OX40 and LAG3 are associated with better prognosis in advanced gastric cancer patients treated with anti-programmed death-1 antibody.


Journal

British journal of cancer
ISSN: 1532-1827
Titre abrégé: Br J Cancer
Pays: England
ID NLM: 0370635

Informations de publication

Date de publication:
05 2020
Historique:
received: 28 10 2019
accepted: 06 03 2020
revised: 12 02 2020
pubmed: 24 3 2020
medline: 23 12 2020
entrez: 24 3 2020
Statut: ppublish

Résumé

Anti-PD-1 monoclonal antibody, nivolumab, has shown efficacy for advanced gastric cancer (AGC). However, the specific immune cell subsets predominantly activated during the period of anti-PD-1 therapy for AGC have not been clarified. Peripheral blood of 30 AGC patients treated with nivolumab was prospectively obtained before the initial and second administrations and at the time of progressive disease (PD). The proportions of immune cell subsets and the serum concentrations of cytokines were systematically analysed by flow cytometry. Associations of subsets and serum cytokines with therapeutic effects were evaluated. After the initial administration, significant increases in activated central/effector memory, activated effector T cells, and activated T-helper 1 subsets were observed. At the time of PD, activated regulatory T cells, LAG3-positive CD4+/CD8+ T cells, and TIM3-positive CD4+/CD8+ T cells increased significantly. Significant positive correlations were shown between progression-free survival and proportions of LAG3-positive CD4+/CD8+ T cells and of OX40-positive CD4+/CD8+ T cells (log-rank p = 0.0008, 0.0003, 0.0035 and 0.0040). Nivolumab therapy enhances activation of central/effector memory and effector subsets of CD4+/CD8+ T cells. The expression levels of LAG-3 and OX40 on T cells correlated with the efficacy of nivolumab therapy and could be reasonable biomarkers for anti-PD-1 therapy.

Sections du résumé

BACKGROUND
Anti-PD-1 monoclonal antibody, nivolumab, has shown efficacy for advanced gastric cancer (AGC). However, the specific immune cell subsets predominantly activated during the period of anti-PD-1 therapy for AGC have not been clarified.
METHODS
Peripheral blood of 30 AGC patients treated with nivolumab was prospectively obtained before the initial and second administrations and at the time of progressive disease (PD). The proportions of immune cell subsets and the serum concentrations of cytokines were systematically analysed by flow cytometry. Associations of subsets and serum cytokines with therapeutic effects were evaluated.
RESULTS
After the initial administration, significant increases in activated central/effector memory, activated effector T cells, and activated T-helper 1 subsets were observed. At the time of PD, activated regulatory T cells, LAG3-positive CD4+/CD8+ T cells, and TIM3-positive CD4+/CD8+ T cells increased significantly. Significant positive correlations were shown between progression-free survival and proportions of LAG3-positive CD4+/CD8+ T cells and of OX40-positive CD4+/CD8+ T cells (log-rank p = 0.0008, 0.0003, 0.0035 and 0.0040).
CONCLUSIONS
Nivolumab therapy enhances activation of central/effector memory and effector subsets of CD4+/CD8+ T cells. The expression levels of LAG-3 and OX40 on T cells correlated with the efficacy of nivolumab therapy and could be reasonable biomarkers for anti-PD-1 therapy.

Identifiants

pubmed: 32203221
doi: 10.1038/s41416-020-0810-1
pii: 10.1038/s41416-020-0810-1
pmc: PMC7217874
doi:

Substances chimiques

Antigens, CD 0
OX40 Ligand 0
PDCD1 protein, human 0
Programmed Cell Death 1 Receptor 0
TNFSF4 protein, human 0
Nivolumab 31YO63LBSN
Lymphocyte Activation Gene 3 Protein 0
Lag3 protein, human 0

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Pagination

1507-1517

Références

GLOBOCAN 2018, Data visualization tools for exploring the global cancer burden in 2018. http://gco.iarc.fr/today/fact-sheets-cancer (2019)
Ajani, J. A., D’Amico, T. A., Almhanna, K., Bentrem, D. J., Chao, J., Das, P. et al. Gastric Cancer, Version 3.2016, NCCN clinical practice guidelines in oncology. J. Natl Compr. Canc. Netw. 14, 1286–1312 (2016).
pubmed: 27697982
Hironaka, S., Ueda, S., Yasui, H., Nishina, T., Tsuda, M., Tsumura, T. et al. Randomized, open-label, phase III study comparing irinotecan with paclitaxel in patients with advanced gastric cancer without severe peritoneal metastasis after failure of prior combination chemotherapy using fluoropyrimidine plus platinum: WJOG 4007 trial. J. Clin. Oncol. 31, 4438–4444 (2013).
pubmed: 24190112
Thuss-Patience, P. C., Kretzschmar, A., Bichev, D., Deist, T., Hinke, A., Breithaupt, K. et al. Survival advantage for irinotecan versus best supportive care as second-line chemotherapy in gastric cancer-a randomised phase III study of the Arbeitsgemeinschaft Internistische Onkologie (AIO). Eur. J. Cancer 47, 2306–2314 (2011).
pubmed: 21742485
Fuchs, C. S., Tomasek, J., Yong, C. J., Dumitru, F., Passalacqua, R., Goswami, C. et al. Ramucirumab monotherapy for previously treated advanced gastric or gastro-oesophageal junction adenocarcinoma (REGARD): an international, randomised, multicentre, placebo-controlled, phase 3 trial. Lancet 383, 31–39 (2014).
pubmed: 24094768
Wilke, H., Muro, K., Van Cutsem, E., Oh, S. C., Bodoky, G., Shimada, Y. et al. Ramucirumab plus paclitaxel versus placebo plus paclitaxel in patients with previously treated advanced gastric or gastro-oesophageal junction adenocarcinoma (RAINBOW): a double-blind, randomised phase 3 trial. Lancet Oncol. 15, 1224–1235 (2014).
pubmed: 25240821
Kang, Y. K., Boku, N., Satoh, T., Ryu, M. H., Chao, Y., Kato, K. et al. Nivolumab in patients with advanced gastric or gastro-oesophageal junction cancer refractory to, or intolerant of, at least two previous chemotherapy regimens (ONO-4538-12, ATTRACTION-2): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 390, 2461–2471 (2017).
pubmed: 28993052 pmcid: 28993052
Zhang, X., Schwartz, J. C., Guo, X., Bhatia, S., Cao, E., Lorenz, M. et al. Structural and functional analysis of the costimulatory receptor programmed death-1. Immunity 20, 337–347 (2004).
pubmed: 15030777
Hsu, J., Hodgins, J. J., Marathe, M., Nicolai, C. J., Bourgeois-Daigneault, M. C., Trevino, T. N. et al. Contribution of NK cells to immunotherapy mediated by PD-1/PD-L1 blockade. J. Clin. Invest 128, 4654–4668 (2018).
pubmed: 30198904 pmcid: 6159991
Yi, J. S., Cox, M. A. & Zajac, A. J. T-cell exhaustion: characteristics, causes and conversion. Immunology 129, 474–481 (2010).
pubmed: 20201977 pmcid: 2842494
Chen, D. S. & Mellman, I. Oncology meets immunology: the cancer-immunity cycle. Immunity 39, 1–10 (2013).
pubmed: 23890059
Weber, J. S., D’Angelo, S. P., Minor, D., Hodi, F. S., Gutzmer, R., Neyns, B. et al. Nivolumab versus chemotherapy in patients with advanced melanoma who progressed after anti-CTLA-4 treatment (CheckMate 037): a randomised, controlled, open-label, phase 3 trial. Lancet Oncol. 16, 375–384 (2015).
Brahmer, J., Reckamp, K. L., Baas, P., Crino, L., Eberhardt, W. E., Poddubskaya, E. et al. Nivolumab versus Docetaxel in Advanced Squamous-Cell Non-Small-Cell Lung Cancer. N. Engl. J. Med. 373, 123–135 (2015).
pubmed: 4681400 pmcid: 4681400
Horn, L., Spigel, D. R., Vokes, E. E., Holgado, E., Ready, N., Steins, M. et al. Nivolumab Versus Docetaxel in Previously Treated Patients With Advanced Non-Small-Cell Lung Cancer: Two-Year Outcomes From Two Randomized, Open-Label, Phase III Trials (CheckMate 017 and CheckMate 057). J. Clin. Oncol. 35, 3924–3933 (2017).
pubmed: 29023213 pmcid: 6075826
Motzer, R. J., Escudier, B., McDermott, D. F., George, S., Hammers, H. J., Srinivas, S. et al. Nivolumab versus Everolimus in Advanced Renal-Cell Carcinoma. N. Engl. J. Med. 373, 1803–1813 (2015).
pubmed: 26406148 pmcid: 5719487
Ansell, S. M., Lesokhin, A. M., Borrello, I., Halwani, A., Scott, E. C., Gutierrez, M. et al. PD-1 blockade with nivolumab in relapsed or refractory Hodgkin’s lymphoma. N. Engl. J. Med. 372, 311–319 (2015).
pubmed: 25482239
Ferris, R. L., Blumenschein, G. Jr., Fayette, J., Guigay, J., Colevas, A. D., Licitra, L. et al. Nivolumab for Recurrent Squamous-Cell Carcinoma of the Head and Neck. N. Engl. J. Med. 375, 1856–1867 (2016).
pubmed: 5564292 pmcid: 5564292
Okazaki, T. & Honjo, T. PD-1 and PD-1 ligands: from discovery to clinical application. Int. Immunol. 19, 813–824 (2007).
pubmed: 17606980
Pardoll, D. & Drake, C. Immunotherapy earns its spot in the ranks of cancer therapy. J. Exp. Med. 209, 201–209 (2012).
pubmed: 22330682 pmcid: 3280881
Maecker, H. T., McCoy, J. P. & Nussenblatt, R. Standardizing immunophenotyping for the Human Immunology Project. Nat. Rev. Immunol. 12, 191–200 (2012).
pubmed: 22343568 pmcid: 3409649
Yamaguchi, K., Mishima, K., Ohmura, H., Hanamura, F., Ito, M., Nakano, M. et al. Activation of central/effector memory T cells and T-helper 1 polarization in malignant melanoma patients treated with anti-programmed death-1 antibody. Cancer Sci. 109, 3032–3042 (2018).
pubmed: 30066977 pmcid: 6172076
Ohmura, H., Yamaguchi, K., Hanamura, F., Ito, M., Makiyama, A., Uchino, K., et al. Activation of central/effector memory T cells in advanced gastric cancer patients treated with antiprogrammed death-1 antibody. J Clin Oncol. 37(Suppl 4), (abstract 54) (2019).
Eisenhauer, E. A., Therasse, P., Bogaerts, J., Schwartz, L. H., Sargent, D., Ford, R. et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur. J. Cancer 45, 228–247 (2009).
pubmed: 19097774
National Cancer Institute. Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. 2010. http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06 14_QuickReference_8.5x11.pdf (2017)
MacLeod, M. K., Kappler, J. W. & Marrack, P. Memory CD4 T cells: generation, reactivation and re-assignment. Immunology 130, 10–15 (2010).
pubmed: 20331469 pmcid: 2855788
Salmon, H., Idoyaga, J., Rahman, A., Leboeuf, M., Remark, R., Jordan, S. et al. Expansion and activation of CD103(+) dendritic cell progenitors at the tumor site enhances tumor responses to therapeutic PD-L1 and BRAF inhibition. Immunity 44, 924–938 (2016).
pubmed: 27096321 pmcid: 4980762
Goldberg, M. V., Maris, C. H., Hipkiss, E. L., Flies, A. S., Zhen, L., Tuder, R. M. et al. Role of PD-1 and its ligand, B7-H1, in early fate decisions of CD8 T cells. Blood 110, 186–192 (2007).
pubmed: 17392506 pmcid: 1896112
Ribas, A., Shin, D. S., Zaretsky, J., Frederiksen, J., Cornish, A., Avramis, E. et al. PD-1 blockade expands intratumoral memory T cells. Cancer Immunol. Res. 4, 194–203 (2016).
pubmed: 26787823 pmcid: 4775381
Forde, P. M., Chaft, J. E. & Pardoll, D. M. Neoadjuvant PD-1 blockade in resectable lung cancer. N. Engl. J. Med. 379, e14 (2018).
pubmed: 30157404
Miyara, M., Yoshioka, Y., Kitoh, A., Shima, T., Wing, K., Niwa, A. et al. Functional delineation and differentiation dynamics of human CD4+ T cells expressing the FoxP3 transcription factor. Immunity 30, 899–911 (2009).
Gambichler, T., Bindsteiner, M., Hoxtermann, S., Terras, S. & Kreuter, A. Circulating CD4+ CD25(high) CD127(low) regulatory T cells are an independent predictor of advanced melanoma. Pigment Cell Melanoma Res. 26, 280–283 (2013).
pubmed: 23205892
Leffers, N., Gooden, M. J., de Jong, R. A., Hoogeboom, B. N., ten Hoor, K. A., Hollema, H. et al. Prognostic significance of tumor-infiltrating T-lymphocytes in primary and metastatic lesions of advanced stage ovarian cancer. Cancer Immunol. Immunother. 58, 449–459 (2009).
pubmed: 18791714
Weber, J. S., Kudchadkar, R. R., Yu, B., Gallenstein, D., Horak, C. E., Inzunza, H. D. et al. Safety, efficacy, and biomarkers of nivolumab with vaccine in ipilimumab-refractory or -naive melanoma. J. Clin. Oncol. 31, 4311–4318 (2013).
pubmed: 24145345 pmcid: 3837092
Chen, D. S. & Mellman, I. Elements of cancer immunity and the cancer-immune set point. Nature 541, 321–330 (2017).
pubmed: 28102259
Jia, B., Zhao, C., Rakszawski, K. L., Claxton, D. F., Ehmann, W. C., Rybka, W. B. et al. Eomes(+)T-bet(low) CD8(+) T cells are functionally impaired and are associated with poor clinical outcome in patients with acute myeloid leukemia. Cancer Res 79, 1635–1645 (2019).
pubmed: 30709927
Li, J., He, Y., Hao, J., Ni, L. & Dong, C. High levels of eomes promote exhaustion of anti-tumor CD8(+) T cells. Front. Immunol. 9, 2981 (2018).
pubmed: 30619337 pmcid: 6305494
Nakano, M., Ito, M., Tanaka, R., Yamaguchi, K., Ariyama, H., Mitsugi, K. et al. PD-1+ TIM-3+ T cells in malignant ascites predict prognosis of gastrointestinal cancer. Cancer Sci. 109, 2986–2992 (2018).
pubmed: 30187676 pmcid: 6125472
Curti, B. D., Kovacsovics-Bankowski, M., Morris, N., Walker, E., Chisholm, L., Floyd, K. et al. OX40 is a potent immune-stimulating target in late-stage cancer patients. Cancer Res. 73, 7189–7198 (2013).
pubmed: 24177180 pmcid: 3922072
Croft, M. Co-stimulatory members of the TNFR family: keys to effective T-cell immunity? Nat. Rev. Immunol. 3, 609–620 (2003).
pubmed: 12974476
Bansal-Pakala, P., Halteman, B. S., Cheng, M. H. & Croft, M. Costimulation of CD8 T cell responses by OX40. J. Immunol. 172, 4821–4825 (2004).
pubmed: 15067059
Mousavi, S. F., Soroosh, P., Takahashi, T., Yoshikai, Y., Shen, H., Lefrancois, L. et al. OX40 costimulatory signals potentiate the memory commitment of effector CD8+ T cells. J. Immunol. 181, 5990–6001 (2008).
pubmed: 18941188 pmcid: 2784683
Soroosh, P., Ine, S., Sugamura, K. & Ishii, N. Differential requirements for OX40 signals on generation of effector and central memory CD4+ T cells. J. Immunol. 179, 5014–5023 (2007).
pubmed: 17911586
Xiao, X., Kroemer, A., Gao, W., Ishii, N., Demirci, G. & Li, X. C. OX40/OX40L costimulation affects induction of Foxp3+ regulatory T cells in part by expanding memory T cells in vivo. J. Immunol. 181, 3193–3201 (2008).
pubmed: 18713990
Gough, M. J., Ruby, C. E., Redmond, W. L., Dhungel, B., Brown, A. & Weinberg, A. D. OX40 agonist therapy enhances CD8 infiltration and decreases immune suppression in the tumor. Cancer Res. 68, 5206–5215 (2008).
pubmed: 18593921
Peng, W., Williams, L. J., Xu, C., Melendez, B., McKenzie, J. A., Chen, Y. et al. Anti-OX40 antibody directly enhances the function of tumor-reactive CD8(+) T cells and synergizes with PI3Kbeta inhibition in PTEN loss melanoma. Clin. Cancer Res. 25, 6406–6416 (2019).
pubmed: 31371342
Martins, M. R., Santos, R. L. D., Jatahy, K. D. N., Matta, M. C. D., Batista, T. P., Junior, J. I. C. et al. Could OX40 agonist antibody promote activation of the anti-tumor immune response in gastric cancer? J. Surg. Oncol. 117, 840–844 (2018).
pubmed: 29529339
Kotani, A., Ishikawa, T., Matsumura, Y., Ichinohe, T., Ohno, H., Hori, T. et al. Correlation of peripheral blood OX40+(CD134+) T cells with chronic graft-versus-host disease in patients who underwent allogeneic hematopoietic stem cell transplantation. Blood 98, 3162–3164 (2001).
pubmed: 11698307
Petty, J. K., He, K., Corless, C. L., Vetto, J. T. & Weinberg, A. D. Survival in human colorectal cancer correlates with expression of the T-cell costimulatory molecule OX-40 (CD134). Am. J. Surg. 183, 512–518 (2002).
pubmed: 12034383
Ladanyi, A., Somlai, B., Gilde, K., Fejos, Z., Gaudi, I. & Timar, J. T-cell activation marker expression on tumor-infiltrating lymphocytes as prognostic factor in cutaneous malignant melanoma. Clin. Cancer Res. 10, 521–530 (2004).
pubmed: 14760073
Long, L., Zhang, X., Chen, F., Pan, Q., Phiphatwatchara, P., Zeng, Y. et al. The promising immune checkpoint LAG-3: from tumor microenvironment to cancer immunotherapy. Genes Cancer 9, 176–189 (2018).
pubmed: 30603054 pmcid: 6305110
Bae, J., Lee, S. J., Park, C. G., Lee, Y. S. & Chun, T. Trafficking of LAG-3 to the surface on activated T cells via its cytoplasmic domain and protein kinase C signaling. J. Immunol. 193, 3101–3112 (2014).
pubmed: 25108024
Hald, S. M., Rakaee, M., Martinez, I., Richardsen, E., Al-Saad, S., Paulsen, E. E. et al. LAG-3 in non-small-cell lung cancer: expression in primary tumors and metastatic lymph nodes is associated with improved survival. Clin. Lung Cancer 19, 249–259.e242 (2018).
pubmed: 29396238
Lee, S. J., Jun, S. Y., Lee, I. H., Kang, B. W., Park, S. Y., Kim, H. J. et al. CD274, LAG3, and IDO1 expressions in tumor-infiltrating immune cells as prognostic biomarker for patients with MSI-high colon cancer. J. Cancer Res. Clin. Oncol. 144, 1005–1014 (2018).
pubmed: 29520442
Zhang, Y., Liu, Y. D., Luo, Y. L., Liu, B. L., Huang, Q. T., Wang, F. et al. Prognostic value of lymphocyte activation Gene-3 (LAG-3) expression in esophageal squamous cell carcinoma. J. Cancer 9, 4287–4293 (2018).
pubmed: 30519331 pmcid: 6277627
He, Y., Yu, H., Rozeboom, L., Rivard, C. J., Ellison, K., Dziadziuszko, R. et al. LAG-3 protein expression in non-small cell lung cancer and its relationship with PD-1/PD-L1 and tumor-infiltrating lymphocytes. J. Thorac. Oncol. 12, 814–823 (2017).
pubmed: 28132868
Lichtenegger, F. S., Rothe, M., Schnorfeil, F. M., Deiser, K., Krupka, C., Augsberger, C. et al. Targeting LAG-3 and PD-1 to enhance T cell activation by antigen-presenting cells. Front. Immunol. 9, 385 (2018).
pubmed: 29535740 pmcid: 5835137
Gros, A., Robbins, P. F., Yao, X., Li, Y. F., Turcotte, S., Tran, E. et al. PD-1 identifies the patient-specific CD8(+) tumor-reactive repertoire infiltrating human tumors. J. Clin. Invest 124, 2246–2259 (2014).
pubmed: 24667641 pmcid: 4001555
Shitara, K., Ozguroglu, M., Bang, Y. J., Di Bartolomeo, M., Mandala, M., Ryu, M. H. et al. Pembrolizumab versus paclitaxel for previously treated, advanced gastric or gastro-oesophageal junction cancer (KEYNOTE-061): a randomised, open-label, controlled, phase 3 trial. Lancet 392, 123–133 (2018).
Marabelle, A., Le, D. T., Ascierto, P. A., Di Giacomo, A. M., De Jesus-Acosta, A., Delord, J. P. et al. Efficacy of Pembrolizumab in patients with noncolorectal high microsatellite instability/mismatch repair-deficient cancer: results from the phase II KEYNOTE-158 Study. J. Clin. Oncol. 38, 1–10 (2020).
pubmed: 31682550

Auteurs

Hirofumi Ohmura (H)

Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Higashi-ku, Fukuoka, Japan.

Kyoko Yamaguchi (K)

Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Higashi-ku, Fukuoka, Japan.

Fumiyasu Hanamura (F)

Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Higashi-ku, Fukuoka, Japan.

Mamoru Ito (M)

Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Higashi-ku, Fukuoka, Japan.

Akitaka Makiyama (A)

Department of Hematology/Oncology, Japan Community Healthcare Organization Kyushu Hospital, Fukuoka, Japan.

Keita Uchino (K)

Department of Clinical Oncology, NTT Medical Center Tokyo, Tokyo, Japan.

Hozumi Shimokawa (H)

Department of Medical Oncology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.

Shingo Tamura (S)

Department of Medical Oncology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.

Taito Esaki (T)

Department of Gastrointestinal and Medical Oncology, National Kyushu Cancer Center, Fukuoka, Japan.

Kenji Mitsugi (K)

Department of Medical Oncology, Hamanomachi Hospital, Fukuoka, Japan.

Yoshihiro Shibata (Y)

Department of Medical Oncology, Fukuoka Wajiro Hospital, Fukuoka, Japan.

Hisanobu Oda (H)

Department of Medical Oncology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan.

Kenji Tsuchihashi (K)

Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Higashi-ku, Fukuoka, Japan.

Hiroshi Ariyama (H)

Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Higashi-ku, Fukuoka, Japan.

Hitoshi Kusaba (H)

Department of Medicine and Comprehensive Biosystemic Science Faculty, Kyushu University, Fukuoka, Japan.

Yoshinao Oda (Y)

Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.

Koichi Akashi (K)

Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Higashi-ku, Fukuoka, Japan.

Eishi Baba (E)

Department of Oncology and Social Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan. e-baba@intmed1.med.kyushu-u.ac.jp.

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