Sequential Immunotherapy Research Articles

Sequential immunotherapy: towards cures for autoimmunity.

Despite major progress in the treatment of autoimmune diseases in the past two decades, most therapies do not cure disease and can be associated with increased risk of infection through broad suppression of the immune system. However, advances in understanding the causes of autoimmune disease and clinical data from novel therapeutic modalities such as chimeric antigen receptor T cell therapies provide evidence that it may be possible to re-establish immune homeostasis and, potentially, prolong remission or even cure autoimmune diseases. Here, we propose a 'sequential immunotherapy' framework for immune system modulation to help achieve this ambitious goal. This framework encompasses three steps: controlling inflammation; resetting the immune system through elimination of pathogenic immune memory cells; and promoting and maintaining immune homeostasis via immune regulatory agents and tissue repair. We discuss existing drugs and those in development for each of the three steps. We also highlight the importance of causal human biology in identifying and prioritizing novel immunotherapeutic strategies as well as informing their application in specific patient subsets, enabling precision medicine approaches that have the potential to transform clinical care.

Abstract 5545: FADD activation renders hepatocellular carcinoma sensitive to immune checkpoint blockade by turning cold tumors hot

Abstract The heterogenicity of hepatocellular carcinoma (HCC) remains a key obstacle in turning the majority of ‘immune-cold’ tumors ‘hot’ for effective immune checkpoint blockade (ICB) therapy. Through studying the naturally-existed ‘hot’ HCC variant lymphoepithelioma-like (LEL)-HCC by RNA and whole exome sequencing analysis, we identified fas-associated death domain (FADD) as one of the top differentially expressed genes that associated with high tumoral CD8+T cell abundance. Of note, FADD upregulation was also observed in HCC patients with better ICB responsiveness. As FADD was mainly expressed in tumor cells from HCC by scRNAseq analysis, we constructed Fadd knockout stable cells using murine HCC cell lines. Interestingly, CRISPR knockout of tumoral Fadd led to increased tumor weights in immunocompetent but not immunodeficient mice, accompanied with decreased tumoral CD8+T cells. Mechanistically, FADD phosphorylation promoted NF-κB transcriptional activity to increase CCL5 secretion from HCC cells via interacting with its nuclear binding partners Src-associated-substrate-during-mitosis-of-68kDa/KH domain containing, RNA binding, signal transduction associated 1 (Sam68/KHDRBS1) and lysine (K)-specific methyltransferase 2D (KMT2D), thus directing CD8+T cell tumor infiltration. In addition, anti-PD1 triggered FADD phosphorylation via IFN-γ and TNF-ɑ release from CD8+T cells in ICB-sensitive but not resistant tumors. Most importantly, sequential FADD activation via genetic and pharmacologic approaches could re-sensitize the therapeutic efficacy of anti-programmed death 1 (PD1) antibody in ICB-resistant orthotopic and spontaneous HCC models by turning cold tumors hot. Taken together, our findings reveal a key molecular feature of ICB-responsive hot tumors that may guide the development of sequential combinatory immunotherapies for the majority of HCC patients with low responsiveness to ICB monotherapy. This project is supported by the University Grants Committee through General Research Fund (24110323, 14107622, 14104820) and the Health and Medical Research Fund (07180556). Citation Format: Jingying Zhou, Jiahuan Lu. FADD activation renders hepatocellular carcinoma sensitive to immune checkpoint blockade by turning cold tumors hot [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 5545.

Remodeling the tumor-immune microenvironment by anti-CTLA4 blockade enhanced subsequent anti-PD-1 efficacy in advanced nasopharyngeal carcinoma

Sequential immunotherapy has shown certain advantages in malignancy. Here, we aim to evaluate the efficacy of sequential anti-CTLA-4 and anti-PD-1 treatment for recurrent or metastatic nasopharyngeal carcinoma patients (R/M NPC). We retrospectively analysis 2 phase I trial of ipilimumab and camrelizumab in Chinese R/M NPC patients. These patients were initially treated with ipilimumab, a CTLA4 blockade, followed by anti-PD-1 treatment. We observed a durable tumor remission in these patients (mPFS: 12.3 months; mDoR: 20.9 months). Multimodal investigations of biopsy samples disclosed remodeling of tumor-immune microenvironment triggered by ipilimumab. In responders, we found increased tumoral PD-L1/PD-L2 expression and T-cell infiltration after ipilimumab treatment, accompanied by reduced stroma and malignant cell components. In contrast, non-responders exhibited increased B-cell infiltration and increased peripheral CD19 + B cells, suggesting a defective transition from memory B cells to plasma cells. This study proposes that sequential therapy can potentially enhance treatment efficacy in chemotherapy-resistant NPC patients and provides insights into how preexisting anti-CTLA4 blockade can influence subsequent anti-PD-1 efficacy by remodeling the TME. Additionally, our results highlight the need for therapeutic strategies targeting naïve/memory B cells.

Unraveling the Therapeutic Benefit of Sequenced Chemo-immunotherapy.

Combination immune-checkpoint inhibition with chemotherapy is a clinical standard, yet concurrent administration may limit the full benefit of immunotherapy by blunting the proliferation and differentiation of CD8 T cells. Identifying patients in whom sequential chemo-immunotherapy or immunotherapy alone is feasible should be a priority to optimize long-term outcomes. See related article by Mariniello et al., p. 1833.

Sequential immunotherapy and targeted therapy for metastatic BRAF V600 mutated melanoma: 4-year survival and biomarkers evaluation from the phase II SECOMBIT trial

No prospective data were available prior to 2021 to inform selection between combination BRAF and MEK inhibition versus dual blockade of programmed cell death protein-1 (PD-1) and cytotoxic T lymphocyte antigen-4 (CTLA-4) as first-line treatment options for BRAFV600-mutant melanoma. SECOMBIT (NCT02631447) was a randomized, three-arm, noncomparative phase II trial in which patients were randomized to one of two sequences with immunotherapy or targeted therapy first, with a third arm in which an 8-week induction course of targeted therapy followed by a planned switch to immunotherapy was the first treatment. BRAF/MEK inhibitors were encorafenib plus binimetinib and checkpoint inhibitors ipilimumab plus nivolumab. Primary outcome of overall survival was previously reported, demonstrating improved survival with immunotherapy administered until progression and followed by BRAF/MEK inhibition. Here we report 4-year survival outcomes, confirming long-term benefit with first-line immunotherapy. We also describe preliminary results of predefined biomarkers analyses that identify a trend toward improved 4-year overall survival and total progression-free survival in patients with loss-of-function mutations affecting JAK or low baseline levels of serum interferon gamma (IFNy). These long-term survival outcomes confirm immunotherapy as the preferred first-line treatment approach for most patients with BRAFV600-mutant metastatic melanoma, and the biomarker analyses are hypothesis-generating for future investigations of predictors of durable benefit with dual checkpoint blockade and targeted therapy.

Development of novel bispecific antibody therapy for multiple myeloma

Over the past decade, new therapeutic modalities have markedly improved clinical outcomes for patients with multiple myeloma. Recently, immunotherapy using both bispecific antibodies (BsAb) and chimeric antigen receptor T cells (CAR-T cells) has induced further anti-myeloma responses. Different agents must be combined to overcome the heterogeneity of myeloma cell clones, and new modalities for the treatment of refractory myeloma must also be developed to strengthen therapeutic effects. We have developed a novel BiTE (bispecific T-cell engager)-based modality, referred to as bridging-BiTE (B-BiTE). B-BiTE is able to bind to both an Fc domain of a human immunoglobulin G monoclonal antibody (mAb) and the human CD3 molecule. This enables rapid generation of a mAb/B-BiTE complex and safely induces dual-lymphoid activation of both human T cells and NK cells against myeloma cells. Importantly, sequential immunotherapy using two different mAb/B-BiTE complexes can produce deep and durable anti-myeloma responses. To further advance treatment of multiple myeloma, it is important to determine how to combine and sequence immunotherapy with other agents while considering management of unique adverse events caused by activated immune cells.

Immunotherapeutic IL-6R and targeting the MCT-1/IL-6/CXCL7/PD-L1 circuit prevent relapse and metastasis of triple-negative breast cancer.

Rationale: Multiple copies in T-cell malignancy 1 (MCT-1) is a prognostic biomarker for aggressive breast cancers. Overexpressed MCT-1 stimulates the IL-6/IL-6R/gp130/STAT3 axis, which promotes epithelial-to-mesenchymal transition and cancer stemness. Because cancer stemness largely contributes to the tumor metastasis and recurrence, we aimed to identify whether the blockade of MCT-1 and IL-6R can render these effects and to understand the underlying mechanisms that govern the process. Methods: We assessed primary tumor invasion, postsurgical local recurrence and distant metastasis in orthotopic syngeneic mice given the indicated immunotherapy and MCT-1 silencing (shMCT-1). Results: We found that shMCT-1 suppresses the transcriptomes of the inflammatory response and metastatic signaling in TNBC cells and inhibits tumor recurrence, metastasis and mortality in xenograft mice. IL-6R immunotherapy and shMCT-1 combined further decreased intratumoral M2 macrophages and T regulatory cells (Tregs) and avoided postsurgical TNBC expansion. shMCT-1 also enhances IL-6R-based immunotherapy effectively in preventing postsurgical TNBC metastasis, recurrence and mortality. Anti-IL-6R improved helper T, cytotoxic T and natural killer (NK) cells in the lymphatic system and decreased Tregs in the recurrent and metastatic tumors. Combined IL-6R and PD-L1 immunotherapies abridged TNBC cell stemness and M2 macrophage activity to a greater extent than monotherapy. Sequential immunotherapy of PD-L1 and IL-6R demonstrated the best survival outcome and lowest postoperative recurrence and metastasis compared with synchronized therapy, particularly in the shMCT-1 context. Multiple positive feedforward loops of the MCT-1/IL-6/IL-6R/CXCL7/PD-L1 axis were identified in TNBC cells, which boosted metastatic niches and immunosuppressive microenvironments. Clinically, MCT-1high/PD-L1high/CXCL7high and CXCL7high/IL-6high/IL-6Rhigh expression patterns predict worse prognosis and poorer survival of breast cancer patients. Conclusion: Systemic targeting the MCT-1/IL-6/IL-6R/CXCL7/PD-L1 interconnections enhances immune surveillance that inhibits the aggressiveness of TNBC.

Optimizing treatment strategies for a MET exon 14 skipping mutation in non-small-cell lung cancer: a case report of sequential immunotherapy and targeted therapy and literature review

Optimizing treatment strategies for a MET exon 14 skipping mutation in non-small-cell lung cancer: a case report of sequential immunotherapy and targeted therapy and literature review

Abstract A022: Immunotherapy of IL-6R Prevents Relapse and Metastasis of Triple-Negative Breast Cancer

Abstract Multiple Copies in T-cell Malignancy-1 (MCT-1 or MCTS1) is a prognostic biomarker for aggressive breast cancers. Overexpressed MCT-1 stimulates the IL-6/IL-6R/gp130/STAT3 axis, promoting epithelial-to-mesenchymal transition, cancer cell stemness and tumor progression. To study the mechanism underlying TNBC immunity and aggressiveness, TNBC cell lines with different MCT-1 expression levels were evaluated. Primary tumor invasion and postsurgical local recurrence and distant metastasis were assessed in orthotopic syngeneic mice given indicated immunotherapy and/or MCT-1 silencing (shMCT-1). We found that shMCT-1 suppresses the transcriptome of inflammatory response and metastatic signaling in TNBC cells and inhibits TNBC progression, metastasis and mortality in xenograft mice. Combined IL-6R immunotherapy and shMCT-1 effect further decreased intratumoral M2 macrophages and T regulatory cells (Tregs) and avoided postsurgical TNBC expansion. Multiple positive feedback loops of the MCT-1/IL-6/IL-6R/CXCL7/PD-L1 axis were identified in TNBC cells, which boost metastatic niches and immunosuppressive microenvironments. MCT-1high/PD-L1high/CXCL7high and CXCL7high/IL-6high/IL-6Rhigh expression patterns predict worse prognosis and poorer survival in breast cancer patients. IL-6R-based immunotherapy more effectively prevented postsurgical TNBC metastasis, recurrence and mortality than anti-PD-L1 immunotherapy. Anti-IL-6R improved helper T, cytotoxic T and natural killer (NK) cells in lymphatic system and decreased Tregs in the recurrent and metastatic tumors, but anti-PD-L1 incapably elevated NK cells. Combined IL-6R and PD-L1 immunotherapies abridged TNBC cell stemness and M2 macrophage activity better than monotherapy. Sequential immunotherapy of PD-L1 and IL-6R demonstrated the best survival outcome, lowest postoperative recurrence and metastasis than synchronized therapy, particularly in shMCT-1 context. Conclusion: Systemic targeting of the MCT-1/IL-6/IL-6R/CXCL7/PD-L1 interconnection enhances the immune surveillance that inhibits aggressiveness of TNBC. Citation Format: Aushia Tanzih Al Haq, Pao-Pao Yang, Christopher Jin, Jou-Ho Shih, Li-Mei Chen, Lu-Hai Wang, Michael P. Snyder, Hsin-Ling Hsu. Immunotherapy of IL-6R Prevents Relapse and Metastasis of Triple-Negative Breast Cancer [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Tumor Immunology and Immunotherapy; 2023 Oct 1-4; Toronto, Ontario, Canada. Philadelphia (PA): AACR; Cancer Immunol Res 2023;11(12 Suppl):Abstract nr A022.

Immune and Genome Profiling of Myeloma Patients Treated with Sequential Immunotherapies Reveal Differential Non-Overlapping Mechanisms of Resistance

Chimeric antigen receptor T cells (CAR T) or bispecific T cell engagers (TCE) targeting multiple myeloma (MM) antigens result in deep responses in relapsed patients. Nevertheless, resistance invariably emerges requiring salvage treatments. Sequential therapies with CAR T or TCE, in patients with or without prior anti-BCMA therapy exposure, reported durable responses. However the genomic and molecular determinants of response to sequential immunotherapies are poorly defined. To define the molecular determinants of response to sequential immunotherapies we identified patients treated with more than one anti-BCMA or -GPRC5D (n=8) regimens. Bone marrow (BM) and peripheral blood (PB) mononuclear cells from these patients were collected prior to each therapy and at the time of progression. Sorted CD138+ cells were subjected to whole genome sequencing (WGS) or single cell CNV (scCNV) and single cell RNA (scRNA) analysis. CD3+ T cells were subjected to CITEseq and functional in vitro cytotoxicity assays. Patient 1 received anti-BCMA CAR T (Ide-cel) with VGPR lasting 7 months (mos) (Figure 1). He subsequently received elranatamab with no response. CITEseq profiling of T cells at progression post CAR T did not reveal expansion of exhausted cytotoxic or regulatory T cells. However, WGS and scCNV of MM cells identified biallelic TNFRSF17 deletion consistent with antigenic escape as cause of resistance. Patient 2 received Ide-cel (DOR = 3.5 mos) followed by elranatamab with no response. CD138+ MM cells retained BCMA expression and in vitro studies with in-house manufactured anti-BCMA CAR T efficiently eliminated his MM cells. Profiling of T cells showed terminal T cells exhaustion (CD45RA +, TOX +, TIGIT +, PDCD1 + and LAG3 +). In contrast to recipients of CAR T, antigenic loss was commonly observed post TCE therapy. Patient 3 received 3 sequential therapies with Ide-cel (DOR = 3 mos), teclistamab (DOR = 6 mos), and then talquetamab with daratumumab with an ongoing response of 11 mos. While T cell exhaustion was not observed, functional loss of BCMA on MM cells was detected post teclistamab, with 2 coexisting clones harboring TNFRSF17 extracellular domain mutations (p.Pro34del, or p.Ser30del) that abrogated teclistamab binding. Similarly in patient 4 progressing on elranatamab (DOR = 21 mos), there was no evidence of T cell exhaustion but rather acquired BCMA mutation (p.Pro34del) in MM cells. Consistent with fit T cells profile, he has an ongoing response (13+ mos) to talquetamab and daratumumab in his next line of therapy. Patient 5 with penta-refractory disease and high disease burden (> 90% BM infiltration) had no response to elranatamab, however achieved an ongoing sCR (DOR = 30 mos) with talquetamab, daratumumab and pomalidomide (Tal-DP). PB T cells did not show exhaustion at the time of progression on elranatamab. A similar pattern was observed in patient 6 with high disease burden and no response to teclistamab but achieved lasting VGPR to Tal-DP (DOR=24 mos) in the next line followed by an acquired biallelic loss of GPRC5D at progression. Patient 7 had a 17 mos remission to talquetamab and daratumumab and similarly to patient 6, he acquired biallelic loss of GPRC5D at progression. He subsequently received elranatamab with no response with elevated serum soluble BCMA (sBCMA=638 ng/ml) level and phenotypic and functional evidence of T cell exhaustion. Patients 5, 6 and 7 illustrate the impact of disease burden and the ensuing sBCMA sink effect on the efficacy of anti-BCMA TCEs. Lastly patient 8 had lasting remissions to elranatamab (DOR 13 mos) and subsequently to talquetamab (DOR 13 mos) with no evidence of T cells exhaustion but rather antigenic escape with acquired functional antigenic losses with clonal BCMA (p.Arg27Pro) and subsequently GPRC5D (p.Asp239Asn) mutation. Highlighting the lack of cross resistance between anti-BCMA therapies, our in vitro studies showed that while mutant BCMA (p.Ser30del or p.Pro34del) abrogated teclistamab mediated T cell killing, T cells transduced with teclistamab based scFv CAR retained cytolytic activity. Therefore, TCE resistance derived from BCMA mutations does not preclude retreatment with another anti-BCMA TCE or CAR T. We here describe variable non-overlapping mechanisms mediating resistance to sequential TCE and CAR T therapies. Dynamic surveillance for antigenic escape and functional evaluation of T cell fitness will optimize immunotherapy sequencing.

GSDME has prognostic and immunotherapeutic significance in residual hepatocellular carcinoma after insufficient radiofrequency ablation

BackgroundHeat stress can induce programmed cell death (PCD). Pyroptosis is a gasdermin-mediated PCD. This study hypothesized that insufficient radiofrequency ablation (IRFA) induced pyroptosis in hepatocellular carcinoma (HCC) and investigated its underlying mechanism and clinical significance. MethodsThermostatic water bath was used to stimulate IRFA in vitro. Cell viability was assessed by MTT assay. IL-1β and HMGB1 were measured by ELISA assay. LDH level was measured by LDH cytotoxicity detection kit. Permeability of cell membrane was assessed by Hoechst33342/PI fluorescence staining. RNA expression was evaluated by qRT-PCR, and protein was assessed by Western Blotting or immunofluorescence or immunohistochemistry. Gene expression with clinicopathological characteristics from HCC patients treated by RFA were analyzed for associations between GSDME expression and prognosis. ResultsOur study revealed that IRFA induced pyroptosis in HCCLM3 and HepG2 cells. GSDME, rather than GSDMD, was cleaved in heat stress-induced pyroptosis in HCCLM3 and HepG2 cells due to caspase-3 activation. However, GSDME overexpression promoted HCC growth in vivo and predicted poor PFS and OS in HCC patients treated by RFA. Heat stress modulated gene expression related to PD-L1 signaling and caspase inhibitors inhibited heat-induced PD-L1 expression in residual HCC after IRFA. Gsdme overexpression caused resistance to PD-L1 inhibitor in residual HCC after IRFA by increasing infiltrating of CD3+PD-1+ or CD3+CTLA-4+ exhausted T cells. ConclusionsThis study indicated that GSDME could serve as a potential prognostic biomarker and help to prescribe personalized sequential immunotherapy for HCC patients receiving RFA.

Survival Analysis of Patients with Locally Advanced Non-Small Cell Lung Cancer Who Received Neoadjuvant Immunotherapy

In the PACIFIC study, immuno-consolidation therapy has a great survival benefit for patients with locally advanced non-small cell lung cancer who had no progression after concurrent chemoradiotherapy. However, there is no clear evidence that earlier immunotherapy intervention can obtain better survival benefits for patients with progression after concurrent or sequential chemoradiotherapy. The purpose of this retrospective study was to further explore impact of early intervention in immunotherapy on survival. All patients who were treated with concurrent or sequential chemoradiotherapy and immunotherapy for LA-NSCLC between September 2019 and December 2021 were eligible. Time-to-event data were assessed by using the Kaplan-Meier estimator, and the Cox proportional hazards model was used for prognostic factor analyses. According to the timing of immunotherapy use, 60 patients with LA non-small cell lung cancer were divided into neoadjuvant group and consolidation group, with 30 patients in each group. All patients completed concurrent or sequential chemoradiotherapy. The median follow-up time in the neoadjuvant and consolidation groups was 20 and 18 months. In the neoadjuvant group, 4 patients died, 15 patients developed tumor progression, and 5 patients had distant metastasis. In the consolidation group, 5 patients died, 15 patients developed tumor progression, and 4 patients had distant metastasis. The median PFS of the neoadjuvant group and the consolidation group were 19 months and 15 months (P = 0.703). Both groups did not reach the median OS. The 1-year and 2-year PFS rates were 72.9%, 63.3% and 41.0%, 48.1%. 1-year and 2-year OS rate were 93.0%, 93.3%, and 74.4%, 76.6%. Disease control rates (DCR) in the both neoadjuvant and consolidation groups were 90%. There was little difference in the incidence of adverse responses between the two groups. Earlier immune intervention may have resulted in treatment effects similar to those observed in the PACIFIC trial, which suggests that the benefits of immunotherapy could be extended to a broader population.

Reinforced antimyeloma therapy via dual-lymphoid activation mediated by a panel of antibodies armed with bridging-BiTE

AbstractImmunotherapy using bispecific antibodies including bispecific T-cell engager (BiTE) has the potential to enhance the efficacy of treatment for relapsed/refractory multiple myeloma. However, myeloma may still recur after treatment because of downregulation of a target antigen and/or myeloma cell heterogeneity. To strengthen immunotherapy for myeloma while overcoming its characteristics, we have newly developed a BiTE-based modality, referred to as bridging-BiTE (B-BiTE). B-BiTE was able to bind to both a human immunoglobulin G–Fc domain and the CD3 molecule. Clinically available monoclonal antibodies (mAbs) were bound with B-BiTE before administration, and the mAb/B-BiTE complex induced antitumor T-cell responses successfully while preserving and supporting natural killer cell reactivity, resulting in enhanced antimyeloma effects via dual-lymphoid activation. In contrast, any unwanted off-target immune-cell reactivity mediated by mAb/B-BiTE complexes or B-BiTE itself appeared not to be observed in vitro and in vivo. Importantly, sequential immunotherapy using 2 different mAb/B-BiTE complexes appeared to circumvent myeloma cell antigen escape, and further augmented immune responses to myeloma relative to those induced by mAb/B-BiTE monotherapy or sequential therapy with 2 mAbs in the absence of B-BiTE. Therefore, this modality facilitates easy and prompt generation of a broad panel of bispecific antibodies that can induce deep and durable antitumor responses in the presence of clinically available mAbs, supporting further advancement of reinforced immunotherapy for multiple myeloma and other refractory hematologic malignancies.

Sequential CAR T cell and targeted alpha immunotherapy in disseminated multiple myeloma

Multiple myeloma (MM) is still an incurable disorder despite improved antibody and cellular therapies against different MM antigens. Single targeted antigens have so far been ineffective against MM with most patients relapsing after initial response. Hence, sequential immunotherapies directed at different targets are expected to perform better than monotherapy alone. Here, we optimized and established in preclinical studies the therapeutic rationale of using targeted alpha therapy (TAT) directed against CD38 antigen (225Ac-DOTA-daratumumab) with CAR T cell therapy directed at CS1 antigen in a systemic MM model. The sequential therapies compared CAR T therapy followed by TAT to TAT followed by CAR T therapy. CAR T cell monotherapy increased median survival from 49 days (d) in untreated controls to 71d with a modest improvement to 89d for 3.7 kBq of TAT given 14d later. When CAR T was followed by 7.4 kBq of TAT 29d later, sequential therapy increased median survival from 47d in untreated controls to 106d, compared to 68d for CAR T monotherapy. When CAR T therapy was followed by untargeted alpha immunotherapy using 7.4 kBq of 225Ac-DOTA-trastuzumab (anti-HER2) antibody 29d later, there was only a slight improvement in response over CAR T monotherapy demonstrating the role of tumor targeting. TAT (7.4 kBq) followed by CAR T therapy was also effective when CAR T therapy was delayed for 21d vs 14d or 28d post TAT, highlighting the importance of timing sequential therapies. Sequential targeted therapies using CS1 CAR T or 225Ac-DOTA-CD38 TAT in either order shows promise over monotherapies alone.

Abstract CT195: Interim safety results from SEPION/AIO-PAK-0118: A multicenter, Phase I/II study of sequential epigenetic and immune targeting in combination with nab-paclitaxel/gemcitabine in patients with advanced pancreatic ductal adenocarcinoma

Abstract Background: Pancreatic ductal adenocarcinoma (PDAC) remains a hard-to-treat cancer entity with limited therapeutic options. We aim to enhance the anti-tumor and pro-immunogenic effect of standard-of-care nab-paclitaxel/gemcitabine (GnP) by concomitant epigenetic targeting followed by immune-modulating maintenance therapy in patients (pts) with treatment-naive metastatic PDAC. This phase 1/2, open-label, multicenter, dose-escalation/dose-expansion study evaluates the safety and tolerability of azacitidine (AZA) and romidepsin (ROM) in combination with GnP and the potential of immune-modulating consolidation with durvalumab and lenalidomide after three cycles of either GnP or GnP plus epigenetic targeting. Here we report interim results of the dose escalation. Methods: In part 1A, dose escalation of three regimen ROM/GnP (arm A), AZA/GnP (arm B) and ROM/AZA/GnP (arm C) for determination of the recommended dose for expansion (RDE) is performed with a 3 + 3 dose escalation scheme using fixed dose levels. For dose expansion (part 1B), one of the treatment arms (Arm C over B over A) is continued using a Simon two-stage design to a maximum of 35 patients. The efficacy of the sequential programmed death-ligand (PD-L)1 blockade in combination with low-dose lenalidomide is evaluated in study part 2 (consolidation part) for pts with controlled disease (DCR) after 3 cycles of part 1 therapy. Evaluation of the consolidation concept in part 2 requires a sufficient DCR based on the statistical considerations. Thus, in addition to pts in part 1A and 1B, pts treated with GnP alone are additionally recruited (standard arm), so that at least 41 pts with controlled disease after 3 cycles of therapy are available for part 2. Key eligibility includes metastatic PDAC (stage IV), ECOG 0-1 and no prior chemotherapy or radiotherapy therapy for stage IV PDAC. Primary objectives include safety and tolerability of AZA and/or ROM in combination with GnP followed by sequential immune targeting with PD-L1 blockade in combination with low-dose lenalidomide. Results: In October 2022, 76 pts were enrolled, of which 67 pts were treated with at least one dose of study medication. The median age in the treated population was 62.8 years (range: 33 - 83), 32 (47.8 %) were female, 80.6 %/13.4 % were included with ECOG 0/1. In part 1A, an RDE of 2mg/m² for ROM (N=3, dose level L-1) and 30mg/m² for AZA (N=6, dose level L1) was established, respectively. The combined administration of AZA (30 mg/m²), ROM (2 mg/m²) and GnP (arm C) led to severe DLTs, namely neutropenia, non-hematologic toxicities (> grade2) and ROM related non-hematologic toxicities (≥ grade2) in all three patients. Given the best safety profile, Arm B was chosen for the expansion part 1B. Conclusions: ROM in combination with GnP showed considerable toxicity at dose level L1 as did the combination of ROM (dose level L-1) and AZA (dose level L1) with GnP. The combination of 30 mg/m2 AZA with GnP was feasible and chosen for further expansion. Dose expansion (part 1B) and sequential immunotherapy consolidation (part 2) are ongoing. Clinical trial information: NCT04257448. Research Sponsor: GWT-TUD GmbH. Citation Format: Jens T. Siveke, Marianne Sinn, Stefan Boeck, Gabriele Siegler, Thomas Seufferlein, Joerg Trojan, Dirk Waldschmidt, Alexander Koenig, Dorothea Schipp, Ines Winkler, Sven Thorsten Liffers, Volker Kunzmann. Interim safety results from SEPION/AIO-PAK-0118: A multicenter, Phase I/II study of sequential epigenetic and immune targeting in combination with nab-paclitaxel/gemcitabine in patients with advanced pancreatic ductal adenocarcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 2 (Clinical Trials and Late-Breaking Research); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(8_Suppl):Abstract nr CT195.

4-year survival and biomarkers evaluation from a phase II study of sequential immunotherapy and targeted therapy for metastatic BRAF V600-mutated melanoma (SECOMBIT)

4-year survival and biomarkers evaluation from a phase II study of sequential immunotherapy and targeted therapy for metastatic BRAF V600-mutated melanoma (SECOMBIT)

4-year survival and biomarkers evaluation from a phase II study of sequential immunotherapy and targeted therapy for metastatic BRAF V600-mutated melanoma (SECOMBIT)

4-year survival and biomarkers evaluation from a phase II study of sequential immunotherapy and targeted therapy for metastatic BRAF V600-mutated melanoma (SECOMBIT)

Neoadjuvant treatment for stage III and IV cutaneous melanoma.

Neoadjuvant treatment for stage III and IV cutaneous melanoma.

Effect of Immunotherapy and Stereotactic Body Radiation Therapy Sequencing on Local Control and Survival in Patients With Spine Metastases

Stereotactic body radiation therapy (SBRT) is commonly used to treat spinal metastases in combination with immunotherapy (IT). The optimal sequencing of these modalities is unclear. This study aimed to investigate whether sequencing of IT and SBRT was associated with differences in local control (LC), overall survival (OS), and toxicity when treating spine metastases. All patients at our institution who received spine SBRT from 2010 to 2019 with systemic therapy data available were reviewed retrospectively. The primary endpoint was LC. Secondary endpoints were toxicity (fracture and radiation myelitis) and OS. Kaplan-Meier analysis was used to determine whether IT sequencing (before versus after SBRT) and use of IT were associated with LC or OS. A total of 191 lesions in 128 patients met inclusion criteria with 50 (26%) lesions in 33 (26%) patients who received IT. Fourteen (11%) patients with 24 (13%) lesions received the first IT dose before SBRT, whereas 19 (15%) patients with 26 (14%) lesions received the first dose after SBRT. LC did not differ between lesions treated with IT before SBRT versus after SBRT (1 year 73% versus 81%, log rank=0.275, P=.600). Fracture risk was not associated with IT timing (χ2=0.137, P=.934) or receipt of IT (χ2=0.508, P=.476), and no radiation myelitis events occurred. Median OS was 31.8 versus 6.6 months for the IT after SBRT versus IT before SBRT cohorts, respectively (log rank=13.193, P < .001). On Cox univariate analysis and multivariate analysis, receipt of IT before SBRT and Karnofsky performance status <80 were associated with worse OS. IT treatment versus none was not associated with any difference in LC (log rank=1.063, P=.303) or OS (log rank=1.736, P=.188). Sequencing of IT and SBRT was not associated with any difference in LC or toxicity, but delivering IT after SBRT versus before SBRT was associated with improved OS.

Therapeutic effect and safety of individualized chemotherapy combined with sequential immunotherapy based on BRCA1 mRNA expression level in unresectable pancreatic cancer.

We aimed to evaluate the efficacy and safety of individualized chemotherapy combined with sequential immunotherapy based on BRCA1 mRNA expression in unresectable pancreatic cancer. The expression of BRCA1 mRNA in tumor tissues of 25 patients with pancreatic cancer was detected in this retrospective study. Patients in the medium and high expression groups were treated with paclitaxel-based chemotherapy: albumin paclitaxel 125mg/m2, gemcitabine 1g/m2, day 1. Patients in the low expression group were treated with oxaliplatin-based chemotherapy: oxaliplatin 85mg/m2, gemcitabine 1g/m2, day 1. Sequential GM-CSF and IL-2 immunotherapy were applied. Patient condition, treatment efficacy and safety were assessed every 4 cycles. A total of 25 patients were enrolled in the study. All of them were observed for toxic side effects and 24 of them were evaluated for efficacy. The median overall survival and median progression-free survival were 11.9 months and 6.3 months. The disease control rate was 91.7%, of which 37.5% (9/24) patients achieved partial remission (PR), 54.2% (13/24) patients achieved stable disease (SD) and 8.3% (2/24) patients were assessed as progressive disease(PD). Of the 15 patients with medium or high expression in BRCA1 mRNA, 7 achieved PR and 8 achieved SD. Of the 9 patients with low BRCA1 mRNA expression, 2 achieved PR, 5 achieved SD and 2 had PD. The proportion of eosinophils in the blood of some patients with good therapeutic effects was significantly higher than that before treatment. Hematological and non-hematological toxicity during the treatment were mostly grade 1~2. The two most common grade 3 to 4 adverse events were fever and thrombocytopenia. Our results suggest that individualized selection of chemotherapy combined with sequential immunotherapy according to BRCA1 mRNA expression level in unresectable pancreatic cancer could control the disease and have controllable adverse reactions.