Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 7-Day Trial for You or Your Team.

Learn More →

A phase ΙI study of five peptides combination with oxaliplatin-based chemotherapy as a first-line therapy for advanced colorectal cancer (FXV study)

A phase ΙI study of five peptides combination with oxaliplatin-based chemotherapy as a first-line... Background: We previously conducted a phase I trial for advanced colorectal cancer (CRC) using five HLA-A*2402-restricted peptides, three derived from oncoantigens and two from vascular endothelial growth factor (VEGF) receptors, and confirmed safety and immunological responses. To evaluate clinical benefits of cancer vaccination treatment, we conducted a phase II trial using the same peptides in combination with oxaliplatin-based chemotherapy as a first-line therapy. Methods: The primary objective of the study was the response rates (RR). Progression free survival (PFS), overall survival (OS), and immunological parameters were evaluated as secondary objective. The planned sample size was more than 40 patients for both HLA2402-matched and -unmatched groups. All patients received a cocktail of five peptides (3 mg each) mixed with 1.5 ml of IFA which was subcutaneously administered weekly for the first 12 weeks followed by biweekly administration. Presence or absence of the HLA-A*2402 genotype were used for classification of patients into two groups. Results: Between February 2009 and November 2012, ninety-six chemotherapy naïve CRC patients were enrolled under the masking of their HLA-A status. Ninety-three patients received mFOLFOX6 and three received XELOX. Bevacizumab was added in five patients. RR was 62.0% and 60.9% in the HLA-A*2402-matched and -unmatched groups, respectively (p = 0.910). The median OS was 20.7 months in the HLA-A*2402-matched group and 24.0 months in the unmatched group (log-rank, p = 0.489). In subgroup with a neutrophil/lymphocyte ratio (NLR) of < 3.0, patients in the HLA-matched group did not survive significantly longer than those in the unmatched group (log-rank, p = 0.289) but showed a delayed response. Conclusions: Although no significance was observed for planned statistical efficacy endpoints, a delayed response was observed in subgroup with a NLR of < 3.0. Biomarkers such as NLR might be useful for selecting patients with a better treatment outcome by the vaccination. Trial registration: Trial registration: UMIN000001791. Keywords: Peptide vaccine, Peptide cocktail, Colorectal cancer, Phase II study, FOLFOX, Chemotherapy * Correspondence: [email protected] Department of Digestive Surgery and Surgical Oncology, Yamaguchi University Graduate School of Medicine, Ube, Japan Full list of author information is available at the end of the article © 2014 Hazama et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 2 of 10 http://www.translational-medicine.com/content/12/1/108 Background conducted a phase II study of a cancer vaccine consisting Colorectal cancer (CRC) is the third most common can- of five peptides in combination with oxaliplatin-based cer and the second leading cause of cancer-related death chemotherapy as a first-line therapy for advanced CRC. in industrialized countries [1]. In the past decade, a com- The purpose of this study was to evaluate the clinical bination treatment of fluorinated-pyrimidine with irinote- benefit of this cancer vaccine treatment by adding to can (FOLFIRI) or oxaliplatin (FOLFOX, XELOX), with oxaliplatin-based chemotherapy. Furthermore, we ex- or without monoclonal antibodies such as anti-vascular plored a predictive biomarker for its response and for endothelial growth factor (VEGF) antibody or anti-epidermal the selection of patients who are likely to exhibit better growth factor receptor (EGFR) antibody, has markedly im- treatment outcomes following the vaccine treatment. proved the prognosis of patients with metastatic CRC We here demonstrate a promising result of our combin- (mCRC) [2-6]. However, most of the patients reveal pro- ation immuno-chemotherapy and predictive biomarkers gression of the disease due to chemo-resistance and lose for immunotherapy. their lives. As an attempt to validate a new treatment modality to Patients and methods overcome the limited disease control status of mCRC, Patients and eligibility criteria we conducted a combination treatment of five thera- Patients were eligible for enrollment when they were ≥ peutic epitope-peptides with chemotherapy. Recent de- 20 years old with a histologically confirmed advanced velopments in genome-based technologies have enabled CRC, had one or more measurable lesions according to us to obtain comprehensive gene expression profiles of the Response Evaluation Criteria in Solid Tumors version malignant cells and compare them with normal cells [7]. 1.0 (RECIST), were naïve for chemotherapy, had ad- We had previously identified three oncoantigens, RNF43 equate functions of critical organs, had an ECOG per- (ring finger protein 43) [8], 34 kDa translocase of the formance status (PS) of 0 or 1, and had a life expectancy outer mitochondrial membrane (TOMM34) [9], and of ≥ 3 months. The exclusion criteria were CNS involve- KOC1 (IMP-3; IGF-II mRNA binding protein 3) [10], as ment, second primary tumors, active infectious disease, targets for the development of cancer peptide vaccines any steroid treatment, or any prior peptide vaccination for CRC. therapies. Written informed consent was obtained from Although immunotherapy using tumor infiltrating cells each patient at the time of enrollment. The study was car- (TIL) or vaccine treatment are promising modalities for ried out in accordance with the Helsinki declaration on the treatment of cancer, recent reports have indicated sev- experimentation on human subjects, was approved by the eral mechanisms in tumor tissues which make cancer cells Institutional Ethics Review Boards of Yamaguchi University escape from immune system attacks [11]. For example, (H20-102) and each study site, and was registered in the the limited antitumor effects of cytotoxic T lymphocytes UMIN Clinical Trials Registry as UMIN000001791. (CTL) were explained by tumor heterogeneity; a subset of tumor cells revealed the down-regulation or absence of Peptides human leukocyte antigen (HLA) or targeted antigen The RNF43-721 (NSQPVWLCL) [20], TOMM34-299 proteins [12,13]. Since the growth of solid neoplasms (KLRQEVKQNL) [9], KOC1(IMP-3)-508 (KTVNELQNL) is almost always accompanied with neovascularization [21], VEGFR1-1084 (SYGVLLWEI) [22] and VEGFR2-169 [14], which is associated with the expression of vascular (RFVPDGNRI) [23] peptides restricted with HLA-A*2402 endothelial growth factor receptor 1 (VEGFR1) [15] and/or were synthesized by American Peptide Company Inc. VEGFR2 [16], our vaccine treatment also included the pep- (Sunnyvale, CA, USA) according to a standard solid-phase tides derived from VEGFR1 and VEGFR2 that target synthesis method, and were purified by reverse-phase high neovascular endothelial cells.WeselectedfiveHLA-A*2402- performance liquid chromatography (HPLC). The purity restricted peptides derived from RNF43, TOMM34, KOC1, (> 95%) and the identity of the peptides were determined VEGFR1, and VEGFR2 for the clinical trial due to the by analytical HPLC and mass spectrometry analysis, re- abundance of the HLA-A*2402 allele in the Japanese spectively. Endotoxin levels and the bio-burden of these population (an allelic frequency of approximately 60%) peptides were tested and determined to be within accept- [17]. We previously performed a phase Ι study of a com- able levels as Good Manufacturing Practice grade for bination vaccine treatment for mCRC, and confirmed the vaccines. safety and the promising potential of our five-peptide- cocktail treatment to improve the prognosis of advanced Study design CRC [18]. This phase II, single arm, non-randomized, HLA-A status FOLFOX (or XELOX) with/without bevacizumab is a double-blind study was conducted to assess the efficacy of widely-used chemotherapy [4] and has been reported to this combination therapy for first-line treatment for ad- possibly reduce the number of Tregs [19]. We therefore vanced CRC. The therapy consisted of a cocktail of five Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 3 of 10 http://www.translational-medicine.com/content/12/1/108 therapeutic epitope-peptides in addition to oxaliplatin- Secondary objectives included comparisons between the containing chemotherapy. Although the peptides used in two groups for progression free survival (PFS), overall sur- this study were HLA-A*2402 restricted peptides, all en- vival (OS), safety, and tolerability. Exploratory end points rolled patients whose HLA-A status were double-blinded included the assessments of tumor and blood-based im- were administrated the same regime of peptide cocktail munological biomarkers. and oxaliplatin-containing chemotherapy. The cocktail of 3 mg each of five peptides derived from Assessments RNF43-721, TOMM34-299, KOC1-508, VEGFR1-1084 Medical history, physical examination, chest X-ray, ECG, and VEGFR2-169, was mixed with 1.5 ml of incomplete and carcinoembryonic antigen (CEA) measurements were Freund’s adjuvant (IFA) (Montanide ISA51; Seppic, Paris, performed within 21 days before starting the treatment. France) and administered subcutaneously into the thigh Assessments of vital signs, ECOG performance status, or axilla regions on day 1 of each week for 13 weeks, then height, weight, and routine blood analysis (hematology the vaccination schedule was reduced to once every 2 weeks. and chemistry) were performed within 7 days of starting Vaccination was continued even if the disease progressed the treatment. During treatment, physical examination, when the patient wished and a primary doctor who pro- hematology, and biochemistry analyses were repeated on vided additional chemotherapies agreed. day 1 of every treatment cycle. Tumor assessments (com- Oxaliplatin-containing regimens were administrated puted tomography scan, magnetic resonance imaging) concurrently with the vaccination. Detailed informations were made before starting the study treatment and were of the chemotherapies were described in Additional file repeated every 4 to 8 weeks after the treatment. The 1. Briefly, mFOLFOX6 [24,25] consisted of oxaliplatin RECIST guidelines were used to define all responses. Signs 2 2 (85 mg/m ) with leucovorin (400 mg/m ), followed by a of hematological toxicity and non-hematological toxicity 2 2 FU (400 mg/m ) bolus, and then 2,400 mg/m continu- were assessed according to CTCAE during therapy and ous infusion with/without bevacizumab (5 mg/kg) [4]. for 28 days after the last study drug dose. This treatment was repeated every 14 days. XELOX [4] consisted of oxaliplatin (130 mg/m ) on day 1 followed Immunological biomarkers by oral capecitabine (1,000 mg/m ) twice daily on days 1 We investigated the neutrophil/lymphocyte ratio (NLR) through 14 of a 21-day cycle with/without bevacizumab and the peripheral blood lymphocyte counts per the entire at a dose of 7.5 mg/kg. white blood cells (lymphocyte-%) before the treatment as predictive markers of the efficacy of the vaccination. NLR Study objectives and lymphocyte-% were determined immediately at each The primary objective was the comparison of the efficacy study site. of the peptide-cocktail plus oxaliplatin-containing regimen on patients with HLA-A*2402 compared with those with- Statistical analysis out HLA-A*2402 by assessing the objective response rate This study was designed to test the hypothesis that a re- (ORR; complete response (CR) and partial response (PR)). gime consisting of vaccination plus oxaliplatin-containing Figure 1 CONSORT diagram. Scheme showing an HLA-A-status double-blind, biologically-randomized phase ΙI study of five therapeutic epitope-peptides combined with oxaliplatin-based chemotherapy as a first-line therapy for advanced colorectal cancer (FXV study). CRC, colorectal cancer; FOLFOX, infusional fluorouracil, leucovorin, and oxaliplatin; XELOX, capecitabine and oxaliplatin; HLA, human leukocyte antigen. Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 4 of 10 http://www.translational-medicine.com/content/12/1/108 Table 1 Baseline Patient Characteristics HLA-unmatched control group and 65% in the HLA- HLA-A*2402 matched study group. A two-sided Alpha level of 0.2 and Characteristics p value a beta level of 0.5 were assumed. Matched Unmatched (n = 50) (n = 46) Response rates were compared by chi-squared test. OS Sex and PFS rates were analyzed by the Kaplan-Meier method and log rank test. For the evaluation of delayed response, Male 25 24 NS we also performed a supplemental analysis of the weighted Female 25 22 log-rank tests with the Harrington-Fleming class of weights Age test for 3 parameter settings (ρ =0 and γ =0.5; ρ =0 Mean 64.3 63.4 NS and γ =1; ρ =0 and γ =2) [26]. Standard error 10.9 8 Statistical analyses were performed using SPSS statis- Range 36-82 38-77 tics version 20 (SPSS, Chicago, IL, USA) and SAS v9.2. A p value < 0.05 was considered statistically significant. Unresectable site Liver 27 35 Results Lung 18 12 Patients Dissemination 5 4 NS Between January 2009 and November 2012, ninety-six Bone 1 2 patients were enrolled in this trial applying the peptide Lymphnode 13 13 cocktail treatment in combination with an oxaliplatin- based regimen in 13 hospitals. Fifty patients had at least Other 5 1 one allele of HLA-A*2402 and forty-six patients had no Number of unresectable sites HLA-A*2402 allele. The peptide vaccination was admin- 136 30 istered to all patients. Among the 96 patients enrolled to 29 11 this trial, 93 patients received mFOLFOX6 and three 35 5 received XELOX. Five patients were additionally treated Resection of primary lesion with bevacizumab (Figure 1). The baseline characteristics were generally well balanced between the HLA-matched yes 41 43 and HLA-unmatched groups, although the proportion of no 9 3 NS rectal cancer was slightly higher in the HLA-matched Chemotherapy group (Table 1). On the cut-off date (25 December, 2013), FOLFOX 48 45 87 patients (91%) revealed the progression of the disease XELOX 2 1 NS with the median OS follow-up period of 38.2 months. (Bevacizumab) 0 (5) Objective response rate Primary minor site The ORR was 62.0% and 60.9% in the HLA-matched and Colon 29 36 0.057 HLA-unmatched groups (p = 0.910), respectively (Table 2). Rectal 21 10 The proportions of CR, PR, and SD as well as the disease FOLFOX. infusional fluorouracil. leucovorin. and oxaliplatin: XELOX. capecitabine control rate were 2.0% (1/50), 60.0% (30/50), 32.0% (16/50), and oxaliplatin; HLA, human leukocyte antigen; NS. not significant. and 94.0% (47/50) in the HLA-matched group, respectively, chemotherapy is more effective for patients with HLA- and 0% (0/46), 60.9% (28/46), 37.0% (17/46), 97.8% (45/46) A*2402 positive aCRC when compared to those without in the HLA-unmatched group, respectively. HLA-A*2402, defining the HLA-A*2402 matched group as the study group and the unmatched group as the con- Progression free survival trol group. Because the response rate of colorectal cancer The median PFS was 7.2 months for the HLA-matched patients to first line-treatment is generally about 50%, we group and 8.7 months for the HLA-unmatched group. There estimated that a minimum of 40 patients for both arms was no significant difference between two groups (Figure 2A, would be required, assuming a response rate of 50% in the P = 0.971). We also performed sub-group analyses using Table 2 Objective Response rate HLA-status HLA-A*2402-matched (n = 50) HLA-A*2402-unmatched (n = 46) Response CR PR SD PD CR PR SD PD Number 1 30 16 3 0 28 17 1 Response rate 31/50 (62.0%) 28/46 (60.9%) Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 5 of 10 http://www.translational-medicine.com/content/12/1/108 Figure 2 Progression free survival and overall survival. A and B, comparison of progression free survival between HLA-A*2402-mached and -unmatched groups; A, all patients; B, the patients who received the vaccination for more than 12 months. C and D, comparison of overall survival between HLA-A*2402-matched and -unmatched groups; C, all patients; D, patients who received the vaccination for more than 12 months. MST, median survival time; HLA, human leukocyte antigen; M, months; *the weighted log-rank tests with the Harrington-Fleming class of weights were performed and resulted in, ρ =0, and γ = 0.5, p = 0.186; ρ =0, and γ =1, ρ =0.080; ρ =0, and γ =2, ρ = 0.101. the patients who received the vaccination for more than (SAEs) were almost similar in the two groups, that of neu- 12 months, but there was also no difference between these tropenia was relatively higher in the HLA-A*2402-matched two groups (Figure 2B, P = 0.946). group than the unmatched group. Interstitial pneumo- nia that led to the death was observed in two cases Overall survival in the HLA-matched group and in one case in the HLA- The median OS was calculated to be 20.7 months in the unmatched group (Table 4). HLA-A*2402-matched group and 24.0 months in the unmatched group. There was no significant difference Immunological biomarkers between the two groups (Figure 2C; log-rank test, p = NLR is defined as the neutrophil to lymphocyte ratio, 0.489; Harrington-Fleming method, ρ =0 and γ =0.5, and in this study we categorized the patients into two p = 0.186; ρ = 0 and γ =1, p = 0.080; ρ = 0 and γ =2, p = groups (< 3 and ≧ 3) according to the papers reported 0.101). Interestingly, when the patients were able to re- previously [27]. In this study, NLR of <3.0 was a prog- ceive the vaccination for more than 12 months, the OS of nostic marker for the longer survival with peptide cock- the HLA-A*2402-matched group was significantly better tail and oxaliplatin-containing chemotherapy (Figure 3A; than that of the unmatched group (Figure 2D; log-rank log-rank test, p = 0.043). The Lymphocyte-% of ≧ 15% test, p = 0.032). was also associated with a long survival (Figure 3B; log- rank test, p = 0.034). Hence, we examined the combined Safety effect of each of these two markers and the HLA types The most common adverse events (AEs) observed in this on the clinical efficacy of the vaccination. In patients trial were neurologic toxicity and hematologic toxicities with a NLR of < 3.0, a significantly longer overall survival (Table 3). There was no significant difference in the inci- was observed in the HLA-A*2402-matched group than dence of AEs including injection site reaction in the two the HLA-A*2402-unmatched group (Figure 3C; log-rank groups. Although the incidences of serious adverse events test, P = 0.289; Harrington-Fleming method, ρ = 0 and γ = Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 6 of 10 http://www.translational-medicine.com/content/12/1/108 Table 3 Frequent and Severe Adverse Events (CTCAE version 3.0) FOLFOX (n = 89), FOLFOX + Bev (n = 4), XELOX + Bev (n = 1) HLA-A*2402-matched (n = 50) HLA-A*2402-unmatched (n = 46) FOLFOX (n = 48), XELOX (n = 2) FOLFOX (n = 41) + Bev (n = 4), XELOX + Bev (n = 1) 123 4 5 1 2 3 4 5 Adverse Event No % No % No % No % No % No % No % No % No % No % Hand-foot syndrome 0 0 0 0 1 2 0 0 0 0 1 200120 0 0 0 Allergy 4 8 3 6 2 4 0 0 0 0 3 749000 0 0 0 Mucositis 2 4 1 2 1 2 0 0 0 0 2 400000 0 0 0 Nausea/vomiting 5 10 1 2 2 4 0 0 0 0 6 13 24120 0 0 0 Neurologic toxicity 15 30 10 20 4 8 0 0 0 17 37 10 22 5 11 1 2 0 0 Anorexia 10 20 3 6 4 8 0 0 0 0 10 22 49240 0 0 0 Diarrhea 3 6 6 12 2 4 0 0 0 0 3 700120 0 0 0 Fatigue/Asthenia 5 10 1 2 2 4 0 0 0 0 5 11 12120 0 0 0 Fever 2 4 0 0 0 0 0 0 0 0 3 724000 0 0 0 Injection site reaction 18 36 18 36 9 18 0 0 0 0 20 43 17 37 3 13 0 0 0 0 Interstitial pneumonia 0 0 0 0 4 8 0 0 2 4 0 000490 0 1 2 Neutropenia 5 10 10 20 10 20 1 2 0 0 8 17 14 30 2 4 1 2 0 0 Leukopenia 10 20 12 24 1 2 0 0 0 0 12 26 9 20 2 4 0 0 0 0 Thrombocytopenia 17 34 3 6 0 0 0 0 0 0 20 43 24000 0 0 0 Bilirubin 2 4 2 4 0 0 0 0 0 0 0 000000 0 0 0 AL-P 11 22 1 2 1 2 0 0 0 0 10 22 12000 0 0 0 Creatinine 3 6 1 2 0 0 0 0 0 0 1 200000 0 0 0 Hemoglobin 11 22 5 10 0 0 0 0 0 0 13 28 7 15 0 0 0 0 0 0 Embolism 0 0 0 0 0 0 0 0 0 0 0 000001 2 0 0 AST/ALT 12 24 0 0 1 2 0 0 0 0 6 13 12000 0 0 0 No gastrointestinal perforation nor bleeding wound healing complication was observed. FOLFOX, infusional fluorouracil, leucovorin, and oxaliplatin; XELOX, capecitabine and oxaliplatin; Bev, bevacizumab; AL-P, alkaline phosphatese; AST, aspartete aminotransfarase; ALT, alanine aminotransferase; CTCAE, the Common Terminology Criteria for Adverse Event version 3.0; HLA, Human leukocyte antigen. 0.5, p = 0.152; ρ =0 and γ =1, p=0.064; ρ =0 and γ =2, p = 0.035) while this difference was not observed in Table 4 Interstitial Pneumonia patients with NLR of ≧ 3.0 (log-lank test, p = 0.962; HLA CTCAE Result of Harrington-Fleming method, ρ =0 and γ = 0.5, p = 0.495; DLLT genotype grade ρ = 0 and γ =1, p =0.346; ρ =0 and γ = 2, p = 0.251). Simi- 2402/2402 3 5FU larly, in a patient group with a lymphocyte% of > 15%, a 2402/1101 3 negative longer overall survival was observed in the HLA-A*2402- matched group (Figure 3D; log-lank test, p = 0.340; 2402/1101 5 negative Harrington-Fleming method, ρ =0 and γ =0.5, p =0.114; 2402/0206 3 negative ρ =0 and γ = 1, p = 0.051; ρ =0 and γ = 2, p = 0.029). 2402/2603 3 5FU 2402/2602 5 negative Discussion 1101/2601 3 5FU We performed a phase II study using a cocktail of five epi- 2601/3101 3 5FU tope peptides, which we previously confirmed its safety, together with oxaliplatin-based chemotherapy. The cock- 1101/3101 3 5FU tail contained three peptides derived from three oncoanti- 3004/3303 5 not examined gens and two peptides targeting VEGFR1 and VEGFR2. 1101/3101 3 not examined This study was an HLA-A-status double-blind, phase ΙI CTCAE, the Common Terminology Criteria for Adverse Event version 3.0; HLA, study of five therapeutic epitope-peptides with oxaliplatin- Human leukocyte antigen; DLTT, drug-induced lymphocyte transformation test; based chemotherapy as a first-line therapy for advanced 5FU, 5-fluorouracil. Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 7 of 10 http://www.translational-medicine.com/content/12/1/108 Figure 3 Biomarkers for the survival and the clinical efficacy of vaccination. Neutrophil/lymphocyte ratio (NLR) < 3.0 and Lymphocyte-% ≧ 15% were considered as indicative factors. A and B, comparison between the favorite group and others. C, comparison of the patients with a NLR of ≧ 3 or a NLR of <3 between the HLA-A*2402-matched and -unmatched groups. D, comparison of the patients with Lymphocyte-% ≧ 15% between the HLA-A*2402 positive and negative groups. Lymphocyte (Ly)-%, the percentage of lymphocytes among the peripheral leukocytes; NLR, neutrophil/lymphocyte ratio; HLA, human leukocyte antigen; L-R, log-rank test; *the weighted log-rank tests with the Harrington-Fleming class of weights were performed and resulted in, ρ = 0, and γ = 0.5, p = 0.152; ρ = 0, and γ = 1, p = 0.064; ρ = 0, and γ = 2, p = 0.035; **the Harrington-Fleming tests were resulted in, ρ = 0, and γ = 0.5, p = 0.495; ρ = 0, and γ =1, ρ = 0.346; ρ = 0, and γ =2, ρ = 0.251; *** the Harrington-Fleming tests were resulted in, ρ = 0, and γ = 0.5, p = 0.114; ρ = 0, and γ =1, ρ = 0.051; ρ = 0, and γ =2, ρ = 0.029. colorectal cancer (FXV study). In this study, we observed obvious tail effect for extremely long survival. Then we many interesting results. examined the efficacy of vaccination by comparing HLA- Firstly, the OS of the HLA-A*2402-matched group was matched group and -unmatched group. In patients with significantly higher compared to that of the unmatched an NLR of < 3.0, a significantly longer survival in the group (log-rank test, p = 0.032) when patients who received HLA-matched group than the HLA-unmatched group the vaccination for more than 12 months (Figure 2D) al- was observed (Figure 3B; log-rank, p = 0.289; Harrington- though no difference in PFS was observed between the Fleming, p = 0.035), while this difference was not observed two groups (Figures 2B). These results indicated that in the two groups with NLR of ≧ 3.0 (log-rank, p = 0.962; the additional effect of vaccination on the standard Harrington-Fleming, p = 0.251). This result also support chemotherapy was likely to be slow-acting as this kind of the idea that it may be critically important to apply delayed response by the vaccine treatment was indicated vaccine treatment to patients with better immune sta- in the guidance for therapeutic cancer vaccines released tus, and NLR might be a one of good predictive markers from the US Food and Drug Administration in October, to select the appropriate patient populations for this 2011 [28]. type of treatment. A similar result was observed when Secondly, neutrophil/lymphocyte ratio (NLR) might be- we analyzed patients with lymphocyte% of ≧ 15%; come a prognostic marker for patients who received the HLA-matched patients with lymphocyte% of ≧ 15 showed peptide vaccine in combination with standard chemo- significantly better prognosis than HLA-unmatched pa- therapy (Figure 3A, log-rank; p = 0.043), and there was an tients (Figure 3D; log-rank, p = 0.340; Harrington-Fleming, Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 8 of 10 http://www.translational-medicine.com/content/12/1/108 p = 0.029). The selection of patients with lower NLR be combined with some agents to modify the immune- and higher lymphocyte percentage might be useful to the suppressive tumor microenvironments. selection of patients who are likely to respond well to In conclusion, our cocktail of five therapeutic epitope vaccine treatment and improve clinical outcomes. peptides appears to be effective in a subset of patients, Vaccinations with a cocktail of five peptides together and warrants a randomized phase III study. In the phase with oxaliplatin-based chemotherapy in metastatic CRC III study, biomarkers such as NLR and lymphocyte-% patients were well tolerated, except for relatively frequent might be useful for assessing the response to the peptide cases (11 cases; 11.4%) of pneumonitis (Tables 3 and 4), vaccine and for selecting patients likely to have a better whose incidence seemed to be higher than previously treatment outcome with the vaccination. reported for oxaliplatin-based chemotherapies although no difference was observed between HLA-matched Conclusions and -unmatched group. Correale et al. reported two This phase II cancer vaccine therapy demonstrated that cases (5.5%) in 36 patients with advanced gastric cancer our therapeutic peptides cocktail was likely to be effect- treated with gemcitabine plus oxaliplatin, folinic acid, and ive in a subset of patients and warrants a randomized 5-fluorouracil (FOLFOX-4) [29]. Usui et al. reported that phase III study. In the phase III study, predictive bio- four cases (3.9%) of pneumonitis among 104 Japanese markers such as NLR and lymphocyte-% should be used patients treated with oxaliplatin-containing regimes for for its response and for selecting patients to have a bet- advanced colorectal cancer [30]. In addition, there have ter treatment outcome with the vaccination. been many case reports of oxaliplatin-related pneumonitis [31-35]. In this study, eleven (11.4%) of 96 patients suf- Additional file fered from severe pneumonitis including three cases with Additional file 1: Summary of the protocol. grade 5 pneumonitis. To investigate the possible cause of pneumonitiswe performed drug-induced lymphocyte trans- Abbreviations formation test (DLTT) for nine patients whose samples RNF43: Ring finger protein 43; TOMM34: 34 kDa-translocase of the outer were available. Among them, five patients (55.6%) were mitochondrial membrane; KOC1: insulin-like growth factor–II mRNA binding judged to be positive to fluorouracil alone, and the remaining protein 3; VEGFR: Vascular endothelial growth factor receptor; HPLC: High performance liquid chromatography; CRC: Colorectal cancer; four patients were negative for all of the antigens tested. ELISPOT: Enzyme-linked immunospot; PBMC: Peripheral blood mononuclear Although the size of this study is not large enough to cells; CTL: Cytotoxic T lymphocytes; RR: Response rates; CR: Complete clinical make any conclusion and there is no difference between response; SD: Stable disease; PD: Progressive disease; PFS: Progression free survival; OS: Overall survival; HLA: Human leukocyte antigen; MST: Median the two groups, this adverse event should be carefully overall survival time; ECOG: Eastern cooperative oncology group; monitored when we will perform the next-step clinical RECIST: Response evaluation criteria in solid tumors; TIL: Tumor infiltrating trial. cells; CTCAE: Common terminology criteria for adverse events version3.0; AEs: Adverse events; SAEs: Serious adverse events; DLTT: Drug-induced Although the efficacy of our peptide vaccine was not lymphocyte transformation test; PS: Performance status; IFA: Incomplete clearly demonstrated in this phase II study, the timing of freund’s adjuvant; CT: Computed tomography; MRI: Magnetic resonance and combination treatment with vaccination might not imaging; NLR: Neutrophil/lymphocyte ratio; FOLFOX: Infusional fluorouracil, leucovorin, and oxaliplatin; XELOX: Capecitabine and oxaliplatin, Tregs, be optimized, and the sample size was limited. Recently, regulatory T cells; MDSCs: Myeloid-derived suppressor cells; IDO: Indoleamine-2,3- regulatory T cells (Tregs) and myeloid-derived suppres- dioxygenase. sor cells (MDSCs) are reported as potent immunosuppres- Competing interests sive cells to protect cancer cells from the host immune Yusuke Nakamura is a stock holder and a scientific advisor of OncoTherapy system [36,37]. Over expression of PD-L1and PD-1 as well Science, Inc. The other authors have no potential conflicts of interest to as up-regulation of indoleamine-2,3-dioxygenase (IDO) in disclose. the tumor microenvironment also inhibit the CTL func- Authors’ contributions tions [38]. Hence, to overcome these immune-escape SH designed, performed and evaluated clinical study, and wrote the mechanisms, various approaches have been taken in the manuscript. YN and MO participated in the design, review and revision of the manuscript. HT, KH, KT, RS, HO, RE, FS, KO, TF, TN, KS, KY, YI, SK, YS, NS, last decade [39,40]. For example, anti-PD1antibody [41], SY, HS, AK, TF, YK and HF assisted to perform clinical study. RT, HT, and TY anti-PD-L1antibody [42], and anti-CTL4 antibody [43] contributed in the data collection and statistical analysis. All authors were applied in clinical trials to overcome the suppressive participated in the data acquisition and discussion of the manuscript and approved the final manuscript. immuno checkpoints, and surprisingly high objective response rates were observed in many types of malignant Acknowledgements neoplasm. Small-molecule inhibitors [44] that block IDO This study was supported partially by the Project for Development of enzymatic activity or cyclophosphamide to reduce the Innovative Research on Cancer Therapeutics (P-DIRECT) of the Ministry of Education, Culture, Sports, Science and Technology of Japan. The authors number of Tregs [45] were also applied in clinical trials to would like to thank Prof. Yusuke Nakamura, Dr. Takuya Tsunoda, Dr. Koji dissolve the suppressive immunity. For the successful Yoshida, Laboratory of Molecular Medicine, Human Genome Center, Institute next generation immunotherapy, peptide vaccine should of Medical Science, The University of Tokyo, for their excellent advice and Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 9 of 10 http://www.translational-medicine.com/content/12/1/108 cooperation and providing all the peptides. The authors also thank Prof. Koji identification of genes for prediction of lymph-node metastasis and Kono, Department of Surgery, National University of Singapore, for his sensitivity to anti-cancer drugs. Oncogene 2003, 22:2192–2205. excellent managements as The Data and Safety Monitoring Committee of 11. Rosenberg SA, Yang JC, Restifo NP: Cancer immunotherapy: moving this study. beyond current vaccines. Nat Med 2004, 10:909–915. 12. Khong HT, Restifo NP: Natural selection of tumor variants in the generation Author details of tumor “escape” phenotypes. Nat Immunol 2002, 3:999–1005. Department of Digestive Surgery and Surgical Oncology, Yamaguchi 13. Ryschich E, Notzel T, Hinz U, Autschbach F, Ferguson J, Simon I, Weitz J, University Graduate School of Medicine, Ube, Japan. Department of Frohlich B, Klar E, Buchler MW, Schmidt J: Control of T-cell-mediated Medicine and Surgery, The University of Chicago, Chicago, IL, USA. immune response by HLA class I in human pancreatic carcinoma. Department of Surgical Oncology, Osaka City University Graduate School of Clin Cancer Res 2005, 11:498–504. Medicine, Osaka, Japan. Department of Surgery, Kure-Kyosai Hospital, Kure, 14. Folkman J: Tumor angiogenesis: therapeutic implications. N Engl J Med Japan. Department of Surgery, Ogori Daiichi General Hospital, Yamaguchi, 1971, 285:1182–1186. Japan. Department of Surgery, Kinki University Faculty of Medicine, 15. Olofsson B, Korpelainen E, Pepper MS, Mandriota SJ, Aase K, Kumar V, Gunji Y, Osaka-Sayama, Japan. Department of Surgery, Kanmon-Medical Center, Jeltsch MM, Shibuya M, Alitalo K, Eriksson U: Vascular endothelial growth factor Shimonoseki, Japan. Department of Surgery, Shimonoseki-Kosei Hospital, B (VEGF-B) binds to VEGF receptor-1 and regulates plasminogen activator Shimonoseki, Japan. Tokyo Women’s Medical University Medical Center East, activity in endothelial cells. Proc Natl Acad Sci U S A 1998, 95:11709–11714. Tokyo, Japan. Department of Pharmacy, Yamaguchi University Hospital, 16. Millauer B, Wizigmann-Voos S, Schnurch H, Martinez R, Moller NP, Risau W, Ube, Japan. Department of Biostatistics, National Cancer Center, Chiba, Ullrich A: High affinity VEGF binding and developmental expression Japan. Division of Cellular Signaling, Institute for Advanced Medical suggest Flk-1 as a major regulator of vasculogenesis and angiogenesis. Research, Keio University School of Medicine, Tokyo, Japan. Cell 1993, 72:835–846. 17. Date Y, Kimura A, Kato H, Sasazuki T: DNA typing of the HLA-A gene: Received: 10 March 2014 Accepted: 16 April 2014 population study and identification of four new alleles in Japanese. Published: 30 April 2014 Tissue Antigens 1996, 47:93–101. 18. Hazama S, Nakamura Y, Takenouchi H, Suzuki N, Tsunedomi R, Inoue Y, Tokuhisa Y, Iizuka N, Yoshino S, Takeda K, Shinozaki H, Kamiya A, Furukawa References H, Oka M: A phase I study of combination vaccine treatment of five 1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM: Estimates of therapeutic epitope-peptides for metastatic colorectal cancer; safety, worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 2010, immunological response, and clinical outcome. J Transl Med 2014, 12:63. 127:2893–2917. 19. Maeda K, Hazama S, Tokuno K, Kan S, Maeda Y, Watanabe Y, Kamei R, 2. Tournigand C, Andre T, Achille E, Lledo G, Flesh M, Mery-Mignard D, Quinaux E, Shindo Y, Maeda N, Yoshimura K, Yoshino S, Oka M: Impact of Couteau C, Buyse M, Ganem G, Landi B, Colin P, Louvet C, de Gramont A: chemotherapy for colorectal cancer on regulatory T-cells and tumor FOLFIRI followed by FOLFOX6 or the reverse sequence in advanced immunity. Anticancer Res 2011, 31:4569–4574. colorectal cancer: a randomized GERCOR study. JClin Oncol 2004, 20. Uchida N, Tsunoda T, Wada S, Furukawa Y, Nakamura Y, Tahara H: Ring 22:229–237. finger protein 43 as a new target for cancer immunotherapy. Clin Cancer 3. Cassidy J, Clarke S, Diaz-Rubio E, Scheithauer W, Figer A, Wong R, Koski S, Res 2004, 10:8577–8586. Lichinitser M, Yang TS, Rivera F, Couture F, Sirzen F, Saltz L: Randomized 21. Suda T, Tsunoda T, Daigo Y, Nakamura Y, Tahara H: Identification of human phase III study of capecitabine plus oxaliplatin compared with fluorouracil/ leukocyte antigen-A24-restricted epitope peptides derived from gene folinic acid plus oxaliplatin as first-line therapy for metastatic colorectal products upregulated in lung and esophageal cancers as novel targets cancer. J Clin Oncol 2008, 26:2006–2012. for immunotherapy. Cancer Sci 2007, 98:1803–1808. 4. Saltz LB, Clarke S, Diaz-Rubio E, Scheithauer W, Figer A, Wong R, Koski S, 22. Ishizaki H, Tsunoda T, Wada S, Yamauchi M, Shibuya M, Tahara H: Inhibition Lichinitser M, Yang TS, Rivera F, Couture F, Sirzen F, Cassidy J: Bevacizumab of tumor growth with antiangiogenic cancer vaccine using epitope in combination with oxaliplatin-based chemotherapy as first-line therapy peptides derived from human vascular endothelial growth factor in metastatic colorectal cancer: a randomized phase III study. J Clin Oncol receptor 1. Clin Cancer Res 2006, 12:5841–5849. 2008, 26:2013–2019. 23. Wada S, Tsunoda T, Baba T, Primus FJ, Kuwano H, Shibuya M, Tahara H: 5. Van Cutsem E, Kohne CH, Hitre E, Zaluski J, Chang Chien CR, Makhson A, Rationale for antiangiogenic cancer therapy with vaccination using D’Haens G, Pinter T, Lim R, Bodoky G, Roh JK, Folprecht G, Ruff P, Stroh C, epitope peptides derived from human vascular endothelial growth Tejpar S, Schlichting M, Nippgen J, Rougier P: Cetuximab and chemotherapy factor receptor 2. Cancer Res 2005, 65:4939–4946. as initial treatment for metastatic colorectal cancer. N Engl J Med 2009, 24. Kato T, Muro K, Yamaguchi K, Bando H, Hazama S, Amagai K, Baba H, Denda T, Shi 360:1408–1417. X, Fukase K, Skamoto J, Mishima H: Cediranib in combination with mFOLFOX6 6. Douillard JY, Siena S, Cassidy J, Tabernero J, Burkes R, Barugel M, in Japanese patients with metastatic colorectal cancer: results from the Humblet Y,BodokyG,CunninghamD,JassemJ,RiveraF,KocakovaI, randomised phase II part of a phase I/II study. Ann Oncol 2012, 23:933–941. Ruff P, Blasinska-Morawiec M, Smakal M, Canon JL, Rother M, Oliner KS, 25. Schmoll HJ, Cunningham D, Sobrero A, Karapetis CS, Rougier P, Koski SL, Wolf M, Gansert J: Randomized, phase III trial of panitumumab with Kocakova I, Bondarenko I, Bodoky G, Mainwaring P, Salazar R, Barker P, infusional fluorouracil, leucovorin, and oxaliplatin (FOLFOX4) versus Mookerjee B, Robertson J, Van Cutsem E: Cediranib with mFOLFOX6 FOLFOX4 alone as first-line treatment in patients with previously versus bevacizumab with mFOLFOX6 as first-line treatment for patients untreated metastatic colorectal cancer: the PRIME study. JClin Oncol with advanced colorectal cancer: a double-blind, randomized phase III 2010, 28:4697–4705. study (HORIZON III). J Clin Oncol 2012, 30:3588–3595. 7. Okabe H, Satoh S, Kato T, Kitahara O, Yanagawa R, Yamaoka Y, Tsunoda T, 26. Fleming T, Harrington D: Counting Processes and Survival Analysis. New York: Furukawa Y, Nakamura Y: Genome-wide analysis of gene expression in John Wiley & Sons; 1991. human hepatocellular carcinomas using cDNA microarray: identification 27. He W, Yin C, Guo G, Jiang C, Wang F, Qiu H, Chen X, Rong R, Zhang B, Xia L: of genes involved in viral carcinogenesis and tumor progression. Cancer Initial neutrophil lymphocyte ratio is superior to platelet lymphocyte ratio Res 2001, 61:2129–2137. as an adverse prognostic and predictive factor in metastatic colorectal 8. Yagyu R, Furukawa Y, Lin YM, Shimokawa T, Yamamura T, Nakamura Y: A cancer. Med Oncol 2013, 30:439. novel oncoprotein RNF43 functions in an autocrine manner in colorectal 28. U.S. Department of Health and Human Services, Food and Drug cancer. Int J Oncol 2004, 25:1343–1348. Administration: Guidance for Industry. Clinical Considerations for 9. Shimokawa T, Matsushima S, Tsunoda T, Tahara H, Nakamura Y, Furukawa Y: Therapeutic Cancer Vaccines. 2011, http://www.fda.gov/downloads/ Identification of TOMM34, which shows elevated expression in the biologicsbloodvaccines/guidancecomplianceregulatoryinformation/ majority of human colon cancers, as a novel drug target. Int J Oncol guidances/vaccines/ucm278673.pdf. 2006, 29:381–386. 29. Correale P, Fulfaro F, Marsili S, Cicero G, Bajardi E, Intrivici C, Vuolo G, Carli 10. Kikuchi T, Daigo Y, Katagiri T, Tsunoda T, Okada K, Kakiuchi S, Zembutsu H, AF, Caraglia M, Del Prete S, Greco E, Gebbia N, Francini G: Gemcitabine Furukawa Y, Kawamura M, Kobayashi K, Imai K, Nakamura Y: Expression (GEM) plus oxaliplatin, folinic acid, and 5-fluorouracil (FOLFOX-4) in profiles of non-small cell lung cancers on cDNA microarrays: Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 10 of 10 http://www.translational-medicine.com/content/12/1/108 patients with advanced gastric cancer. Cancer Chemother Pharmacol 2005, 56:563–568. 30. Usui K, Katou Y, Furushima K, Tanaka Y, Tanai C, Ishihara T: Interstitial lung disease during chemotherapy combined with oxaliplatin and/or bevacizumab in advanced colorectal cancer patients. Jpn J Clin Oncol 2011, 41:498–502. 31. Gagnadoux F, Roiron C, Carrie E, Monnier-Cholley L, Lebeau B: Eosinophilic lung disease under chemotherapy with oxaliplatin for colorectal cancer. Am J Clin Oncol 2002, 25:388–390. 32. Fuse N, Doi T, Ohtsu A, Takeuchi S, Kojima T, Taku K, Tahara M, Muto M, Asaka M, Yoshida S: Feasibility of oxaliplatin and infusional fluorouracil/ leucovorin (FOLFOX4) for Japanese patients with unresectable metastatic colorectal cancer. Jpn J Clin Oncol 2007, 37:434–439. 33. Arevalo Lobera S, Sagastibeltza Marinelarena N, Elejoste Echeberria I, Mele Olive M, EganaOtano L, Basterretxea BadiolaL, LaCasta MunoaA,Azkue GabilondoM: Fatal pneumonitis induced by oxaliplatin. Clin Transl Oncol 2008, 10:764–767. 34. Pontes LB, Armentano DP, Soares A, Gansl RC: Fatal pneumonitis induced by oxaliplatin: description of three cases. Case Rep Oncol 2012, 5:104–109. 35. Muneoka K, Shirai Y, Sasaki M, Wakai T, Sakata J, Hatakeyama K: Interstitial pneumonia arising in a patient treated with oxaliplatin, 5-fluorouracil, and, leucovorin (FOLFOX). Int J Clin Oncol 2009, 14:457–459. 36. Facciabene A, Motz GT, Coukos G: T-regulatory cells: key players in tumor immune escape and angiogenesis. Cancer Res 2012, 72:2162–2171. 37. Lindau D, Gielen P, Kroesen M, Wesseling P, Adema GJ: The immunosuppressive tumour network: myeloid-derived suppressor cells, regulatory T cells and natural killer T cells. Immunology 2013, 138:105–115. 38. Gajewski TF, Schreiber H, Fu YX: Innate and adaptive immune cells in the tumor microenvironment. Nat Immunol 2013, 14:1014–1022. 39. Okazaki T, Tanaka Y, Nishio R, Mitsuiye T, Mizoguchi A, Wang J, Ishida M, Hiai H, Matsumori A, Minato N, Honjo T: Autoantibodies against cardiac troponin I are responsible for dilated cardiomyopathy in PD-1-deficient mice. Nat Med 2003, 9:1477–1483. 40. Pardoll DM: The blockade of immune checkpoints in cancer immunotherapy. Nat Rev Cancer 2012, 12:252–264. 41. Topalian SL, Hodi FS, Brahmer JR, Gettinger SN, Smith DC, McDermott DF, Powderly JD, Carvajal RD, Sosman JA, Atkins MB, Leming PD, Spigel DR, Antonia SJ, Horn L, Drake CG, Pardoll DM, Chen L, Sharfman WH, Anders RA, Taube JM, McMiller TL, Xu H, Korman AJ, Jure-Kunkel M, Agrawal S, McDonald D, Kollia GD, Gupta A, Wigginton JM, Sznol M: Safety, activity, and immune correlates of anti-PD-1 antibody in cancer. NEngl J Med 2012, 366:2443–2454. 42. Brahmer JR, Tykodi SS, Chow LQ, Hwu WJ, Topalian SL, Hwu P, Drake CG, Camacho LH, Kauh J, Odunsi K, Pitot HC, Hamid O, Bhatia S, Martins R, Eaton K, Chen S, Salay TM, Alaparthy S, Grosso JF, Korman AJ, Parker SM, Agrawal S, Goldberg SM, Pardoll DM, Gupta A, Wigginton JM: Safety and activity of anti-PD-L1 antibody in patients with advanced cancer. N Engl J Med 2012, 366:2455–2465. 43. Wolchok JD, Kluger H, Callahan MK, Postow MA, Rizvi NA, Lesokhin AM, Segal NH, Ariyan CE, Gordon RA, Reed K, Burke MM, Caldwell A, Kronenberg SA, Agunwamba BU, Zhang X, Lowy I, Inzunza HD, Feely W, Horak CE, Hong Q, Korman AJ, Wigginton JM, Gupta A, Sznol M: Nivolumab plus ipilimumab in advanced melanoma. N Engl J Med 2013, 369:122–133. 44. Liu X, Shin N, Koblish HK, Yang G, Wang Q, Wang K, Leffet L, Hansbury MJ, Thomas B, Rupar M, Waeltz P, Bowman KJ, Polam P, Sparks RB, Yue EW, Li Y, Wynn R, Fridman JS, Burn TC, Combs AP, Newton RC, Scherle PA: Selective inhibition of IDO1 effectively regulates mediators of antitumor immunity. Blood 2010, 115:3520–3530. 45. Walter S, Weinschenk T, Stenzl A, Zdrojowy R, Pluzanska A, Szczylik C, Staehler M, Brugger W, Dietrich PY, Mendrzyk R, Hilf N, Schoor O, Fritsche J, Mahr A, Submit your next manuscript to BioMed Central Maurer D, Vass V, Trautwein C, Lewandrowski P, Flohr C, Pohla H, Stanczak JJ, and take full advantage of: Bronte V, Mandruzzato S, Biedermann T, Pawelec G, Derhovanessian E, Yamagishi H, Miki T, Hongo F, Takaha N: Multipeptide immune response to cancer vaccine IMA901 after single-dose cyclophosphamide associates with • Convenient online submission longer patient survival. Nat Med 2012, 18:1254–1261. • Thorough peer review • No space constraints or color figure charges doi:10.1186/1479-5876-12-108 Cite this article as: Hazama et al.: Aphase ΙI study of five peptides • Immediate publication on acceptance combination with oxaliplatin-based chemotherapy as a first-line • Inclusion in PubMed, CAS, Scopus and Google Scholar therapy for advanced colorectal cancer (FXV study). Journal of Translational Medicine 2014 12:108. • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Translational Medicine Springer Journals

A phase ΙI study of five peptides combination with oxaliplatin-based chemotherapy as a first-line therapy for advanced colorectal cancer (FXV study)

Download PDF
10 pages

Loading next page...
 
/lp/springer-journals/a-phase-i-study-of-five-peptides-combination-with-oxaliplatin-based-pLLtivAlVc

References (90)

Publisher
Springer Journals
Copyright
Copyright © 2014 by Hazama et al.; licensee BioMed Central Ltd.
Subject
Biomedicine; Biomedicine general; Medicine/Public Health, general
eISSN
1479-5876
DOI
10.1186/1479-5876-12-108
pmid
24884643
Publisher site
See Article on Publisher Site

Abstract

Background: We previously conducted a phase I trial for advanced colorectal cancer (CRC) using five HLA-A*2402-restricted peptides, three derived from oncoantigens and two from vascular endothelial growth factor (VEGF) receptors, and confirmed safety and immunological responses. To evaluate clinical benefits of cancer vaccination treatment, we conducted a phase II trial using the same peptides in combination with oxaliplatin-based chemotherapy as a first-line therapy. Methods: The primary objective of the study was the response rates (RR). Progression free survival (PFS), overall survival (OS), and immunological parameters were evaluated as secondary objective. The planned sample size was more than 40 patients for both HLA2402-matched and -unmatched groups. All patients received a cocktail of five peptides (3 mg each) mixed with 1.5 ml of IFA which was subcutaneously administered weekly for the first 12 weeks followed by biweekly administration. Presence or absence of the HLA-A*2402 genotype were used for classification of patients into two groups. Results: Between February 2009 and November 2012, ninety-six chemotherapy naïve CRC patients were enrolled under the masking of their HLA-A status. Ninety-three patients received mFOLFOX6 and three received XELOX. Bevacizumab was added in five patients. RR was 62.0% and 60.9% in the HLA-A*2402-matched and -unmatched groups, respectively (p = 0.910). The median OS was 20.7 months in the HLA-A*2402-matched group and 24.0 months in the unmatched group (log-rank, p = 0.489). In subgroup with a neutrophil/lymphocyte ratio (NLR) of < 3.0, patients in the HLA-matched group did not survive significantly longer than those in the unmatched group (log-rank, p = 0.289) but showed a delayed response. Conclusions: Although no significance was observed for planned statistical efficacy endpoints, a delayed response was observed in subgroup with a NLR of < 3.0. Biomarkers such as NLR might be useful for selecting patients with a better treatment outcome by the vaccination. Trial registration: Trial registration: UMIN000001791. Keywords: Peptide vaccine, Peptide cocktail, Colorectal cancer, Phase II study, FOLFOX, Chemotherapy * Correspondence: [email protected] Department of Digestive Surgery and Surgical Oncology, Yamaguchi University Graduate School of Medicine, Ube, Japan Full list of author information is available at the end of the article © 2014 Hazama et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 2 of 10 http://www.translational-medicine.com/content/12/1/108 Background conducted a phase II study of a cancer vaccine consisting Colorectal cancer (CRC) is the third most common can- of five peptides in combination with oxaliplatin-based cer and the second leading cause of cancer-related death chemotherapy as a first-line therapy for advanced CRC. in industrialized countries [1]. In the past decade, a com- The purpose of this study was to evaluate the clinical bination treatment of fluorinated-pyrimidine with irinote- benefit of this cancer vaccine treatment by adding to can (FOLFIRI) or oxaliplatin (FOLFOX, XELOX), with oxaliplatin-based chemotherapy. Furthermore, we ex- or without monoclonal antibodies such as anti-vascular plored a predictive biomarker for its response and for endothelial growth factor (VEGF) antibody or anti-epidermal the selection of patients who are likely to exhibit better growth factor receptor (EGFR) antibody, has markedly im- treatment outcomes following the vaccine treatment. proved the prognosis of patients with metastatic CRC We here demonstrate a promising result of our combin- (mCRC) [2-6]. However, most of the patients reveal pro- ation immuno-chemotherapy and predictive biomarkers gression of the disease due to chemo-resistance and lose for immunotherapy. their lives. As an attempt to validate a new treatment modality to Patients and methods overcome the limited disease control status of mCRC, Patients and eligibility criteria we conducted a combination treatment of five thera- Patients were eligible for enrollment when they were ≥ peutic epitope-peptides with chemotherapy. Recent de- 20 years old with a histologically confirmed advanced velopments in genome-based technologies have enabled CRC, had one or more measurable lesions according to us to obtain comprehensive gene expression profiles of the Response Evaluation Criteria in Solid Tumors version malignant cells and compare them with normal cells [7]. 1.0 (RECIST), were naïve for chemotherapy, had ad- We had previously identified three oncoantigens, RNF43 equate functions of critical organs, had an ECOG per- (ring finger protein 43) [8], 34 kDa translocase of the formance status (PS) of 0 or 1, and had a life expectancy outer mitochondrial membrane (TOMM34) [9], and of ≥ 3 months. The exclusion criteria were CNS involve- KOC1 (IMP-3; IGF-II mRNA binding protein 3) [10], as ment, second primary tumors, active infectious disease, targets for the development of cancer peptide vaccines any steroid treatment, or any prior peptide vaccination for CRC. therapies. Written informed consent was obtained from Although immunotherapy using tumor infiltrating cells each patient at the time of enrollment. The study was car- (TIL) or vaccine treatment are promising modalities for ried out in accordance with the Helsinki declaration on the treatment of cancer, recent reports have indicated sev- experimentation on human subjects, was approved by the eral mechanisms in tumor tissues which make cancer cells Institutional Ethics Review Boards of Yamaguchi University escape from immune system attacks [11]. For example, (H20-102) and each study site, and was registered in the the limited antitumor effects of cytotoxic T lymphocytes UMIN Clinical Trials Registry as UMIN000001791. (CTL) were explained by tumor heterogeneity; a subset of tumor cells revealed the down-regulation or absence of Peptides human leukocyte antigen (HLA) or targeted antigen The RNF43-721 (NSQPVWLCL) [20], TOMM34-299 proteins [12,13]. Since the growth of solid neoplasms (KLRQEVKQNL) [9], KOC1(IMP-3)-508 (KTVNELQNL) is almost always accompanied with neovascularization [21], VEGFR1-1084 (SYGVLLWEI) [22] and VEGFR2-169 [14], which is associated with the expression of vascular (RFVPDGNRI) [23] peptides restricted with HLA-A*2402 endothelial growth factor receptor 1 (VEGFR1) [15] and/or were synthesized by American Peptide Company Inc. VEGFR2 [16], our vaccine treatment also included the pep- (Sunnyvale, CA, USA) according to a standard solid-phase tides derived from VEGFR1 and VEGFR2 that target synthesis method, and were purified by reverse-phase high neovascular endothelial cells.WeselectedfiveHLA-A*2402- performance liquid chromatography (HPLC). The purity restricted peptides derived from RNF43, TOMM34, KOC1, (> 95%) and the identity of the peptides were determined VEGFR1, and VEGFR2 for the clinical trial due to the by analytical HPLC and mass spectrometry analysis, re- abundance of the HLA-A*2402 allele in the Japanese spectively. Endotoxin levels and the bio-burden of these population (an allelic frequency of approximately 60%) peptides were tested and determined to be within accept- [17]. We previously performed a phase Ι study of a com- able levels as Good Manufacturing Practice grade for bination vaccine treatment for mCRC, and confirmed the vaccines. safety and the promising potential of our five-peptide- cocktail treatment to improve the prognosis of advanced Study design CRC [18]. This phase II, single arm, non-randomized, HLA-A status FOLFOX (or XELOX) with/without bevacizumab is a double-blind study was conducted to assess the efficacy of widely-used chemotherapy [4] and has been reported to this combination therapy for first-line treatment for ad- possibly reduce the number of Tregs [19]. We therefore vanced CRC. The therapy consisted of a cocktail of five Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 3 of 10 http://www.translational-medicine.com/content/12/1/108 therapeutic epitope-peptides in addition to oxaliplatin- Secondary objectives included comparisons between the containing chemotherapy. Although the peptides used in two groups for progression free survival (PFS), overall sur- this study were HLA-A*2402 restricted peptides, all en- vival (OS), safety, and tolerability. Exploratory end points rolled patients whose HLA-A status were double-blinded included the assessments of tumor and blood-based im- were administrated the same regime of peptide cocktail munological biomarkers. and oxaliplatin-containing chemotherapy. The cocktail of 3 mg each of five peptides derived from Assessments RNF43-721, TOMM34-299, KOC1-508, VEGFR1-1084 Medical history, physical examination, chest X-ray, ECG, and VEGFR2-169, was mixed with 1.5 ml of incomplete and carcinoembryonic antigen (CEA) measurements were Freund’s adjuvant (IFA) (Montanide ISA51; Seppic, Paris, performed within 21 days before starting the treatment. France) and administered subcutaneously into the thigh Assessments of vital signs, ECOG performance status, or axilla regions on day 1 of each week for 13 weeks, then height, weight, and routine blood analysis (hematology the vaccination schedule was reduced to once every 2 weeks. and chemistry) were performed within 7 days of starting Vaccination was continued even if the disease progressed the treatment. During treatment, physical examination, when the patient wished and a primary doctor who pro- hematology, and biochemistry analyses were repeated on vided additional chemotherapies agreed. day 1 of every treatment cycle. Tumor assessments (com- Oxaliplatin-containing regimens were administrated puted tomography scan, magnetic resonance imaging) concurrently with the vaccination. Detailed informations were made before starting the study treatment and were of the chemotherapies were described in Additional file repeated every 4 to 8 weeks after the treatment. The 1. Briefly, mFOLFOX6 [24,25] consisted of oxaliplatin RECIST guidelines were used to define all responses. Signs 2 2 (85 mg/m ) with leucovorin (400 mg/m ), followed by a of hematological toxicity and non-hematological toxicity 2 2 FU (400 mg/m ) bolus, and then 2,400 mg/m continu- were assessed according to CTCAE during therapy and ous infusion with/without bevacizumab (5 mg/kg) [4]. for 28 days after the last study drug dose. This treatment was repeated every 14 days. XELOX [4] consisted of oxaliplatin (130 mg/m ) on day 1 followed Immunological biomarkers by oral capecitabine (1,000 mg/m ) twice daily on days 1 We investigated the neutrophil/lymphocyte ratio (NLR) through 14 of a 21-day cycle with/without bevacizumab and the peripheral blood lymphocyte counts per the entire at a dose of 7.5 mg/kg. white blood cells (lymphocyte-%) before the treatment as predictive markers of the efficacy of the vaccination. NLR Study objectives and lymphocyte-% were determined immediately at each The primary objective was the comparison of the efficacy study site. of the peptide-cocktail plus oxaliplatin-containing regimen on patients with HLA-A*2402 compared with those with- Statistical analysis out HLA-A*2402 by assessing the objective response rate This study was designed to test the hypothesis that a re- (ORR; complete response (CR) and partial response (PR)). gime consisting of vaccination plus oxaliplatin-containing Figure 1 CONSORT diagram. Scheme showing an HLA-A-status double-blind, biologically-randomized phase ΙI study of five therapeutic epitope-peptides combined with oxaliplatin-based chemotherapy as a first-line therapy for advanced colorectal cancer (FXV study). CRC, colorectal cancer; FOLFOX, infusional fluorouracil, leucovorin, and oxaliplatin; XELOX, capecitabine and oxaliplatin; HLA, human leukocyte antigen. Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 4 of 10 http://www.translational-medicine.com/content/12/1/108 Table 1 Baseline Patient Characteristics HLA-unmatched control group and 65% in the HLA- HLA-A*2402 matched study group. A two-sided Alpha level of 0.2 and Characteristics p value a beta level of 0.5 were assumed. Matched Unmatched (n = 50) (n = 46) Response rates were compared by chi-squared test. OS Sex and PFS rates were analyzed by the Kaplan-Meier method and log rank test. For the evaluation of delayed response, Male 25 24 NS we also performed a supplemental analysis of the weighted Female 25 22 log-rank tests with the Harrington-Fleming class of weights Age test for 3 parameter settings (ρ =0 and γ =0.5; ρ =0 Mean 64.3 63.4 NS and γ =1; ρ =0 and γ =2) [26]. Standard error 10.9 8 Statistical analyses were performed using SPSS statis- Range 36-82 38-77 tics version 20 (SPSS, Chicago, IL, USA) and SAS v9.2. A p value < 0.05 was considered statistically significant. Unresectable site Liver 27 35 Results Lung 18 12 Patients Dissemination 5 4 NS Between January 2009 and November 2012, ninety-six Bone 1 2 patients were enrolled in this trial applying the peptide Lymphnode 13 13 cocktail treatment in combination with an oxaliplatin- based regimen in 13 hospitals. Fifty patients had at least Other 5 1 one allele of HLA-A*2402 and forty-six patients had no Number of unresectable sites HLA-A*2402 allele. The peptide vaccination was admin- 136 30 istered to all patients. Among the 96 patients enrolled to 29 11 this trial, 93 patients received mFOLFOX6 and three 35 5 received XELOX. Five patients were additionally treated Resection of primary lesion with bevacizumab (Figure 1). The baseline characteristics were generally well balanced between the HLA-matched yes 41 43 and HLA-unmatched groups, although the proportion of no 9 3 NS rectal cancer was slightly higher in the HLA-matched Chemotherapy group (Table 1). On the cut-off date (25 December, 2013), FOLFOX 48 45 87 patients (91%) revealed the progression of the disease XELOX 2 1 NS with the median OS follow-up period of 38.2 months. (Bevacizumab) 0 (5) Objective response rate Primary minor site The ORR was 62.0% and 60.9% in the HLA-matched and Colon 29 36 0.057 HLA-unmatched groups (p = 0.910), respectively (Table 2). Rectal 21 10 The proportions of CR, PR, and SD as well as the disease FOLFOX. infusional fluorouracil. leucovorin. and oxaliplatin: XELOX. capecitabine control rate were 2.0% (1/50), 60.0% (30/50), 32.0% (16/50), and oxaliplatin; HLA, human leukocyte antigen; NS. not significant. and 94.0% (47/50) in the HLA-matched group, respectively, chemotherapy is more effective for patients with HLA- and 0% (0/46), 60.9% (28/46), 37.0% (17/46), 97.8% (45/46) A*2402 positive aCRC when compared to those without in the HLA-unmatched group, respectively. HLA-A*2402, defining the HLA-A*2402 matched group as the study group and the unmatched group as the con- Progression free survival trol group. Because the response rate of colorectal cancer The median PFS was 7.2 months for the HLA-matched patients to first line-treatment is generally about 50%, we group and 8.7 months for the HLA-unmatched group. There estimated that a minimum of 40 patients for both arms was no significant difference between two groups (Figure 2A, would be required, assuming a response rate of 50% in the P = 0.971). We also performed sub-group analyses using Table 2 Objective Response rate HLA-status HLA-A*2402-matched (n = 50) HLA-A*2402-unmatched (n = 46) Response CR PR SD PD CR PR SD PD Number 1 30 16 3 0 28 17 1 Response rate 31/50 (62.0%) 28/46 (60.9%) Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 5 of 10 http://www.translational-medicine.com/content/12/1/108 Figure 2 Progression free survival and overall survival. A and B, comparison of progression free survival between HLA-A*2402-mached and -unmatched groups; A, all patients; B, the patients who received the vaccination for more than 12 months. C and D, comparison of overall survival between HLA-A*2402-matched and -unmatched groups; C, all patients; D, patients who received the vaccination for more than 12 months. MST, median survival time; HLA, human leukocyte antigen; M, months; *the weighted log-rank tests with the Harrington-Fleming class of weights were performed and resulted in, ρ =0, and γ = 0.5, p = 0.186; ρ =0, and γ =1, ρ =0.080; ρ =0, and γ =2, ρ = 0.101. the patients who received the vaccination for more than (SAEs) were almost similar in the two groups, that of neu- 12 months, but there was also no difference between these tropenia was relatively higher in the HLA-A*2402-matched two groups (Figure 2B, P = 0.946). group than the unmatched group. Interstitial pneumo- nia that led to the death was observed in two cases Overall survival in the HLA-matched group and in one case in the HLA- The median OS was calculated to be 20.7 months in the unmatched group (Table 4). HLA-A*2402-matched group and 24.0 months in the unmatched group. There was no significant difference Immunological biomarkers between the two groups (Figure 2C; log-rank test, p = NLR is defined as the neutrophil to lymphocyte ratio, 0.489; Harrington-Fleming method, ρ =0 and γ =0.5, and in this study we categorized the patients into two p = 0.186; ρ = 0 and γ =1, p = 0.080; ρ = 0 and γ =2, p = groups (< 3 and ≧ 3) according to the papers reported 0.101). Interestingly, when the patients were able to re- previously [27]. In this study, NLR of <3.0 was a prog- ceive the vaccination for more than 12 months, the OS of nostic marker for the longer survival with peptide cock- the HLA-A*2402-matched group was significantly better tail and oxaliplatin-containing chemotherapy (Figure 3A; than that of the unmatched group (Figure 2D; log-rank log-rank test, p = 0.043). The Lymphocyte-% of ≧ 15% test, p = 0.032). was also associated with a long survival (Figure 3B; log- rank test, p = 0.034). Hence, we examined the combined Safety effect of each of these two markers and the HLA types The most common adverse events (AEs) observed in this on the clinical efficacy of the vaccination. In patients trial were neurologic toxicity and hematologic toxicities with a NLR of < 3.0, a significantly longer overall survival (Table 3). There was no significant difference in the inci- was observed in the HLA-A*2402-matched group than dence of AEs including injection site reaction in the two the HLA-A*2402-unmatched group (Figure 3C; log-rank groups. Although the incidences of serious adverse events test, P = 0.289; Harrington-Fleming method, ρ = 0 and γ = Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 6 of 10 http://www.translational-medicine.com/content/12/1/108 Table 3 Frequent and Severe Adverse Events (CTCAE version 3.0) FOLFOX (n = 89), FOLFOX + Bev (n = 4), XELOX + Bev (n = 1) HLA-A*2402-matched (n = 50) HLA-A*2402-unmatched (n = 46) FOLFOX (n = 48), XELOX (n = 2) FOLFOX (n = 41) + Bev (n = 4), XELOX + Bev (n = 1) 123 4 5 1 2 3 4 5 Adverse Event No % No % No % No % No % No % No % No % No % No % Hand-foot syndrome 0 0 0 0 1 2 0 0 0 0 1 200120 0 0 0 Allergy 4 8 3 6 2 4 0 0 0 0 3 749000 0 0 0 Mucositis 2 4 1 2 1 2 0 0 0 0 2 400000 0 0 0 Nausea/vomiting 5 10 1 2 2 4 0 0 0 0 6 13 24120 0 0 0 Neurologic toxicity 15 30 10 20 4 8 0 0 0 17 37 10 22 5 11 1 2 0 0 Anorexia 10 20 3 6 4 8 0 0 0 0 10 22 49240 0 0 0 Diarrhea 3 6 6 12 2 4 0 0 0 0 3 700120 0 0 0 Fatigue/Asthenia 5 10 1 2 2 4 0 0 0 0 5 11 12120 0 0 0 Fever 2 4 0 0 0 0 0 0 0 0 3 724000 0 0 0 Injection site reaction 18 36 18 36 9 18 0 0 0 0 20 43 17 37 3 13 0 0 0 0 Interstitial pneumonia 0 0 0 0 4 8 0 0 2 4 0 000490 0 1 2 Neutropenia 5 10 10 20 10 20 1 2 0 0 8 17 14 30 2 4 1 2 0 0 Leukopenia 10 20 12 24 1 2 0 0 0 0 12 26 9 20 2 4 0 0 0 0 Thrombocytopenia 17 34 3 6 0 0 0 0 0 0 20 43 24000 0 0 0 Bilirubin 2 4 2 4 0 0 0 0 0 0 0 000000 0 0 0 AL-P 11 22 1 2 1 2 0 0 0 0 10 22 12000 0 0 0 Creatinine 3 6 1 2 0 0 0 0 0 0 1 200000 0 0 0 Hemoglobin 11 22 5 10 0 0 0 0 0 0 13 28 7 15 0 0 0 0 0 0 Embolism 0 0 0 0 0 0 0 0 0 0 0 000001 2 0 0 AST/ALT 12 24 0 0 1 2 0 0 0 0 6 13 12000 0 0 0 No gastrointestinal perforation nor bleeding wound healing complication was observed. FOLFOX, infusional fluorouracil, leucovorin, and oxaliplatin; XELOX, capecitabine and oxaliplatin; Bev, bevacizumab; AL-P, alkaline phosphatese; AST, aspartete aminotransfarase; ALT, alanine aminotransferase; CTCAE, the Common Terminology Criteria for Adverse Event version 3.0; HLA, Human leukocyte antigen. 0.5, p = 0.152; ρ =0 and γ =1, p=0.064; ρ =0 and γ =2, p = 0.035) while this difference was not observed in Table 4 Interstitial Pneumonia patients with NLR of ≧ 3.0 (log-lank test, p = 0.962; HLA CTCAE Result of Harrington-Fleming method, ρ =0 and γ = 0.5, p = 0.495; DLLT genotype grade ρ = 0 and γ =1, p =0.346; ρ =0 and γ = 2, p = 0.251). Simi- 2402/2402 3 5FU larly, in a patient group with a lymphocyte% of > 15%, a 2402/1101 3 negative longer overall survival was observed in the HLA-A*2402- matched group (Figure 3D; log-lank test, p = 0.340; 2402/1101 5 negative Harrington-Fleming method, ρ =0 and γ =0.5, p =0.114; 2402/0206 3 negative ρ =0 and γ = 1, p = 0.051; ρ =0 and γ = 2, p = 0.029). 2402/2603 3 5FU 2402/2602 5 negative Discussion 1101/2601 3 5FU We performed a phase II study using a cocktail of five epi- 2601/3101 3 5FU tope peptides, which we previously confirmed its safety, together with oxaliplatin-based chemotherapy. The cock- 1101/3101 3 5FU tail contained three peptides derived from three oncoanti- 3004/3303 5 not examined gens and two peptides targeting VEGFR1 and VEGFR2. 1101/3101 3 not examined This study was an HLA-A-status double-blind, phase ΙI CTCAE, the Common Terminology Criteria for Adverse Event version 3.0; HLA, study of five therapeutic epitope-peptides with oxaliplatin- Human leukocyte antigen; DLTT, drug-induced lymphocyte transformation test; based chemotherapy as a first-line therapy for advanced 5FU, 5-fluorouracil. Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 7 of 10 http://www.translational-medicine.com/content/12/1/108 Figure 3 Biomarkers for the survival and the clinical efficacy of vaccination. Neutrophil/lymphocyte ratio (NLR) < 3.0 and Lymphocyte-% ≧ 15% were considered as indicative factors. A and B, comparison between the favorite group and others. C, comparison of the patients with a NLR of ≧ 3 or a NLR of <3 between the HLA-A*2402-matched and -unmatched groups. D, comparison of the patients with Lymphocyte-% ≧ 15% between the HLA-A*2402 positive and negative groups. Lymphocyte (Ly)-%, the percentage of lymphocytes among the peripheral leukocytes; NLR, neutrophil/lymphocyte ratio; HLA, human leukocyte antigen; L-R, log-rank test; *the weighted log-rank tests with the Harrington-Fleming class of weights were performed and resulted in, ρ = 0, and γ = 0.5, p = 0.152; ρ = 0, and γ = 1, p = 0.064; ρ = 0, and γ = 2, p = 0.035; **the Harrington-Fleming tests were resulted in, ρ = 0, and γ = 0.5, p = 0.495; ρ = 0, and γ =1, ρ = 0.346; ρ = 0, and γ =2, ρ = 0.251; *** the Harrington-Fleming tests were resulted in, ρ = 0, and γ = 0.5, p = 0.114; ρ = 0, and γ =1, ρ = 0.051; ρ = 0, and γ =2, ρ = 0.029. colorectal cancer (FXV study). In this study, we observed obvious tail effect for extremely long survival. Then we many interesting results. examined the efficacy of vaccination by comparing HLA- Firstly, the OS of the HLA-A*2402-matched group was matched group and -unmatched group. In patients with significantly higher compared to that of the unmatched an NLR of < 3.0, a significantly longer survival in the group (log-rank test, p = 0.032) when patients who received HLA-matched group than the HLA-unmatched group the vaccination for more than 12 months (Figure 2D) al- was observed (Figure 3B; log-rank, p = 0.289; Harrington- though no difference in PFS was observed between the Fleming, p = 0.035), while this difference was not observed two groups (Figures 2B). These results indicated that in the two groups with NLR of ≧ 3.0 (log-rank, p = 0.962; the additional effect of vaccination on the standard Harrington-Fleming, p = 0.251). This result also support chemotherapy was likely to be slow-acting as this kind of the idea that it may be critically important to apply delayed response by the vaccine treatment was indicated vaccine treatment to patients with better immune sta- in the guidance for therapeutic cancer vaccines released tus, and NLR might be a one of good predictive markers from the US Food and Drug Administration in October, to select the appropriate patient populations for this 2011 [28]. type of treatment. A similar result was observed when Secondly, neutrophil/lymphocyte ratio (NLR) might be- we analyzed patients with lymphocyte% of ≧ 15%; come a prognostic marker for patients who received the HLA-matched patients with lymphocyte% of ≧ 15 showed peptide vaccine in combination with standard chemo- significantly better prognosis than HLA-unmatched pa- therapy (Figure 3A, log-rank; p = 0.043), and there was an tients (Figure 3D; log-rank, p = 0.340; Harrington-Fleming, Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 8 of 10 http://www.translational-medicine.com/content/12/1/108 p = 0.029). The selection of patients with lower NLR be combined with some agents to modify the immune- and higher lymphocyte percentage might be useful to the suppressive tumor microenvironments. selection of patients who are likely to respond well to In conclusion, our cocktail of five therapeutic epitope vaccine treatment and improve clinical outcomes. peptides appears to be effective in a subset of patients, Vaccinations with a cocktail of five peptides together and warrants a randomized phase III study. In the phase with oxaliplatin-based chemotherapy in metastatic CRC III study, biomarkers such as NLR and lymphocyte-% patients were well tolerated, except for relatively frequent might be useful for assessing the response to the peptide cases (11 cases; 11.4%) of pneumonitis (Tables 3 and 4), vaccine and for selecting patients likely to have a better whose incidence seemed to be higher than previously treatment outcome with the vaccination. reported for oxaliplatin-based chemotherapies although no difference was observed between HLA-matched Conclusions and -unmatched group. Correale et al. reported two This phase II cancer vaccine therapy demonstrated that cases (5.5%) in 36 patients with advanced gastric cancer our therapeutic peptides cocktail was likely to be effect- treated with gemcitabine plus oxaliplatin, folinic acid, and ive in a subset of patients and warrants a randomized 5-fluorouracil (FOLFOX-4) [29]. Usui et al. reported that phase III study. In the phase III study, predictive bio- four cases (3.9%) of pneumonitis among 104 Japanese markers such as NLR and lymphocyte-% should be used patients treated with oxaliplatin-containing regimes for for its response and for selecting patients to have a bet- advanced colorectal cancer [30]. In addition, there have ter treatment outcome with the vaccination. been many case reports of oxaliplatin-related pneumonitis [31-35]. In this study, eleven (11.4%) of 96 patients suf- Additional file fered from severe pneumonitis including three cases with Additional file 1: Summary of the protocol. grade 5 pneumonitis. To investigate the possible cause of pneumonitiswe performed drug-induced lymphocyte trans- Abbreviations formation test (DLTT) for nine patients whose samples RNF43: Ring finger protein 43; TOMM34: 34 kDa-translocase of the outer were available. Among them, five patients (55.6%) were mitochondrial membrane; KOC1: insulin-like growth factor–II mRNA binding judged to be positive to fluorouracil alone, and the remaining protein 3; VEGFR: Vascular endothelial growth factor receptor; HPLC: High performance liquid chromatography; CRC: Colorectal cancer; four patients were negative for all of the antigens tested. ELISPOT: Enzyme-linked immunospot; PBMC: Peripheral blood mononuclear Although the size of this study is not large enough to cells; CTL: Cytotoxic T lymphocytes; RR: Response rates; CR: Complete clinical make any conclusion and there is no difference between response; SD: Stable disease; PD: Progressive disease; PFS: Progression free survival; OS: Overall survival; HLA: Human leukocyte antigen; MST: Median the two groups, this adverse event should be carefully overall survival time; ECOG: Eastern cooperative oncology group; monitored when we will perform the next-step clinical RECIST: Response evaluation criteria in solid tumors; TIL: Tumor infiltrating trial. cells; CTCAE: Common terminology criteria for adverse events version3.0; AEs: Adverse events; SAEs: Serious adverse events; DLTT: Drug-induced Although the efficacy of our peptide vaccine was not lymphocyte transformation test; PS: Performance status; IFA: Incomplete clearly demonstrated in this phase II study, the timing of freund’s adjuvant; CT: Computed tomography; MRI: Magnetic resonance and combination treatment with vaccination might not imaging; NLR: Neutrophil/lymphocyte ratio; FOLFOX: Infusional fluorouracil, leucovorin, and oxaliplatin; XELOX: Capecitabine and oxaliplatin, Tregs, be optimized, and the sample size was limited. Recently, regulatory T cells; MDSCs: Myeloid-derived suppressor cells; IDO: Indoleamine-2,3- regulatory T cells (Tregs) and myeloid-derived suppres- dioxygenase. sor cells (MDSCs) are reported as potent immunosuppres- Competing interests sive cells to protect cancer cells from the host immune Yusuke Nakamura is a stock holder and a scientific advisor of OncoTherapy system [36,37]. Over expression of PD-L1and PD-1 as well Science, Inc. The other authors have no potential conflicts of interest to as up-regulation of indoleamine-2,3-dioxygenase (IDO) in disclose. the tumor microenvironment also inhibit the CTL func- Authors’ contributions tions [38]. Hence, to overcome these immune-escape SH designed, performed and evaluated clinical study, and wrote the mechanisms, various approaches have been taken in the manuscript. YN and MO participated in the design, review and revision of the manuscript. HT, KH, KT, RS, HO, RE, FS, KO, TF, TN, KS, KY, YI, SK, YS, NS, last decade [39,40]. For example, anti-PD1antibody [41], SY, HS, AK, TF, YK and HF assisted to perform clinical study. RT, HT, and TY anti-PD-L1antibody [42], and anti-CTL4 antibody [43] contributed in the data collection and statistical analysis. All authors were applied in clinical trials to overcome the suppressive participated in the data acquisition and discussion of the manuscript and approved the final manuscript. immuno checkpoints, and surprisingly high objective response rates were observed in many types of malignant Acknowledgements neoplasm. Small-molecule inhibitors [44] that block IDO This study was supported partially by the Project for Development of enzymatic activity or cyclophosphamide to reduce the Innovative Research on Cancer Therapeutics (P-DIRECT) of the Ministry of Education, Culture, Sports, Science and Technology of Japan. The authors number of Tregs [45] were also applied in clinical trials to would like to thank Prof. Yusuke Nakamura, Dr. Takuya Tsunoda, Dr. Koji dissolve the suppressive immunity. For the successful Yoshida, Laboratory of Molecular Medicine, Human Genome Center, Institute next generation immunotherapy, peptide vaccine should of Medical Science, The University of Tokyo, for their excellent advice and Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 9 of 10 http://www.translational-medicine.com/content/12/1/108 cooperation and providing all the peptides. The authors also thank Prof. Koji identification of genes for prediction of lymph-node metastasis and Kono, Department of Surgery, National University of Singapore, for his sensitivity to anti-cancer drugs. Oncogene 2003, 22:2192–2205. excellent managements as The Data and Safety Monitoring Committee of 11. Rosenberg SA, Yang JC, Restifo NP: Cancer immunotherapy: moving this study. beyond current vaccines. Nat Med 2004, 10:909–915. 12. Khong HT, Restifo NP: Natural selection of tumor variants in the generation Author details of tumor “escape” phenotypes. Nat Immunol 2002, 3:999–1005. Department of Digestive Surgery and Surgical Oncology, Yamaguchi 13. Ryschich E, Notzel T, Hinz U, Autschbach F, Ferguson J, Simon I, Weitz J, University Graduate School of Medicine, Ube, Japan. Department of Frohlich B, Klar E, Buchler MW, Schmidt J: Control of T-cell-mediated Medicine and Surgery, The University of Chicago, Chicago, IL, USA. immune response by HLA class I in human pancreatic carcinoma. Department of Surgical Oncology, Osaka City University Graduate School of Clin Cancer Res 2005, 11:498–504. Medicine, Osaka, Japan. Department of Surgery, Kure-Kyosai Hospital, Kure, 14. Folkman J: Tumor angiogenesis: therapeutic implications. N Engl J Med Japan. Department of Surgery, Ogori Daiichi General Hospital, Yamaguchi, 1971, 285:1182–1186. Japan. Department of Surgery, Kinki University Faculty of Medicine, 15. Olofsson B, Korpelainen E, Pepper MS, Mandriota SJ, Aase K, Kumar V, Gunji Y, Osaka-Sayama, Japan. Department of Surgery, Kanmon-Medical Center, Jeltsch MM, Shibuya M, Alitalo K, Eriksson U: Vascular endothelial growth factor Shimonoseki, Japan. Department of Surgery, Shimonoseki-Kosei Hospital, B (VEGF-B) binds to VEGF receptor-1 and regulates plasminogen activator Shimonoseki, Japan. Tokyo Women’s Medical University Medical Center East, activity in endothelial cells. Proc Natl Acad Sci U S A 1998, 95:11709–11714. Tokyo, Japan. Department of Pharmacy, Yamaguchi University Hospital, 16. Millauer B, Wizigmann-Voos S, Schnurch H, Martinez R, Moller NP, Risau W, Ube, Japan. Department of Biostatistics, National Cancer Center, Chiba, Ullrich A: High affinity VEGF binding and developmental expression Japan. Division of Cellular Signaling, Institute for Advanced Medical suggest Flk-1 as a major regulator of vasculogenesis and angiogenesis. Research, Keio University School of Medicine, Tokyo, Japan. Cell 1993, 72:835–846. 17. Date Y, Kimura A, Kato H, Sasazuki T: DNA typing of the HLA-A gene: Received: 10 March 2014 Accepted: 16 April 2014 population study and identification of four new alleles in Japanese. Published: 30 April 2014 Tissue Antigens 1996, 47:93–101. 18. Hazama S, Nakamura Y, Takenouchi H, Suzuki N, Tsunedomi R, Inoue Y, Tokuhisa Y, Iizuka N, Yoshino S, Takeda K, Shinozaki H, Kamiya A, Furukawa References H, Oka M: A phase I study of combination vaccine treatment of five 1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM: Estimates of therapeutic epitope-peptides for metastatic colorectal cancer; safety, worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 2010, immunological response, and clinical outcome. J Transl Med 2014, 12:63. 127:2893–2917. 19. Maeda K, Hazama S, Tokuno K, Kan S, Maeda Y, Watanabe Y, Kamei R, 2. Tournigand C, Andre T, Achille E, Lledo G, Flesh M, Mery-Mignard D, Quinaux E, Shindo Y, Maeda N, Yoshimura K, Yoshino S, Oka M: Impact of Couteau C, Buyse M, Ganem G, Landi B, Colin P, Louvet C, de Gramont A: chemotherapy for colorectal cancer on regulatory T-cells and tumor FOLFIRI followed by FOLFOX6 or the reverse sequence in advanced immunity. Anticancer Res 2011, 31:4569–4574. colorectal cancer: a randomized GERCOR study. JClin Oncol 2004, 20. Uchida N, Tsunoda T, Wada S, Furukawa Y, Nakamura Y, Tahara H: Ring 22:229–237. finger protein 43 as a new target for cancer immunotherapy. Clin Cancer 3. Cassidy J, Clarke S, Diaz-Rubio E, Scheithauer W, Figer A, Wong R, Koski S, Res 2004, 10:8577–8586. Lichinitser M, Yang TS, Rivera F, Couture F, Sirzen F, Saltz L: Randomized 21. Suda T, Tsunoda T, Daigo Y, Nakamura Y, Tahara H: Identification of human phase III study of capecitabine plus oxaliplatin compared with fluorouracil/ leukocyte antigen-A24-restricted epitope peptides derived from gene folinic acid plus oxaliplatin as first-line therapy for metastatic colorectal products upregulated in lung and esophageal cancers as novel targets cancer. J Clin Oncol 2008, 26:2006–2012. for immunotherapy. Cancer Sci 2007, 98:1803–1808. 4. Saltz LB, Clarke S, Diaz-Rubio E, Scheithauer W, Figer A, Wong R, Koski S, 22. Ishizaki H, Tsunoda T, Wada S, Yamauchi M, Shibuya M, Tahara H: Inhibition Lichinitser M, Yang TS, Rivera F, Couture F, Sirzen F, Cassidy J: Bevacizumab of tumor growth with antiangiogenic cancer vaccine using epitope in combination with oxaliplatin-based chemotherapy as first-line therapy peptides derived from human vascular endothelial growth factor in metastatic colorectal cancer: a randomized phase III study. J Clin Oncol receptor 1. Clin Cancer Res 2006, 12:5841–5849. 2008, 26:2013–2019. 23. Wada S, Tsunoda T, Baba T, Primus FJ, Kuwano H, Shibuya M, Tahara H: 5. Van Cutsem E, Kohne CH, Hitre E, Zaluski J, Chang Chien CR, Makhson A, Rationale for antiangiogenic cancer therapy with vaccination using D’Haens G, Pinter T, Lim R, Bodoky G, Roh JK, Folprecht G, Ruff P, Stroh C, epitope peptides derived from human vascular endothelial growth Tejpar S, Schlichting M, Nippgen J, Rougier P: Cetuximab and chemotherapy factor receptor 2. Cancer Res 2005, 65:4939–4946. as initial treatment for metastatic colorectal cancer. N Engl J Med 2009, 24. Kato T, Muro K, Yamaguchi K, Bando H, Hazama S, Amagai K, Baba H, Denda T, Shi 360:1408–1417. X, Fukase K, Skamoto J, Mishima H: Cediranib in combination with mFOLFOX6 6. Douillard JY, Siena S, Cassidy J, Tabernero J, Burkes R, Barugel M, in Japanese patients with metastatic colorectal cancer: results from the Humblet Y,BodokyG,CunninghamD,JassemJ,RiveraF,KocakovaI, randomised phase II part of a phase I/II study. Ann Oncol 2012, 23:933–941. Ruff P, Blasinska-Morawiec M, Smakal M, Canon JL, Rother M, Oliner KS, 25. Schmoll HJ, Cunningham D, Sobrero A, Karapetis CS, Rougier P, Koski SL, Wolf M, Gansert J: Randomized, phase III trial of panitumumab with Kocakova I, Bondarenko I, Bodoky G, Mainwaring P, Salazar R, Barker P, infusional fluorouracil, leucovorin, and oxaliplatin (FOLFOX4) versus Mookerjee B, Robertson J, Van Cutsem E: Cediranib with mFOLFOX6 FOLFOX4 alone as first-line treatment in patients with previously versus bevacizumab with mFOLFOX6 as first-line treatment for patients untreated metastatic colorectal cancer: the PRIME study. JClin Oncol with advanced colorectal cancer: a double-blind, randomized phase III 2010, 28:4697–4705. study (HORIZON III). J Clin Oncol 2012, 30:3588–3595. 7. Okabe H, Satoh S, Kato T, Kitahara O, Yanagawa R, Yamaoka Y, Tsunoda T, 26. Fleming T, Harrington D: Counting Processes and Survival Analysis. New York: Furukawa Y, Nakamura Y: Genome-wide analysis of gene expression in John Wiley & Sons; 1991. human hepatocellular carcinomas using cDNA microarray: identification 27. He W, Yin C, Guo G, Jiang C, Wang F, Qiu H, Chen X, Rong R, Zhang B, Xia L: of genes involved in viral carcinogenesis and tumor progression. Cancer Initial neutrophil lymphocyte ratio is superior to platelet lymphocyte ratio Res 2001, 61:2129–2137. as an adverse prognostic and predictive factor in metastatic colorectal 8. Yagyu R, Furukawa Y, Lin YM, Shimokawa T, Yamamura T, Nakamura Y: A cancer. Med Oncol 2013, 30:439. novel oncoprotein RNF43 functions in an autocrine manner in colorectal 28. U.S. Department of Health and Human Services, Food and Drug cancer. Int J Oncol 2004, 25:1343–1348. Administration: Guidance for Industry. Clinical Considerations for 9. Shimokawa T, Matsushima S, Tsunoda T, Tahara H, Nakamura Y, Furukawa Y: Therapeutic Cancer Vaccines. 2011, http://www.fda.gov/downloads/ Identification of TOMM34, which shows elevated expression in the biologicsbloodvaccines/guidancecomplianceregulatoryinformation/ majority of human colon cancers, as a novel drug target. Int J Oncol guidances/vaccines/ucm278673.pdf. 2006, 29:381–386. 29. Correale P, Fulfaro F, Marsili S, Cicero G, Bajardi E, Intrivici C, Vuolo G, Carli 10. Kikuchi T, Daigo Y, Katagiri T, Tsunoda T, Okada K, Kakiuchi S, Zembutsu H, AF, Caraglia M, Del Prete S, Greco E, Gebbia N, Francini G: Gemcitabine Furukawa Y, Kawamura M, Kobayashi K, Imai K, Nakamura Y: Expression (GEM) plus oxaliplatin, folinic acid, and 5-fluorouracil (FOLFOX-4) in profiles of non-small cell lung cancers on cDNA microarrays: Hazama et al. Journal of Translational Medicine 2014, 12:108 Page 10 of 10 http://www.translational-medicine.com/content/12/1/108 patients with advanced gastric cancer. Cancer Chemother Pharmacol 2005, 56:563–568. 30. Usui K, Katou Y, Furushima K, Tanaka Y, Tanai C, Ishihara T: Interstitial lung disease during chemotherapy combined with oxaliplatin and/or bevacizumab in advanced colorectal cancer patients. Jpn J Clin Oncol 2011, 41:498–502. 31. Gagnadoux F, Roiron C, Carrie E, Monnier-Cholley L, Lebeau B: Eosinophilic lung disease under chemotherapy with oxaliplatin for colorectal cancer. Am J Clin Oncol 2002, 25:388–390. 32. Fuse N, Doi T, Ohtsu A, Takeuchi S, Kojima T, Taku K, Tahara M, Muto M, Asaka M, Yoshida S: Feasibility of oxaliplatin and infusional fluorouracil/ leucovorin (FOLFOX4) for Japanese patients with unresectable metastatic colorectal cancer. Jpn J Clin Oncol 2007, 37:434–439. 33. Arevalo Lobera S, Sagastibeltza Marinelarena N, Elejoste Echeberria I, Mele Olive M, EganaOtano L, Basterretxea BadiolaL, LaCasta MunoaA,Azkue GabilondoM: Fatal pneumonitis induced by oxaliplatin. Clin Transl Oncol 2008, 10:764–767. 34. Pontes LB, Armentano DP, Soares A, Gansl RC: Fatal pneumonitis induced by oxaliplatin: description of three cases. Case Rep Oncol 2012, 5:104–109. 35. Muneoka K, Shirai Y, Sasaki M, Wakai T, Sakata J, Hatakeyama K: Interstitial pneumonia arising in a patient treated with oxaliplatin, 5-fluorouracil, and, leucovorin (FOLFOX). Int J Clin Oncol 2009, 14:457–459. 36. Facciabene A, Motz GT, Coukos G: T-regulatory cells: key players in tumor immune escape and angiogenesis. Cancer Res 2012, 72:2162–2171. 37. Lindau D, Gielen P, Kroesen M, Wesseling P, Adema GJ: The immunosuppressive tumour network: myeloid-derived suppressor cells, regulatory T cells and natural killer T cells. Immunology 2013, 138:105–115. 38. Gajewski TF, Schreiber H, Fu YX: Innate and adaptive immune cells in the tumor microenvironment. Nat Immunol 2013, 14:1014–1022. 39. Okazaki T, Tanaka Y, Nishio R, Mitsuiye T, Mizoguchi A, Wang J, Ishida M, Hiai H, Matsumori A, Minato N, Honjo T: Autoantibodies against cardiac troponin I are responsible for dilated cardiomyopathy in PD-1-deficient mice. Nat Med 2003, 9:1477–1483. 40. Pardoll DM: The blockade of immune checkpoints in cancer immunotherapy. Nat Rev Cancer 2012, 12:252–264. 41. Topalian SL, Hodi FS, Brahmer JR, Gettinger SN, Smith DC, McDermott DF, Powderly JD, Carvajal RD, Sosman JA, Atkins MB, Leming PD, Spigel DR, Antonia SJ, Horn L, Drake CG, Pardoll DM, Chen L, Sharfman WH, Anders RA, Taube JM, McMiller TL, Xu H, Korman AJ, Jure-Kunkel M, Agrawal S, McDonald D, Kollia GD, Gupta A, Wigginton JM, Sznol M: Safety, activity, and immune correlates of anti-PD-1 antibody in cancer. NEngl J Med 2012, 366:2443–2454. 42. Brahmer JR, Tykodi SS, Chow LQ, Hwu WJ, Topalian SL, Hwu P, Drake CG, Camacho LH, Kauh J, Odunsi K, Pitot HC, Hamid O, Bhatia S, Martins R, Eaton K, Chen S, Salay TM, Alaparthy S, Grosso JF, Korman AJ, Parker SM, Agrawal S, Goldberg SM, Pardoll DM, Gupta A, Wigginton JM: Safety and activity of anti-PD-L1 antibody in patients with advanced cancer. N Engl J Med 2012, 366:2455–2465. 43. Wolchok JD, Kluger H, Callahan MK, Postow MA, Rizvi NA, Lesokhin AM, Segal NH, Ariyan CE, Gordon RA, Reed K, Burke MM, Caldwell A, Kronenberg SA, Agunwamba BU, Zhang X, Lowy I, Inzunza HD, Feely W, Horak CE, Hong Q, Korman AJ, Wigginton JM, Gupta A, Sznol M: Nivolumab plus ipilimumab in advanced melanoma. N Engl J Med 2013, 369:122–133. 44. Liu X, Shin N, Koblish HK, Yang G, Wang Q, Wang K, Leffet L, Hansbury MJ, Thomas B, Rupar M, Waeltz P, Bowman KJ, Polam P, Sparks RB, Yue EW, Li Y, Wynn R, Fridman JS, Burn TC, Combs AP, Newton RC, Scherle PA: Selective inhibition of IDO1 effectively regulates mediators of antitumor immunity. Blood 2010, 115:3520–3530. 45. Walter S, Weinschenk T, Stenzl A, Zdrojowy R, Pluzanska A, Szczylik C, Staehler M, Brugger W, Dietrich PY, Mendrzyk R, Hilf N, Schoor O, Fritsche J, Mahr A, Submit your next manuscript to BioMed Central Maurer D, Vass V, Trautwein C, Lewandrowski P, Flohr C, Pohla H, Stanczak JJ, and take full advantage of: Bronte V, Mandruzzato S, Biedermann T, Pawelec G, Derhovanessian E, Yamagishi H, Miki T, Hongo F, Takaha N: Multipeptide immune response to cancer vaccine IMA901 after single-dose cyclophosphamide associates with • Convenient online submission longer patient survival. Nat Med 2012, 18:1254–1261. • Thorough peer review • No space constraints or color figure charges doi:10.1186/1479-5876-12-108 Cite this article as: Hazama et al.: Aphase ΙI study of five peptides • Immediate publication on acceptance combination with oxaliplatin-based chemotherapy as a first-line • Inclusion in PubMed, CAS, Scopus and Google Scholar therapy for advanced colorectal cancer (FXV study). Journal of Translational Medicine 2014 12:108. • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

Journal

Journal of Translational Medicine – Springer Journals

Published: Apr 30, 2014

There are no references for this article.