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Initiated: September 2011
Last Review: July 2022
Genetic Test: Melanoma and Glioma, Testing to Predict Response to Targeted Therapy
The identification of specific, targetable oncogenic "driver mutations" in a subset of melanomas and gliomas has resulted in a reclassification of solid tumors to include molecular subtypes that may direct targeted therapy depending on the presence of specific variants. BRAF and MEK inhibitors, alone or in combination with checkpoint inhibitors, are drugs designed to target a somatic variant in the BRAF gene. BRAF and MEK inhibitors were originally developed for patients with advanced melanoma. BRAF encodes a kinase component in the RAF-MEK-ERK signal transduction phosphorylation cascade. Variants in BRAF cause constitutive kinase activity, which is believed to promote oncogenic proliferation. Direct and specific inhibition of the mutated kinase has been shown to retard tumor growth significantly and may improve patient survival. Checkpoint inhibitors are monoclonal antibodies that were initially developed to target tumors expressing high levels of PD-L1. Tumors with a high tumor mutational burden (TMB) may also predict benefit from checkpoint inhibitor immunotherapy.
Overall incidence rates for melanoma have been increasing for at least 30 years. In advanced (Stage 4) melanoma, the disease has spread beyond the original area of skin and nearby lymph nodes. Although only a small proportion of cases are Stage 4 at diagnosis, prognosis is extremely poor; 5-year survival is about 15-20%.
Variants in the BRAF kinase gene are common in tumors of patients with advanced melanoma and result in constitutive activation of a key signaling pathway (RAF-MEK-ERK pathway) that is associated with oncogenic proliferation. In general, 50-70% of melanoma tumors harbor a BRAF mutation and of these, 80% are positive for BRAFV600E, and 16% are positive for BRAF V600K (Vultur, 2011). Thus, 405-60% of advanced melanoma patients might respond to a BRAF inhibitor targeted to this mutated kinase.
BRAF inhibitors (e.g., vemurafenib, dabrafenib) and MEK inhibitors (e.g., trametinib, cobimetinib) have been developed for use in patients with advanced melanoma. Vemurafenib (trade name Zelboraf®, also known as PLX4032 and RO5185426) was developed using a fragment-based, structure-guided approach that allowed the synthesis of a compound with high potency to inhibit the BRAFV600E mutated kinase and with significantly lower potency to inhibit most of many other kinases tested (Bollag, 2010). Preclinical studies demonstrated that vemurafenib selectively blocked the RAF/MEK/ERK pathway in BRAF mutant cells (Sondergaard, 2010; Joseph, 2010; Yang, 2010) and caused regression of BRAF mutant human melanoma xenografts in murine models (Bollag, 2010). Paradoxically, preclinical studies also showed that melanoma tumors with the BRAF wild-type gene sequence could respond to mutant BRAF-specific inhibitors with accelerated growth, (Sondergaard, 2010; Joseph, 2010; Yang, 2010) suggesting that it may be harmful to administer BRAF inhibitors to patients with BRAF wild-type melanoma tumors. Potentiated growth in BRAF wild-type tumors has not yet been confirmed in melanoma patients, as the supportive clinical trials were enrichment trials, enrolling only patients with tumors positive for the BRAFV600E mutation.
Gliomas encompass a heterogeneous group of tumors and the classification of gliomas has changed over time. In 2016, the World Health Organization (WHO) updated its classification of gliomas based on both histopathologic appearance and molecular parameters (Louis, 2016). The classification ranges from grade I to IV, corresponding to the degree of malignancy (aggressiveness), with WHO grade I being least aggressive and grade IV being most aggressive.
There is considerable interest in targeted therapies that inhibit the RAF-MEK-ERK pathway, particularly in patients with high-grade and low-grade gliomas whose tumors are in locations that prevent full resection. Evidence from early-phase trials in patients with BRAF variant-positive melanoma with brain metastases have suggested some efficacy for brain tumor response with vemurafenib and dabrafenib indicating that these agents might be potential therapies for primary brain tumors (Dummer, 2014; Long, 2012).
Tumor mutational burden (TMB), a measure of gene mutations within cancer cells, is an emerging biomarker of outcomes with immunotherapy in multiple solid tumor types. Initially, assessments of TMB involved whole exome sequencing (WES). More recently, targeted next-generation sequencing (NGS) panels are being adapted to estimate TMB. Currently, FoundationOne CDx is the only U.S. Food and Drug Administration (FDA)-approved panel for estimating TMB, but others are in development (Merino, 2020).
Targeted treatments approved by the U.S. Food and Drug Administration (FDA) for patients with melanoma along with the concurrently approved diagnostic tests:
Pembrolizumab (Keytruda®; Merck)
2020: treatment of adult and pediatric patients with unresectable or metastatic tumor mutation burden-high (TMB-H) [≥10 mutations/megabase] solid tumors, that have progressed following prior treatment and who have no satisfactory treatment options
FDA Approval of Companion Diagnostic Test:
2020: FoundationOne CDx™ (Foundation Medicine)
Atezolizumab (Tecentriq®; Genentech)
2020: treatment of patients with unresectable or metastatic melanoma with BRAF V600 variants in combination with cobimetinib and vemurafenib3
For cobimetinib in combination with vemurafenib:
2016: cobas® 4800 BRAF V600 Mutation Test (Roche)
Entrectinib (Rozyltrek®; Genentech)
2019: treatment of adults and pediatric patients 12 years of age and older with solid tumors that have a NTRK gene fusion without a known acquired resistance mutation, that are metastatic or where surgical treatment is likely to result in severe morbidity, and have progressed following treatment or have no satisfactory standard therapy
No FDA-approved companion diagnostic
Larotrectinib (Vitrakvi®; Loxo Oncology/Bayer)
2018: treatment of adult and pediatric patients with solid tumors that have a NTRK gene fusion without a known acquired resistance mutation, that are metastatic or where surgical resection is likely to result in severe morbidity, and who have no satisfactory alternative treatments or whose cancer has progressed following treatment
Vemurafenib (Zelboraf®; Roche/Genentech and Plexxikon)
2011: treatment of patients with unresectable or metastatic melanoma with BRAF V600 variants
Dabrafenib (Tafinlar®; GlaxoSmithKline)
2013: treatment of patients with unresectable or metastatic melanoma with BRAF V600E
2014: Used in combination with trametinib to treat patients with unresectable or metastatic melanoma with BRAF V600E or V600K variants
2018: Used in combination with trametinib for adjuvant treatment of patients with resected stage III melanoma with BRAF V600E or V600K variants
2013: THxID™ BRAF kit (bioMérieux)
Trametinib (Mekinist™; GlaxoSmithKline)
2013: treatment of patients with unresectable or metastatic melanoma with BRAF V600E or V600K variants
2014: Used in combination with dabrafenib to treat patients with unresectable or metastatic melanoma with BRAF V600E or V600K variants
2018: Used in combination with dabrafenib for adjuvant treatment of patients with resected stage III melanoma with BRAF V600E or V600K variants
Cobimetinib (Cotellic®; Genentech)
2015: Used in combination with vemurafenib to treat patients with unresectable or metastatic melanoma with a BRAF V600E or V600K variants
Binimetinib (Mektovi®; Array BioPharma)
2018: Used in combination with encorafenib to treat patients with unresectable or metastatic melanoma with a BRAF V600E or V600K mutation.
Encorafenib (Bravtovi®; Array BioPharma)
2018: Used in combination with binimetinib to treat patients with unresectable or metastatic melanoma with a BRAF V600E or V600K mutation
FDA product code: OWD.
Effective January 2012, there is a specific CPT code for this testing:
81210 BRAF (v-raf murine sarcoma viral oncogen homolog B1) (e.g., colon cancer), gene analysis, V600E variant.
Effective July 2022
Testing for the BRAF V600 variants in tumor tissue of individuals with unresectable or metastatic melanoma meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness to select treatment with FDA-approved BRAF inhibitors (i.e., vemurafenib, dabrafenib or trametinib), MEK inhibitors, or immunotherapy.
Testing for BRAF V600 variants in tumor tissue of individuals with resected stage III melanoma meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness to select treatment with FDA-approved BRAF inhibitors (i.e., vemurafenib, dabrafenib or trametinib) or MEK inhibitors.
Analysis of BRAF V600E variant meets member benefit certificate primary coverage criteria to predict treatment response to BRAF and MEK-inhibitor combination therapy (e.g., dabrafenib [Tafinlar] and trametinib [Mekinist]), in individuals with BRAF V600E–mutated melanoma.
Coverage of testing meets member benefit certificate primary coverage criteria for one test per lifetime.
Testing for the BRAF V600 variants for all other indications, including but not limited to, use in individuals with lesser stage melanoma, resectable melanoma, non-melanoma tumors or glioma does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
For members with contracts without primary coverage criteria, testing for the BRAF V600 variants for all other indications, including but not limited to, use in individuals with lesser stage melanoma, resectable melanoma, non-melanoma tumors or glioma is considered investigational. Investigational services are considered specific contract exclusions in most member benefit certificates of coverage
Testing for tumor mutational burden (TMB) in individuals with unresectable or metastatic melanoma or glioma to select individuals for treatment with FDA-approved immunotherapy does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
For members with contracts without primary coverage criteria, testing for tumor mutational burden (TMB) in individuals with unresectable or metastatic melanoma or glioma to select individuals for treatment with FDA-approved immunotherapy is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Analysis of BRAF V600E variant to predict treatment response to all other therapy combinations in individuals with BRAF V600E–mutated melanoma does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
For members with contracts without primary coverage criteria, analysis of BRAF V600E variant to predict treatment response to all other therapy combinations in individuals with BRAF V600E–mutated melanoma does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
Testing for the BRAF V600 variants in tumor tissue of patients with unresectable or metastatic melanoma meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness to select treatment with FDA-approved BRAF inhibitors (i.e., vemurafenib, dabrafenib or trametinib), MEK inhibitors, or immunotherapy.
Testing for BRAF V600 variants in tumor tissue of patients with resected stage III melanoma meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness to select treatment with FDA-approved BRAF inhibitors (i.e., vemurafenib, dabrafenib or trametinib) or MEK inhibitors.
Testing for the BRAF V600 variants for all other indications, including but not limited to, use in patients with lesser stage melanoma, resectable melanoma, non-melanoma tumors or glioma does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
For members with contracts without primary coverage criteria, testing for the BRAF V600 variants for all other indications, including but not limited to, use in patients with lesser stage melanoma, resectable melanoma, non-melanoma tumors or glioma is considered investigational. Investigational services are considered specific contract exclusions in most member benefit certificates of coverage
Testing for tumor mutational burden (TMB) in patients with unresectable or metastatic melanoma or glioma to select patients for treatment with FDA-approved immunotherapy does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
For members with contracts without primary coverage criteria, testing for tumor mutational burden (TMB) in patients with unresectable or metastatic melanoma or glioma to select patients for treatment with FDA-approved immunotherapy is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Effective Prior to November 2021
Testing for the BRAF V600 variants in tumor tissue of patients with unresectable or metastatic melanoma meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness to select treatment with FDA-approved BRAF inhibitors (i.e., vemurafenib, dabrafenib or trametinib).
Testing for BRAF V600 variants in tumor tissue of patients with resected stage III melanoma meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness to select treatment with FDA-approved BRAF inhibitors (i.e., vemurafenib, dabrafenib or trametinib).
For members with contracts without primary coverage criteria, testing for the BRAF V600 variants for all other indications, including but not limited to, use in patients with lesser stage melanoma, resectable melanoma, non-melanoma tumors or glioma is considered investigational. Investigational services are considered specific contract exclusions in most member benefit certificates of coverage.
Effective October 2014 - September 2017
Testing for the BRAF V600 mutations in tumor tissue of patients with unresectable or metastatic melanoma meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness to select treatment with FDA-approved BRAF inhibitors (i.e., vemurafenib, dabrafenib or trametinib).
Testing for the BRAF V600 mutations for all other indications, including but not limited to, use in patients with lesser stage melanoma, or with non-melanoma tumors does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
For members with contracts without primary coverage criteria, testing for the BRAF V600 mutations for all other indications, including but not limited to, use in patients with lesser stage melanoma, or with non-melanoma tumors is considered investigational. Investigational services are considered specific contract exclusions in most member benefit certificates of coverage.
Effective October 2013- September 2014
Testing for the BRAF V600 mutations in tumor tissue of patients with stage IIIC or IV melanoma meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness to select treatment with FDA-approved BRAF inhibitors (i.e., vemurafenib, dabrafenib or trametinib).
Effective prior to October 2013
Testing for the BRAF V600E mutation in tumor tissue of patients with stage IIIC or IV melanoma meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness to select treatment with vemurafenib.
Testing for the BRAF V600E mutation for all other indications, including but not limited to, use in patients with lesser stage melanoma, or with non-melanoma tumors does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
For members with contracts without primary coverage criteria, testing for the BRAF V600E mutation for all other indications, including but not limited to, use in patients with lesser stage melanoma, or with non-melanoma tumors is considered investigational. Investigational services are considered specific contract exclusions in most member benefit certificates of coverage.
Analytic Validity
The analytic validity of a genetic test is its ability to accurately and reliably measure the genotype (or analyte) of interest in the clinical laboratory, and in specimens representative of the population of interest (Teutsch, 2009). Submission to the Office of In Vitro Diagnostics of the FDA for marketing clearance or approval of a diagnostic test requires an extensive demonstration of the analytic validity of the test. Data for cleared or approved tests are summarized in the kit insert (prepared by the manufacturer) and in the Summary of Safety and Effectiveness of the test (prepared by the FDA and publicly available).
The cobas® 4800 BRAF V600 Mutation Test is a real-time polymerase chain reaction (PCR) test intended for the qualitative detection of the BRAFV 600E mutation specifically in DNA that has been extracted from formalin-fixed, paraffin-embedded (FFPE) human melanoma tissue.
Correlation of cobas 4800 BRAF V600 Mutation Test results to Sanger sequencing was tested in the Phase III trial of vemurafenib (Chapman, 2011) on 596 consecutive patients, of which 449 were evaluable. The percent agreement of the BRAF V600 mutation test with Sanger sequencing is shown in the first line of Table 1 when only V600E results were counted as positive. The cobas 4800 BRAF V600 Mutation Test detected 27 V600 mutations (primarily V600K) that were not V600E by Sanger Sequencing. Limited evidence suggests that patients with V600K mutated tumors may also respond to vemurafenib.
Tumor specimens from the patients enrolled in the phase II trial (Ribas, 2011) were also sequenced by Sanger sequencing; specimens that were invalid by Sanger, or that were identified as V600K mutation or as V600 wild type by Sanger were re-sequenced by the more sensitive 454 pyrosequencing method to resolve differences. Correlation to 454 pyrosequencing was 100% if V600K-positive samples were counted as true positives.
Regulatory documents contain additional data detailing the evaluation of analytic sensitivity and specificity, cross reactivity, interference, reproducibility, repeatability, and additional studies of test robustness. In general, correlation with sequencing and extensive analytic validation data support that the test is a sensitive, specific, and robust assay for the detection of the V600E mutation in FFPE melanoma specimens. Patients with V600K mutations will also be identified as positive, although it is not clear that all patients with V600K mutations will be positive. There is very limited evidence that patients with V600K mutations may respond to vemurafenib. Infrequently, patients with V600E2 and V600D mutations may also be detected. Additionally, the method is available as a kit and is partially automated, which should result in wide access and rapid turnaround time relative to the reference standard of sequencing.
Clinical Validity and Utility
The clinical validity of a genetic test is its ability to accurately and reliably predict the clinically defined disorder or phenotype of interest; the clinical utility of a genetic test is the evidence of improved measurable clinical outcomes, and its usefulness and added value to patient management decision-making compared with current management without genetic testing (Teutsch. 2009).
When a treatment is developed for a specific biological target that characterizes only some patients with a particular disease, and a test is co-developed to identify diseased patients with that target, clinical validity and clinical utility studies are no longer separate and sequential. Rather, the clinical studies of treatment benefit, which use the test to select patients, provide evidence of both clinical validity and clinical utility. The primary evidence of clinical validity and utility for the cobas® 4800 BRAF V600 Mutation Test is provided by the Phase III clinical trial of vemurafenib. In addition, evidence from Phase I and Phase II trials is supportive. All trials were enrichment trial designs, in which all patients were positive for a V600 mutation (with a few exceptions in the Phase I trial). The justification for this was both efficiency and possibly potential for harm to patients with BRAF wild type tumors.
Phase III Clinical Trial. This comparative trial, also known as BRIM-3, randomly assigned 675 patients to either vemurafenib (960 mg twice daily orally) or dacarbazine (1,000 mg/m2 body surface area by IV infusion every 3 weeks) to determine whether vemurafenib would prolong the rate of overall or progression-free survival, compared to dacarbazine (Chapman, 2011). All enrolled patients had unresectable, previously untreated stage IIIC or IV melanoma with no active CNS metastases. Melanoma specimens from all patients tested positive for the BRAFV600E mutation on the cobas 4800 BRAF V600 Mutation Test. Included were 19 patients with BRAFV600K mutations and one with a BRAFV600D mutation.
Tumor assessments including CT were performed at baseline, at weeks 6 and 12, and every 9 weeks thereafter. Tumor responses were determined by the investigators according to the RECIST, version 1.1. Primary endpoints were the rate of overall survival and progression-free survival. An interim analysis was planned at 98 deaths and a final analysis at 196 deaths; the published report is the interim analysis, reporting 118 deaths. The median survival had not been reached. Adverse events in the vemurafenib group included grade 2 or 3 photosensitivity skin reactions in 12% of patients, and cutaneous squamous cell carcinoma in 18% of patients. The data and safety monitoring board determined that both co-primary endpoints had met prespecified criteria for statistical significance and recommended that patients in the dacarbazine group be allowed to cross over and receive vemurafenib. The results of this trial comprised the data supporting the efficacy and safety of vemurafenib for submission to the FDA, and established the safety and effectiveness of the cobas 4800 BRAF V600 Mutation Test, resulting in co-approval of drug and companion test.
Phase II Clinical Trial. A Phase II trial, also known as BRIM-2, is currently ongoing at 13 centers. All patients were selected with the cobas 4800 BRAF V600 Mutation Test; 122 cases had BRAFV600E–positive melanoma and 10 cases were positive for BRAFV600K. The early results of this trial have been published only as a meeting abstract and a meeting slide presentation (Robas. 2011). The target overall response rate (primary outcome) was 30%, with a lower boundary of the 95% confidence interval (CI) of at least 20%. At a median follow-up of 10 months, this target was met with an overall response rate of 53% by IRC (95% CI: 44-62%). At 10 months, 27% of patients were still on treatment; the majority of discontinuations were due to disease progression. The most common adverse events of any grade were arthralgias (58%), skin rash (52%), and photosensitivity (52%). The most common grade 3 adverse event was squamous cell carcinoma; these were seen in about 25% of patients, tended to occur in the first 2 months of treatment, and were managed with local excision. There were very few grade 4 adverse events.
Phase I Clinical Trial. The major goals of this trial were to first determine the maximum dose in a dose-escalation phase, then determine the objective response rate and monitor toxicity (Flaherty, 2010). This trial used a PCR assay that was likely a prototype of the final test; only a brief description of the assay was provided in the publication. In the dose-escalation phase, 5 patients with metastatic melanoma tumors who did not have the BRAFV600E mutation received 240 mg or more vemurafenib twice daily (final recommended dose is 960 mg twice daily); of these, none responded. In the extension phase of the trial, 26 of 32 patients with the BRAFV600E mutation responded (81%; 24 partial, 2 complete responses).
Ongoing Clinical Trials
Despite impressive response rates in the Phase I trial, the duration of response to vemurafenib was limited to between 2 and 18 months suggesting the development of resistance; in some patients with BRAFV600E-positive tumors there was no response at all, which was interpreted as primary resistance. Investigations of the mechanisms of resistance have reported evidence of different molecular mechanisms potentially responsible for resistance in different patients (16, 17). It is likely that combined inhibition of BRAF and other key molecular targets, and the use of different combinations in different patients, will be needed in the future. For example, a clinical trial is already underway combining treatment with vemurafenib and a MEK inhibitor in patients who have already been treated with vemurafenib (NCT01271803).
As noted, the BRAF inhibitor dabrafenib is currently in phase II and III clinical trials (NCT01227889; NCT01266967), and is expected to be submitted to the FDA, along with a companion diagnostic test, relatively quickly.
A large proportion of patients with advanced melanoma have a mutation in the BRAF gene. The Phase III clinical trial of vemurafenib in melanoma patients positive for the BRAFV600E mutation reported a benefit in overall survival and progression-free survival for vemurafenib treatment. These results, which are corroborated by earlier trials, support the clinical validity and clinical utility of the cobas 4800 BRAF V600 Mutation Test, the companion diagnostic test for vemurafenib. Using the test to select patients for treatment results in improved outcomes compared to the usual standard of care, dacarbazine. Thus, this test, and any other tests approved by the FDA to detect the BRAFV600E mutation to select advanced melanoma patients for vemurafenib treatment, may be considered medically necessary.
A literature search conducted through September 2012 did not reveal any new information that would prompt a change in the coverage statement.
Two new BRAF inhibitors received FDA approval since the last policy update. This update contains information relating to these new treatments.
Dabrafenib
The THxID™ BRAF kit is a real-time PCR test intended for the qualitative detection of BRAF V600E and V600K mutations in DNA samples extracted from formalin-fixed paraffin-embedded (FFPE) human melanoma tissue (FDA, 2013). Two oligonucleotide probes labeled with different fluorescent dyes (one for internal controls and the other for mutation sequence alleles) are measured at characteristic wavelengths and compared by an autoanalyzer. Results are reported as either "mutation(s) detected" or "mutation(s) not detected" (or "invalid," which requires troubleshooting and a repeat of the test). The threshold of detection, defined as the smallest proportion of mutated alleles for which the assay yields a positive result in 95% of tests, is 5% for V600E and V600K mutations.
Correlation of the THxID BRAF assay with Sanger sequencing was tested in 898 consecutive clinical trial samples. Forty-three samples (5%) were invalid or quantity not sufficient. Excluding these samples, there were 35 discordant cases (4%). The THxID BRAF kit detected as V600E mutation-positive 2 samples determined by Sanger sequencing to be V600D mutation-positive.
One Phase III randomized, controlled, open-label trial of dabrafenib for advanced (stage IV or unresectable stage III) melanoma has been published (Hauschild, 2012); the results of this trial are summarized in Table 3. The main objective of this RCT was to study the efficacy of dabrafenib vs. standard dacarbazine treatment in patients selected to have BRAF V600E mutated metastatic melanoma. Two-hundred-fifty patients were randomized 3:1 to receive oral dabrafenib 150 mg twice daily versus intravenous dacarbazine 1,000 mg/m2 every 3 weeks. The primary outcome was progression-free survival (PFS), and secondary outcomes were overall survival, objective response rate, and adverse events.
Median progression-free survival for the dabrafenib and dacarbazine groups was 5.1 months and 2.7 months, respectively. Overall survival did not differ significantly between groups; 11% of patients in the dabrafenib group died compared to 14% in the dacarbazine group (hazard ratio: 0.61, 95% CI: 0.25–1.48). However, 28 patients (44%) in the dacarbazine arm crossed over at disease progression to receive dabrafenib. The objective response rate, defined as complete plus partial responses, was greater in the dabrafenib group (50%, 95% CI: 42.4–57.1%) compared to the dacarbazine group (6%, 95% CI: 1.8–15.5%). Treatment-related adverse events grade 2 or higher occurred in 53% of patients who received dabrafenib and in 44% of patients who received dacarbazine. Grade 3-4 adverse events were uncommon in both groups. The most common serious adverse events were cutaneous squamous cell carcinoma (7% vs. none in controls); serious non-infectious, febrile drug reactions (3% grade 3 pyrexia vs. none in controls); and severe hyperglycemia (>250-500 mg/dL), requiring medical management in non-diabetic patients or change in management of diabetic patients (6% vs. none in controls). Results demonstrated that targeting dabrafenib against BRAF V600E mutated melanoma results in a benefit in progression-free survival. Patients were allowed to cross over at the time of progression, and the effect of dabrafenib on overall survival was favorable but not statistically significant.
All tissue specimens from patients screened for enrollment in the clinical trial were analyzed centrally by a clinical trial assay. Outcomes were linked retrospectively to BRAF testing by the THxID BRAF kit. Of 250 patients enrolled in the trial, specimens from 237 patients (177 [95%] in the dabrafenib arm and 55 [87%] in the dacarbazine arm) were retested with the THxID BRAF kit. Reanalysis of the primary end point, PFS, in patients who were V600E positive by the THxID BRAF kit showed a treatment effect that was nearly identical to the overall result by central assay. Additional analysis for discordant results assumed a worst case scenario, i.e., a hazard ratio of 1 for patients V600E-mutation-positive by the THxID BRAF test but mutation negative by central assay. The hazard ratio was 0.34 (95% CI: 0.23–0.50) (FDA, 2013).
Trametinib.
The clinical efficacy and safety of trametinib was assessed in the Phase III, open-label METRIC trial (Flaherty, 2012). Patients with stage IV or unresectable stage IIIC cutaneous melanoma were randomized 2:1 to receive trametinib 2 mg orally once daily (n=214) or chemotherapy (n=108), either dacarbazine 1,000 mg/m2 IV every 3 weeks or paclitaxel 175 mg/m2 IV every 3 weeks at investigator discretion. Most patients (67%) were previously untreated. The primary efficacy endpoint was PFS; secondary endpoints included overall survival, overall response rate, and safety. Tumor assessments were performed at baseline and at weeks 6, 12, 21, and 30 and then every 12 weeks.
Median PFS was 4.8 months (95% CI: 4.3–4.9) in the trametinib arm and 1.5 months (95% CI: 1.4-2.7) in the chemotherapy arm, a statistically significant difference. (Table 3) Although median overall survival had not been reached at the time of the report publication, 6-month survival was statistically longer in the trametinib group than in the chemotherapy group (p=0.01); 51 of 108 patients (47%) in the chemotherapy group crossed over at disease progression to receive trametinib. In the trametinib and chemotherapy groups, adverse events led to dose interruption in 35% and 22% of patients, respectively, and to dose reduction in 27% and 10% of patients, respectively. Decreased ejection fraction or ventricular dysfunction was observed in 14 patients (7%) in the trametinib group; 2 patients had grade 3 cardiac events that led to permanent drug discontinuation. Twelve percent of the trametinib group and 3% of the chemotherapy grouped experienced grade 3 hypertension. Nine percent of patients in the trametinib group experienced ocular events (mostly grade 1 or 2), most commonly blurred vision (4%). The most common adverse events in the trametinib group were rash, diarrhea, peripheral edema, and fatigue; rash was grade 3 or 4 in 16 patients (8%). Cutaneous squamous cell carcinoma was not observed during treatment.
Tumor tissue was evaluated for BRAF mutations at a central site using a clinical trial assay. Retrospective THxID BRAF analysis was conducted on tumor samples from 289 patients (196 [92%] in the trametinib arm and 93 [86%] in the chemotherapy arm). Reanalysis of PFS in patients who were V600E or V600K-positive by the THxID BRAF kit showed a treatment effect that was almost identical to the overall result by central assay. Additional analysis for discordant results assuming a worst case scenario as above yielded a hazard ratio of 0.48 (95% CI: 0.35–0.63) (FDA, 2013).
Resistance to BRAF inhibitors
Median duration of response in the Phase I (extension), II, and III studies of vemurafenib was approximately 6 months, 6.7 months, and 5.5 months, respectively, suggesting the development of resistance; (Chapman, 2011; Sosman, 2012; Flaherty, 2010) in some patients with BRAFV600E-positive tumors, there was no response at all, which was interpreted as primary resistance. Investigations of the mechanisms of resistance have reported evidence of different molecular mechanisms potentially responsible for resistance in different patients (Johannessen, 2010; Nazarian, 2010). It is likely that combined inhibition of BRAF and other key molecular targets, and the use of different combinations in different patients, will be needed in the future. For example, MEK proteins are also components of the MAP kinase signal-transduction pathway; like BRAF inhibitors, MEK inhibitors, such as trametinib, have been designed to interfere with this pathway and may be used in combination. An open-label Phase I/II trial examined the pharmacokinetics, safety, and efficacy of dabrafenib plus trametinib combination therapy in 247 patients with metastatic (stage IV) melanoma and BRAF V600E or V600K mutations (Flaherty, 2012). Maximum tolerated combination dosing was not reached. One dose-limiting toxic effect, recurrent neutrophilic panniculitis, occurred in 24 patients who received the highest dose level (dabrafenib 150 mg twice daily plus trametinib 2 mg daily), and this was the recommended dose for efficacy testing. Median PFS, the primary efficacy endpoint, was 9.4 months in the combination therapy group (n=54) and 5.8 months in the dabrafenib (150 mg twice daily) monotherapy group (n=54; hazard ratio 0.39, 95% CI: 0.25–0.62; p<0.001). Complete or partial response occurred in 76% of patients in the combination therapy group and 54% of the monotherapy group (p=0.03). Median duration of response was 10.5 (95% CI: 7.4–14.9) months and 5.6 months (95% CI: 4.5–7.4), respectively. Cutaneous squamous cell carcinoma occurred in 7% of the combination therapy group and 19% of the monotherapy group (p=0.09). Fever was more common in the combination therapy group (71% vs. 26% monotherapy; p=<0.001). Other trials of vemurafenib, dabrafenib, and trametinib in combination with each other and with other treatments (e.g., high-dose interleukin-2) are currently in progress, as listed below.
A search of the ClinicalTrials.gov website identified a number of ongoing Phase III trials of BRAF inhibitor therapy in melanoma. Most trials study combination therapy. All trials are in patients with unresectable stage III or stage IV melanoma, except for NCT01667419 under "Single agents" and NCT01682083 under "Combination treatments," which are in patients with completely resected melanoma.
Currently active Phase III trials of BRAF inhibitor therapy for melanoma:
NCT01898585- An Open-Label Study of Zelboraf (Vemurafenib) in Patients with BRAF V600-Mutation Positive Metastatic Melanoma. This is a single-arm study with an estimated completion date of June 2015.
NCT01667419- BRIM8: A Study of Vemurafenib Adjuvant Therapy in Patient s With Resected Cutaneous BRAF Mutant Melanoma. This double-blind RCT has an estimated completion date of June 2016.
NCT01683188- High-Dose Interleukin-2 + Vemurafenib in Patients with BRAF Mutation Positive Metastatic Melanoma (PROCLIVITY 01). Estimated completion date of April 2016.
NCT01584648- A Study Comparing Trametinib and Dabrafenib Combination Therapy to Dabrafenib Monotherapy in Subjects With BRAF-mutant Melanoma. This is a double-blind, RCT with a completion date of September 2013.
NCT01597908- Dabrafenib Plus Trametinib vs. Vemurafenib Alone in Unresectable or Metastatic BRAF V600E/K Cutaneous Melanoma (COMBI-V). Open-label, RCT with estimated completion date of March 2014.
NCT01682083- The BRAF Inhibitor Dabrafenib in Combination With the MEK Inhibitor Mutation-positive Melanoma After Surgical Resection (COMBI-AD). Double-blind, RCT with a completion date of July 2015.
NCT01689519- coBRIM: A Phase 3 Study Comparing GDC-0973 (Cobimetinib), a MEK Inhibitor, in Combination With Vemurafenib vs. Vemurafenib Alone in Patients With Metastatic Melanoma. Double-blind RCT with scheduled completion date of August 2016.
NCT01909453- Study Comparing Combination of the RAF Kinase Inhibitor LGX818 Plus the MEK Inhibitor MEK 162 and LGX818 Monotherapy Versus Vemurafenib in Unresectable or Metastatic BRAF V600 Mutant Melanoma (COLUMBUS). Open-label RCT with an estimated scheduled completion date of June 2017.
A large proportion of patients with advanced melanoma have a mutation in the BRAF gene. There are 2 Phase III randomized controlled trials (RCTs) of BRAF inhibitors (vemurafenib and dabrafenib) in advanced melanoma patients who are positive for the BRAFV600E mutation and 1 Phase III trial of a MEK inhibitor (trametinib) in advanced melanoma patients who are positive for BRAF V600E or V600K mutations. All of the trials reported a benefit in progression-free survival for treatment with a BRAF inhibitor. In addition, the vemurafenib and trametinib trials reported a significant improvement in overall mortality; the dabrafenib trial did not demonstrate a difference in overall survival. These results support the clinical validity and clinical utility of the cobas 4800 BRAF V600 Mutation Test to select patients for treatment with vemurafenib, and the THxID BRAF kit to select patients for treatment with dabrafenib and trametinib.
A literature search conducted through September 2016 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
Combination BRAF (Dabrafenib) and MEK (Trametinib) Inhibition
Efficacy of combination treatment with dabrafenib and trametinib has been established with 2 phase 3 clinical trials (Long, 2015; Robert, 2015; Long, 2014; NCCN, 2016).
Clinical efficacy of combination treatment with dabrafenib and trametinib was evaluated in the phase 3 open-label by Long and colleagues (Long, 2015; Long 2014). In this study, 4234 patients with unresectable stage IIC or stage IV melanoma with a BRAF V600E or V600K mutation were randomized to either a combination of dabrafenib and trametinib or dabrafenib and placebo. The primary end point was progression-free survival, reported in a first publication followed by a second publication in which longer term overall survival was reported (Long, 2015).
Median PFS was 9.3 months in the dabrafenib-trametinib group and 8.8 months in the dabrafenib-only group. The overall response rate was 67% in the dabrafenib-trametinib group and 51% in the dabrafenibonly group. An interim overall survival analysis showed a difference in survival which was statistically significant with standard statistical criteria, but did not cross the prespecified stopping boundary. The rate of cutaneous squamous cell carcinoma was lower in the dabrafenib-trametinib group (2% vs 9%), whereas pyrexia occurred in more patients (51% vs 28%). In the longer term study assessing overall survival, median survival was 25.1 months in the dabrafenib-trametinib group versus 18.7 months in the dabrafenib-only group.
This update focuses on the use of testing for BRAF pathogenic variants in individuals with glioma.
Currently there is no standard method for testing BRAF status in neuropathology. DNA-based tests for melanomas and IHC are used. The analytic validity of these methods is described in the previous section on melanoma.
Clinical Validity and Clinical Utility
Sorafenib is a multikinase inhibitor with potent in vitro activity against both BRAF wild-type and V600E variant as well as vascular endothelial growth factor receptors (VEGFR), platelet-derived growth factor receptors (PDGFR), and c-KIT. Several phase 2 single-arm prospective studies have investigated the use of sorafenib in newly diagnosed and recurrent, adult and pediatric, low- and high-grade gliomas in various combinations with other treatments. Results have not shown sorafenib to be effective. Most studies did not report BRAF V600 variant status.
Hyman et al (2015) published results of a multicenter phase 2 "basket" study of vemurafenib in BRAF V600 variant–positive nonmelanoma cancers (Hyman, 2015). A total of 122 patients with BRAF V600 pathogenic variants were enrolled, including 8 patients with gliomas. Response was assessed by site investigators using RECIST criteria. Of the 8 glioma patients, 2 died before the 1-month evaluation; 4 had stable disease at 12, 6, 4, and 3 months and 2 had progressive disease at 2 and 7 months, all respectively.
Studies of sorafenib in patients with newly diagnosed and recurrent gliomas combined with various other treatments have not shown benefit, although most did not report BRAF V600 status. Evaluation of the BRAF and MEK inhibitors vemurafenib, dabrafenib, and trametinib in patients with gliomas has been limited to 1 phase 2 "basket" study (including 8 patients with glioma), case reports, and small case series. Several early phase studies are ongoing.
Annual policy review completed with a literature search using the MEDLINE database through June 2018. The key identified literature is summarized below.
The primary evidence of clinical validity and utility for the cobas 4800 BRAF V600 Mutation Test is provided by the phase 3 clinical trial of vemurafenib that enrolled patients testing positive for a V600 variant.
The BRIM-3 trial as reported by Chapman et al (2011) randomized a total of 675 patients to vemurafenib (960 mg twice daily orally) or to dacarbazine (1000 mg/m2 body surface area by intravenous infusion every 3 weeks) to determine whether vemurafenib would prolong the rate of OS or PFS compared with dacarbazine (Chapman, 2011). All enrolled patients had unresectable, previously untreated stage IIIC or IV melanoma with no active central nervous system metastases. Melanoma specimens from all patients tested positive for the BRAF V600E variant on the cobas 4800 BRAF V600 Mutation Test. Included were 19 patients with BRAF V600K variants and 1 with a BRAF V600D variant.
Tumor assessments, including computed tomography, were performed at baseline, at weeks 6 and 12, and every 9 weeks after that. Tumor responses were determined by investigators using Response Evaluation Criteria in Solid Tumors (RECIST), version 1.1. Primary end points were the rate of OS and PFS. An interim analysis was planned at 98 deaths and a final analysis at 196 deaths; the published report is the interim analysis. The data and safety monitoring board determined that both coprimary end points had met prespecified stopping criteria and recommended that patients in the dacarbazine group be allowed to cross over to receive vemurafenib. At the time the trial was halted, 118 patients had died; median survival had not been reached. Results for OS strongly favored vemurafenib, with a hazard ratio (HR) of 0.37 (95% confidence interval [CI], 0.26 to 0.55). Adverse events in the vemurafenib group included grade 2 or 3 photosensitivity skin reactions in 12% of patients and cutaneous squamous cell carcinoma in 18%. The results of this trial comprised the efficacy and safety data supporting vemurafenib submission to FDA and established safety and effectiveness of the cobas 4800 BRAF V600 Mutation Test, resulting in coapproval of both the drug and companion test.
In 2017, final OS results from BRIM-3 were reported by Chapman et al (Chapman, 2017). Eighty-four (25%) of the 338 dacarbazine patients crossed over to vemurafenib and overall 173 (51%) of the 338 patients in the dacarbazine group and 175 of the 337 patients (52%) in the vemurafenib group received subsequent anticancer therapies, most commonly ipilimumab. Median OS without censoring at crossover was 13.6 months (95% CI, 12.0 to 15.4) in vemurafenib vs 10.3 months (95% CI, 9.1 to 12.8 months) in dacarbazine (HR=0.81; 95% CI, 0.68 to 0.96); p=0.01).
Combination BRAF Plus MEK Inhibitors
Dabrafenib and Trametinib
The efficacy of combination dabrafenib plus trametinib treatment has been established with two phase 3 clinical trials (Long, 2015; Robert, 2015; Long, 2014). This combination agent was evaluated in the phase 3 open-label trial by Long et al (Long, 2014; Long 2015). In this trial, 4234 patients with unresectable stage IIC or stage IV melanoma with a BRAF V600E or V600K variant were randomized to dabrafenib plus trametinib or dabrafenib plus placebo. The primary end point was PFS, as reported in a first publication, followed by a second publication in which longer term OS was reported (Long, 2014; Long, 2015).
Median PFS was 11.0 months in the dabrafenib plus trametinib group and 8.8 months in the dabrafenib-only group. The overall response rate was 67% in the dabrafenib plus trametinib group and 51% in the dabrafenib-only group. An interim OS analysis showed a statistically significant difference using standard statistical criteria, but the difference did not cross the prespecified stopping boundary. The rate of cutaneous squamous cell carcinoma was lower in the dabrafenib plus trametinib group (2% vs 9%), whereas pyrexia occurred in more patients (51% vs 28%). In the longer term study assessing OS, median survival was 25.1 months in the dabrafenib plus trametinib group and 18.7 months in the dabrafenib-only group.
Encorafenib Plus Binimetinib
Dummer et al reported on results of a phase 3 COLUMBUS RCT comparing encorafenib, a BRAF inhibitor, alone or in combination with the MEK inhibitor binimetinib, with vemurafenib in patients who had advanced BRAF V600-variant unresectable or metastatic melanoma (Dummer, 2018). The COLUMBUS trial was conducted in 162 hospitals in 28 countries between 2013 and 2015; patients were randomized (1:1:1) to oral encorafenib 450 mg once daily plus oral binimetinib 45 mg twice daily (n=192), oral encorafenib 300 mg once daily (n=194), or oral vemurafenib 960 mg twice daily (n=191). The primary outcome was PFS for encorafenib plus binimetinib vs vemurafenib. Analyses were done on the intention-to-treat population. Median follow-up was 17 months. PFS was significantly increased with encorafenib plus binimetinib compared with vemurafenib (median PFS=14.9 months vs 7.3 months in the vemurafenib group; HR=0.54; 95% CI, 0.41 to 0.71; p<0.001; see Table 2). OS was not reported. The most common grade 3 or 4 adverse events were increased γ-glutamyltransferase (9%), increased creatine phosphokinase (7%), and hypertension (6%) in the encorafenib plus binimetinib group; palmoplantar erythrodysesthesia syndrome (14%), myalgia (10%), and arthralgia (9%) in the encorafenib group; and arthralgia (6%) in the vemurafenib group.
Clinically Valid and Clinical Usefulness
Two RCTs of BRAF and/or MEK inhibitors in patients with resected stage III BRAF-variant melanoma, have been reported by Long et al in 2017 and Maio et al in 2018.
Long et al reported on results of COMBI-AD, a phase 3 RCT comparing adjuvant combination therapy using dabrafenib plus trametinib with placebo in 870 patients who had stage III melanoma with BRAF V600E or V600K variants (Long, 2017). In 2013 and 2014 when patients were being enrolled in COMBI-AD, observation was the standard of care after resection of stage III melanoma in most countries. With a median follow-up of 2.8 years, the 3-year rate of relapse-free survival was 58% in the combination group and 39% in the placebo group (HR=0.47; 95% CI, 0.39 to 0.58; p<0.001). OS rates at 3 years were 86% and 77%, respectively (HR=0.57; 95% CI, 0.42 to 0.79; p<0.001).
Maio et al reported on results of BRIM8, a phase 3 RCT comparing adjuvant vemurafenib monotherapy with placebo in 498 patients who had stage IIC, IIIA, IIIB, or IIIC BRAF V600 variant-positive melanoma (Maio, 2018). Patients with stage IIC, IIIA, or IIIB disease were enrolled in cohort 1 (n=314), and patients with stage IIIC disease were enrolled in cohort 2 (n=184). As stated previously, during enrollment, observation was standard care for stage III melanoma. A hierarchical testing strategy was prespecified for the primary outcome (disease-free survival) based on the assumption that observing a biologic effect in higher risk disease (ie, cohort 2) would suggest a treatment effect across the continuum of melanoma given the effect is already established in metastatic melanoma. In the hierarchical strategy, only a p value of 0.05 or less in cohort 2 would allow for results in cohort 1 to be considered significant. The median trial follow-up was 34 months (interquartile range, 26-42 months) in cohort 2 and 31 months (interquartile range, 26-41 months) in cohort 1. In cohort 2, median disease-free survival was 23 months (95% CI, 19 to 27 months) in the vemurafenib group and 15 months (95% CI, 11 to 36 months) in the placebo group (HR=0.80; 95% CI, 0.54 to 1.18; p=0.26). In cohort 1, median disease-free survival was not reached (95% CI, not estimable) in the vemurafenib group and 37 months (95% CI, 21 to not estimable) in the placebo group (HR=0.54; 95% CI, 0.37 to 0.78); however, this result cannot be considered statistically significant because of the prespecified hierarchical testing strategy.
In summary, RCTs of BRAF and MEK inhibitor therapy in stage III melanoma patients selected by BRAF V600 variant testing have shown reductions in recurrence risk. One well-conducted RCT of combination BRAF and MEK inhibitor treatment with dabrafenib plus trametinib has shown superiority for recurrence risk and OS in BRAF variant-positive, stage III patients compared with placebo. Single-agent BRAF inhibitor treatment using vemurafenib compared with placebo showed numeric benefit for disease-free survival in patients with stage IIC, IIIA, or IIIB BRAF V600 variant-positive melanoma but this result must be considered exploratory given the lack of statistically significant benefit in stage IIIC disease and the hierarchical statistical testing strategy. There are no RCTs directly comparing BRAF and MEK inhibitor therapy with immunotherapy as an adjuvant treatment for stage III patients with BRAF pathogenic variants.
A literature search was conducted through June 2019. There was no new information identified that would prompt a change in the coverage statement.
Annual policy review completed with a literature search using the MEDLINE database through June 2021. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
Ascierto et al published long-term outcomes from the COLUMBUS trial (Ascierto, 2020). The median follow-up for OS was 48.8 months. Compared with vemurafenib, the combination of encorafenib plus binimetinib significantly reduced the risk of death by 39% (HR, 0.61; 95% CI, 0.48 to 0.79) and increased the duration of PFS (HR, 0.51; 95% CI, 0.39 to 0.67). The OS rates at 3 years were 47%, 41%, and 31% for encorafenib plus binimetinib, encorafenib, and vemurafenib groups, respectively. All subgroup analyses favored combination treatment with encorafenib plus binimetinib versus treatment with vemurafenib alone.
Gutzmer et al reported primary results from IMspire150, a phase 3, double-blind RCT of atezolizumab, vemurafenib, and cobimetinib (n=256) compared to placebo, vemurafenib, and cobimetinib (n=258) as first-line treatment for unresectable advanced BRAF V600-positive melanoma (Gutzmer, 2020). The primary endpoint was investigator-assessed PFS. The median follow-up in the overall study population was 18.9 months. At data cut-off, 327 patients had progressive disease by investigator assessment or had died, including 148 (58%) of patients in the atezolizumab group and 179 (69%) in the control group. The atezolizumab with vemurafenib and cobimetinib group experienced a median PFS per investigator assessment of 15.1 months (95% CI, 0.63 to 0.97) compared to 10.6 months (95% CI, 9.3 to 12.7) in the control group. A 77% concordance rate for progressive disease assessment by study investigators versus independent review committee was reported. The primary reason for discordant results (n=109) was the assessment of progressive disease per study investigators but not the independent review committee. The prevalence of treatment-related adverse events was comparable between the 2 groups. PD-L1 expression status was not significantly associated with the treatment effect.
Marabelle et al reported the association of TMB-high (TMB-H) status to response to pembrolizumab in patients with various previously treated unresectable or metastatic solid tumors enrolled in a prespecified exploratory analysis of the nonrandomized, phase 2 KEYNOTE-158 study (NCT02628067) (Marabelle, 2020). TMB-H was defined as ≥10 mutations per megabase according to the FoundationOne CDx panel. The proportion of patients with an objective response in the TMB-H group was 29%. At a median follow-up of approximately 3 years, the median duration of response was not reached in the TMB-H group and was 33.1 months in the non-TMB-H group. TMB-H status was associated with improved response irrespective of PD-L1 status. Median PFS and OS did not differ between the high and non-high TMB groups. Objective responses were observed in 24 (35%; 95% CI, 24 to 48) of 68 participants who had both TMB-H status and PD-L1-positive tumours (ie, PD-L1 combined positive score of ≥1) and in 6 (21%; 8 to 40) of 29 participants who had TMB-H status and PD-L1-negative tumors.
Notably, patients with melanoma or glioma were not included in these analyses. Study eligible cancers were limited to anal, biliary, cervical, endometrial, mesothelioma, neuroendocrine, salivary, small-cell lung, thyroid, and vulvar. The prescribing information for pembrolizumab includes a "Limitation of Use" stating that the safety and effectiveness of pembrolizumab in pediatric patients with TMB-H central nervous system cancers have not been established.
Several early phase "basket" studies, case reports, and small case series have suggested clinical benefit with vemurafenib, dabrafenib, and trametinib in patients with glioma and BRAF V600 pathogenic variants (Hyman, 2015; Kaley, 2018; Brown, 2017; Marks, 2018; Wen, 2022). Ongoing phase 3 studies of targeted therapy with these agents were not identified.
0037U Targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden
81210 BRAF (B Raf proto oncogene, serine/threonine kinase) (eg, colon cancer, melanoma), gene analysis, V600 variant(s)
References: American Cancer Society.(2011) Melanoma Skin Cancer. http://www.cancer.org/Cancer/SkinCancer-Melanoma/DetailedGuide/melanoma-skin-cancer-key-statistics. Last accessed September 12, 2011.
Anderson S, Bloom KJ, Vallera DU et al.(2012) Multisite Analytic Performance Studies of a Real-Time Polymerase Chain Reaction Assay for the Detection of BRAF V600E Mutations in Formalin-Fixed, Paraffin-Embedded Tissue Specimens of Malignant Melanoma. Arch Pathol Lab Med 2012; 136(11):1385-91.
Ascierto PA, Dummer R, Gogas HJ, et al.(2020) Update on tolerability and overall survival in COLUMBUS: landmark analysis of a randomised phase 3 trial of encorafenib plus binimetinib vs vemurafenib or encorafenib in patients with BRAF V600-mutant melanoma. Eur J Cancer. Feb 2020; 126: 33-44. PMID 31901705
Brown NF, Carter T, Kitchen N, et al.(2017) Dabrafenib and trametinib in BRAFV600E mutated glioma. CNS Oncol. Oct 2017; 6(4): 291-296. PMID 28984141
Center For Drug Evaluation and Research.(2011) Summary review for vemurafenib. Available at http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/202429Orig1s000SumR.pdf Last accessed September 12, 2011.
Chapman PB, Hauschild A, Robert C et al.(2011) Improved survival with vemurafenib in melanoma with BRAF V600E mutation. N Engl J Med 2011; 364(26):2507-16.
Chapman PB, Hauschild A, Robert C, et al.(2011) Improved survival with vemurafenib in melanoma with BRAF V600E mutation. N Engl J Med 2011;364:2507-16.
Chapman PB, Robert C, Larkin J, et al.(2017) Vemurafenib in patients with BRAFV600 mutation-positive metastatic melanoma: final overall survival results of the randomized BRIM-3 study. Ann Oncol. Oct 1 2017;28(10):2581-2587. PMID 28961848
Dummer R, Ascierto PA, Gogas HJ, et al.(2018) Encorafenib plus binimetinib versus vemurafenib or encorafenib in patients with BRAF-mutant melanoma (COLUMBUS): a multicentre, open-label, randomised phase 3 trial. Lancet Oncol. May 2018;19(5):603-615. PMID 29573941
Dummer R, Goldinger SM, Turtschi CP, et al.(2014) Vemurafenib in patients with BRAF(V600) mutation-positive melanoma with symptomatic brain metastases: final results of an open-label pilot study. Eur J Cancer. Feb 2014; 50(3): 611-21. PMID 24295639
FDA. Companion diagnostic devices: in vitro and imaging tools. Available online at: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/InVitroDiagnostics/ucm301431.htm. Last accessed September 2013.
FDA. Draft guidance for industry and food and drug administration staff: in vitro companion diagnostic devices. Available at http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm262292.htm.
FDA. Draft guidance for industry and food and drug administration staff: in vitro companion diagnostic devices. July 14, 2011. Available online at: http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm262292.htm. Last accessed September 2013.
FDA. THxID™-BRAF kit for use on the ABI 7500 Fast Dx Real-Time PCR Instrument - P120014. BioMérieux labeling, May 2013. Available online at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cftopic/pma/pma.cfm?num=p120014. Last accessed September 2013.
Flaherty KT, Infante JR, Daud A et al.(2012) Combined BRAF and MEK Inhibition in Melanoma with BRAF V600 Mutations. N Engl J Med 2012; 367(18):1694-703.
Flaherty KT, Puzanov I, Kim KB, et al.(2010) Inhibition of mutated, activated BRAF in metastatic melanoma. N Engl J Med 2010;363:809-19.
Flaherty KT, Robert C, Hersey P et al.(2012) Improved Survival with MEK Inhibition in BRAF-Mutated Melanoma. N Engl J Med 2012; 367(2):107-14.
Flaherty KT.(2010) Narrative Review: BRAF opens the door to therapeutic advances in melanoma. Ann Intern Med. 2010;153:587-591.
Food and Drug Administration.(2017) SUMMARY OF SAFETY AND EFFECTIVENESS DATA (SSED): FoundationOne CDx™. https://www.accessdata.fda.gov/cdrh_docs/pdf17/P170019B.pdf. Accessed April 26, 2018.
Genentech, Inc. Zelboraf® (vemurafenib) tablet prescribing information, July 2013. Available online at: http://www.zelboraf.com/. Last accessed September 2013.
GlaxoSmithKline. Mekinist (trametinib) tablets prescribing information, May 2013. Available online at: http://www.mekinist.com/. Last accessed September 2013.
GlaxoSmithKline. Tafinlar (dabrafenib) capsules prescribing information, May 2013. Available online at: http://www.tafinlar.com/. Last accessed September 2013.
Gogas HJ, Kirkwood JM, Sondak VK.(2007) Chemotherapy for metastatic melanoma: time for a change? Cancer 2007; 109(3):455-64.
Gutzmer R, Stroyakovskiy D, Gogas H, et al.(2020) Atezolizumab, vemurafenib, and cobimetinib as first-line treatment for unresectable advanced BRAF V600 mutation-positive melanoma (IMspire150): primary analysis of the randomised, double-blind, placebo-controlled, phase 3 trial. Lancet. Jun 13 2020; 395(10240): 1835-1844. PMID 32534646
Hauschild A, Grob JJ, Demidov LV et al.(2012) Dabrafenib in BRAF-mutated metastatic melanoma: a multicentre, open-label, phase 3 randomised controlled trial. Lancet 2012; 380(9839):358-65.
Hyman DM, Puzanov I, Subbiah V, et al.(2015) Vemurafenib in multiple nonmelanoma cancers with BRAF V600 mutations. N Engl J Med. Aug 20 2015;373(8):726-736. PMID 26287849
Johannessen CM, Boehm JS, Kim SY et al.(2010) COT drives resistance to RAF inhibition through MAP kinase pathway reactivation. Nature 2010; 468(7326):968-72.
Joseph EW, Pratilas CA, Poulikakos PI et al.(2010) The RAF inhibitor PLX4032 inhibits ERK signaling and tumor cell proliferation in a V600E BRAF-selective manner. Proc Natl Acad Sci U S A 2010; 107(33):14903-8.
Kaley T, Touat M, Subbiah V, et al.(2018) BRAF Inhibition in BRAF V600 -Mutant Gliomas: Results From the VE-BASKET Study. J Clin Oncol. Dec 10 2018; 36(35): 3477-3484. PMID 30351999
King AJ, Patrick DR, Batorsky RS et al.(2006) Demonstration of a genetic therapeutic index for tumors expressing oncogenic BRAF by the kinase inhibitor SB-590885. Cancer Res 2006; 66(23):11100-5. Cancer Res 2006; 66(23):11100-5.
Label information for ipilimumab.(2011) Center For Drug Evaluation and Research. Available at http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/125377s0000lbl.pdf. Last accessed September 12, 2011.
Long GV, Hauschild A, Santinami M, et al.(2017) Adjuvant Dabrafenib plus Trametinib in Stage III BRAF-Mutated Melanoma. N Engl J Med. Nov 9 2017;377(19):1813-1823. PMID 28891408
Long GV, Stroyakovskiy D, Gogas H, et al.(2014) Combined BRAF and MEK inhibition versus BRAF inhibition alone in melanoma. N Engl J Med. Nov 13 2014;371(20):1877-1888. PMID 25265492
Long GV, Stroyakovskiy D, Gogas H, et al.(2015) Dabrafenib and trametinib versus dabrafenib and placebo for Val600 BRAF-mutant melanoma: a multicentre, double-blind, phase 3 randomised controlled trial. Lancet. Aug 1 2015;386(9992):444-451. PMID 26037941
Long GV, Trefzer U, Davies MA, et al.(2012) Dabrafenib in patients with Val600Glu or Val600Lys BRAF-mutant melanoma metastatic to the brain (BREAK-MB): a multicentre, open-label, phase 2 trial. Lancet Oncol. Nov 2012; 13(11): 1087-95. PMID 23051966
Louis DN, Ohgaki H, Wiestler HOD, et al.(2016) WHO Classification of Tumours of the Central Nervous System. Revised. 4th ed. Lyon: WHO Press; 2016.
Maio M, Lewis K, Demidov L, et al.(2018) Adjuvant vemurafenib in resected, BRAF(V600) mutation-positive melanoma (BRIM8): a randomised, double-blind, placebo-controlled, multicentre, phase 3 trial. Lancet Oncol. Apr 2018;19(4):510-520. PMID 29477665
Marabelle A, Le DT, Ascierto PA, et al.(2020) Efficacy of Pembrolizumab in Patients With Noncolorectal High Microsatellite Instability/Mismatch Repair-Deficient Cancer: Results From the Phase II KEYNOTE-158 Study. J Clin Oncol. Jan 01 2020; 38(1): 1-10. PMID 31682550
Marks AM, Bindra RS, DiLuna ML, et al.(2018) Response to the BRAF/MEK inhibitors dabrafenib/trametinib in an adolescent with a BRAF V600E mutated anaplastic ganglioglioma intolerant to vemurafenib. Pediatr Blood Cancer. May 2018; 65(5): e26969. PMID 29380516
Merino DM, McShane LM, Fabrizio D, et al.(2020) Establishing guidelines to harmonize tumor mutational burden (TMB): in silico assessment of variation in TMB quantification across diagnostic platforms: phase I of the Friends of Cancer Research TMB Harmonization Project. J Immunother Cancer. Mar 2020; 8(1). PMID 32217756
National Comprehensive Cancer Network (NCCN).(2016) Clinical Practic Guidelines in Oncology, Melanoma v1.2016. http://www.nccn.org/professionals/physician_gls/pdf/melanoma.pdf.
Nazarian R, Shi H, Wang Q et al.(2010) Melanomas acquire resistance to B-RAF(V600E) inhibition by RTK or N-RAS upregulation. Nature 2010; 468(7326):973-7.
Ribas A, Kim KB, Schuchter LM et al. Ribas A, Kim KB, Schuchter LM et al.(2011) BRIM-2: An open-label, multicenter phase II study of vemurafenib in previously treated patients with BRAF V600E mutation-positive metastatic melanoma. J Clin Oncol 2011; 29 (Suppl):Abstract 8509.
Robert C, Karaszewska B, Schachter J, et al.(2015) Improved overall survival in melanoma with combined dabrafenib and trametinib. N Engl J Med. Jan 1 2015;372(1):30-39. PMID 25399551
Rubinstein JC, Sznol M, Pavlick AC et al.(2010) Incidence of the V600K mutation among melanoma patients with BRAF mutations, and potential therapeutic response to the specific BRAF inhibitor PLX4032. J Transl Med 2010; 8:67.
Sondergaard JN, Nazarian R, Wang Q et al.(2010) Differential sensitivity of melanoma cell lines with BRAFV600E mutation to the specific Raf inhibitor PLX4032. J Transl Med 2010; 8:39.
Takle AK, Brown MJ, Davies S et al.(2006) The identification of potent and selective imidazole-based inhibitors of B-Raf kinase. Bioorg Med Chem Lett 2006; 16(2):378-81.
Teutsch SM, Bradley LA, Palomaki GE et al.(2009) The Evaluation of Genomic Applications in Practice and Prevention (EGAPP) Initiative: methods of the EGAPP Working Group. Genet Med 2009; 11(1):3-14.
Vultur A, Villanueva J, Herlyn M.(2011) Targeting BRAF in advanced melanoma: a first step toward manageable disease. Clin Cancer Res. 2011 Apr 1;17(7):1658-1663.
Vultur A, Villanueva J, Herlyn M.(2011) Targeting BRAF in advanced melanoma: a first step toward manageable disease. Nature 2010; 467(7315):596-9.
Wen PY, Stein A, van den Bent M, et al.(2022) Dabrafenib plus trametinib in patients with BRAF V600E -mutant low-grade and high-grade glioma (ROAR): a multicentre, open-label, single-arm, phase 2, basket trial. Lancet Oncol. Jan 2022; 23(1): 53-64. PMID 34838156
Yang H, Higgins B, Kolinsky K et al.(2010) RG7204 (PLX4032), a selective BRAFV600E inhibitor, displays potent antitumor activity in preclinical melanoma models. Cancer Res 2010; 70(13):5518-27.


I was delirious with joy when I first heard The Beaches' "Money" on Toronto's Indie88. First, because it's an amazing song. Second, because there's not enough crunchy guitar rock coming from young bands. And third, because there aren't enough female voices in rock – especially kickass garage-y power-chord-driven rock.
Maybe The Beaches (Jordan Miller thumping and wailing on bass and lead vocals, sister Kylie Miller shredding on lead guitar, Eliza Enman McDaniel spanking the drums, and Leandra Earl laying down keyboards and rhythm guitar) will usher in a new era of women in rock that will stick around a lot longer (like, forever) than the all-too-short mid-90s era of Juliana Hatfield, Liz Phair, PJ Harvey and company.
This is a debut album?: Like, seriously. I know they released a couple EPs before this, and I haven't had a chance to listen to those yet, but it just seems like they emerged from the musical womb as fully-formed rock goddesses.
"Highway 6": The title alone conjures fond memories of our annual (often multi-annual) trip up Highway 6 to Sauble Beach. It's a leisurely, often contemplative trip through rural Ontario, passing loads of farmland, the occasional small town, a giant Muskoka chair and my favourite: a little stone building in the middle of farm country that houses a computer store. The actual highway aside, I love so much about this, the quietest, slowest-tempo song on the album. I love the sparse drums, muted guitar, droning keys and falsetto vocals, which somehow remind me of a quiet winter's night with the soft glow of streetlights. I love how high and impassioned Jordan's voice gets in the last minute or so. I love the bass-y keyboard part we're treated to just for a few bars at the end.
Big, bad bottom: Yeah, I'm a guitar guy, but above all I'm a music guy and when something's good, it's good. You don't get enough emphasis on bass guitar in rock songs. Maybe it helps that their front woman is also their bass player, but The Beaches often bring that big, bad bass right up front and it rumbles right through me and it's a beautiful thing.
"Money": I need to make money, too, so I can relate. Can't we all? Dolla' bills aside, y'all, this is the lead single for a reason. It's the best song on the album. It's the song that made me fall in love with this band. Jordan's wonderfully disinterested, deep-voiced vocals in the verse remind me a little of The Strokes' Julian Casablancas. (Kylie's guitar riffs on this one are also very Strokesian.) Then she goes high to belt out that chorus that's such a simple, syrupy-sweet earworm. "Woo!" It's all about the "woo!" One night I was having trouble getting to sleep and that chorus wouldn't stop playing in my head. It didn't help with the getting-to-sleep thing, but I love it anyway.
Did I say "syrupy-sweet earworm?": I did. And that's the thing about this whole album. Song. Is. Awesome. It's filled with the most spectacular hooks. Like, every song. How do you write 12 songs for one album that dig deep into your brain like that? That's a gift. It's the best kind of power pop: it has delicious Top 40 hooks, but tons of rock-and-roll edge to balance it out.
The 9-syllable 1-syllable word: I never thought I'd love hearing the word "on" so much, when Jordan passionately belts it out in "Turn Me On," stretching it out over nine syllables.
The guitar: If I'm not mistaken, there's only one guitar solo on this album, a fabulously fuzzed-out freakfest in "Late Show." There's some really cool lead stuff in "Gold," too, but I wouldn't quite call it a solo. But, and I said this of Dear Rouge's debut album, too, it just makes me want more guitar solos! Actually, I watched this video from Indie88 before I bought the album and the killer jam at the end made me expect more wailing on the record. Maybe they save that for the live show, which I'm so psyched to check out at The Phoenix in Toronto on December 1 (they also play there December 2, both gigs opening for the blazingly awesome Death From Above).


Up and coming boutique looking for a logo design similar to the one below and would like for the background to be black as well and include a crown that I would like very detailed like the one below. The crown is to be rose gold above the name, Empress Boutique in legible font maybe even script in white colored font. Creative minds are appreciated and any suggestions are welcomed. This is logo for a up and coming fashion boutique so this logo may possibly be on flyers and business cards as well as tee shirts for advertisement so the color and detail is very important. A cash reward as well as reference for other projects for the chosen logo.


I am a type of person who likes to know new people. In fact, that's what I believe the religion promotes the believers to do – to know people. Aren't we created with so many different tribes for we to know each other? I take that understanding from the Holy Quran to personally obligate myself to get to know people each and everyday.
Maybe some have seen that most of the time I'll behave like not-a-senior but rather a child isn't it? But the fact is that, I am a fourth year student! Don't you see the obvious contradiction?
Well, I'd like to say that personally I think age doesn't matter and age doesn't indicate anything regarding your level of maturity. To an extent, I would say maturity must not necessarily be shown in typical behavioral characteristics: calm, controlled, not talkative etc. Most importantly, what I believe is that, in whatever age you are now, be yourself. Let the nature brings you towards being the real you. I mean, as long as you can push yourselves towards betterment from time to time, that's maturity to me.
Comparing between one to another by taking the age as a reference is somehow unnecessarily factual. This is because the speed to develop level of maturity may vary from one to another depending on the environment and backgrounds one is in and of course not to mention one's capability.
By the way, these few weeks I have been hectic with, ok, to tell the truth, with Friendster! Haha... So many juniors (sisters especially) who add me as friends and of course I'll reply their "application" with approval and a reply testimonial thanking their willingness to view my profile and adding me as a friend. In the same testimonial, it says also a wish for them to greet me whenever and where ever they see me around the campus. One of my weaknesses is to remember people's names and sometimes people's faces. It's because the one shown in the pictures must not always likely the same like the real look. Huhu... usually the real person looks more beautiful than in the picture.
tp wat tak amik pedulik hal sekeliling sbb juniors wat budus ngan kami...diorg jeles sbb kitorg dah nk abis kot..ahaks..
Haih, akak ni pun dah tua, tp perangai budak-budak takleh hilang. Tmbh plak bongsu, lagi la budak. Haiya...but in some instance, I can be very mature plak. Cam lalang betul. Tp bukan lalang jahat, lalang tak jahat.
the real person looks more beautiful than in the picture.
zaki ada peminat dikalangan senior!!!
hoit ona! ko ni mmg tak teragak2.. betik sungguh.
Best kan jd senior? Aku tak sbb all my juniors semua sama umur atau lebih tua.
wah!wahhhh!!terglamer ler ..oleh kerna dah mjadi seniorrrrr..ramai lah pulokk para sister juniorrr..yg add kat friendster yeakk??
p'soalannya mgapa tak ramai lelaki??
knp tutup muka dgn belon? nmpk comel.hehe..hurm2..malu dgn junior permpuan ke????? =P haha..
Tak pernah nampak kat Wackos pun..?
maybe pasal ni kes gombak kot? ye la ramai orang kot, tu yang macam masing2 buat hal masing2 tuh. serius, pas pindah ke kuantan, itulah value yang memang takde kat gombak yang dapat aku rase..
pada aku, respect tidak memandang soal umur. setiap drpd kite kena memainkan peranan untuk menghormati dan dihormati..
tapi ye la~ kekadang memang ade orang yang susah sangat nak tunjukkan rasa hormat dan kehormatan diri sendiri..
eh, jgn citer kat sini. citer kat message friendster. bleh? citer la...nak tau gak apa org ckp kat blakang.


text:
Q: Alternative to case statement I need your suggestions on writing an SQL query other than using CASE statement in Oracle.I have a table named SYSTEM_SPECS with following data
Customer_Id     Disk_space_allocated
C001                    44G
C002                    1300G
C003                    1503G
C004                    1780G

I wrote following SQL query using Oracle case statement to get count of customer_id based on ranges for disk_space_allocated
select

  case

    when to_number(substr(disk_space_allocated,0,length(disk_space_allocated) -1  )) <= 300

    then '1-300'

    when to_number(substr(disk_space_allocated,0,length(disk_space_allocated) -1  )) <= 500

    then '300-500'

    when to_number(substr(disk_space_allocated,0,length(disk_space_allocated) -1 )) <= 700

    then '500-700'

    when to_number(substr(disk_space_allocated,0,length(disk_space_allocated) -1  )) <= 900

    then '700-900'

    else '900+'

  end      as diskallocated,

  count(*) as number_of_customers

from SYSTEM_SPECS

group by

  case

    when to_number(substr(disk_space_allocated,0,length(disk_space_allocated) -1 )) <= 300

    then '1-300'

    when to_number(substr(disk_space_allocated,0,length(disk_space_allocated) -1 )) <= 500

    then '300-500'

    when to_number(substr(disk_space_allocated,0,length(disk_space_allocated) -1 )) <= 700

    then '500-700'

    when to_number(substr(disk_space_allocated,0,length(disk_space_allocated) -1 )) <= 900

    then '700-900'

    else '900+'

  end;

Can this query be written is some other form?

A: Firstly your logic is wrong you are calculating <=700 and saying it between 500-700, if it is <=700 then by default it is <=500 and <=300. then we can not call it between 500-700. Try below query
select
  count(*) as number_of_customers,b.var as "Less Than below value"
from SYSTEM_SPECS a,
(select 300 + (level-1)*200 var
 from dual
connect by level <= 4) b
where to_number(substr(a.disk_space_allocated,0,length(a.disk_space_allocated) -1 )) <= b.var
group by b.var
order by b.var

Final answer for your question with the help of @Alex
with ranges as (
      select case when level = 1 then 0 else 100 end + (level-1) * 200 low_value,
        case when level = 5 then 99999999 else 100 + (level) * 200 end high_value
      from dual
      connect by level <= 5
    )
    select r.low_value ||'-'|| r.high_value as diskallocated,
      count(customer_id) as number_of_customers
    from ranges r
    left join system_specs ss
    on to_number(substr(ss.disk_space_allocated, 1, length(ss.disk_space_allocated) -1 )) > r.low_value
    and to_number(substr(ss.disk_space_allocated, 1, length(ss.disk_space_allocated) -1 )) <= r.high_value
    group by r.low_value, r.high_value
    order by r.low_value, r.high_value;

redpajama_set_name: RedPajamaStackExchange


A delegation of South Korean officials and civilian experts will on Friday visit North Korea to make arrangements for the opening of a liaison office in the North's border city of Kaesong.
According to the unification ministry, this 14-member team which is led by Vice Unification Minister Chun Hae-sung, will leave for Kaesong today to inspect facilities, Yonhap reported.
Following the North Korean leader Kim Jong-Un's and South Korean President Moon Jae-In's summit in April and May, the two Koreas decided to open the liaison office at an early date in anticipation of increased cross-border exchanges.
From 2004 to 2016, the two Koreas operated the joint industrial complex.
South Korea's capital with the North's cheap and skillful labor had set a successful example of economic cooperation between the two Koreas.
But, in protest at the North's continued missile and nuclear provocations, South Korea closed the factory park in early 2016.
However, the opening of the liaison office is seen as a first step to implement promises the two leaders made in their recent summits.


Discussion in 'Archived Classifieds' started by Drumcode, Mar 4, 2013.
It's still in great condition as it was when I received it, no marks at all from what I can see. It's never been taken out of the house.
Payment via BT, Postage via collect+.
You say it has no marks on it. How shiny are the keys from use ? Also, how's the battery life ? How many cycles ?
The don't have any wear on them from what I can see. It's tricky to get decent pictures using my iphone.
Ok, let me know. Any other issues or problems that a buyer should be aware of ? Reason for sale ? I suppose I'm concerned as to why this is at least a 3rd owner machine now.
The battery has had 477 cycles.
It's in great condition. I don't like saying its "as new" as obviously this machine is nearly 3 years old, but there are no scratches or dents at all. It has never left the house.
Reason for sale is that it has barely been used over the last month or 2. I prefer to browse the Internet on the iPad. I could also use the cash for a upcoming holiday so I've decided to sell.
Let me know if its of interest.
Thanks for the info. I think I'd be interested in offering £415 for it. At 477 cycles, the battery is approaching the time when the system profiler will suggest changing it. I'd also need to upgrade the hard drive to a bigger one.
£415 is a little on the low side.
I'd consider meeting in the middle at £445?
Sorry, £415's the highest I'd go. A new hard drive will cost £35 ish, and when the battery needs replacing, that could be £100. If I add those to £445, I'm close to the amount of money required to buy a used, newer i5 Macbook.
If it helps you any, I'll squeeze my offer up to £425 ?
If you can round it up to £430 then we have a deal.
I can post it tomorrow for you.


The all wood watch Ebony Nova is equipped with high-quality Japanese quartz movement and stainless steel tri-fold clasp with push buttons. Diameter of the dial 1.7 inches. Strap and case are made of 100% natural dark ebony wood.


We have many lines of brick and stone to offer! Here are some examples of how the products are displayed! Our showroom is packed with displays ranging from hand carry boards to actual sample walls of various products. That way you can really get a feel for what a product looks like!


When you think of workplace injuries, you most often think of something unexpected, like a light fixture falling on someone, or a piece of equipment malfunctioning and hurting somebody. But there are other types of injuries that develop over time. These are called repetitive motion injuries.
In many lines of work, a person goes through the same motions each day, whether it's typing, sitting, standing, bending, or lifting. Over the course of time, this repeated motion can cause wear and tear on our muscles and joints.
If you have been injured because of profession related repetitive stress, give us a call. We can help you understand the specifics of your case and determine your rights.
Call The Horwitz Law Group at (312) 641-9200 or send us an email to set up your free consultation with a repetitive motion injury lawyer.


Katie Bouman, the computer scientist behind the first black hole image 506 by tigerlily | 212 comments on Hacker News.
Katie Bouman, the computer scientist behind the first black hole image 16 by tigerlily | 1 comments on Hacker News.
Katie Bouman, the computer scientist behind the first black hole image 3 by tigerlily | 0 comments on Hacker News.


Too many transportation companies try to transact business without having the proper licenses and knowledge infrastructure in place. This is exactly why we went through the onerous process to become an official licensed customs broker in Canada in 2005.
With professional licensed customs brokers at the helm and a number of staff following the latest in customs regulations worldwide, we are well versed in all current legislation.


The Toyota Corolla GTI-16 was first produced in the late 80s, but the majority were made in the 90s. As such, this is a 90s hot hatch, and a mint condition one today will cost you in excess of £8k thanks to their rarity. This is one of the most retro looking hot hatches in the world. It was powered by a 1.6-litre engine, and it was a good performer in the twisties.


Laurence Moroney is a Developer Advocate at Google Brain, working on AI and Machine Learning with TensorFlow. He's also the host of several YouTube shows for developers, including 'TensorFlow Meets', 'Coding TensorFlow' and 'Coffee with a Googler'. He's spoken around the world on topics to do with AI, and is particularly passionate about teaching developers the opportunities that come with Machine Learning and Deep Learning. He's the author of more then 20 programming books on web and mobile development. When not Googling, he's also the author of best selling science fiction novels and comic books, and is the produced screenwriter of a sci-fi TV series.


text:
September 29, 2004 Special Dispatch No. 791
MEMRI TV Project: Saudi IQRA TV Examines Public Attitudes toward Jews
Saudi Arabia | Special Dispatch No. 791
The following dispatch, recorded and translated by MEMRI's TV Monitor Project, are excerpts from a show on Saudi Arabia's IQRA TV Channel, which featured "man on the street" interviews about feelings about Jews. To view a segment from this show, visit http://memritv.org/clip/en/275.htm: [1]
Interviewer: 'Would You, as a Human Being, be Willing to Shake Hands with a Jew?'
Respondent 1:
"Of course I wouldn't be willing to shake hands with a Jew, for religious reasons and because of what is happening now in Palestine, and for many reasons that don't allow me to shake a Jew's hand."
"No. Because the Jews are eternal enemies. The murderous Jews violate all agreements. I can't shake hands with someone who I know is full of hatred towards me."
"No, the Jew is an enemy. How can I shake my enemy's hand?"
Interviewer: "Would you refuse to shake hands with a Jew?"
"Of course, so I wouldn't have to consider amputating my hand afterwards."
Interviewer: 'If a Child Asks You Who 'Who are the Jews,' What Would You Answer?'
"The enemies of Allah and His Prophet."
"The Jew is the occupier of our lands."
"The murderers of prophets. Our eternal enemies, of course."
"The murderers of prophets, that's it."
"Allah's wrath is upon them, as the Koran says. Allah's wrath is upon them and they all stray from the path of righteousness. They are the filthiest people on the face of this earth because they care only about themselves - not the Christians, not the Muslims, nor any other religion.
"The solution is clear, not only to me but to everyone. If only [the Muslims] declared Jihad, we would see who stays home. We have a few countries… There is one country with a population of over 60-70 million people. If we let them only march, with no weapons even, they would completely trample the Jews, they would turn them into rotten carcasses under their feet. There is another country that donated money, saying, 'I am behind you, I'll support you with weapons, just wage [ Jihad ].'
"But the cowardice inside us, deep within our hearts, was instilled by the Arab leaders, may Allah forgive them. They breast-fed us with it from the day we were born to this very day it has grown with us."
[1] IQRA TV (Saudi Arabia), September 26, 2004.

redpajama_set_name: RedPajamaCommonCrawl


Diving industry has become one of the most booming industries worldwide as people are taking lots of interest in exploring sea life. Diving into exotic seas has become latest trend among people and it is the main reason why leading tour companies have started included sea diving into their packages. Sea diving is also a hobby of many passionate people who are not afraid of exploring opportunities beyond their limits. If you are seeking for becoming pa rt of diving industry or mastering the art of diving then you should opt for divemaster internships. We are offering different types of internship that you can choose according to your requirements and enhance your diving abilities. Best thing about opting for our internship is that you don't have to invest too much money for learning diving skills and becoming professional diver.
You don't have to worry about your career by opting for our internships as you are choosing dependable people. There are many organizations that are offering internship but never provide detailed information about procedures and steps that are essential for safe diving. It is the main reason why you should opt for our dependable service as we will make sure that you are learning each detail of diving art, precisely.
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Revealing Remarkable Tips To Save A Bundle On Baby Nursery Furniture!!


Now that the 2018 college football regular season has officially ended, all eyes are looking ahead to the College Football Playoff and the Heisman Trophy Presentation.
We have seen many players emerge as stars and put their name in the Heisman conversation, like Will Grier of West Virginia, Dwayne Haskins of Ohio State, and Trevor Lawrence of Clemson. But two names stand out the most in the Heisman watch – Kyler Murray of Oklahoma and Tua Tagovailia of Alabama.
Many experts agree that the Heisman is now a two-horse race, and one of these great quarterbacks will take home the trophy.
Murray's statistics are much more impressive when compared with Tagovailia's.
He has more passing yards, more rushing yards, more passing touchdowns, more rushing touchdowns, and a better pass completion percentage than the Alabama quarterback.
So, one might think Murray is a lock to win the Heisman since his numbers are much better.
However, there is just one problem.
Tagovailia's team is so dominant that he hardly ever plays the fourth quarter.
Alabama is blowing teams out so badly that Coach Nick Saban removes the first team offense from almost every game and puts in his backups.
So if Tagovailia is only playing three quarters in every game, obviously Murray is going to have better stats.
However, if you compare the stats of both quarterbacks in just the first three quarters of every game this year, Murray still has the better stats.
In just quarters one through three, Murray has more passing yards, more rushing yards, more rushing touchdowns, and a higher completion percentage. But Tagovailia has more passing touchdowns, more total touchdowns, and is responsible for more total points.
Taking out the fourth quarter from their stats certainly levels the playing field a little more, but Murray is still the clear-cut favorite.
He has been much more impressive this season, leading an Oklahoma team that has absolutely no defense to a record of 11-1.
This season, he has 3,674 passing yards and an additional 853 yards on the ground. He has thrown for 37 touchdowns and ran for 11 more for a total of 48 and has only turned the ball over seven times.
These are some of the most impressive numbers we have seen in college football in a long time.
Murray clearly deserves the Heisman Trophy and it would be an absolute travesty if the voting committee chooses to award Tagovailia instead of him.