Lynn M. Schuchter

Combined BRAF and MEK Inhibition in Melanoma with BRAF V600 Mutations

BACKGROUND Resistance to therapy with BRAF kinase inhibitors is associated with reactivation of the mitogen-activated protein kinase (MAPK) pathway. To address this problem, we conducted a phase 1 and 2 trial of combined treatment with dabrafenib, a selective BRAF inhibitor, and trametinib, a selective MAPK kinase (MEK) inhibitor. METHODS In this open-label study involving 247 patients with metastatic melanoma and BRAF V600 mutations, we evaluated the pharmacokinetic activity and safety of oral dabrafenib (75 or 150 mg twice daily) and trametinib (1, 1.5, or 2 mg daily) in 85 patients and then randomly assigned 162 patients to receive combination therapy with dabrafenib (150 mg) plus trametinib (1 or 2 mg) or dabrafenib monotherapy. The primary end points were the incidence of cutaneous squamous-cell carcinoma, survival free of melanoma progression, and response. Secondary end points were overall survival and pharmacokinetic activity. RESULTS Dose-limiting toxic effects were infrequently observed in patients receiving combination therapy with 150 mg of dabrafenib and 2 mg of trametinib (combination 150/2). Cutaneous squamous-cell carcinoma was seen in 7% of patients receiving combination 150/2 and in 19% receiving monotherapy (P=0.09), whereas pyrexia was more common in the combination 150/2 group than in the monotherapy group (71% vs. 26%). Median progression-free survival in the combination 150/2 group was 9.4 months, as compared with 5.8 months in the monotherapy group (hazard ratio for progression or death, 0.39; 95% confidence interval, 0.25 to 0.62; P<0.001). The rate of complete or partial response with combination 150/2 therapy was 76%, as compared with 54% with monotherapy (P=0.03). CONCLUSIONS Dabrafenib and trametinib were safely combined at full monotherapy doses. The rate of pyrexia was increased with combination therapy, whereas the rate of proliferative skin lesions was nonsignificantly reduced. Progression-free survival was significantly improved. (Funded by GlaxoSmithKline; ClinicalTrials.gov number, NCT01072175.).

Survival in BRAF V600–Mutant Advanced Melanoma Treated with Vemurafenib

BACKGROUND Approximately 50% of melanomas harbor activating (V600) mutations in the serine-threonine protein kinase B-RAF (BRAF). The oral BRAF inhibitor vemurafenib (PLX4032) frequently produced tumor regressions in patients with BRAF V600-mutant metastatic melanoma in a phase 1 trial and improved overall survival in a phase 3 trial. METHODS We designed a multicenter phase 2 trial of vemurafenib in patients with previously treated BRAF V600-mutant metastatic melanoma to investigate the efficacy of vemurafenib with respect to overall response rate (percentage of treated patients with a tumor response), duration of response, and overall survival. The primary end point was the overall response rate as ascertained by the independent review committee; overall survival was a secondary end point. RESULTS A total of 132 patients had a median follow-up of 12.9 months (range, 0.6 to 20.1). The confirmed overall response rate was 53% (95% confidence interval [CI], 44 to 62; 6% with a complete response and 47% with a partial response), the median duration of response was 6.7 months (95% CI, 5.6 to 8.6), and the median progression-free survival was 6.8 months (95% CI, 5.6 to 8.1). Primary progression was observed in only 14% of patients. Some patients had a response after receiving vemurafenib for more than 6 months. The median overall survival was 15.9 months (95% CI, 11.6 to 18.3). The most common adverse events were grade 1 or 2 arthralgia, rash, photosensitivity, fatigue, and alopecia. Cutaneous squamous-cell carcinomas (the majority, keratoacanthoma type) were diagnosed in 26% of patients. CONCLUSIONS Vemurafenib induces clinical responses in more than half of patients with previously treated BRAF V600-mutant metastatic melanoma. In this study with a long follow-up, the median overall survival was approximately 16 months. (Funded by Hoffmann-La Roche; ClinicalTrials.gov number, NCT00949702.).

Radiation and dual checkpoint blockade activate non-redundant immune mechanisms in cancer

Immune checkpoint inhibitors result in impressive clinical responses, but optimal results will require combination with each other and other therapies. This raises fundamental questions about mechanisms of non-redundancy and resistance. Here we report major tumour regressions in a subset of patients with metastatic melanoma treated with an anti-CTLA4 antibody (anti-CTLA4) and radiation, and reproduced this effect in mouse models. Although combined treatment improved responses in irradiated and unirradiated tumours, resistance was common. Unbiased analyses of mice revealed that resistance was due to upregulation of PD-L1 on melanoma cells and associated with T-cell exhaustion. Accordingly, optimal response in melanoma and other cancer types requires radiation, anti-CTLA4 and anti-PD-L1/PD-1. Anti-CTLA4 predominantly inhibits T-regulatory cells (Treg cells), thereby increasing the CD8 T-cell to Treg (CD8/Treg) ratio. Radiation enhances the diversity of the T-cell receptor (TCR) repertoire of intratumoral T cells. Together, anti-CTLA4 promotes expansion of T cells, while radiation shapes the TCR repertoire of the expanded peripheral clones. Addition of PD-L1 blockade reverses T-cell exhaustion to mitigate depression in the CD8/Treg ratio and further encourages oligoclonal T-cell expansion. Similarly to results from mice, patients on our clinical trial with melanoma showing high PD-L1 did not respond to radiation plus anti-CTLA4, demonstrated persistent T-cell exhaustion, and rapidly progressed. Thus, PD-L1 on melanoma cells allows tumours to escape anti-CTLA4-based therapy, and the combination of radiation, anti-CTLA4 and anti-PD-L1 promotes response and immunity through distinct mechanisms.

American Society of Clinical Oncology Clinical Practice Guidelines for the Use of Chemotherapy and Radiotherapy Protectants

PURPOSE Because toxicities associated with chemotherapy and radiotherapy can adversely affect short- and long-term patient quality of life, can limit the dose and duration of treatment, and may be life-threatening, specific agents designed to ameliorate or eliminate certain chemotherapy and radiotherapy toxicities have been developed. Variability in interpretation of the available data pertaining to the efficacy of the three United States Food and Drug Administration-approved agents that have potential chemotherapy- and radiotherapy-protectant activity-dexrazoxane, mesna, and amifostine-and questions about the role of these protectant agents in cancer care led to concern about the appropriate use of these agents. The American Society of Clinical Oncology sought to establish evidence-based, clinical practice guidelines for the use of dexrazoxane, mesna, and amifostine in patients who are not enrolled on clinical treatment trials. METHODS A multidisciplinary Expert Panel reviewed the clinical data regarding the activity of dexrazoxane, mesna, and amifostine. A computerized literature search was performed using MEDLINE. In addition to reports collected by individual Panel members, all articles published in the English-speaking literature from June 1997 through December 1998 were collected for review by the Panel chairpersons, and appropriate articles were distributed to the entire Panel for review. Guidelines for use, levels of evidence, and grades of recommendation were reviewed and approved by the Panel. Outcomes considered in evaluating the benefit of a chemotherapy- or radiotherapy-protectant agent included amelioration of short- and long-term chemotherapy- or radiotherapy-related toxicities, risk of tumor protection by the agent, toxicity of the protectant agent itself, quality of life, and economic impact. To the extent that these data were available, the Panel placed the greatest value on lesser toxicity that did not carry a concomitant risk of tumor protection. RESULTS AND CONCLUSION Mesna: (1) Mesna, dosed as detailed in these guidelines, is recommended to decrease the incidence of standard-dose ifosfamide-associated urothelial toxicity. (2) There is insufficient evidence on which to base a guideline for the use of mesna to prevent urothelial toxicity with ifosfamide doses that exceed 2.5 g/m(2)/d. (3) Either mesna or forced saline diuresis is recommended to decrease the incidence of urothelial toxicity associated with high-dose cyclophosphamide use in the stem-cell transplantation setting. Dexrazoxane: (1) The use of dexrazoxane is not routinely recommended for patients with metastatic breast cancer who receive initial doxorubicin-based chemotherapy. (2) The use of dexrazoxane may be considered for patients with metastatic breast cancer who have received a cumulative dosage of 300 mg/m(2) or greater of doxorubicin in the metastatic setting and who may benefit from continued doxorubicin-containing therapy. (3) The use of dexrazoxane in the adjuvant setting is not recommended outside of a clinical trial. (4) The use of dexrazoxane can be considered in adult patients who have received more than 300 mg/m(2) of doxorubicin-based therapy for tumors other than breast cancer, although caution should be used in settings in which doxorubicin-based therapy has been shown to improve survival because of concerns of tumor protection by dexrazoxane. (5) There is insufficient evidence to make a guideline for the use of dexrazoxane in the treatment of pediatric malignancies, with epirubicin-based regimens, or with high-dose anthracycline-containing regimens. Similarly, there is insufficient evidence on which to base a guideline for the use of dexrazoxane in patients with cardiac risk factors or underlying cardiac disease. (6) Patients receiving dexrazoxane should continue to be monitored for cardiac toxicity. Amifostine: (1) Amifostine may be considered for the reduction of nephrotoxicity in patients receiving cisplatin-based chemoth

Sentinel Lymph Node Biopsy for Melanoma: American Society of Clinical Oncology and Society of Surgical Oncology Joint Clinical Practice Guideline

PURPOSE The American Society of Clinical Oncology (ASCO) and Society of Surgical Oncology (SSO) sought to provide an evidence-based guideline on the use of lymphatic mapping and sentinel lymph node (SLN) biopsy in staging patients with newly diagnosed melanoma. METHODS A comprehensive systematic review of the literature published from January 1990 through August 2011 was completed using MEDLINE and EMBASE. Abstracts from ASCO and SSO annual meetings were included in the evidence review. An Expert Panel was convened to review the evidence and develop guideline recommendations. RESULTS Seventy-three studies met full eligibility criteria. The evidence review demonstrated that SLN biopsy is an acceptable method for lymph node staging of most patients with newly diagnosed melanoma. RECOMMENDATIONS SLN biopsy is recommended for patients with intermediate-thickness melanomas (Breslow thickness, 1 to 4 mm) of any anatomic site; use of SLN biopsy in this population provides accurate staging. Although there are few studies focusing on patients with thick melanomas (T4; Breslow thickness, > 4 mm), SLN biopsy may be recommended for staging purposes and to facilitate regional disease control. There is insufficient evidence to support routine SLN biopsy for patients with thin melanomas (T1; Breslow thickness, < 1 mm), although it may be considered in selected patients with high-risk features when staging benefits outweigh risks of the procedure. Completion lymph node dissection (CLND) is recommended for all patients with a positive SLN biopsy and achieves good regional disease control. Whether CLND after a positive SLN biopsy improves survival is the subject of the ongoing Multicenter Selective Lymphadenectomy Trial II.

Pharmacodynamic Effects and Mechanisms of Resistance to Vemurafenib in Patients With Metastatic Melanoma

PURPOSE To assess pharmacodynamic effects and intrinsic and acquired resistance mechanisms of the BRAF inhibitor vemurafenib in BRAF(V600)-mutant melanoma, leading to an understanding of the mechanism of action of vemurafenib and ultimately to optimization of metastatic melanoma therapy. METHODS In the phase II clinical study NP22657 (BRIM-2), patients received oral doses of vemurafenib (960 mg twice per day). Serial biopsies were collected to study changes in mitogen-activated protein kinase (MAPK) signaling, cell-cycle progression, and factors causing intrinsic or acquired resistance by immunohistochemistry, DNA sequencing, or somatic mutation profiling. Results Vemurafenib inhibited MAPK signaling and cell-cycle progression. An association between the decrease in extracellular signal-related kinase (ERK) phosphorylation and objective response was observed in paired biopsies (n = 22; P = .013). Low expression of phosphatase and tensin homolog showed a modest association with lower response. Baseline mutations in MEK1(P124) coexisting with BRAF(V600) were noted in seven of 92 samples; their presence did not preclude objective tumor responses. Acquired resistance to vemurafenib associated with reactivation of MAPK signaling as observed by elevated ERK1/2 phosphorylation levels in progressive lesions and the appearance of secondary NRAS(Q61) mutations or MEK1(Q56P) or MEK1(E203K) mutations. These two activating MEK1 mutations had not previously been observed in vivo in biopsies of progressive melanoma tumors. CONCLUSION Vemurafenib inhibits tumor proliferation and oncogenic BRAF signaling through the MAPK pathway. Acquired resistance results primarily from MAPK reactivation driven by the appearance of secondary mutations in NRAS and MEK1 in subsets of patients. The data suggest that inhibition downstream of BRAF should help to overcome acquired resistance.

A Prognostic Model for Predicting 10-Year Survival in Patients with Primary Melanoma

Malignant melanoma is currently the eighth most common cancer in the United States; 10 years ago, it was the 20th most common. The population-based mortality rate has continued to increase, whereas the case fatality rate has steadily declined to less than 20% [1]. Diagnosis of malignant melanoma earlier than was previously possible is primarily responsible for this improved survival rate. Contributing to earlier recognition of malignant melanoma are the identification of risk markers (such as dysplastic nevi) and improved understanding of clinical characteristics of the biologically early forms [2-4]. Another substantive advance has been the clarification of prognostic factors for patients with primary American Joint Commission on Cancer stage I cutaneous melanoma ( 1.5 mm) and stage II cutaneous melanoma (>1.51 mm); these factors are predominantly pathologic variables that were described by Clark and colleagues [5], Breslow [6], and other investigators [7]. Survival is routinely predicted almost exclusively on the basis of tumor thickness. Although this is an excellent correlate of prognosis, it is imprecise. Death results from thin melanomas, and survival occurs with thick melanomas. Evaluation of other variables improves the ability to predict survival in patients with melanoma. Variables that can be added include the anatomical site of the primary tumor; sex and age of the patient; mitotic rate of the tumor; presence of ulceration, microscopic satellites, or tumor-infiltrating lymphocytes; tumor regression or angiogenesis; and the Clark level of invasion (maximum penetration of the melanoma lesion into levels of the dermis or subcutaneous tissue) [8, 9]. We previously described a multivariable model that predicted 8-year survival of patients with primary melanomas more accurately than did tumor thickness alone [10]. In that model, six variables were found to independently predict survival. These variables (in order of their relative predictive strength) are mitotic rate, presence of tumor-infiltrating lymphocytes, tumor thickness, site of the primary lesion, sex of the patient, and histologic regression of the tumor. Although this model includes powerful predictors of survival, some of the variables used to generate it are not routinely included in standard pathology reports. Therefore, the model cannot be readily generalized for clinical use. To document this, we reviewed 100 randomly selected pathology reports of primary melanomas from community-based hospital pathologists, independent pathology laboratories, and specialized dermatopathology laboratories. Tumor thickness was recorded in 76% of cases; Clark level, in 68%; and histologic subtype, in 64%. However, tumor infiltrating lymphocytes and tumor regression were described in fewer than 20% of cases, and the mitotic rate was reported even less frequently (fewer than 5% of cases). Notably, no pathologists specified pure, invasive, radial-growth-phase melanoma, although such lesions almost never metastasize [10]. Given the limited availability of these histologic variables, we sought to develop a prognostic model based on clinical and pathologic data that are routinely available to the clinician. The model is intended to estimate the chance of survival, within 10 years of definitive therapy, in a patient with primary malignant melanoma. The ability to predict outcome more accurately in these patients could identify patients who are at high risk for recurrence; these patients could then be included in trials of adjuvant therapy. Further trials are becoming increasingly important as effective therapies for post-surgical treatment of melanoma are identified and tested [11-13]. Methods Patients The Pigmented Lesion Group at the University of Pennsylvania prospectively evaluated 624 patients with primary melanoma between 1 September 1972 and 31 December 1979. The pathologic variables were ascertained in an independent study of the primary tumors on two separate occasions by two pathologists who had no knowledge of outcome. Definitive treatment of the primary melanoma consisted of wide re-excision of the primary site to yield negative margins. We excluded 136 cases from analysis. Reasons for exclusion were competing causes of death before 10 years of follow-up with no evidence of melanoma (n = 44), lack of prospective follow-up (n = 22), metastatic disease evident beyond the primary site at presentation (n = 29), inadequate surgical treatment (n = 14), unknown cause of death before 10 years of follow-up (n = 5), occurrence of a high-risk primary tumor after 1979 (n = 2), existence of noncutaneous primary tumors (n = 5), loss to follow-up (n = 10), and unclassified tumor thickness or level (n = 5). Therefore, the final study group consisted of 488 patients who were followed prospectively for at least 10 years. Surviving patients were followed for no more than 20 years. Five patients who died of melanoma after 10 years of follow-up were considered to be 10-year survivors. Our description of what is generally included in melanoma pathology reports was drawn from the last 100 cases submitted for review at the Hospital of the University of Pennsylvania. Forty-three percent of the reports were from community-based hospitals, 17% were from independent pathology laboratories, and 40% were from specialized dermatopathology practices. We did not intend to evaluate current melanoma pathology reporting in nonacademic settings but rather to evaluate which prognostic factors are frequently reported on pathology reports. Validation of the model required a test using patient data that had not been used to generate the model. This sample consisted of 142 patients who had primary melanoma and were identified in an identical manner in 1980 and 1981, with blinded histopathologic assessment of melanoma and 10 years of follow-up data. Clinical and pathologic variables that have been identified as prognostic indicators of survival and that are readily available to the clinician were used to develop the prediction model [7, 9]. Clinical variables included age and sex of the patient and site of the primary lesion. Pathologic variables included histologic subtype, Clark level, and tumor thickness. Tumor thickness was measured from the stratum granulosum epidermidis to the depth of the tumor at its thickest part, according to the method of Breslow [6]. Anatomical site of the primary melanoma was divided into two categories: extremity (upper and lower) and axis. Axial or volar primaries, including melanomas arising on the trunk, head, neck, and palms and soles (volar) and under the nails (subungual), were designated as axis lesions. Lesions on other parts of the body were designated as extremity lesions. Female and male patients were studied. Histologic subtypes of melanoma included superficial spreading melanoma (71%), nodular melanoma (12%), lentigo maligna melanoma (6%), acral-lentiginous melanoma (3%), and other lesions (8%), using standard pathologic criteria. Age at the time of diagnosis was recorded. The Clark level of invasion was determined as described elsewhere [5]. Patient outcome was assigned to two categories: alive at 10 years (with or without evidence of melanoma) or dead from melanoma before 10 years. The 10-year interval was chosen because death from melanoma beyond 10 years is uncommon. We chose to analyze survival as a binary outcome (alive at 10 years compared with dead before 10 years). This method was chosen instead of evaluating the survival time or time to death because our primary objective was to differentiate between patients with high and low probabilities for surviving disease. This differentiation, in turn, can aid patient management and identify candidates for adjuvant therapy trials. Therefore, we were not interested in determining the contribution of prognostic factors that lengthen survival but do not necessarily prevent death. Statistical Analysis We used a univariate logistic regression model to test the six clinical and pathologic variables for their association with death. Patient age and tumor thickness were tested as continuous and nominal variables, and the Clark level was tested as a nominal variable. Tumor site was initially evaluated as a variable falling into one of four categories (trunk, head or neck, subungual or volar location, and extremity) but was subsequently reduced to two categories, axis and extremity. Variables that were statistically significantly associated with survival were retained for testing in a multivariable logistic regression model [14]. A manual stepwise procedure was used to determine the best model. The predicted probability that a patient would survive 10 years was generated using the estimated model variables. The logistic equation is presented as a footnote in Table 1. Table 1. Adjusted Odds Ratios for Independent Predictors of Survival* Figure 1 is a box and whisker plot that shows the distribution of probabilities that were estimated by our model for survival of patients who were alive and those who were dead at 10 years [15]. The boundary lines of the boxes represent the 25th and 75th percentiles of the data; the lines drawn through the interior of the boxes mark the 50th percentiles (the medians). The whiskers are drawn from the edges of each box to the most extreme point a maximum distance of 1.5 times greater and 1.5 times less than the interquartile ranges. Any value more extreme is considered an outlier and is designated by an asterisk. The predictive ability of the four-variable model was compared with that of tumor thickness in two ways. First, receiver-operating characteristic (ROC) curves were calculated [16, 17]. Second, the McNemar test was used to compare the percentages of correct predictions. Goodness of fit was assessed by using the Hosmer-Lemeshow test [14]. Figure 1. Results Overall Of the 488 prospectively followed patients, 108 died of melanoma before 10 years. The median follow-up was 13.

Thin Primary Cutaneous Malignant Melanoma: A Prognostic Tree for 10-Year Metastasis Is More Accurate Than American Joint Committee on Cancer Staging

PURPOSE The majority of invasive primary melanomas are thin (< or = 1.00 mm). Since the current staging system imperfectly predicts outcome in patients with such lesions, we sought to develop a more effective classification scheme to better identify both patients at high risk of metastasis who are candidates for further staging and therapy and those with little risk. PATIENTS AND METHODS This prospective cohort study included 884 patients who had thin invasive melanomas. A tree-structured analysis of 10-year metastasis was used to develop a new classification scheme. RESULTS The overall 10-year metastasis rate was 6.5% (95% CI, 4.8% to 8.1%). The prognostic tree defined four risk groups: high-risk: men with vertical growth phase (VGP) lesions that had mitotic rates (MRs) greater than 0, and for whom the 10-year metastasis rate was 31% (22% to 42%; n = 90); moderate-risk: women with VGP lesions that had MRs greater than 0 and for whom the rate was 13% (9% to 18%; n = 136); low-risk: patients with VGP lesions that had MR of 0 for whom the rate was 4% (2% to 7%; n = 247); and minimal-risk: patients with invasive lesions without VGP for whom the rate was 0.5% (0% to 1.2%; n = 411). Survival curves differed significantly among the four groups (P <.001). CONCLUSION Growth phase, mitotic rate, and sex are important prognostic factors for patients with thin melanomas, and they identify subgroups at substantial risk for metastasis. After validation in other populations, the proposed prognostic tree will be useful in the design of clinical trials and clinical management.

Targeting ER stress–induced autophagy overcomes BRAF inhibitor resistance in melanoma

Melanomas that result from mutations in the gene encoding BRAF often become resistant to BRAF inhibition (BRAFi), with multiple mechanisms contributing to resistance. While therapy-induced autophagy promotes resistance to a number of therapies, especially those that target PI3K/mTOR signaling, its role as an adaptive resistance mechanism to BRAFi is not well characterized. Using tumor biopsies from BRAF(V600E) melanoma patients treated either with BRAFi or with combined BRAF and MEK inhibition, we found that BRAFi-resistant tumors had increased levels of autophagy compared with baseline. Patients with higher levels of therapy-induced autophagy had drastically lower response rates to BRAFi and a shorter duration of progression-free survival. In BRAF(V600E) melanoma cell lines, BRAFi or BRAF/MEK inhibition induced cytoprotective autophagy, and autophagy inhibition enhanced BRAFi-induced cell death. Shortly after BRAF inhibitor treatment in melanoma cell lines, mutant BRAF bound the ER stress gatekeeper GRP78, which rapidly expanded the ER. Disassociation of GRP78 from the PKR-like ER-kinase (PERK) promoted a PERK-dependent ER stress response that subsequently activated cytoprotective autophagy. Combined BRAF and autophagy inhibition promoted tumor regression in BRAFi-resistant xenografts. These data identify a molecular pathway for drug resistance connecting BRAFi, the ER stress response, and autophagy and provide a rationale for combination approaches targeting this resistance pathway.

Combined MTOR and autophagy inhibition: Phase I trial of hydroxychloroquine and temsirolimus in patients with advanced solid tumors and melanoma

The combination of temsirolimus (TEM), an MTOR inhibitor, and hydroxychloroquine (HCQ), an autophagy inhibitor, augments cell death in preclinical models. This phase 1 dose-escalation study evaluated the maximum tolerated dose (MTD), safety, preliminary activity, pharmacokinetics, and pharmacodynamics of HCQ in combination with TEM in cancer patients. In the dose escalation portion, 27 patients with advanced solid malignancies were enrolled, followed by a cohort expansion at the top dose level in 12 patients with metastatic melanoma. The combination of HCQ and TEM was well tolerated, and grade 3 or 4 toxicity was limited to anorexia (7%), fatigue (7%), and nausea (7%). An MTD was not reached for HCQ, and the recommended phase II dose was HCQ 600 mg twice daily in combination with TEM 25 mg weekly. Other common grade 1 or 2 toxicities included fatigue, anorexia, nausea, stomatitis, rash, and weight loss. No responses were observed; however, 14/21 (67%) patients in the dose escalation and 14/19 (74%) patients with melanoma achieved stable disease. The median progression-free survival in 13 melanoma patients treated with HCQ 1200mg/d in combination with TEM was 3.5 mo. Novel 18-fluorodeoxyglucose positron emission tomography (FDG-PET) measurements predicted clinical outcome and provided further evidence that the addition of HCQ to TEM produced metabolic stress on tumors in patients that experienced clinical benefit. Pharmacodynamic evidence of autophagy inhibition was evident in serial PBMC and tumor biopsies only in patients treated with 1200 mg daily HCQ. This study indicates that TEM and HCQ is safe and tolerable, modulates autophagy in patients, and has significant antitumor activity. Further studies combining MTOR and autophagy inhibitors in cancer patients are warranted.