Vemurafenib in patients with BRAFV600E-positive metastatic or unresectable papillary thyroid cancer refractory to radioactive iodine: a non-randomised, multicentre, open-label, phase 2 trial

Abstract

Summary Background About half of patients with papillary thyroid cancer have tumours with activating BRAFV600E mutations. Vemurafenib, an oncogenic BRAF kinase inhibitor approved for BRAF-positive melanoma, showed clinical benefit in three patients with BRAFV600E-positive papillary thyroid cancer in a phase 1 trial. We aimed to establish the activity of vemurafenib in patients with BRAFV600E-positive papillary thyroid cancer. Methods We did an open-label, non-randomised, phase 2 trial at ten academic centres and hospitals worldwide in patients aged 18 years or older with histologically confirmed recurrent or metastatic papillary thyroid cancer refractory to radioactive iodine and positive for the BRAFV600E mutation. Participants either had never received a multikinase inhibitor targeting VEGFR (cohort 1) or had been treated previously with a VEGFR multikinase inhibitor (cohort 2). Patients received vemurafenib 960 mg orally twice daily. The primary endpoint was investigator-assessed best overall response in cohort 1 (confirmed on two assessments 4 weeks or longer apart). Analyses were planned to have a minimum median follow-up of 15 months (data cutoff April 18, 2014) and were done in safety, intention-to-treat, and per-protocol populations. This trial is closed and is registered at ClinicalTrials.gov, number NCT01286753. Findings Between June 23, 2011, and Jan 15, 2013, 51 patients were enrolled to the study, 26 in cohort 1 and 25 in cohort 2. Median duration of follow-up was 18·8 months (IQR 14·2–26·0) in cohort 1 and 12·0 months (6·7–20·3) in cohort 2. Partial responses were recorded in ten of 26 patients in cohort 1 (best overall response 38·5%, 95% CI 20·2–59·4). Grade 3 or 4 adverse events were recorded in 17 (65%) of 26 patients in cohort 1 and 17 (68%) of 25 patients in cohort 2; the most common grade 3 and 4 adverse events were squamous cell carcinoma of the skin (seven [27% ] in cohort 1, five [20% ] in cohort 2), lymphopenia (two [8% ] in each cohort), and increased γ-glutamyltransferase (one [4% ] in cohort 1, three [12% ] in cohort 2). Two individuals in cohort 2 died due to adverse events, one from dyspnoea and one from multiorgan failure, but neither was treatment related. Serious adverse events were reported for 16 (62%) of 26 patients in cohort 1 and 17 (68%) of 25 patients in cohort 2. Interpretation Vemurafenib showed antitumour activity in patients with progressive, BRAFV600E-positive papillary thyroid cancer refractory to radioactive iodine who had never been treated with a multikinase inhibitor. As such, this agent represents a potential new treatment option for these patients.

Treatment of refractory thyroid cancer

“…The presence of BRAF mutation was an inclusion criterion in phase 2 trials with a BRAF inhibitor, either 297 vemurafenib or dabrafenib (Brose, et al 2016;Dadu, et al 2015;Falchook, et al 2015) and positive results 298 were observed, and these results may be improved by a combination with a MEK inhibitor. Mutation in ALK 299 (Anaplastic Lymphoma Kinase) gene has been reported in few patients with refractory DTC and can be the 300 target of an ALK inhibitor (Kelly, et al 2014).…”

Development of Upper Aerodigestive Tract Complications in Patients with Stage IV Thyroid Cancer Receiving Tyrosine Kinase Inhibitors

“…These include the selective BRAF V600E inhibitors dabrafenib and vemurafenib. Although these agents are currently approved for use in patients with melanoma, their safety and efficacy have been reported in patients with metastatic RAI-refractory DTC (20,21). These TKIs have been shown to have clinical benefit without reports of fistula development, and work through inhibition of the mutated BRAF kinase commonly seen in patients with DTC.…”

Novel Therapies Against Aggressive Differentiated Thyroid Carcinomas

“…Severe AEs were noted in 65 and 68% of the two groups, respectively, [29,48] with 22% developing cutaneous squamous cell carcinoma [28,30].…”

“…Vemurafenib was efficient in some BRAFV600E-positive advanced RAIRTC patients (partial responses of 35-38.5% in naive patients and 26-29% in those previously exposed to a VEGFR inhibitor) [29][30][48][49]. Severe AEs were noted in 65 and 68% of the two groups, respectively, [29,48] with 22% developing cutaneous squamous cell carcinoma [28,30].…”