practice. More recently, immune therapy became the new gold standard for systemic therapy, together with anti-BRAF and anti-MEK targeted therapy for BRAF mutated patients, and was tested in the association with antiangiogenic agents, given the evidence of efficacy from the combination of antiangiogenics with ICIs not only in preclinical, but also in the clinical settings for other cancers including renal clear cell or non-small cell lung cancer. Hodi and colleagues performed an investigational phase I trial in 46 patients with advanced melanoma without brain metastases receiving a first (37%) or second (63%) line treatment with Ipilimumab and Bevacizumab: the best overall response rate (ORR) was 19.6% with a disease control rate of 67.4% and a median time to progression of 9 months (78). The immunohistochemical analysis of serial biopsies of target lesions revealed changes in melanoma-associated endothelium with increased expression of E-selectin (78). In a more recent phase IB/II trial, Taylor and colleagues treated patients with advanced solid tumors including melanoma with the association of Pembrolizumab and Lenvatinib, an inhibitor of multiple kinases including VEGFR. Among the 21 patients of the melanoma subcohort, the ORR was 33% and also included 1 complete response, while the disease control rate was 81% (79). Recently, Arance and colleagues presented the preliminary results of the phase 2 LEAP004 trial investigating the association of Lenvatinib and Pembrolizumab in 103 patients with advanced melanoma progressing on immunotherapy in second or further line of treatment. The median progression-free survival was 4.2 months with a median overall survival of 13.9 months and a 21.4% response rate, supporting a possible role in overcoming resistance to immunotherapy by Lenvatinib (80). These encouraging data are now furtherly being investigated in a randomized phase III trial specifically dedicated to advanced melanoma. Moreover, other studies are currently ongoing, mostly still in the recruitment phase, for treatment associations of antiangiogenics with anti-PD1 (Nivolumab or Pembrolizumab) or anti-PDL1 (Avelumab) inhibitors (Table 2). As previously described, angiogenesis plays a major role in the natural history of melanoma, from its intrinsic aggressiveness to some forms of resistance to systemic therapy. Despite widely intertwined mechanisms between angiogenesis and immunity, the efficacy of antiangiogenic therapies is currently insufficient. Hence, much interest is addressed to the ongoing clinical trials of combined antiangiogenic and immune therapies, to pursue better outcomes in the therapy of advanced melanoma.
Table 1
| Reference | Phase | Clinical setting | Line of treatment in metastatic setting | Arm 1 | Arm 2 | Primary endpoints | Secondary endpoints | Further analyses |
|---|---|---|---|---|---|---|---|---|
| Del Vecchio et al. (70) | II | Stage IV cutaneous melanoma. | 1st line | Bevacizumab + Fotemustine (20 pts) | None | CR 1/20 PR 2/20 SD 10/20 | TTP 8 m OS 20 m G3 toxicity 14/20 pts | Reduction of VEGF levels post-therapy |
| Tarhini et al. (71) | II | Stage III unresectable or stage IV cutaneous melanoma. No active brain metastases. | 1st line or further | Aflibercept (40 pts) | None | ORR 7.5% | PFS 4 m Os 16 m | Hypertension correlated with OS |
| Von Moos et al. (72) | II | Stage IV cutaneous melanoma. No brain metastases. | 1st line | Bevacizumab + Temozolomide (62 pts) | None | SD 52% | ORR 16% PFS 4 m OS 10 m | OS higher in BRAF wt 12 vs 9 m |
| Kim et al. (73) | II randomized | Stage IV melanoma. No brain metastases. | 1st line | Carboplatin + Paclitaxel + Placebo (71 pts) | Carboplatin + Paclitaxel + Bevacizumab (143 pts) | PFS 4 vs 5 m | OS 9 vs 12 m OR 11/67 vs 36/141 DOR 8 vs 7 m G3-G5 toxicity 57 vs 45% | |
| Schuster et al. (74) | II | Stage IV melanoma. No brain metastases. | 2nd line | Bevacizumab (35 pts) | None | DCR 31% | PFS 2 m OS 9 m Toxicity 7/11 pts who had disease control developed hypertension | |
| Minor et al. (75) | II | Stage IV melanoma. No active brain metastases. cKit mutated. | 2nd line or further. No prior immunotherapy. | Sunitinib (10 pts) | None | ORR 3/4 in mutated cKIT pts; 1/6 in amplified or overexpressed cKIT pts. | ||
| Mahalingam et al. (76) | II | Stage III unresectable or stage IV cutaneous melanoma. No active brain metastases. | 2nd or 3rd line | Bevacizumab + Sorafenib (14 pts) | None | ORR 0% SD 21% | PFS 8 m G3-G4 toxicity 43% | Low VEGF values correlated with longer PFS |
| Ferrucci et al. (77) | II | Stage IV cutaneous melanoma. No brain metastases. | 1st line | Bevacizumab + Dacarbazine (40 pts) | None | ORR 19% | TTP 5 m Discontinuation 92% G3-G4 toxicity 22% | |
| NCT02158520 | II randomized | Stage IV melanoma. No brain metastases | 1st line or further | Nab-Paclitaxel + Bevacizumab (12 pts) | Ipilimumab (12 pts) | PFS 129 vs 94 days | OS 18 vs 27 m ORR (2 vs 0 CR; 1 vs 1 PR) G3-G4 Toxicity (9 vs 7) | Recruitment completed. (24 enrolled pts vs 176 initially designed) |
Clinical trials of the association of antiangiogenic treatments with old drugs in advanced melanoma.
Table 2
| Reference | Phase | Clinical setting | Line of treatment in metastatic setting | Arm 1 | Arm 2 | Primary endpoints | Secondary endpoints | Further details |
|---|---|---|---|---|---|---|---|---|
| Hodi et al. (78) | I | Stage III unresectable or stage IV melanoma. No brain metastases | 1st or 2nd line (46 pts) | Ipilimumab + Bevacizumab | None | ORR 8 PR, 22 SD | DCR 67% OS 25 m | |
| NCT01950390 | II randomized | Stage III unresectable or IV cutaneous melanoma. No brain metastases | 1st or 2nd line (168 pts) | Ipilimumab | Ipilimumab + Bevacizumab | OS | PFS ORR | Active, not recruiting. Results pending |
| Taylor et al. (79) | IB/II | Advanced solid tumors including melanoma | 2nd or 3rd line (21 pts with melanoma) | Pembrolizumab + Lenvatinib | None | Safety | ORR at week 24 48% in melanoma (1 CR and 9 PR) | |
| Arance et al. (80) | II | Stage III unresectable or IV cutaneous melanoma. | 2nd or further line (103 pts) | Pembrolizumab + Lenvatinib | None | ORR 21.4% | PFS 4.2 m OS 13.9 m | |
| NCT03820986 | III randomized | Stage III unresectable or IV cutaneous melanoma. No active brain metastases | 1st or 2nd line (660 pts) | Pembrolizumab + Lenvatinib | Pembrolizumab + Placebo | PRS OS | ORR DOR Toxicity | Active, recruiting |
| NCT01495988 | II | Stage IIIC unresectable or stage IV melanoma. BRAF V600E/V600K positive. No active brain metastases | 1st or further line (10 pts enrolled, vs initially designed 180 pts) | Vemurafenib + Cobimetinib + Bevacizumab (arm 2) | Vemurafenib + Cobimetinib (arm 1) Vemurafenib (arm 3) Vemurafenib + Bevacizumab (arm 4) | PFS | OS RR Toxicity (2 pts in arm 2. 1 of them, multi-organ failure) | Slow accrural, toxicity, change in priorities |
| NCT04356729 | II | Stage III unresectable or IV cutaneous melanoma PDL1 negative. No active brain metastases | Any line (no prior immunotherapy) | Atezolizumab + Bevacizumab (30 estimated pts) | None | ORR | OS TTP DOR Safety Change in TILs | Not yet recruiting |
| NCT03175432 | II | Stage IV melanoma with brain metastases. BRAF wt | Progression after anti-PD1 | Atezolizumab + Bevacizumab + Cobimetinib | None | Intracranial ORR Safety | ORR DOR Neurocognitive function | Recruiting. Estimated 60 pts |
| NCT02681549 | II | Stage IV melanoma or NSCLC with brain metastases | 2nd or further line | Pembrolizumab + Bevacizumab | None | Intracranial ORR | Need for steroids ORR PFS Safety Biomarkers | Recruiting. Estimated 53 pts |
| NCT03239145 | I | Advanced solid tumors. No active brain metastases | 2nd or further line | Pembrolizumab + Trebananib | None | Maximum dose | ORR PFS OS | Recruiting. Estimated 60 pts |
Clinical trials on the association of antiangiogenic with immunotherapy or anti-BRAF/anti-MEK targeted therapy in advanced melanoma.
Statements
Author contributions
All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The reviewer MM declared a shared affiliation with one of the authors, DQ, MG, to the handling editor at time of review.
References
1
HanahanDWeinbergRA. Hallmarks of cancer: the next generation. Cell (2011) 144(5):646–74. doi: 10.1016/j.cell.2011.02.013
2
CookeVGLeBleuVSKeskinDKhanZO’ConnellJTTengYet al. Pericyte depletion results in hypoxia-associated epithelial-to-mesenchymal transition and metastasis mediated by met signaling pathway. Cancer Cell (2012) 21(1):66–81. doi: 10.1016/j.ccr.2011.11.024
3
NagyJAChangSHShihSCDvorakAMDvorakHF. Heterogeneity of the tumor vasculature. Semin Thromb Hemost (2010) 36(3):321–31. doi: 10.1055/s-0030-1253454
4
BalukPHashizumeHMcDonaldDM. Cellular abnormalities of blood vessels as targets in cancer. Curr Opin Genet Dev (2005) 15(1):102–11. doi: 10.1016/j.gde.2004.12.005
5
JainRK. Antiangiogenesis strategies revisited: from starving tumors to alleviating hypoxia. Cancer Cell (2014) 26(5):605–22. doi: 10.1016/j.ccell.2014.10.006
6
HanahanDFolkmanJ. Patterns and emerging mechanisms of the angiogenic switch during tumorigenesis. Cell (1996) 86(3):353–64. doi: 10.1016/s0092-8674(00)80108-7
7
ChoWCJourGAungPP. Role of angiogenesis in melanoma progression: update on key angiogenic mechanisms and other associated components. Semin Cancer Biol (2019) 59:175–86. doi: 10.1016/j.semcancer.2019.06.015
8
WarrenBAShubikP. The growth of the blood supply to melanoma transplants in the hamster cheek pouch. Lab Invest (1966) 15(2):464–78
9
JourGIvanDAungPP. Angiogenesis in melanoma: an update with a focus on current targeted therapies. J Clin Pathol (2016) 69(6):472–83. doi: 10.1136/jclinpath-2015-203482
10
BaeriswylVChristoforiG. The angiogenic switch in carcinogenesis. Semin Cancer Biol (2009) 19(5):329–37. doi: 10.1016/j.semcancer.2009.05.003
11
BergersGBenjaminLE. Tumorigenesis and the angiogenic switch. Nat Rev Cancer (2003) 3(6):401–10. doi: 10.1038/nrc1093
12
ApteRSChenDSFerraraN. VEGF in Signaling and Disease: Beyond Discovery and Development. Cell (2019) 176(6):1248–64. doi: 10.1016/j.cell.2019.01.021
13
VartanianAStepanovaEGrigorievaISolomkoEBaryshnikovALichinitserM. VEGFR1 and PKCα signaling control melanoma vasculogenic mimicry in a VEGFR2 kinase-independent manner. Melanoma Res (2011) 21(2):91–8. doi: 10.1097/CMR.0b013e328343a237
14
FerraraN. Vascular endothelial growth factor. Arterioscler Thromb Vasc Biol (2009) 29(6):789–91. doi: 10.1161/ATVBAHA.108.179663
15
Mac GabhannFPopelAS. Systems biology of vascular endothelial growth factors. Microcirculation (2008) 15(8):715–38. doi: 10.1080/10739680802095964
16
CarmelietP. VEGF as a key mediator of angiogenesis in cancer. Oncology (2005) 69 Suppl 3:4–10. doi: 10.1159/000088478
17
ZiogasACGavalasNGTsiatasMTsitsilonisOPolitiETerposEet al. VEGF directly suppresses activation of T cells from ovarian cancer patients and healthy individuals via VEGF receptor Type 2. Int J Cancer (2012) 130(4):857–64. doi: 10.1002/ijc.26094
18
MulliganJKRosenzweigSAYoungMR. Tumor secretion of VEGF induces endothelial cells to suppress T cell functions through the production of PGE2. J Immunother (2010) 33(2):126–35. doi: 10.1097/CJI.0b013e3181b91c9c
19
GabrilovichDIChenHLGirgisKRCunninghamHTMenyGMNadafSet al. Production of vascular endothelial growth factor by human tumors inhibits the functional maturation of dendritic cells. Nat Med (1996) 2(10):1096–103. doi: 10.1038/nm1096-1096
20
OyamaTRanSIshidaTNadafSKerrLCarboneDPet al. Vascular endothelial growth factor affects dendritic cell maturation through the inhibition of nuclear factor-kappa B activation in hemopoietic progenitor cells. J Immunol (1998) 160(3):1224–32.
21
LiBLalaniASHardingTCLuanBKoprivnikarKHuan TuGet al. Vascular endothelial growth factor blockade reduces intratumoral regulatory T cells and enhances the efficacy of a GM-CSF-secreting cancer immunotherapy. Clin Cancer Res (2006) 12(22):6808–16. doi: 10.1158/1078-0432.CCR-06-1558
22
TermeMPernotSMarcheteauESandovalFBenhamoudaNColussiOet al. VEGFA-VEGFR pathway blockade inhibits tumor-induced regulatory T-cell proliferation in colorectal cancer. Cancer Res (2013) 73(2):539–49. doi: 10.1158/0008-5472.CAN-12-2325
23
GriffioenAWDamenCABlijhamGHGroenewegenG. Tumor angiogenesis is accompanied by a decreased inflammatory response of tumor-associated endothelium. Blood (1996) 88(2):667–73. doi: 10.1002/(sici)1097-0215(19990118)80:2<315::aid-ijc23>3.0.co;2-I
24
DirkxAEOude EgbrinkMGKuijpersMJvan der NietSTHeijnenVVBouma-ter SteegeJCet al. Tumor angiogenesis modulates leukocyte-vessel wall interactions in vivo by reducing endothelial adhesion molecule expression. Cancer Res (2003) 63(9):2322–9.
25
VoronTColussiOMarcheteauEPernotSNizardMPointetALet al. VEGF-A modulates expression of inhibitory checkpoints on CD8+ T cells in tumors. J Exp Med (2015) 212(2):139–48. doi: 10.1084/jem.20140559
26
RahmaOEHodiFS. The Intersection between Tumor Angiogenesis and Immune Suppression. Clin Cancer Res (2019) 25(18):5449–57. doi: 10.1158/1078-0432.CCR-18-1543
27
WadaJSuzukiHFuchinoRYamasakiANagaiSYanaiKet al. The contribution of vascular endothelial growth factor to the induction of regulatory T-cells in malignant effusions. Anticancer Res (2009) 29(3):881–8.
28
HuangYChenXDikovMMNovitskiySVMosseCAYangLet al. Distinct roles of VEGFR-1 and VEGFR-2 in the aberrant hematopoiesis associated with elevated levels of VEGF. Blood (2007) 110(2):624–31. doi: 10.1182/blood-2007-01-065714
29
VarneyMLJohanssonSLSinghRK. Tumour-associated macrophage infiltration, neovascularization and aggressiveness in malignant melanoma: role of monocyte chemotactic protein-1 and vascular endothelial growth factor-A. Melanoma Res (2005) 15(5):417–25. doi: 10.1097/00008390-200510000-00010
30
OsadaTChongGTansikRHongTSpectorNKumarRet al. The effect of anti-VEGF therapy on immature myeloid cell and dendritic cells in cancer patients. Cancer Immunol Immunother (2008) 57(8):1115–24. doi: 10.1007/s00262-007-0441-x
31
KusmartsevSEruslanovEKüblerHTsengTSakaiYSuZet al. Oxidative stress regulates expression of VEGFR1 in myeloid cells: link to tumor-induced immune suppression in renal cell carcinoma. J Immunol (2008) 181(1):346–53. doi: 10.4049/jimmunol.181.1.346
32
FacciabeneAPengXHagemannISBalintKBarchettiAWangLPet al. Tumour hypoxia promotes tolerance and angiogenesis via CCL28 and T(reg) cells. Nature (2011) 475(7355):226–30. doi: 10.1038/nature10169
33
FukumuraDKloepperJAmoozgarZDudaDGJainRK. Enhancing cancer immunotherapy using antiangiogenics: opportunities and challenges. Nat Rev Clin Oncol (2018) 15(5):325–40. doi: 10.1038/nrclinonc.2018.29
34
AugustinHGKohGYThurstonGAlitaloK. Control of vascular morphogenesis and homeostasis through the angiopoietin-Tie system. Nat Rev Mol Cell Biol (2009) 10(3):165–77. doi: 10.1038/nrm2639
35
Abdul PariAASinghalMHübersCMoglerCSchiebBGamppAet al. Tumor Cell-Derived Angiopoietin-2 Promotes Metastasis in Melanoma. Cancer Res (2020) 80(12):2586–98. doi: 10.1158/0008-5472.CAN-19-2660
36
HelfrichIEdlerLSuckerAThomasMChristianSSchadendorfD. Augustin HG.Angiopoietin-2 levels are associated with disease progression in metastatic malignant melanoma. Clin Cancer Res (2009) 15(4):1384–92. doi: 10.1158/1078-0432.CCR-08-1615
37
SinghalMAugustinHG. Beyond Angiogenesis: Exploiting Angiocrine Factors to Restrict Tumor Progression and Metastasis. Cancer Res (2020) 80(4):659–62. doi: 10.1158/0008-5472.CAN-19-3351
38
CoffeltSBTalAOScholzADe PalmaMPatelSUrbichCet al. Angiopoietin-2 regulates gene expression in TIE2-expressing monocytes and augments their inherent proangiogenic functions. Cancer Res (2010) 70(13):5270–80. doi: 10.1158/0008-5472.CAN-10-0012
39
CoffeltSBChenYYMuthanaMWelfordAFTalAOScholzAet al. Angiopoietin 2 stimulates TIE2-expressing monocytes to suppress T cell activation and to promote regulatory T cell expansion. J Immunol (2011) 186(7):4183–90. doi: 10.4049/jimmunol.1002802
40
BaldTQuastTLandsbergJRogavaMGloddeNLopez-RamosDet al. Ultraviolet-radiation-induced inflammation promotes angiotropism and metastasis in melanoma. Nature (2014) 507(7490):109–13. doi: 10.1038/nature13111
41
FuXQLiuBWangYPLiJKZhuPLLiTet al. Activation of STAT3 is a key event in TLR4 signaling-mediated melanoma progression. Cell Death Dis (2020) 11(4):246. doi: 10.1038/s41419-020-2440-1
42
KortylewskiMJoveRYuH. Targeting STAT3 affects melanoma on multiple fronts. Cancer Metastasis Rev (2005) 24(2):315–27. doi: 10.1007/s10555-005-1580-1
43
AlbiniABrunoANoonanDMMortaraL. Contribution to Tumor Angiogenesis From Innate Immune Cells Within the Tumor Microenvironment: Implications for Immunotherapy. Front Immunol (2018) 9:527. doi: 10.3389/fimmu.2018.00527
44
RiboldiEMussoTMoroniEUrbinatiCBernasconiSRusnatiMet al. Cutting edge: proangiogenic properties of alternatively activated dendritic cells. J Immunol (2005) 175(5):2788–92. doi: 10.4049/jimmunol.175.5.2788
45
OwenJLMohamadzadehM. Macrophages and chemokines as mediators of angiogenesis. Front Physiol (2013) 4:159. doi: 10.3389/fphys.2013.00159
46
MurdochCMuthanaMCoffeltSBLewisCE. The role of myeloid cells in the promotion of tumour angiogenesis. Nat Rev Cancer (2008) 8(8):618–31. doi: 10.1038/nrc2444
47
TianLGoldsteinAWangHChing LoHSun KimIWelteTet al. Mutual regulation of tumour vessel normalization and immunostimulatory reprogramming. Nature (2017) 544(7649):250–4. doi: 10.1038/nature21724
48
GaoJShiLZZhaoHChenJXiongLHeQet al. Loss of IFN-γ Pathway Genes in Tumor Cells as a Mechanism of Resistance to Anti-CTLA-4 Therapy. Cell (2016) 167(2):397–404.e9. doi: 10.1016/j.cell.2016.08.069
49
Bourbié-VaudaineSBlanchardNHivrozCRoméoPH. Dendritic cells can turn CD4+ T lymphocytes into vascular endothelial growth factor-carrying cells by intercellular neuropilin-1 transfer. J Immunol (2006) 177(3):1460–9. doi: 10.4049/jimmunol.177.3.1460
50
RafiiSButlerJMDingBS. Angiocrine functions of organ-specific endothelial cells. Nature (2016) 529(7586):316–25. doi: 10.1038/nature17040
51
BoettcherSGerosaRCRadpourRBauerJAmpenbergerFHeikenwalderMet al. Endothelial cells translate pathogen signals into G-CSF-driven emergency granulopoiesis. Blood (2014) 124(9):1393–403. doi: 10.1182/blood-2014-04-570762
52
BuckanovichRJFacciabeneAKimSBenenciaFSasaroliDBalintKet al. Endothelin B receptor mediates the endothelial barrier to T cell homing to tumors and disables immune therapy. Nat Med (2008) 14(1):28–36. doi: 10.1038/nm1699
53
DewhirstMWSecombTW. Transport of drugs from blood vessels to tumour tissue. Nat Rev Cancer (2017) 17(12):738–50. doi: 10.1038/nrc.2017.93
54
YangJYanJLiuB. Targeting VEGF/VEGFR to Modulate Antitumor Immunity. Front Immunol (2018) 9:978. doi: 10.3389/fimmu.2018.00978
55
SchmittnaegelMRigamontiNKadiogluECassaráAWyser RmiliCKiialainenAet al. Dual angiopoietin-2 and VEGFA inhibition elicits antitumor immunity that is enhanced by PD-1 checkpoint blockade. Sci Transl Med (2017) 9(385):eaak9670. doi: 10.1126/scitranslmed.aak9670
56
De PalmaMBiziatoDPetrovaTV. Microenvironmental regulation of tumour angiogenesis. Nat Rev Cancer (2017) 17(8):457–74. doi: 10.1038/nrc.2017.51
57
De AlmeidaPEMakJHernandezGJesudasonRHeraultAJavinalVet al. Anti-VEGF Treatment Enhances CD8+ T-cell Antitumor Activity by Amplifying Hypoxia. Cancer Immunol Res (2020) 8(6):806–18. doi: 10.1158/2326-6066.CIR-19-0360
58
WinklerFKozinSVTongRTChaeSSBoothMFGarkavtsevIet al. Kinetics of vascular normalization by VEGFR2 blockade governs brain tumor response to radiation: role of oxygenation, angiopoietin-1, and matrix metalloproteinases. Cancer Cell (2004) 6(6):553–63. doi: 10.1016/j.ccr.2004.10.011
59
HuangYYuanJRighiEKamounWSAncukiewiczMNezivarJet al. Vascular normalizing doses of antiangiogenic treatment reprogram the immunosuppressive tumor microenvironment and enhance immunotherapy. Proc Natl Acad Sci U S A (2012) 109(43):17561–6. doi: 10.1073/pnas.1215397109
60
ŞenbabaoğluYGejmanRSWinerAGLiuMVan AllenEMde VelascoGet al. Tumor immune microenvironment characterization in clear cell renal cell carcinoma identifies prognostic and immunotherapeutically relevant messenger RNA signatures. Genome Biol (2016) 17(1):231. doi: 10.1186/s13059-016-1092-z
61
DonnemTReynoldsARKuczynskiEAGatterKVermeulenPBKerbelRSet al. Non-angiogenic tumours and their influence on cancer biology. Nat Rev Cancer (2018) 18(5):323–36. doi: 10.1038/nrc.2018.14
62
CroceLCoperchiniFMagriFChiovatoLRotondiM. The multifaceted anti-cancer effects of BRAF-inhibitors. Oncotarget (2019) 10(61):6623–40. doi: 10.18632/oncotarget.27304
63
LeslieCBowyerSEWhiteAGrieu-IacopettaFTrevenenMIacopettaBet al. FOXP3+ T regulatory lymphocytes in primary melanoma are associated with BRAF mutation but not with response to BRAF inhibitor. Pathology (2015) 47(6):557–63. doi: 10.1097/PAT.0000000000000314
64
KhaliliJSLiuSRodríguez-CruzTGWhittingtonMWardellSLiuCet al. Oncogenic BRAF(V600E) promotes stromal cell-mediated immunosuppression via induction of interleukin-1 in melanoma. Clin Cancer Res (2012) 18(19):5329–40. doi: 10.1158/1078-0432.CCR-12-1632
65
KimKJeonSKimTMJungCK. Immune Gene Signature Delineates a Subclass of Papillary Thyroid Cancer with Unfavorable Clinical Outcomes. Cancers (Basel) (2018) 10(12):494. doi: 10.3390/cancers10120494
66
SharmaATrivediNRZimmermanMATuvesonDASmithCDRobertsonGP. Mutant V599EB-Raf regulates growth and vascular development of malignant melanoma tumors. Cancer Res (2005) 65(6):2412–21. doi: 10.1158/0008-5472.CAN-04-2423
67
AtzoriMGCeciCRuffiniFTrapaniMBarbacciaMLTentoriLet al. Role of VEGFR-1 in melanoma acquired resistance to the BRAF inhibitor vemurafenib. J Cell Mol Med (2020) 24(1):465–75. doi: 10.1111/jcmm.14755
68
WuXGiobbie-HurderALiaoXConnellyCConnollyEMLiJet al. Angiopoietin-2 as a Biomarker and Target for Immune Checkpoint Therapy. Cancer Immunol Res (2017) 5(1):17–28. doi: 10.1158/2326-6066.CIR-16-0206
69
AllenEJabouilleARiveraLBLodewijckxIMissiaenRSteriVet al. Combined antiangiogenic and anti-PD-L1 therapy stimulates tumor immunity through HEV formation. Sci Transl Med (2017) 9(385):eaak9679. doi: 10.1126/scitranslmed.aak9679
70
Del VecchioMMortariniRCanovaSDi GuardoLPimpinelliNSertoliMRet al. Bevacizumab plus fotemustine as first-line treatment in metastatic melanoma patients: clinical activity and modulation of angiogenesis and lymphangiogenesis factors. Clin Cancer Res (2010) 16(23):5862–72. doi: 10.1158/1078-0432.CCR-10-2363
71
TarhiniAAFrankelPMargolinKAChristensenSRuelCShipe-SpotloeJet al. Aflibercept (VEGF Trap) in inoperable stage III or stage iv melanoma of cutaneous or uveal origin. Clin Cancer Res (2011) 17(20):6574–81. doi: 10.1158/1078-0432.CCR-11-1463
72
von MoosRSeifertBSimcockMGoldingerSMGillessenSOchsenbeinAet al. Swiss Group for Clinical Cancer Research (SAKK). First-line temozolomide combined with bevacizumab in metastatic melanoma: a multicentre phase II trial (SAKK 50/07). Ann Oncol (2012) 23(2):531–6. doi: 10.1093/annonc/mdr126
73
KimKBSosmanJAFruehaufJPLinetteGPMarkovicSNMcDermottDFet al. BEAM: a randomized phase II study evaluating the activity of bevacizumab in combination with carboplatin plus paclitaxel in patients with previously untreated advanced melanoma. J Clin Oncol (2012) 30(1):34–41. doi: 10.1200/JCO.2011.34.6270
74
SchusterCEikesdalHPPuntervollHGeislerJGeislerSHeinrichDet al. Clinical efficacy and safety of bevacizumab monotherapy in patients with metastatic melanoma: predictive importance of induced early hypertension. PloS One (2012) 7(6):e38364. doi: 10.1371/journal.pone.0038364
75
MinorDRKashani-SabetMGarridoMO’DaySJHamidOBastianBC. Sunitinib therapy for melanoma patients with KIT mutations. Clin Cancer Res (2012) 18(5):1457–63. doi: 10.1158/1078-0432.CCR-11-1987
76
MahalingamDMalikLBeeramMRodonJSankhalaKMitaAet al. Phase II study evaluating the efficacy, safety, and pharmacodynamic correlative study of dual antiangiogenic inhibition using bevacizumab in combination with sorafenib in patients with advanced malignant melanoma. Cancer Chemother Pharmacol (2014) 74(1):77–84. doi: 10.1007/s00280-014-2479-8
77
FerrucciPFMinchellaIMosconiMGandiniSVerrecchiaFCocorocchioEet al. Dacarbazine in combination with bevacizumab for the treatment of unresectable/metastatic melanoma: a phase II study. Melanoma Res (2015) 25(3):239–45. doi: 10.1097/CMR.0000000000000146
78
HodiFSLawrenceDLezcanoCWuXZhouJSasadaTet al. Bevacizumab plus ipilimumab in patients with metastatic melanoma. Cancer Immunol Res (2014) 2(7):632–42. doi: 10.1158/2326-6066.CIR-14-0053
79
TaylorMHLeeCHMakkerVRascoDDutcusCEWuJet al. Phase IB/II Trial of Lenvatinib Plus Pembrolizumab in Patients With Advanced Renal Cell Carcinoma, Endometrial Cancer, and Other Selected Advanced Solid Tumors. J Clin Oncol (2020) 38(11):1154–63. doi: 10.1200/JCO.19.01598
80
Arance FernandezAMO’DaySJDe la Cruz MerinoLPetrellaTJamarRNyLet al. Lenvatinib (len) plus pembrolizumab (pembro) for advanced melanoma (MEL) that progressed on PD1 or PDL1 inhibitor: initial results of LEAP-004. Ann Oncol (2020) 31) suppl_4:S1142–215. doi: 10.1016/annonc/annonc325
Summary
Keywords
neoangiogenesis, melanoma, combination strategy, antiangiogenics, immunotherapy
Citation
Quaresmini D and Guida M (2020) Neoangiogenesis in Melanoma: An Issue in Biology and Systemic Treatment. Front. Immunol. 11:584903. doi: 10.3389/fimmu.2020.584903
Received
18 July 2020
Accepted
12 October 2020
Published
29 October 2020
Volume
11 - 2020
Edited by
Ronca Roberto, University of Brescia, Italy
Reviewed by
Rodabe N. Amaria, University of Texas MD Anderson Cancer Center, United States; Michele Montrone, Istituto Nazionale dei Tumori (IRCCS), Italy
Updates
Copyright
© 2020 Quaresmini and Guida.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Michele Guida, micguida57@gmail.com
This article was submitted to Cancer Immunity and Immunotherapy, a section of the journal Frontiers in Immunology
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