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Abstract
SummaryAt the ESMO (European Society for Medical Oncology) 2020 several interesting albeit not practice-changing studies in the field of pancreatic cancer were presented. The Canadian phase II randomized PA.7 trial investigated the additional benefit of dual checkpoint inhibition with durvalumab and tremelimumab to a standard chemotherapy regimen as first-line treatment in patients with metastatic pancreatic ductal adenocarcinoma (mPDAC). Unfortunately, no significant improvement of responses or outcome could be achieved rendering this study a negative trial. Within the German platform-based QoliXane trial, quality of life was shown to be an essential prognosticator of survival with fatigue and nausea being independently associated with outcome of patients. Moreover, promising results could be observed with new targeted therapy approaches, which may lead to its investigation in larger randomized clinical trials.
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Wang Y, Liang Y, Xu H, Zhang X, Mao T, Cui J, Yao J, Wang Y, Jiao F, Xiao X, Hu J, Xia Q, Zhang X, Wang X, Sun Y, Fu D, Shen L, Xu X, Xue J, Wang L. Single-cell analysis of pancreatic ductal adenocarcinoma identifies a novel fibroblast subtype associated with poor prognosis but better immunotherapy response. Cell Discov 2021; 7:36. [PMID: 34035226 PMCID: PMC8149399 DOI: 10.1038/s41421-021-00271-4] [Citation(s) in RCA: 103] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/06/2021] [Indexed: 02/06/2023] Open
Abstract
The current pathological and molecular classification of pancreatic ductal adenocarcinoma (PDAC) provides limited guidance for treatment options, especially for immunotherapy. Cancer-associated fibroblasts (CAFs) are major players of desmoplastic stroma in PDAC, modulating tumor progression and therapeutic response. Using single-cell RNA sequencing, we explored the intertumoral heterogeneity among PDAC patients with different degrees of desmoplasia. We found substantial intertumoral heterogeneity in CAFs, ductal cancer cells, and immune cells between the extremely dense and loose types of PDACs (dense-type, high desmoplasia; loose-type, low desmoplasia). Notably, no difference in CAF abundance was detected, but a novel subtype of CAFs with a highly activated metabolic state (meCAFs) was found in loose-type PDAC compared to dense-type PDAC. MeCAFs had highly active glycolysis, whereas the corresponding cancer cells used oxidative phosphorylation as a major metabolic mode rather than glycolysis. We found that the proportion and activity of immune cells were much higher in loose-type PDAC than in dense-type PDAC. Then, the clinical significance of the CAF subtypes was further validated in our PDAC cohort and a public database. PDAC patients with abundant meCAFs had a higher risk of metastasis and a poor prognosis but showed a dramatically better response to immunotherapy (64.71% objective response rate, one complete response). We characterized the intertumoral heterogeneity of cellular components, immune activity, and metabolic status between dense- and loose-type PDACs and identified meCAFs as a novel CAF subtype critical for PDAC progression and the susceptibility to immunotherapy.
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Affiliation(s)
- Yu Wang
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Department of Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pancreatic Disease, Shanghai, China
| | - Yiyi Liang
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Department of Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pancreatic Disease, Shanghai, China
| | - Haiyan Xu
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Department of Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pancreatic Disease, Shanghai, China
| | - Xiao Zhang
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Department of Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pancreatic Disease, Shanghai, China
| | - Tiebo Mao
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Department of Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pancreatic Disease, Shanghai, China
| | - Jiujie Cui
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Department of Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pancreatic Disease, Shanghai, China
| | - Jiayu Yao
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Department of Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pancreatic Disease, Shanghai, China
| | - Yongchao Wang
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Department of Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pancreatic Disease, Shanghai, China
| | - Feng Jiao
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Department of Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pancreatic Disease, Shanghai, China
| | - Xiuying Xiao
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Department of Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pancreatic Disease, Shanghai, China
| | - Jiong Hu
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Department of Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pancreatic Disease, Shanghai, China
| | - Qing Xia
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Department of Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pancreatic Disease, Shanghai, China
| | - Xiaofei Zhang
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Department of Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pancreatic Disease, Shanghai, China
| | - Xujun Wang
- Department of Bioinformatics and Biostatistics, Shanghai Jiao Tong University, Shanghai, China
| | - Yongwei Sun
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Lei Shen
- Shanghai Institute of Immunology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaojiang Xu
- Zhanjiang Central Hospital, Guangdong Medical University, 2 Cunjin Rd, Chikan District, Zhanjiang, Guangdong Province, China.
| | - Jing Xue
- State Key Laboratory of Oncogenes and Related Genes, Stem Cell Research Center, Renji Hospital, School of Medicine, Shanghai Cancer Institute, Shanghai Jiao Tong University, Shanghai, China.
| | - Liwei Wang
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Department of Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
- Shanghai Key Laboratory of Pancreatic Disease, Shanghai, China.
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Gu M, Gao Y, Chang P. KRAS Mutation Dictates the Cancer Immune Environment in Pancreatic Ductal Adenocarcinoma and Other Adenocarcinomas. Cancers (Basel) 2021; 13:cancers13102429. [PMID: 34069772 PMCID: PMC8157241 DOI: 10.3390/cancers13102429] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 04/22/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary The vast majority of patients with pancreatic ductal adenocarcinomas harbor KRAS mutations in their tumors. Functionally, mutated KRAS is not only dedicated to tumor cell proliferation, survival and invasiveness, but also causing the immunosuppression in this cancer. In this situation, current data indicating the therapeutic effects of immune checkpoint inhibitors on pancreatic ductal adenocarcinomas are still not satisfying. In order to reflect the present bottleneck of immune checkpoint inhibitors in managing this cancer, we mainly provide information associated with the mechanism by which KRAS mutations establish the immunosuppressive milieus in pancreatic ductal adenocarcinomas. Together with other advances in this field, future directions to overcome the KRAS mutation-induced immunosuppression in pancreatic ductal adenocarcinomas are raised as well. Meanwhile, lung adenocarcinomas and colorectal adenocarcinomas are enumerated to compare with pancreatic ductal adenocarcinomas, aiming to indicate the specificity of KRAS mutations in dictating tumoral immune milieus among these cancers. Abstract Generally, patients with pancreatic ductal adenocarcinoma, especially those with wide metastatic lesions, have a poor prognosis. Recently, a breakthrough in improving their survival has been achieved by using first-line chemotherapy, such as gemcitabine plus nab-paclitaxel or oxaliplatin plus irinotecan plus 5-fluorouracil plus calcium folinate. Unfortunately, regimens with high effectiveness are still absent in second- or later-line settings. In addition, although immunotherapy using checkpoint inhibitors definitively represents a novel method for metastatic cancers, monotherapy using checkpoint inhibitors is almost completely ineffective for pancreatic ductal adenocarcinomas largely due to the suppressive immune milieu in such tumors. Critically, the genomic alteration pattern is believed to impact cancer immune environment. Surprisingly, KRAS gene mutation is found in almost all pancreatic ductal adenocarcinomas. Moreover, KRAS mutation is indispensable for pancreatic carcinogenesis. On these bases, a relationship likely exists between this oncogene and immunosuppression in this cancer. During pancreatic carcinogenesis, KRAS mutation-driven events, such as metabolic reprogramming, cell autophagy, and persistent activation of the yes-associated protein pathway, converge to cause immune evasion. However, intriguingly, KRAS mutation can dictate a different immune environment in other types of adenocarcinoma, such as colorectal adenocarcinoma and lung adenocarcinoma. Overall, the KRAS mutation can drive an immunosuppression in pancreatic ductal adenocarcinomas or in colorectal carcinomas, but this mechanism is not true in KRAS-mutant lung adenocarcinomas, especially in the presence of TP53 inactivation. As a result, the response of these adenocarcinomas to checkpoint inhibitors will vary.
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Affiliation(s)
- Meichen Gu
- Department of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China;
| | - Yanli Gao
- Department of Pediatric Ultrasound, The First Hospital of Jilin University, Changchun 130021, China;
| | - Pengyu Chang
- Department of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China;
- Correspondence: ; Tel.: +86-88783840; Fax: +86-431-88783840
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Cherri S, Noventa S, Zaniboni A. Pancreatic adenocarcinoma: Beyond first line, where are we? World J Gastroenterol 2021; 27:1847-1863. [PMID: 34007126 PMCID: PMC8108033 DOI: 10.3748/wjg.v27.i17.1847] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/09/2021] [Accepted: 04/13/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is considered one of the most aggressive cancers, with an increasing incidence in recent years. To date, chemotherapy is still the standard of care for advanced metastatic disease, unfortunately providing only a slight advantage in terms of survival. The molecular and cellular characteristics of pancreatic cancer cells, as well as the cells that characterize the pancreatic tumour microenvironment, are the basis of the mechanisms of resistance to treatment. After progression during first-line treatment, few patients are eligible for second-line treatment due to the loss of performance status. To date, a clear survival advantage has not yet been demonstrated for second-line chemotherapy. Precision medicine could be the key to increasing responses to cancer treatment and finally impacting survival in this difficult-to-treat disease. In this review, we analyze current recommendations in the second-line setting and potential future prospects.
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Affiliation(s)
- Sara Cherri
- Department of Oncology, Fondazione Poliambulanza, Brescia 25124, Italy
| | - Silvia Noventa
- Department of Oncology, Fondazione Poliambulanza, Brescia 25124, Italy
| | - Alberto Zaniboni
- Department of Oncology, Fondazione Poliambulanza, Brescia 25124, Italy
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Kiaie SH, Sanaei MJ, Heshmati M, Asadzadeh Z, Azimi I, Hadidi S, Jafari R, Baradaran B. Immune checkpoints in targeted-immunotherapy of pancreatic cancer: New hope for clinical development. Acta Pharm Sin B 2021; 11:1083-1097. [PMID: 34094821 PMCID: PMC8144893 DOI: 10.1016/j.apsb.2020.12.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/29/2020] [Accepted: 09/14/2020] [Indexed: 12/13/2022] Open
Abstract
Immunotherapy has been recently considered as a promising alternative for cancer treatment. Indeed, targeting of immune checkpoint (ICP) strategies have shown significant success in human malignancies. However, despite remarkable success of cancer immunotherapy in pancreatic cancer (PCa), many of the developed immunotherapy methods show poor therapeutic outcomes in PCa with no or few effective treatment options thus far. In this process, immunosuppression in the tumor microenvironment (TME) is found to be the main obstacle to the effectiveness of antitumor immune response induced by an immunotherapy method. In this paper, the latest findings on the ICPs, which mediate immunosuppression in the TME have been reviewed. In addition, different approaches for targeting ICPs in the TME of PCa have been discussed. This review has also synopsized the cutting-edge advances in the latest studies to clinical applications of ICP-targeted therapy in PCa.
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Affiliation(s)
- Seyed Hossein Kiaie
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz 5173957616, Iran
- Nano Drug Delivery Research Center, Kermanshah University of Medical Sciences, Kermanshah 6715847141, Iran
| | - Mohammad Javad Sanaei
- Cellular and Molecular Research Center, Basic Health Sciences Institute, Shahrekord University of Medical Sciences, Shahrekord 8815713471, Iran
| | - Masoud Heshmati
- Cellular and Molecular Research Center, Basic Health Sciences Institute, Shahrekord University of Medical Sciences, Shahrekord 8815713471, Iran
| | - Zahra Asadzadeh
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz 5173957616, Iran
| | - Iman Azimi
- School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Hobart 7001, Tasmania, Australia
| | - Saleh Hadidi
- Clinical Biochemistry Research Center, Basic Health Sciences Institute, Shahrekord University of Medical Sciences, Shahrekord 8815713471, Iran
| | - Reza Jafari
- Solid Tumor Research Center, Cellular and Molecular Medicine Institute, Urmia University of Medical Sciences, Urmia 5714783734, Iran
- Department of Immunology and Genetics, School of Medicine, Urmia University of Medical Sciences, Urmia 5714783734, Iran
| | - Behzad Baradaran
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz 5173957616, Iran
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Evaluating the efficacy and safety of immune checkpoint inhibitors by detecting the exposure-response: An inductive review. Int Immunopharmacol 2021; 97:107703. [PMID: 33933843 DOI: 10.1016/j.intimp.2021.107703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 11/23/2022]
Abstract
Immune checkpoint inhibitors (ICIs) have been demonstrated an effective treatment in multiple tumor type, which restore the immune response to against cancer cell. Currently, approved ICIs include anti-cytotoxic T-lymphocyte antigen-4 (CTLA-4); anti-programmed cell death 1 (PD-1) and anti-programmed cell death ligand 1 (PD-L1) monoclonal antibodies (mAbs). In most these drugs, unique pharmacokinetic (PK) and pharmacodynamics (PD) have shown significant influence on clinical outcomes, which occurred by target-mediated drug concentration and time-varying drug clearance. An exposure-response (E-R) relationship has been used to describe the safety and efficacy of ICIs, and shown a plateaued E-R and time dependent changes in exposure. Using an enzyme linked immunosorbent assay (ELISA) or LC-MS/MS method to measure the peak concentration, trough concentration or area under the curve (AUC) of ICIs to assess the drug exposure. There are lots of covariates that have an influence on exposure, such as sex, clearance, body weight and tumor burden. In this review, we pooled data from studies of concentration or other pharmacokinetics parameter of mAbs to assess E-R in efficacy and safety.
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57
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Sivakumar S, Abu-Shah E, Ahern DJ, Arbe-Barnes EH, Jainarayanan AK, Mangal N, Reddy S, Rendek A, Easton A, Kurz E, Silva M, Soonawalla Z, Heij LR, Bashford-Rogers R, Middleton MR, Dustin ML. Activated Regulatory T-Cells, Dysfunctional and Senescent T-Cells Hinder the Immunity in Pancreatic Cancer. Cancers (Basel) 2021; 13:1776. [PMID: 33917832 PMCID: PMC8068251 DOI: 10.3390/cancers13081776] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/20/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer has one of the worst prognoses of any human malignancy and leukocyte infiltration is a major prognostic marker of the disease. As current immunotherapies confer negligible survival benefits, there is a need to better characterise leukocytes in pancreatic cancer to identify better therapeutic strategies. In this study, we analysed 32 human pancreatic cancer patients from two independent cohorts. A multi-parameter mass-cytometry analysis was performed on 32,000 T-cells from eight patients. Single-cell RNA sequencing dataset analysis was performed on a cohort of 24 patients. Multiplex immunohistochemistry imaging and spatial analysis were performed to map immune infiltration into the tumour microenvironment. Regulatory T-cell populations demonstrated highly immunosuppressive states with high TIGIT, ICOS and CD39 expression. CD8+ T-cells were found to be either in senescence or an exhausted state. The exhausted CD8 T-cells had low PD-1 expression but high TIGIT and CD39 expression. These findings were corroborated in an independent pancreatic cancer single-cell RNA dataset. These data suggest that T-cells are major players in the suppressive microenvironment of pancreatic cancer. Our work identifies multiple novel therapeutic targets that should form the basis for rational design of a new generation of clinical trials in pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Shivan Sivakumar
- Department of Oncology, University of Oxford, Oxford OX3 7DQ, UK; (S.S.); (A.E.); (M.R.M.)
- Kennedy Institute of Rheumatology, University of Oxford, Oxford OX3 7FY, UK; (D.J.A.); (A.K.J.); (E.K.)
- Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
| | - Enas Abu-Shah
- Kennedy Institute of Rheumatology, University of Oxford, Oxford OX3 7FY, UK; (D.J.A.); (A.K.J.); (E.K.)
- Sir William Dunn School of Pathology, University of Oxford, Oxford OX1 3RE, UK
| | - David J. Ahern
- Kennedy Institute of Rheumatology, University of Oxford, Oxford OX3 7FY, UK; (D.J.A.); (A.K.J.); (E.K.)
| | | | - Ashwin K. Jainarayanan
- Kennedy Institute of Rheumatology, University of Oxford, Oxford OX3 7FY, UK; (D.J.A.); (A.K.J.); (E.K.)
- Interdisciplinary Bioscience Doctoral Training Program and Exeter College, University of Oxford, Oxford OX3 7DQ, UK
| | - Nagina Mangal
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX3 9DU, UK;
| | - Srikanth Reddy
- Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK; (S.R.); (M.S.); (Z.S.)
| | - Aniko Rendek
- Department of Pathology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK;
| | - Alistair Easton
- Department of Oncology, University of Oxford, Oxford OX3 7DQ, UK; (S.S.); (A.E.); (M.R.M.)
| | - Elke Kurz
- Kennedy Institute of Rheumatology, University of Oxford, Oxford OX3 7FY, UK; (D.J.A.); (A.K.J.); (E.K.)
| | - Michael Silva
- Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK; (S.R.); (M.S.); (Z.S.)
| | - Zahir Soonawalla
- Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK; (S.R.); (M.S.); (Z.S.)
| | - Lara R. Heij
- Department of General, Gastrointestinal, Hepatobiliary and Transplant Surgery, RWTH Aachen University Hospital, 52074 Aachen, Germany;
- Institute of Pathology, University Hospital RWTH Aachen, 52074 Aachen, Germany
| | | | - Mark R. Middleton
- Department of Oncology, University of Oxford, Oxford OX3 7DQ, UK; (S.S.); (A.E.); (M.R.M.)
- Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
- Oxford NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
| | - Michael L. Dustin
- Kennedy Institute of Rheumatology, University of Oxford, Oxford OX3 7FY, UK; (D.J.A.); (A.K.J.); (E.K.)
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Arias-Pinilla GA, Modjtahedi H. Therapeutic Application of Monoclonal Antibodies in Pancreatic Cancer: Advances, Challenges and Future Opportunities. Cancers (Basel) 2021; 13:cancers13081781. [PMID: 33917882 PMCID: PMC8068268 DOI: 10.3390/cancers13081781] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 03/31/2021] [Accepted: 04/04/2021] [Indexed: 02/07/2023] Open
Abstract
Pancreatic cancer remains as one of the most aggressive cancer types. In the absence of reliable biomarkers for its early detection and more effective therapeutic interventions, pancreatic cancer is projected to become the second leading cause of cancer death in the Western world in the next decade. Therefore, it is essential to discover novel therapeutic targets and to develop more effective and pancreatic cancer-specific therapeutic agents. To date, 45 monoclonal antibodies (mAbs) have been approved for the treatment of patients with a wide range of cancers; however, none has yet been approved for pancreatic cancer. In this comprehensive review, we discuss the FDA approved anticancer mAb-based drugs, the results of preclinical studies and clinical trials with mAbs in pancreatic cancer and the factors contributing to the poor response to antibody therapy (e.g. tumour heterogeneity, desmoplastic stroma). MAb technology is an excellent tool for studying the complex biology of pancreatic cancer, to discover novel therapeutic targets and to develop various forms of antibody-based therapeutic agents and companion diagnostic tests for the selection of patients who are more likely to benefit from such therapy. These should result in the approval and routine use of antibody-based agents for the treatment of pancreatic cancer patients in the future.
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Affiliation(s)
- Gustavo A. Arias-Pinilla
- Department of Oncology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK;
- School of Life Sciences, Pharmacy and Chemistry, Kingston University London, Kingston-upon-Thames, Surrey KT1 2EE, UK
| | - Helmout Modjtahedi
- School of Life Sciences, Pharmacy and Chemistry, Kingston University London, Kingston-upon-Thames, Surrey KT1 2EE, UK
- Correspondence: ; Tel.: +44-02084-172240
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Miyazawa M, Katsuda M, Kawai M, Hirono S, Okada KI, Kitahata Y, Yamaue H. Advances in immunotherapy for pancreatic ductal adenocarcinoma. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 28:419-430. [PMID: 33742512 DOI: 10.1002/jhbp.944] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 12/14/2022]
Abstract
Advances in immunotherapy against advanced cancers can be considered stunning and epoch-making. Meanwhile, efficacy of immune-based therapies, especially immune checkpoint inhibitors, remains insufficient in pancreatic ductal adenocarcinoma, differing from other immunogenic cancers. To date, neither immunotherapies targeting immune system acceleration nor release of immunologic brakes have been able to overcome the robust immune barrier in the pancreatic tumor microenvironment, which is characterized by rich fibrotic stroma and accumulation of immunosuppressive myeloid cells. However, by receiving an immune checkpoint blockade, patients with abundant tumor-infiltrating lymphocytes in pancreatic ductal adenocarcinoma clearly have better prognosis, and patients with mismatch repair deficiency have achieved better outcomes, albeit in a small population of pancreatic ductal adenocarcinoma. We overview recent preclinical and clinical studies that have been concerned with immune-based therapies including cancer vaccine and immune checkpoint inhibitors. By providing a deep insight into the immunosuppressive tumor microenvironment, we suggest the possibility of comprehensive immune intensification that could reverse the tumor microenvironment, making it conducive to cytotoxic T lymphocyte activity for overcoming pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Motoki Miyazawa
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masahiro Katsuda
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Manabu Kawai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Seiko Hirono
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Ken-Ichi Okada
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yuji Kitahata
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
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Javadrashid D, Baghbanzadeh A, Derakhshani A, Leone P, Silvestris N, Racanelli V, Solimando AG, Baradaran B. Pancreatic Cancer Signaling Pathways, Genetic Alterations, and Tumor Microenvironment: The Barriers Affecting the Method of Treatment. Biomedicines 2021; 9:373. [PMID: 33918146 PMCID: PMC8067185 DOI: 10.3390/biomedicines9040373] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/21/2021] [Accepted: 03/30/2021] [Indexed: 02/06/2023] Open
Abstract
Genetic alterations, especially the K-Ras mutation, carry the heaviest burden in the progression of pancreatic precursor lesions into pancreatic ductal adenocarcinoma (PDAC). The tumor microenvironment is one of the challenges that hinder the therapeutic approaches from functioning sufficiently and leads to the immune evasion of pancreatic malignant cells. Mastering the mechanisms of these two hallmarks of PDAC can help us in dealing with the obstacles in the way of treatment. In this review, we have analyzed the signaling pathways involved in PDAC development and the immune system's role in pancreatic cancer and immune checkpoint inhibition as next-generation therapeutic strategy. The direct targeting of the involved signaling molecules and the immune checkpoint molecules, along with a combination with conventional therapies, have reached the most promising results in pancreatic cancer treatment.
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Affiliation(s)
- Darya Javadrashid
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz 5166614766, Iran; (D.J.); (A.B.); (A.D.)
| | - Amir Baghbanzadeh
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz 5166614766, Iran; (D.J.); (A.B.); (A.D.)
| | - Afshin Derakhshani
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz 5166614766, Iran; (D.J.); (A.B.); (A.D.)
- IRCCS Istituto Tumori “Giovanni Paolo II” of Bari, 70124 Bari, Italy;
| | - Patrizia Leone
- Guido Baccelli Unit of Internal Medicine, Department of Biomedical Sciences and Human Oncology, School of Medicine, Aldo Moro University of Bari, 70124 Bari, Italy; (P.L.); (V.R.)
| | - Nicola Silvestris
- IRCCS Istituto Tumori “Giovanni Paolo II” of Bari, 70124 Bari, Italy;
- Department of Biomedical Sciences and Human Oncology, School of Medicine, Aldo Moro University of Bari, 70124 Bari, Italy
| | - Vito Racanelli
- Guido Baccelli Unit of Internal Medicine, Department of Biomedical Sciences and Human Oncology, School of Medicine, Aldo Moro University of Bari, 70124 Bari, Italy; (P.L.); (V.R.)
| | - Antonio Giovanni Solimando
- IRCCS Istituto Tumori “Giovanni Paolo II” of Bari, 70124 Bari, Italy;
- Guido Baccelli Unit of Internal Medicine, Department of Biomedical Sciences and Human Oncology, School of Medicine, Aldo Moro University of Bari, 70124 Bari, Italy; (P.L.); (V.R.)
| | - Behzad Baradaran
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz 5166614766, Iran; (D.J.); (A.B.); (A.D.)
- Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz 5166614766, Iran
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Brouwer TP, Vahrmeijer AL, de Miranda NFCC. Immunotherapy for pancreatic cancer: chasing the light at the end of the tunnel. Cell Oncol (Dordr) 2021; 44:261-278. [PMID: 33710604 PMCID: PMC7985121 DOI: 10.1007/s13402-021-00587-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Checkpoint blockade immunotherapy has had a significant impact on the survival of a subset of patients with advanced cancers. It has been particularly effective in immunogenic cancer types that present large numbers of somatic mutations in their genomes. To date, all conventional immunotherapies have failed to produce significant clinical benefits for patients diagnosed with pancreatic cancer, probably due to its poor immunogenic properties, including low numbers of neoantigens and highly immune-suppressive microenvironments. CONCLUSIONS Herein, we discuss advances that have recently been made in cancer immunotherapy and the potential of this field to deliver effective treatment options for pancreatic cancer patients. Preclinical investigations, combining different types of therapies, highlight possibilities to enhance anti-tumor immunity and to generate meaningful clinical responses in pancreatic cancer patients. Results from completed and ongoing (pre)clinical trials are discussed.
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Affiliation(s)
- Thomas P Brouwer
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands, PO Box 9600, 2300 RC
| | | | - Noel F C C de Miranda
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands, PO Box 9600, 2300 RC.
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62
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Liu X, Li Z, Wang Y. Advances in Targeted Therapy and Immunotherapy for Pancreatic Cancer. Adv Biol (Weinh) 2021; 5:e1900236. [PMID: 33729700 DOI: 10.1002/adbi.201900236] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 08/19/2020] [Indexed: 12/24/2022]
Abstract
Pancreatic cancer is a highly aggressive malignancy with an overall 5-year survival rate of <6% due to therapeutic resistance and late-stage diagnosis. These statistics have not changed despite 50 years of research and therapeutic development. Pancreatic cancer is predicted to become the second leading cause of cancer mortality by the year 2030. Currently, the treatment options for pancreatic cancer are limited. This disease is usually diagnosed at a late stage, which prevents curative surgical resection. Chemotherapy is the most frequently used approach for pancreatic cancer treatment and has limited effects. In many other cancer types, targeted therapy and immunotherapy have made great progress and have been shown to be very promising prospects; these treatments also provide hope for pancreatic cancer. The need for research on targeted therapy and immunotherapy is pressing due to the poor prognosis of pancreatic cancer, and in recent years, there have been some breakthroughs for targeted therapy and immunotherapy in pancreatic cancer. This review summarizes the current preclinical and clinical studies of targeted therapy and immunotherapy for pancreatic cancer and ends by describing the challenges and outlook.
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Affiliation(s)
- Xiaoxiao Liu
- CAS Key Laboratory of Tissue Microenvironment and Tumor, SINH - Changzheng Hospital Joint Center for Translational Medicine, Institutes for Translational Medicine (CAS-SMMU), Shanghai Institute of Nutrition and Health, University of Chinese Academy of Sciences, Chinese Academy of Sciences, Shanghai, 200031, China
| | - Zhang Li
- CAS Key Laboratory of Tissue Microenvironment and Tumor, SINH - Changzheng Hospital Joint Center for Translational Medicine, Institutes for Translational Medicine (CAS-SMMU), Shanghai Institute of Nutrition and Health, University of Chinese Academy of Sciences, Chinese Academy of Sciences, Shanghai, 200031, China
| | - Yuexiang Wang
- CAS Key Laboratory of Tissue Microenvironment and Tumor, SINH - Changzheng Hospital Joint Center for Translational Medicine, Institutes for Translational Medicine (CAS-SMMU), Shanghai Institute of Nutrition and Health, University of Chinese Academy of Sciences, Chinese Academy of Sciences, Shanghai, 200031, China
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Role of targeted immunotherapy for pancreatic ductal adenocarcinoma (PDAC) treatment: An overview. Int Immunopharmacol 2021; 95:107508. [PMID: 33725635 DOI: 10.1016/j.intimp.2021.107508] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/18/2021] [Accepted: 02/12/2021] [Indexed: 12/15/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest solid tumors with a high mortality rate and poor survival rate. Depending on the tumor stage, PDAC is either treated by resection surgery, chemotherapies, or radiotherapies. Various chemotherapeutic agents have been used to treat PDAC, alone or in combination. Despite the combinations, chemotherapy exhibits many side-effects leading to an increase in the toxicity profile amongst the PDAC patients. Additionally, these standard chemotherapeutic agents have only a modest impact on patient survival due to their limited efficacy. PDAC was previously considered as an immunologically silent malignancy, but recent findings have demonstrated that effective immune-mediated tumor cell death can be used for its treatment. PDAC is characterized by an immunosuppressive tumor microenvironment accompanied by the major expression of myeloid-derived suppressor cells (MDSC) and M2 tumor-associated macrophages. In contrast, the expression of CD8+ T cells is significantly low. Additionally, infiltration of mast cells in PDAC correlates with the poor prognosis. Immunotherapeutic agents target the immunity mediators and empower them to suppress the tumor and effectively treat PDAC. Different targets are studied and exploited to induce an antitumor immune response in PDAC patients. In recent times, site-specific delivery of immunotherapeutics also gained attention among researchers to effectively treat PDAC. In the present review, existing immunotherapies for PDAC treatment along with their limitations are addressed in detail. The review also includes the pathophysiology, traditional strategies and significance of targeted immunotherapies to combat PDAC effectively. Separately, the identification of ideal targets for the targeted therapy of PDAC is also reviewed exhaustively. Additionally, the review also addresses the applications of targeted immunotherapeutics like checkpoint inhibitors, adoptive T-cell therapy etc.
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64
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Carpenter E, Nelson S, Bednar F, Cho C, Nathan H, Sahai V, di Magliano MP, Frankel TL. Immunotherapy for pancreatic ductal adenocarcinoma. J Surg Oncol 2021; 123:751-759. [PMID: 33595893 DOI: 10.1002/jso.26312] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 12/14/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains a lethal cancer with an urgent need for better medical therapies. Efforts have been made to investigate the efficacy of immunotherapy, particularly given the hallmarks of immune suppression and exhaustion in PDAC tumors. Here, we review the molecular components responsible for the immune-privileged state in PDAC and provide an overview of the immunotherapeutic strategies for PDAC including vaccine therapy, checkpoint blockade, myeloid-targeted therapy, and immune agonist therapy.
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Affiliation(s)
- Eileen Carpenter
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Sarah Nelson
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Filip Bednar
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Clifford Cho
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Vaibhav Sahai
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Timothy L Frankel
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Liu X, Jiang J, Liao Y, Tang I, Zheng E, Qiu W, Lin M, Wang X, Ji Y, Mei K, Liu Q, Chang CH, Wainberg ZA, Nel AE, Meng H. Combination Chemo-Immunotherapy for Pancreatic Cancer Using the Immunogenic Effects of an Irinotecan Silicasome Nanocarrier Plus Anti-PD-1. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2021; 8:2002147. [PMID: 33747719 PMCID: PMC7967046 DOI: 10.1002/advs.202002147] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/24/2020] [Indexed: 05/07/2023]
Abstract
There is an urgent need to develop new life-prolonging therapy for pancreatic ductal adenocarcinoma (PDAC). It is demonstrated that improved irinotecan delivery by a lipid bilayer coated mesoporous silica nanoparticle, also known as a silicasome, can improve PDAC survival through a chemo-immunotherapy response in an orthotopic Kras-dependent pancreatic cancer model. This discovery is premised on the weak-basic properties of irinotecan, which neutralizes the acidic lysosomal pH in PDAC cells. This effect triggers a linked downstream cascade of events that include autophagy inhibition, endoplasmic reticulum stress, immunogenic cell death (ICD), and programmed death-ligand 1 (PD-L1) expression. ICD is characterized by calreticulin expression and high-mobility group box 1 (HMGB1) release in dying Kras-induced pancreatic cancer (KPC) cells, which is demonstrated in a vaccination experiment to prevent KPC tumor growth on the contralateral site. The improved delivery of irinotecan by the silicasome is accompanied by robust antitumor immunity, which can be synergistically enhanced by anti-PD-1 in the orthotopic model. Immunophenotyping confirms the expression of calreticulin, HMGB1, PD-L1, and an autophagy marker, in addition to perforin and granzyme B deposition. The chemo-immunotherapy response elicited by the silicasome is more robust than free or a liposomal drug, Onivyde. The silicasome plus anti-PD-1 leads to significantly enhanced survival improvement, and is far superior to anti-PD-1 plus either free irinotecan or Onivyde.
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Affiliation(s)
- Xiangsheng Liu
- Division of NanomedicineDepartment of MedicineUniversity of CaliforniaLos AngelesCA90095USA
- California NanoSystems InstituteUniversity of CaliforniaLos AngelesCA90095USA
- Present address:
The Cancer Hospital of the University of Chinese Academy of SciencesInstitute of Basic Medicine and Cancer (IBMC)Chinese Academy of SciencesHangzhouZhejiang310022China
| | - Jinhong Jiang
- California NanoSystems InstituteUniversity of CaliforniaLos AngelesCA90095USA
| | - Yu‐Pei Liao
- Division of NanomedicineDepartment of MedicineUniversity of CaliforniaLos AngelesCA90095USA
| | - Ivanna Tang
- Division of NanomedicineDepartment of MedicineUniversity of CaliforniaLos AngelesCA90095USA
| | - Emily Zheng
- Division of NanomedicineDepartment of MedicineUniversity of CaliforniaLos AngelesCA90095USA
| | - Waveley Qiu
- Division of NanomedicineDepartment of MedicineUniversity of CaliforniaLos AngelesCA90095USA
| | - Matthew Lin
- Division of NanomedicineDepartment of MedicineUniversity of CaliforniaLos AngelesCA90095USA
| | - Xiang Wang
- Division of NanomedicineDepartment of MedicineUniversity of CaliforniaLos AngelesCA90095USA
- California NanoSystems InstituteUniversity of CaliforniaLos AngelesCA90095USA
| | - Ying Ji
- Division of NanomedicineDepartment of MedicineUniversity of CaliforniaLos AngelesCA90095USA
| | - Kuo‐Ching Mei
- Division of NanomedicineDepartment of MedicineUniversity of CaliforniaLos AngelesCA90095USA
| | - Qi Liu
- California NanoSystems InstituteUniversity of CaliforniaLos AngelesCA90095USA
| | - Chong Hyun Chang
- California NanoSystems InstituteUniversity of CaliforniaLos AngelesCA90095USA
| | - Zev A. Wainberg
- Division of Hematology OncologyDepartment of MedicineUniversity of CaliforniaLos AngelesCA90095USA
| | - Andre E. Nel
- Division of NanomedicineDepartment of MedicineUniversity of CaliforniaLos AngelesCA90095USA
- California NanoSystems InstituteUniversity of CaliforniaLos AngelesCA90095USA
| | - Huan Meng
- Division of NanomedicineDepartment of MedicineUniversity of CaliforniaLos AngelesCA90095USA
- California NanoSystems InstituteUniversity of CaliforniaLos AngelesCA90095USA
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66
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Javadrashid D, Baghbanzadeh A, Hemmat N, Hajiasgharzadeh K, Nourbakhsh NS, Lotfi Z, Baradaran B. Envisioning the immune system to determine its role in pancreatic ductal adenocarcinoma: Culprit or victim? Immunol Lett 2021; 232:48-59. [PMID: 33647329 DOI: 10.1016/j.imlet.2021.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 02/15/2021] [Accepted: 02/24/2021] [Indexed: 12/16/2022]
Abstract
Pancreatic ductal adenocarcinoma has a poor 5-year survival rate that makes it one of the most fatal human malignancies. Unfortunately, despite the serious improvement in the survival of most cancers, there has been a minor advance in pancreatic cancer (PC). Major advances in PC treatment have been assessed over the bygone twenty-year time span, yet some complications make the survival of the patients shorter. Getting to know the PC tumor microenvironment (TME) and the immunosuppression that happens during the pathogenesis of this malignancy could be a great help to understand the nature of the immune system and find better treatment modalities based on it. Although many immune cells are present in PC, immunosuppression of the TME leads to severe immune dysfunction in the patients, therefore immune effectors fail to do their functions. Lately, immunotherapy has been presented as one of the promising treatment strategies for different malignancies including hepatocellular carcinoma, melanoma, non-small cell lung cancer, and kidney cancer. In PC, there has been shown promising results centered around the TME, immune checkpoint inhibitors, cancer vaccines, and other approaches especially when used as combinational therapy. Here we dig a little deeper into the role of the immune system and possible therapeutic options in the treatment of PC.
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Affiliation(s)
- Darya Javadrashid
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amir Baghbanzadeh
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nima Hemmat
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | | | - Ziba Lotfi
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Behzad Baradaran
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran; Department of Immunology, Tabriz University of Medical Sciences, Tabriz, Iran.
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67
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Targeted Therapies for Pancreatic Cancer: Overview of Current Treatments and New Opportunities for Personalized Oncology. Cancers (Basel) 2021; 13:cancers13040799. [PMID: 33672917 PMCID: PMC7918504 DOI: 10.3390/cancers13040799] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/05/2021] [Accepted: 02/10/2021] [Indexed: 02/06/2023] Open
Abstract
Cytotoxic chemotherapy remains the only treatment option for most pancreatic ductal adenocarcinoma patients. Currently, the median overall survival of patients with advanced disease rarely exceeds 1 year. The complex network of pancreatic cancer composed of immune cells, endothelial cells, and cancer-associated fibroblasts confers intratumoral and intertumoral heterogeneity with distinct proliferative and metastatic propensity. This heterogeneity can explain why tumors do not behave uniformly and are able to escape therapy. The advance in technology of whole-genome sequencing has now provided the possibility of identifying every somatic mutation, copy-number change, and structural variant in a given cancer, giving rise to personalized targeted therapies. In this review, we provide an overview of the current and emerging treatment strategies in pancreatic cancer. By highlighting new paradigms in pancreatic ductal adenocarcinoma treatment, we hope to stimulate new thoughts for clinical trials aimed at improving patient outcomes.
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68
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Fazio N, Abdel-Rahman O. Immunotherapy in Neuroendocrine Neoplasms: Where Are We Now? Curr Treat Options Oncol 2021; 22:19. [PMID: 33559013 DOI: 10.1007/s11864-021-00817-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 12/19/2022]
Abstract
OPINION STATEMENT Immune checkpoint inhibitors (ICIs) represent a breakthrough in the management of many hard-to-treat cancers over the past decade with demonstrable improvement in survival outcomes. We reviewed the state of the art of ICIs in neuroendocrine neoplasms (NENs). While ICIs have become part of the standard of care for the management of small cell lung cancer (SCLC), their role is still unclear in the management of extra-pulmonary (EP) poorly differentiated neuroendocrine carcinomas (NECs) as well as in the management of well-differentiated neuroendocrine tumors (NETs). Conflicting results derived from the various studies in NETs and EP NECs therefore for specific settings, such as the lung NETs, or therapeutic regimen, e.g., combo vs single agent, for ICIs benefit. Therefore, at the moment, no ICIs approach is justified for NETs and EP NECs in clinical practice. Future investigations should be designed with the aim to overcome the several limitations of the current trials, e.g., lacking of a central pathology review or heterogeneity of the cohorts, in order to reduce the risk of biases. Future trials combining ICIs with other biological agents are welcome. This review aims to provide a comprehensive overview of the biological rationale and evolving clinical applications of the use of ICIs in the management of NENs (both well-differentiated and poorly differentiated groups).
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Affiliation(s)
- Nicola Fazio
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IEO, IRCCS, Via Ripamonti 435, 20141, Milan, Italy.
| | - Omar Abdel-Rahman
- Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, Alberta, Canada
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69
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Principe DR, Korc M, Kamath SD, Munshi HG, Rana A. Trials and tribulations of pancreatic cancer immunotherapy. Cancer Lett 2021; 504:1-14. [PMID: 33549709 DOI: 10.1016/j.canlet.2021.01.031] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/28/2021] [Accepted: 01/29/2021] [Indexed: 02/09/2023]
Abstract
Immunotherapy has revolutionized cancer treatment in the last decade, and strategies to re-activate cytotoxic immunity are now standard of care in several malignancies. Despite rapid advances in immunotherapy for most solid cancers, progress in immunotherapy against pancreatic ductal adenocarcinoma (PDAC) has been exceptionally difficult. This is true for several approaches, most notably immune checkpoint inhibitors (ICIs) and GM-CSF cell-based vaccines (GVAX). Though many immunotherapies have been explored in clinical trials, few have shown significant therapeutic efficacy. Further, many have shown high rates of serious adverse effects and dose-limiting toxicities, and to date, immunotherapy regimens have not been successfully implemented in PDAC. Here, we provide a comprehensive summary of the key clinical trials exploring immunotherapy in PDAC, followed by a brief discussion of emerging molecular mechanisms that may explain the relative failure of immunotherapy in pancreas cancer thus far.
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Affiliation(s)
- Daniel R Principe
- Medical Scientist Training Program, University of Illinois College of Medicine, Chicago, IL, USA; Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, Chicago, IL, USA.
| | - Murray Korc
- Department of Developmental and Cell Biology, University of California, Irvine, CA, USA
| | - Suneel D Kamath
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Hidayatullah G Munshi
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Jesse Brown VA Medical Center, Chicago, IL, USA
| | - Ajay Rana
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, Chicago, IL, USA; Jesse Brown VA Medical Center, Chicago, IL, USA.
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70
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Smith PL, Yogaratnam Y, Samad M, Kasow S, Dalgleish AG. Effect of Gemcitabine based chemotherapy on the immunogenicity of pancreatic tumour cells and T-cells. Clin Transl Oncol 2021; 23:110-121. [PMID: 32661823 PMCID: PMC7820186 DOI: 10.1007/s12094-020-02429-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/12/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE Chemotherapy for advanced pancreatic cancer has limited efficacy due to the difficultly of treating established tumours and the evolution of tumour resistance. Chemotherapies for pancreatic cancer are typically studied for their cytotoxic properties rather than for their ability to increase the immunogenicity of pancreatic tumour cells. In this study Gemcitabine in combination with immune modulatory chemotherapies Oxaliplatin, zoledronic acid and pomalidomide was studied to determine how combination therapy alters the immunogenicity of pancreatic tumour cell lines and subsequent T-cell responses. METHODS Pancreatic tumour cell lines were stimulated with the chemotherapeutic agents and markers of immune recognition were assessed. The effect of chemotherapeutic agents on DC function was measured using uptake of CFSE-stained PANC-1 cells, changes in markers of maturation and their ability to activate CD8+ T-cells. The effect of chemotherapeutic agents on T-cell priming prior to activation using anti-CD3 and anti-CD28 antibodies was determined by measuring IFN-γ expression and Annexin V staining using flow cytometry. RESULTS These agents demonstrate both additive and inhibitory properties on a range of markers of immunogenicity. Gemcitabine was notable for its ability to induce the upregulation of human leukocyte antigen and checkpoints on pancreatic tumour cell lines whilst inhibiting T-cell activation. Pomalidomide demonstrated immune modulatory properties on dendritic cells and T-cells, even in the presence of gemcitabine. DISCUSSION These data highlight the complex interactions of different agents in the modulation of tumour immunogenicity and immune cell activation and emphasise the complexity in rationally designing chemo immunogenic combinations for use with immunotherapy.
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Affiliation(s)
- P L Smith
- ST Georges University of London, 1 Cranmer Terrace, London, SW17 0RE, UK.
| | - Y Yogaratnam
- ST Georges University of London, 1 Cranmer Terrace, London, SW17 0RE, UK
| | - M Samad
- ST Georges University of London, 1 Cranmer Terrace, London, SW17 0RE, UK
| | - S Kasow
- ST Georges University of London, 1 Cranmer Terrace, London, SW17 0RE, UK
| | - A G Dalgleish
- ST Georges University of London, 1 Cranmer Terrace, London, SW17 0RE, UK
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71
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Iovanna J. Implementing biological markers as a tool to guide clinical care of patients with pancreatic cancer. Transl Oncol 2020; 14:100965. [PMID: 33248412 PMCID: PMC7704461 DOI: 10.1016/j.tranon.2020.100965] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/04/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022] Open
Abstract
A major obstacle for the effective treatment of PDAC is its molecular heterogeneity. Stratification of PDAC using markers highly specific, reproducible, sensitive, easily measurable and inexpensive is necessary. At the early stages, clinician’s priority lies in rapid diagnosis, so that the patient receives surgery without delay. At advanced disease stages, priority is to determine the tumor subtype and select a suitable effective treatment.
A major obstacle for the effective treatment of pancreatic ductal adenocarcinoma (PDAC) is its molecular heterogeneity, reflected by the diverse clinical outcomes and responses to therapies that occur. The tumors of patients with PDAC must therefore be closely examined and classified before treatment initiation in order to predict the natural evolution of the disease and the response to therapy. To stratify patients, it is absolutely necessary to identify biological markers that are highly specific and reproducible, and easily measurable by inexpensive sensitive techniques. Several promising strategies to find biomarkers are already available or under development, such as the use of liquid biopsies to detect circulating tumor cells, circulating free DNA, methylated DNA, circulating RNA, and exosomes and extracellular vesicles, as well as immunological markers and molecular markers. Such biomarkers are capable of classifying patients with PDAC and predicting their therapeutic sensitivity. Interestingly, developing chemograms using primary cell lines or organoids and analyzing the resulting high-throughput data via artificial intelligence would be highly beneficial to patients. How can exploiting these biomarkers benefit patients with resectable, borderline resectable, locally advanced, and metastatic PDAC? In fact, the utility of these biomarkers depends on the patient's clinical situation. At the early stages of the disease, the clinician's priority lies in rapid diagnosis, so that the patient receives surgery without delay; at advanced disease stages, where therapeutic possibilities are severely limited, the priority is to determine the PDAC tumor subtype so as to estimate the clinical outcome and select a suitable effective treatment.
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Affiliation(s)
- Juan Iovanna
- Centre de Recherche en Cancérologie de Marseille (CRCM), INSERM U1068, CNRS UMR 7258, Aix-Marseille Université and Institut Paoli-Calmettes, Parc Scientifique et Technologique de Luminy, 163 Avenue de Luminy, 13288 Marseille, France.
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Olaoba OT, Ligali FC, Alabi ZO, Akinyemi AO, Ayinde KS. Of immune checkpoint maladies and remedies: The throwing of jabs in the oncogenic ring of PDAC. Biochim Biophys Acta Rev Cancer 2020; 1875:188483. [PMID: 33232723 DOI: 10.1016/j.bbcan.2020.188483] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/07/2020] [Accepted: 11/17/2020] [Indexed: 02/07/2023]
Abstract
The upregulation of co-inhibitory checkpoint receptors/ligands that inactivate antitumor T-cells, the enhancement of Tregs-mediated trogocytosis that contribute delayed maturation of antigen presenting cell (APC), and the high Tregs/CD+8 ratio that maintained low threshold of CD+8 cells in the tumor microenvironment (TME); all represent the nuances in the immune evasive strategies of pancreatic ductal adenocarcinoma (PDAC). PDAC is the most aggressive type of pancreatic cancers characterized by poor prognosis and extremely low survivability. Over the years, fraternity of scientists have developed therapeutic agents that can bolster the capacity of the antitumor immunity, usually via the inhibition of immune checkpoints. While this immune checkpoint inhibition therapy represents one major jab from immunity to PDAC, this cancer remains highly resistant due to the acme of desmoplasia in its TME. In this review, we discuss the mechanisms of various checkpoint receptors/ligands axes that are relevant to the fitness of PDAC in its oncogenic ring. These checkpoints include PD-1, CTLA-4, ICOS, TIM-3, TIGIT, BTLA, BTN3A, and VISTA. In addition, we provided evidences that are relevant to the understanding of immune checkpoint inhibition, with extensive outline of immune checkpoint inhibitors that are critical to the treatment of PDAC. Finally, we discuss recently known intricacies of PDAC-mediated immunosuppression, and current advances in treatment options. Having realized that the overall scenario between PDAC and antitumor immunity is like the throwing of jabs in a ring, we therefore discuss future directions and prospect that can knock out PDAC in favor of immunity and humanity.
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Affiliation(s)
- Olamide T Olaoba
- Laboratory of Functional and Structural Biochemistry, Federal University Sao Carlos, Sao Carlos, SP, Brazil
| | - Funmilayo C Ligali
- Department of Biochemistry and Nutrition, Nigeria Institute of Medical Research, Lagos, Nigeria
| | - Zaccheaus O Alabi
- Laboratory of Biomolecular Biochemistry of Microorganisms, Federal University Sao Carlos, Sao Carlos, SP, Brazil
| | - Amos O Akinyemi
- Medicinal Chemistry Laboratory, Federal University Sao Carlos, Sao Carlos, SP, Brazil
| | - Kehinde S Ayinde
- Institute of Biology, State University of Campinas, Campinas, SP, Brazil.
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A pectin-like polysaccharide from Polygala tenuifolia inhibits pancreatic cancer cell growth in vitro and in vivo by inducing apoptosis and suppressing autophagy. Int J Biol Macromol 2020; 162:107-115. [DOI: 10.1016/j.ijbiomac.2020.06.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/24/2020] [Accepted: 06/08/2020] [Indexed: 12/31/2022]
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74
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Huber M, Brehm CU, Gress TM, Buchholz M, Alashkar Alhamwe B, Pogge von Strandmann E, Slater EP, Bartsch JW, Bauer C, Lauth M. The Immune Microenvironment in Pancreatic Cancer. Int J Mol Sci 2020; 21:E7307. [PMID: 33022971 PMCID: PMC7583843 DOI: 10.3390/ijms21197307] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 09/28/2020] [Accepted: 09/29/2020] [Indexed: 02/07/2023] Open
Abstract
The biology of solid tumors is strongly determined by the interactions of cancer cells with their surrounding microenvironment. In this regard, pancreatic cancer (pancreatic ductal adenocarcinoma, PDAC) represents a paradigmatic example for the multitude of possible tumor-stroma interactions. PDAC has proven particularly refractory to novel immunotherapies, which is a fact that is mediated by a unique assemblage of various immune cells creating a strongly immunosuppressive environment in which this cancer type thrives. In this review, we outline currently available knowledge on the cross-talk between tumor cells and the cellular immune microenvironment, highlighting the physiological and pathological cellular interactions, as well as the resulting therapeutic approaches derived thereof. Hopefully a better understanding of the complex tumor-stroma interactions will one day lead to a significant advancement in patient care.
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Affiliation(s)
- Magdalena Huber
- Institute for Medical Microbiology and Hospital Hygiene, Philipps University Marburg, 35043 Marburg, Germany;
| | - Corinna U. Brehm
- Institute of Pathology, University Hospital Giessen-Marburg, 35043 Marburg, Germany;
| | - Thomas M. Gress
- Department of Gastroenterology, Endocrinology, Metabolism and Infectiology, Center for Tumor- and Immunology (ZTI), Philipps University Marburg, 35043 Marburg, Germany; (T.M.G.); (M.B.); (C.B.)
| | - Malte Buchholz
- Department of Gastroenterology, Endocrinology, Metabolism and Infectiology, Center for Tumor- and Immunology (ZTI), Philipps University Marburg, 35043 Marburg, Germany; (T.M.G.); (M.B.); (C.B.)
| | - Bilal Alashkar Alhamwe
- Institute for Tumor Immunology, Clinic for Hematology, Oncology and Immunology, Center for Tumor Biology and Immunology (ZTI), Philipps University Marburg, 35043 Marburg, Germany; (E.P.v.S.); (B.A.A.)
| | - Elke Pogge von Strandmann
- Institute for Tumor Immunology, Clinic for Hematology, Oncology and Immunology, Center for Tumor Biology and Immunology (ZTI), Philipps University Marburg, 35043 Marburg, Germany; (E.P.v.S.); (B.A.A.)
| | - Emily P. Slater
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps University Marburg, Baldingerstrasse, 35043 Marburg, Germany;
| | - Jörg W. Bartsch
- Department of Neurosurgery, Philipps University Marburg, Baldingerstrasse, 35043 Marburg, Germany;
| | - Christian Bauer
- Department of Gastroenterology, Endocrinology, Metabolism and Infectiology, Center for Tumor- and Immunology (ZTI), Philipps University Marburg, 35043 Marburg, Germany; (T.M.G.); (M.B.); (C.B.)
| | - Matthias Lauth
- Department of Gastroenterology, Endocrinology, Metabolism and Infectiology, Center for Tumor- and Immunology (ZTI), Philipps University Marburg, 35043 Marburg, Germany; (T.M.G.); (M.B.); (C.B.)
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Hessmann E, Buchholz SM, Demir IE, Singh SK, Gress TM, Ellenrieder V, Neesse A. Microenvironmental Determinants of Pancreatic Cancer. Physiol Rev 2020; 100:1707-1751. [DOI: 10.1152/physrev.00042.2019] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) belongs to the most lethal solid tumors in humans. A histological hallmark feature of PDAC is the pronounced tumor microenvironment (TME) that dynamically evolves during tumor progression. The TME consists of different non-neoplastic cells such as cancer-associated fibroblasts, immune cells, endothelial cells, and neurons. Furthermore, abundant extracellular matrix components such as collagen and hyaluronic acid as well as matricellular proteins create a highly dynamic and hypovascular TME with multiple biochemical and physical interactions among the various cellular and acellular components that promote tumor progression and therapeutic resistance. In recent years, intensive research efforts have resulted in a significantly improved understanding of the biology and pathophysiology of the TME in PDAC, and novel stroma-targeted approaches are emerging that may help to improve the devastating prognosis of PDAC patients. However, none of anti-stromal therapies has been approved in patients so far, and there is still a large discrepancy between multiple successful preclinical results and subsequent failure in clinical trials. Furthermore, recent findings suggest that parts of the TME may also possess tumor-restraining properties rendering tailored therapies even more challenging.
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Affiliation(s)
- Elisabeth Hessmann
- Department of Gastroenterology, Gastrointestinal Oncology, and Endocrinology, University Medical Centre Goettingen, Georg August University, Goettingen, Germany; Department of Surgery, Klinikum rechts der Isar, Technische Universität München, School of Medicine Munich, Munich, Germany; Sonderforschungsbereich/Collaborative Research Centre 1321 Modeling and Targeting Pancreatic Cancer, Munich, Germany; Deutsches Konsortium für Translationale Krebsforschung (DKTK) Munich Site, Munich, Germany; and
| | - Soeren M. Buchholz
- Department of Gastroenterology, Gastrointestinal Oncology, and Endocrinology, University Medical Centre Goettingen, Georg August University, Goettingen, Germany; Department of Surgery, Klinikum rechts der Isar, Technische Universität München, School of Medicine Munich, Munich, Germany; Sonderforschungsbereich/Collaborative Research Centre 1321 Modeling and Targeting Pancreatic Cancer, Munich, Germany; Deutsches Konsortium für Translationale Krebsforschung (DKTK) Munich Site, Munich, Germany; and
| | - Ihsan Ekin Demir
- Department of Gastroenterology, Gastrointestinal Oncology, and Endocrinology, University Medical Centre Goettingen, Georg August University, Goettingen, Germany; Department of Surgery, Klinikum rechts der Isar, Technische Universität München, School of Medicine Munich, Munich, Germany; Sonderforschungsbereich/Collaborative Research Centre 1321 Modeling and Targeting Pancreatic Cancer, Munich, Germany; Deutsches Konsortium für Translationale Krebsforschung (DKTK) Munich Site, Munich, Germany; and
| | - Shiv K. Singh
- Department of Gastroenterology, Gastrointestinal Oncology, and Endocrinology, University Medical Centre Goettingen, Georg August University, Goettingen, Germany; Department of Surgery, Klinikum rechts der Isar, Technische Universität München, School of Medicine Munich, Munich, Germany; Sonderforschungsbereich/Collaborative Research Centre 1321 Modeling and Targeting Pancreatic Cancer, Munich, Germany; Deutsches Konsortium für Translationale Krebsforschung (DKTK) Munich Site, Munich, Germany; and
| | - Thomas M. Gress
- Department of Gastroenterology, Gastrointestinal Oncology, and Endocrinology, University Medical Centre Goettingen, Georg August University, Goettingen, Germany; Department of Surgery, Klinikum rechts der Isar, Technische Universität München, School of Medicine Munich, Munich, Germany; Sonderforschungsbereich/Collaborative Research Centre 1321 Modeling and Targeting Pancreatic Cancer, Munich, Germany; Deutsches Konsortium für Translationale Krebsforschung (DKTK) Munich Site, Munich, Germany; and
| | - Volker Ellenrieder
- Department of Gastroenterology, Gastrointestinal Oncology, and Endocrinology, University Medical Centre Goettingen, Georg August University, Goettingen, Germany; Department of Surgery, Klinikum rechts der Isar, Technische Universität München, School of Medicine Munich, Munich, Germany; Sonderforschungsbereich/Collaborative Research Centre 1321 Modeling and Targeting Pancreatic Cancer, Munich, Germany; Deutsches Konsortium für Translationale Krebsforschung (DKTK) Munich Site, Munich, Germany; and
| | - Albrecht Neesse
- Department of Gastroenterology, Gastrointestinal Oncology, and Endocrinology, University Medical Centre Goettingen, Georg August University, Goettingen, Germany; Department of Surgery, Klinikum rechts der Isar, Technische Universität München, School of Medicine Munich, Munich, Germany; Sonderforschungsbereich/Collaborative Research Centre 1321 Modeling and Targeting Pancreatic Cancer, Munich, Germany; Deutsches Konsortium für Translationale Krebsforschung (DKTK) Munich Site, Munich, Germany; and
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Amin S, Baine MJ, Meza JL, Lin C. The Association of the Sequence of Immunotherapy With the Survival of Unresectable Pancreatic Adenocarcinoma Patients: A Retrospective Analysis of the National Cancer Database. Front Oncol 2020; 10:1518. [PMID: 32983998 PMCID: PMC7492650 DOI: 10.3389/fonc.2020.01518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/15/2020] [Indexed: 12/21/2022] Open
Abstract
Background: Immunotherapy has shown great success in various malignancies. However, its efficacy in pancreatic ductal adenocarcinoma (PDAC) remains a challenge, and the lack of understanding about the appropriate timing of immunotherapy with other standard-of-care cancer treatments may be one of the causes. The objective of the current study is to investigate the impact of the timing of immunotherapy with chemotherapy and radiation therapy (RT) on the overall survival (OS) of PDAC patients who did not receive surgical resection of the pancreatic tumor. Materials and Methods: Patients with pancreatic adenocarcinoma who did not receive surgical resection of the pancreatic tumor were identified from the National Cancer Database (NCDB). Cox proportional hazard models were employed to compare the OS between patients who received immunotherapy with chemotherapy or RT with a different sequence of treatment. The multivariable analysis was adjusted for age of diagnosis, race, sex, place of living, income, education, treatment facility type, insurance status, and year of diagnosis. Results: In total, 705 patients received chemotherapy and immunotherapy, while 226 received radiation therapy and immunotherapy. In the multivariable analysis, there was no significant difference in the OS of patients who started immunotherapy 31–90 days before the start of chemotherapy with a hazard ratio (HR) of [HR:1.057 (CI: 0.716–1.56; p < 0.781)] and patients who started immunotherapy 91–180 days before the start of chemotherapy [HR: 0.900 (CI: 0.584–1.388; p < 0.635)] compared to patients who started chemotherapy and immunotherapy within 30 days of each other. There was also no significant difference in the OS of patients who started RT> 30 days before the start of immunotherapy [HR: 0.636 (CI: 0.346–1.171; p < 0.146)] and patients who started immunotherapy > 30 days before the start of RT [HR: 0.660 (CI: 0.328–1.329; p < 0.246)] compared to patients who started RT and immunotherapy within 30 days of each other. Conclusion: The sequence of immunotherapy with chemotherapy or RT was not associated with improved OS. Future studies with a larger subgroup sample size investigating the impact of the timing of immunotherapy with chemotherapy and RT on the OS of PDAC patients who do not receive surgical resection of the pancreatic tumor are needed.
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Affiliation(s)
- Saber Amin
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, United States
| | - Michael J Baine
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, United States
| | - Jane L Meza
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, United States
| | - Chi Lin
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, United States
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Sahin I, Turen S, Santapuram P, Sahin IH. The tumor microenvironment of pancreatic adenocarcinoma and immune checkpoint inhibitor resistance: a perplex relationship. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2020; 3:699-709. [PMID: 35582227 PMCID: PMC8992554 DOI: 10.20517/cdr.2020.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/11/2020] [Accepted: 08/28/2020] [Indexed: 11/12/2022]
Abstract
Pancreatic cancer is one of the most aggressive cancers with a high mortality rate even among patients with early-stage disease. Although recent studies with novel therapeutic approaches have led to modest improvement in survival outcomes, limited progress is achieved for the use of immunotherapeutics in this challenging cancer. Immune checkpoint inhibitors, thus far, single-agent or in combination, have not yielded significant improvement in survival outcomes except in mismatch repair-deficient pancreatic cancer. The tumor microenvironment of pancreatic cancer has been considered as an attractive target for over a decade based on preclinical studies that suggested it may adversely affect drug delivery and antitumor immunity. In this review article, we elaborate on the biology of pancreatic cancer microenvironment, its highly complicated interaction with cancer cells, and the immune system. We also discuss plausible explanations that led to the failure of immune checkpoint inhibitors as therapeutic agents and the potential impacts of pancreatic cancer stroma on these negative studies.
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Affiliation(s)
- Irem Sahin
- Baskent University School of Medicine, Department of Medicine Ankara, Ankara 06810, Turkey
| | - Sevda Turen
- TC Istanbul Kültür University, Faculty of Health Sciences, Department of Nursing, Istanbul 34158, Turkey
| | - Pranav Santapuram
- Emory University School of Medicine, Department of Medicine, Atlanta, GA 30322, USA
| | - Ibrahim Halil Sahin
- Moffitt Cancer Center, Department of Gastrointestinal Oncology, Tampa, FL 33612, USA
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Grossberg AJ, Chu LC, Deig CR, Fishman EK, Hwang WL, Maitra A, Marks DL, Mehta A, Nabavizadeh N, Simeone DM, Weekes CD, Thomas CR. Multidisciplinary standards of care and recent progress in pancreatic ductal adenocarcinoma. CA Cancer J Clin 2020; 70:375-403. [PMID: 32683683 PMCID: PMC7722002 DOI: 10.3322/caac.21626] [Citation(s) in RCA: 241] [Impact Index Per Article: 60.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 12/12/2022] Open
Abstract
Despite tremendous gains in the molecular understanding of exocrine pancreatic cancer, the prognosis for this disease remains very poor, largely because of delayed disease detection and limited effectiveness of systemic therapies. Both incidence rates and mortality rates for pancreatic cancer have increased during the past decade, in contrast to most other solid tumor types. Recent improvements in multimodality care have substantially improved overall survival, local control, and metastasis-free survival for patients who have localized tumors that are amenable to surgical resection. The widening gap in prognosis between patients with resectable and unresectable or metastatic disease reinforces the importance of detecting pancreatic cancer sooner to improve outcomes. Furthermore, the developing use of therapies that target tumor-specific molecular vulnerabilities may offer improved disease control for patients with advanced disease. Finally, the substantial morbidity associated with pancreatic cancer, including wasting, fatigue, and pain, remains an under-addressed component of this disease, which powerfully affects quality of life and limits tolerance to aggressive therapies. In this article, the authors review the current multidisciplinary standards of care in pancreatic cancer with a focus on emerging concepts in pancreatic cancer detection, precision therapy, and survivorship.
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Affiliation(s)
- Aaron J. Grossberg
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
- Brenden-Colson Center for Pancreatic Care, Oregon Health & Science University, Portland, OR
- Cancer Early Detection Advanced Research Center, Oregon Health & Science University, Portland, OR
| | - Linda C. Chu
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher R. Deig
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
| | - Eliot K. Fishman
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William L. Hwang
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
- Broad Institute of Harvard and MIT, Cambridge, MA
| | - Anirban Maitra
- Departments of Pathology and Translational Molecular Pathology, Sheikh Ahmed Pancreatic Cancer Research Center, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel L. Marks
- Brenden-Colson Center for Pancreatic Care, Oregon Health & Science University, Portland, OR
- Department of Pediatrics and Pape Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR
| | - Arnav Mehta
- Broad Institute of Harvard and MIT, Cambridge, MA
- Dana Farber Cancer Institute, Boston, MA
| | - Nima Nabavizadeh
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
| | - Diane M. Simeone
- Departments of Surgery and Pathology, Perlmutter Cancer Center, NYU Langone Health, New York, NY
| | - Colin D. Weekes
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Charles R. Thomas
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
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Hegde S. Pancreatic Cancer Immuno-oncology in the Era of Precision Medicine. Indian J Surg Oncol 2020; 12:118-127. [PMID: 33994737 DOI: 10.1007/s13193-020-01192-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022] Open
Abstract
Pancreatic malignancies carry a dismal prognosis globally, with pancreatic adenocarcinomas (PDAC) being particularly aggressive and stubborn. Unfortunately, several therapeutic strategies that show promise in other cancers have failed to make sizeable impact on pancreatic tumor outcomes. Responses to immunotherapies are especially rare in pancreatic cancer, and patients are in need of innovative approaches that can result in more durable responses. Current research in preclinical models and humans has suggested this resistance is due to a uniquely inflammatory and dysfunctional tumor microenvironment; these findings lay the groundwork for targeting these barriers and improving outcomes. Clinical analyses have also revealed unprecedented heterogeneity in tumor and stromal biology of PDAC, underscoring the need for more personalized approaches and combinatorial therapies. This review will highlight the current state of translational research focusing on PDAC immunity, summarize ongoing clinical efforts to tackle PDAC vulnerabilities, and underscore some unresolved challenges in implementing therapies more broadly. A better understanding of immune contexture and tumor heterogeneity in this disease will greatly accelerate drug discovery and implementation of precision medicine for PDAC.
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Affiliation(s)
- Samarth Hegde
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY USA
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80
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Regulation and modulation of antitumor immunity in pancreatic cancer. Nat Immunol 2020; 21:1152-1159. [PMID: 32807942 DOI: 10.1038/s41590-020-0761-y] [Citation(s) in RCA: 122] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 07/15/2020] [Indexed: 02/06/2023]
Abstract
Pancreatic ductal adenocarcinoma carries a dismal prognosis, and outcomes have improved little with modern therapeutics. Checkpoint-based immunotherapy has failed to elicit responses in the vast majority of patients with pancreatic cancer. Alongside tumor cell-intrinsic mechanisms associated with oncogenic KRAS-induced inflammation, the tolerogenic myeloid cell infiltrate has emerged as a critical impediment to adaptive antitumor immune responses. Furthermore, the discovery of an intratumoral microbiome and the elucidation of host-microbe interactions that curtail antitumor immunity also present opportunities for intervention. Here we review the mechanisms of immunotherapy resistance in pancreatic ductal adenocarcinoma and discuss strategies to directly augment T cell responses in parallel with myeloid cell- and microbiome-targeted approaches that may enable immune-mediated control of this malignancy.
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81
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Saka D, Gökalp M, Piyade B, Cevik NC, Arik Sever E, Unutmaz D, Ceyhan GO, Demir IE, Asimgil H. Mechanisms of T-Cell Exhaustion in Pancreatic Cancer. Cancers (Basel) 2020; 12:cancers12082274. [PMID: 32823814 PMCID: PMC7464444 DOI: 10.3390/cancers12082274] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/28/2020] [Accepted: 08/03/2020] [Indexed: 02/07/2023] Open
Abstract
T-cell exhaustion is a phenomenon that represents the dysfunctional state of T cells in chronic infections and cancer and is closely associated with poor prognosis in many cancers. The endogenous T-cell immunity and genetically edited cell therapies (CAR-T) failed to prevent tumor immune evasion. The effector T-cell activity is perturbed by an imbalance between inhibitory and stimulatory signals causing a reprogramming in metabolism and the high levels of multiple inhibitory receptors like programmed cell death protein-1 (PD-1), cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), T cell immunoglobulin and mucin domain-containing protein 3 (TIM-3), and Lymphocyte-activation gene 3 (Lag-3). Despite the efforts to neutralize inhibitory receptors by a single agent or combinatorial immune checkpoint inhibitors to boost effector function, PDAC remains unresponsive to these therapies, suggesting that multiple molecular mechanisms play a role in stimulating the exhaustion state of tumor-infiltrating T cells. Recent studies utilizing transcriptomics, mass cytometry, and epigenomics revealed a critical role of Thymocyte selection-associated high mobility group box protein (TOX) genes and TOX-associated pathways, driving T-cell exhaustion in chronic infection and cancer. Here, we will review recently defined molecular, genetic, and cellular factors that drive T-cell exhaustion in PDAC. We will also discuss the effects of available immune checkpoint inhibitors and the latest clinical trials targeting various molecular factors mediating T-cell exhaustion in PDAC.
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Affiliation(s)
- Didem Saka
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul 34684, Turkey; (D.S.); (M.G.); (B.P.); (N.C.C.); (E.A.S.); (H.A.)
| | - Muazzez Gökalp
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul 34684, Turkey; (D.S.); (M.G.); (B.P.); (N.C.C.); (E.A.S.); (H.A.)
| | - Betül Piyade
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul 34684, Turkey; (D.S.); (M.G.); (B.P.); (N.C.C.); (E.A.S.); (H.A.)
| | - Nedim Can Cevik
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul 34684, Turkey; (D.S.); (M.G.); (B.P.); (N.C.C.); (E.A.S.); (H.A.)
| | - Elif Arik Sever
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul 34684, Turkey; (D.S.); (M.G.); (B.P.); (N.C.C.); (E.A.S.); (H.A.)
| | - Derya Unutmaz
- Jackson Laboratory of Genomic Medicine, Farmington, CT 06032, USA;
| | - Güralp O. Ceyhan
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul 34684, Turkey; (D.S.); (M.G.); (B.P.); (N.C.C.); (E.A.S.); (H.A.)
- Correspondence: (G.O.C.); (I.E.D.); Tel.: +90-5320514424 (G.O.C.); +49-8941405868 (I.E.D.)
| | - Ihsan Ekin Demir
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul 34684, Turkey; (D.S.); (M.G.); (B.P.); (N.C.C.); (E.A.S.); (H.A.)
- Department of Surgery, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
- Correspondence: (G.O.C.); (I.E.D.); Tel.: +90-5320514424 (G.O.C.); +49-8941405868 (I.E.D.)
| | - Hande Asimgil
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul 34684, Turkey; (D.S.); (M.G.); (B.P.); (N.C.C.); (E.A.S.); (H.A.)
- Department of Surgery, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
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Mazloom A, Ghalehsari N, Gazivoda V, Nimkar N, Paul S, Gregos P, Rateshwar J, Khan U. Role of Immune Checkpoint Inhibitors in Gastrointestinal Malignancies. J Clin Med 2020; 9:E2533. [PMID: 32781500 PMCID: PMC7463795 DOI: 10.3390/jcm9082533] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/28/2020] [Accepted: 07/31/2020] [Indexed: 12/24/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of several solid and hematological malignancies. ICIs are not only able to produce long and durable responses, but also very well tolerated by patients. There are several approved indications of use of ICIs in treatment of metastatic gastrointestinal malignancies including gastric, esophageal, colorectal and hepatocellular carcinoma. In addition, ICIs can be used in microsatellite instability-high (MSI-H) and high tumor mutational burden (TMB) tumors in chemotherapy-resistant setting. Despite having good efficacy and superior safety profile, ICIs are clinically active in small subset of patients, therefore, there is a huge unmet need to enhance their efficacy and discover new predictive biomarkers. There are several ongoing clinical trials that are exploring the role of ICIs in various gastrointestinal cancers either as single agent or in combination with chemotherapy, radiation therapy, targeted agents or other immunotherapeutic agents. In this review, we discuss the published and ongoing trials for ICIs in gastrointestinal malignancies, including esophageal, gastric cancer, pancreatic, hepatocellular, biliary tract, colorectal and anal cancers. Specifically, we focus on the use of ICIs in each line of therapy and discuss the future directions of these agents in each type of gastrointestinal cancer.
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Affiliation(s)
- Anita Mazloom
- Department of Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital—Weill Cornell Medicine, Brooklyn, NY 11215, USA; (A.M.); (N.G.); (N.N.); (S.P.); (P.G.); (J.R.)
| | - Nima Ghalehsari
- Department of Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital—Weill Cornell Medicine, Brooklyn, NY 11215, USA; (A.M.); (N.G.); (N.N.); (S.P.); (P.G.); (J.R.)
| | - Victor Gazivoda
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY 11219, USA;
| | - Neil Nimkar
- Department of Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital—Weill Cornell Medicine, Brooklyn, NY 11215, USA; (A.M.); (N.G.); (N.N.); (S.P.); (P.G.); (J.R.)
| | - Sonal Paul
- Department of Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital—Weill Cornell Medicine, Brooklyn, NY 11215, USA; (A.M.); (N.G.); (N.N.); (S.P.); (P.G.); (J.R.)
| | - Peter Gregos
- Department of Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital—Weill Cornell Medicine, Brooklyn, NY 11215, USA; (A.M.); (N.G.); (N.N.); (S.P.); (P.G.); (J.R.)
| | - Janice Rateshwar
- Department of Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital—Weill Cornell Medicine, Brooklyn, NY 11215, USA; (A.M.); (N.G.); (N.N.); (S.P.); (P.G.); (J.R.)
| | - Uqba Khan
- Department of Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital—Weill Cornell Medicine, Brooklyn, NY 11215, USA; (A.M.); (N.G.); (N.N.); (S.P.); (P.G.); (J.R.)
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Nsingwane Z, Candy G, Devar J, Omoshoro-Jones J, Smith M, Nweke E. Immunotherapeutic strategies in pancreatic ductal adenocarcinoma (PDAC): current perspectives and future prospects. Mol Biol Rep 2020; 47:6269-6280. [PMID: 32661873 DOI: 10.1007/s11033-020-05648-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 07/08/2020] [Indexed: 01/08/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is among the deadliest human malignancies with a dismal prognosis. During PDAC progression, the immune response is affected as cancer cells evade detection and elimination. Recently, there have been advances in the treatment of PDAC using immunotherapy, although a lot more work is yet to be done. In this review, we discuss these advances, challenges and potentials. We focus on existing and potential immune targets for PDAC, drugs used to target them, and some clinical trials conducted so far with them. Finally, novel targets in the tumour microenvironment such as stromal cells and other potential future areas to explore including bacterial therapy and the use of neoantigens in immunotherapy are highlighted.
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Affiliation(s)
- Zanele Nsingwane
- Department of Surgery, Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa.
| | - Geoffrey Candy
- Department of Surgery, Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
| | - John Devar
- Department of Surgery, Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
| | - Jones Omoshoro-Jones
- Department of Surgery, Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
| | - Martin Smith
- Department of Surgery, Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
| | - Ekene Nweke
- Department of Surgery, Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
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Principe DR, Narbutis M, Kumar S, Park A, Viswakarma N, Dorman MJ, Kamath SD, Grippo PJ, Fishel ML, Hwang RF, Thummuri D, Underwood PW, Munshi HG, Trevino JG, Rana A. Long-Term Gemcitabine Treatment Reshapes the Pancreatic Tumor Microenvironment and Sensitizes Murine Carcinoma to Combination Immunotherapy. Cancer Res 2020; 80:3101-3115. [PMID: 32238357 PMCID: PMC7777391 DOI: 10.1158/0008-5472.can-19-2959] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/10/2020] [Accepted: 03/19/2020] [Indexed: 12/17/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a leading cause of cancer-related death with a median survival time of 6-12 months. Most patients present with disseminated disease and the majority are offered palliative chemotherapy. With no approved treatment modalities for patients who progress on chemotherapy, we explored the effects of long-term gemcitabine administration on the tumor microenvironment to identify potential therapeutic options for chemorefractory PDAC. Using a combination of mouse models, primary cell line-derived xenografts, and established tumor cell lines, we first evaluated chemotherapy-induced alterations in the tumor secretome and immune surface proteins by high throughput proteomic arrays. In addition to enhancing antigen presentation and immune checkpoint expression, gemcitabine consistently increased the synthesis of CCL/CXCL chemokines and TGFβ-associated signals. These secreted factors altered the composition of the tumor stroma, conferring gemcitabine resistance to cancer-associated fibroblasts in vitro and further enhancing TGFβ1 biosynthesis. Combined gemcitabine and anti-PD-1 treatment in transgenic models of murine PDAC failed to alter disease course unless mice also underwent genetic or pharmacologic ablation of TGFβ signaling. In the setting of TGFβ signaling deficiency, gemcitabine and anti-PD-1 led to a robust CD8+ T-cell response and decrease in tumor burden, markedly enhancing overall survival. These results suggest that gemcitabine successfully primes PDAC tumors for immune checkpoint inhibition by enhancing antigen presentation only following disruption of the immunosuppressive cytokine barrier. Given the current lack of third-line treatment options, this approach warrants consideration in the clinical management of gemcitabine-refractory PDAC. SIGNIFICANCE: These data suggest that long-term treatment with gemcitabine leads to extensive reprogramming of the pancreatic tumor microenvironment and that patients who progress on gemcitabine-based regimens may benefit from multidrug immunotherapy.See related commentary by Carpenter et al., p. 3070 GRAPHICAL ABSTRACT: http://cancerres.aacrjournals.org/content/canres/80/15/3101/F1.large.jpg.
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Affiliation(s)
- Daniel R Principe
- Medical Scientist Training Program, University of Illinois College of Medicine, Chicago, Illinois.
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Matthew Narbutis
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Sandeep Kumar
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Alex Park
- University of Illinois College of Medicine, Chicago, Illinois
| | - Navin Viswakarma
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Matthew J Dorman
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Suneel D Kamath
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Paul J Grippo
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Melissa L Fishel
- Department of Pediatrics, Indiana University School of Medicine, Indiana University, Indianapolis, Indiana
| | - Rosa F Hwang
- Department of Breast Surgical Oncology, Division of Surgery, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Dinesh Thummuri
- Department of Pharmacodynamics, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Patrick W Underwood
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Hidayatullah G Munshi
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Jesse Brown VA Medical Center, Chicago, Illinois
| | - Jose G Trevino
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Ajay Rana
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois.
- Jesse Brown VA Medical Center, Chicago, Illinois
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85
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Bouchart C, Navez J, Closset J, Hendlisz A, Van Gestel D, Moretti L, Van Laethem JL. Novel strategies using modern radiotherapy to improve pancreatic cancer outcomes: toward a new standard? Ther Adv Med Oncol 2020; 12:1758835920936093. [PMID: 32684987 PMCID: PMC7343368 DOI: 10.1177/1758835920936093] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 05/22/2020] [Indexed: 12/11/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains one of the most aggressive solid tumours with an estimated 5-year overall survival rate of 7% for all stages combined. In this highly resistant disease that is located in the vicinity of many radiosensitive organs, the role of radiotherapy (RT) and indications for its use in this setting have been debated for a long time and are still under investigation. Although a survival benefit has yet to be clearly demonstrated for RT, it is the only technique, other than surgery, that has been demonstrated to lead to local control improvement. The adjuvant approach is now strongly challenged by neoadjuvant treatments that could spare patients with rapidly progressive systemic disease from unnecessary surgery and may increase free margin (R0) resection rates for those eligible for surgery. Recently developed dose-escalated RT treatments, designed either to maintain full-dose chemotherapy or to deliver a high biologically effective dose, particularly to areas of contact between the tumour and blood vessels, such as hypofractionated ablative RT (HFA-RT) or stereotactic body RT (SBRT), are progressively changing the treatment landscape. These modern strategies are currently being tested in prospective clinical trials with encouraging preliminary results, paving the way for more effective treatment combinations using novel targeted therapies. This review summarizes the current literature regarding the use of RT for the treatment of primary PDAC, describes the limitations of conventional RT, and discusses the emerging role of dose-escalated RT and heavy-particle RT.
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Affiliation(s)
- Christelle Bouchart
- Department of Radiation-Oncology, Institut Jules Bordet, Boulevard de Waterloo, 121, Brussels, 1000, Belgium
| | - Julie Navez
- Department of Hepato-Biliary-Pancreatic Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean Closset
- Department of Hepato-Biliary-Pancreatic Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Alain Hendlisz
- Department of Gastroenterology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Dirk Van Gestel
- Department of Radiation-Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Luigi Moretti
- Department of Radiation-Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Luc Van Laethem
- Department of Gastroenterology, Hepatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Shui L, Cheng K, Li X, Shui P, Li S, Peng Y, Li J, Guo F, Yi C, Cao D. Durable Response and Good Tolerance to the Triple Combination of Toripalimab, Gemcitabine, and Nab-Paclitaxel in a Patient With Metastatic Pancreatic Ductal Adenocarcinoma. Front Immunol 2020; 11:1127. [PMID: 32636837 PMCID: PMC7318868 DOI: 10.3389/fimmu.2020.01127] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/07/2020] [Indexed: 02/05/2023] Open
Abstract
Background: The performance of immune checkpoint inhibitor (ICI) monotherapy was proved to be disappointing in pancreatic ductal adenocarcinoma (PDAC). Increasing evidence has shown the promising efficacy of ICIs combined with systemic therapy in the first-line treatment in solid tumors. Case presentation: We reported a case of a metastatic PDAC patient who had a long-term partial response and good tolerance to the combined approach of toripalimab (a novel PD-1 inhibitor) and gemcitabine plus nab-paclitaxel (GA). PD-L1 positive expression was detected in his liver metastases. Besides, we described a phenomenon of pseudo-progression of this patient during the course of therapy. Conclusion: As the first-line treatment of metastatic PDAC patients, GA plus toripalimab may provide a novel combined approach with favorable response and manageable toxicity. Further clinical trials are needed to confirm the results. Pseudo-progression requires special attention and to be differentiated with true progression in patients undergoing immunotherapy.
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Affiliation(s)
- Lin Shui
- Department of Abdominal Oncology, State Key Laboratory of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Ke Cheng
- Department of Abdominal Oncology, State Key Laboratory of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaofen Li
- Department of Abdominal Oncology, State Key Laboratory of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Pixian Shui
- School of Pharmacy, Southwest Medical University, Luzhou, China
| | - Shuangshuang Li
- Department of Abdominal Oncology, State Key Laboratory of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yang Peng
- Department of Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jian Li
- Department of Pharmacy, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Fengzhu Guo
- State Key Laboratory of Biotherapy, Lung Cancer Center, Cancer Center, West China Hospital of Sichuan University, Chengdu, China
| | - Cheng Yi
- Department of Abdominal Oncology, State Key Laboratory of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Dan Cao
- Department of Abdominal Oncology, State Key Laboratory of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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87
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Amin S, Baine M, Meza J, Alam M, Lin C. The impact of immunotherapy on the survival of pancreatic adenocarcinoma patients who do not receive definitive surgery of the tumor. Clin Transl Radiat Oncol 2020; 24:34-40. [PMID: 32613090 PMCID: PMC7317682 DOI: 10.1016/j.ctro.2020.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/26/2020] [Accepted: 06/01/2020] [Indexed: 12/18/2022] Open
Abstract
Background and Purpose Immunotherapy has shown great efficacy in many cancers, but its role in pancreatic ductal adenocarcinoma (PDAC) remains unclear. The objective of this study was to investigate the impact of immunotherapy on the overall survival of PDAC patients who did not receive definitive surgery of the pancreatic primary tumor site using the National Cancer Database (NCDB). Materials and Methods Patients with pancreatic adenocarcinoma who did not receive surgery were identified from NCDB. Cox proportional hazard models were employed to assess the impact of immunotherapy on survival after adjusting for age at diagnosis, race, sex, place of living, income, education, treatment facility type, insurance status, year of diagnosis, and treatment types such as chemotherapy and radiation therapy. Results Of 263,886 patients who were analyzed, 911 (0.35%) received immunotherapy. Among patients who received chemotherapy (101,546), and chemoradiation (30,226) therapy, 555/101,546 (0.55%) received chemotherapy plus immunotherapy, and 299/3,022 (9.9%) received chemoradiation plus immunotherapy. In a multivariable analysis adjusted for the factors mentioned above, immunotherapy was associated with significantly improved OS (HR: 0.866 (0.800–0.937); P < 0.001) compared to no immunotherapy. Chemotherapy plus immunotherapy was significantly associated with improved OS (HR: 0.848 (0.766–0.938); P < 0.001) compared to chemotherapy without immunotherapy. Further, chemoradiation plus immunotherapy was associated with significantly improved OS (HR: 0.813 (0.707–0.936); P < 0.001) compared to chemoradiation alone. Conclusion In this study, the addition of immunotherapy to chemotherapy and chemoradiation therapy was associated with significantly improved OS in PDAC patients without definitive surgery. The study warrants future clinical trials of immunotherapy in PDAC.
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Affiliation(s)
- Saber Amin
- Department of Radiation Oncology, University of Nebraska Medical Center, USA
| | - Michael Baine
- Department of Radiation Oncology, University of Nebraska Medical Center, USA
| | - Jane Meza
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, USA
| | - Morshed Alam
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, USA
| | - Chi Lin
- Department of Radiation Oncology, University of Nebraska Medical Center, USA
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Abdkarimi S, Razi Soofiyani S, Elham G, Mashhadi Abdolahi H, Safarzadeh E, Baradaran B. Targeting immune checkpoints: Building better therapeutic puzzle in pancreatic cancer combination therapy. Eur J Cancer Care (Engl) 2020; 29:e13268. [PMID: 32459388 DOI: 10.1111/ecc.13268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/30/2020] [Accepted: 04/30/2020] [Indexed: 12/24/2022]
Abstract
Pancreatic cancer is related to a very weak diagnosis; the close parallel between disease incidence and mortality rates from pancreatic cancer reflects the fatal nature of this disease. Although early detection procedures are growing, they are not applicable yet for pancreatic cancer. The majority of cancer patients suffer from advanced disease, in which surgery has no potential effect. Based on the growing evidence, it is predicated that cancer immunotherapy alone or in combination will probably be an essential section of different cancer treatment methods. There are different kinds of immune processes, including various antitumour and tumour-promoting leukocytes. Moreover, tumour cells utilise numerous approaches to overwhelm the immune response. Use of antibody in the therapeutic protocols is proving significant success and is probably a key element of cancer treatment. This method is directed against numerous negative immunologic regulators and immune checkpoints. In the present review, the clinical outlines of immune checkpoint inhibition are discussed in pancreatic cancer.
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Affiliation(s)
- Sina Abdkarimi
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saiedeh Razi Soofiyani
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Molecular Medicine Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Goli Elham
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hossein Mashhadi Abdolahi
- Tabriz Health Services Management Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Elham Safarzadeh
- Department of Immunology and Microbiology, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Behzad Baradaran
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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89
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Mucciolo G, Roux C, Scagliotti A, Brugiapaglia S, Novelli F, Cappello P. The dark side of immunotherapy: pancreatic cancer. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2020; 3:491-520. [PMID: 35582441 PMCID: PMC8992483 DOI: 10.20517/cdr.2020.13] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/23/2020] [Accepted: 04/07/2020] [Indexed: 12/13/2022]
Abstract
Since the journal Science deemed cancer immunotherapy as the "breakthrough of the year" in 2014, there has been an explosion of clinical trials involving immunotherapeutic approaches that, in the last decade - thanks also to the renaissance of the immunosurveillance theory (renamed the three Es theory) - have been continuously and successfully developed. In the latest update of the development of the immuno-oncology drug pipeline, published last November by Nature Review Drug Discovery, it was clearly reported that the immunoactive drugs under study almost doubled in just two years. Of the different classes of passive and active immunotherapies, "cell therapy" is the fastest growing. The aim of this review is to discuss the preclinical and clinical studies that have focused on different immuno-oncology approaches applied to pancreatic cancer, which we assign to the "dark side" of immunotherapy, in the sense that it represents one of the solid tumors showing less response to this type of therapeutic strategy.
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Affiliation(s)
- Gianluca Mucciolo
- Center for Experimental Research and Medical Studies (CERMS), Città della Salute e della Scienza di Torino, Turin 10126, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin 10126, Italy
- The two authors contributed equally
| | - Cecilia Roux
- Center for Experimental Research and Medical Studies (CERMS), Città della Salute e della Scienza di Torino, Turin 10126, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin 10126, Italy
- The two authors contributed equally
| | - Alessandro Scagliotti
- Center for Experimental Research and Medical Studies (CERMS), Città della Salute e della Scienza di Torino, Turin 10126, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin 10126, Italy
| | - Silvia Brugiapaglia
- Center for Experimental Research and Medical Studies (CERMS), Città della Salute e della Scienza di Torino, Turin 10126, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin 10126, Italy
| | - Francesco Novelli
- Center for Experimental Research and Medical Studies (CERMS), Città della Salute e della Scienza di Torino, Turin 10126, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin 10126, Italy
- Molecular Biotechnology Center, University of Turin, Turin 10126, Italy
| | - Paola Cappello
- Center for Experimental Research and Medical Studies (CERMS), Città della Salute e della Scienza di Torino, Turin 10126, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin 10126, Italy
- Molecular Biotechnology Center, University of Turin, Turin 10126, Italy
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90
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Mehta A, Hwang WL, Weekes C. The present and future of systemic and microenvironment-targeted therapy for pancreatic adenocarcinoma. ANNALS OF PANCREATIC CANCER 2020; 3:3. [PMID: 33294843 PMCID: PMC7720884 DOI: 10.21037/apc-2020-pda-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Metastatic pancreatic adenocarcinoma remains one of the deadliest cancer diagnoses with 5-year survival rates as low as 3%. For decades, gemcitabine remained the mainstay of systemic therapy before the approvals of FOLFIRINOX and gemcitabine with nab-paclitaxel. Despite these advances in the early 2010s, almost all patients progress on systemic chemotherapy and significant effort is needed to identify novel therapeutic targets. A promising array of approaches is currently under investigation, enabled by deeper understanding of the immune system within the tumor microenvironment (TME) and of the key vulnerabilities in pathways essential for tumor survival. In this review, we will explore the different approaches to boost tumor immunity and to target tumor metabolic pathways that are currently under clinical investigation for systemic treatment, and highlight the promising therapeutic areas that may give rise to the next generation of therapies for pancreatic cancer.
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Affiliation(s)
- Arnav Mehta
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
- Dana Farber Cancer Institute, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - William L. Hwang
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
- Koch Institute for Integrative Cancer Research, Cambridge, MA, USA
| | - Colin Weekes
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
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91
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Schizas D, Charalampakis N, Kole C, Economopoulou P, Koustas E, Gkotsis E, Ziogas D, Psyrri A, Karamouzis MV. Immunotherapy for pancreatic cancer: A 2020 update. Cancer Treat Rev 2020; 86:102016. [PMID: 32247999 DOI: 10.1016/j.ctrv.2020.102016] [Citation(s) in RCA: 255] [Impact Index Per Article: 63.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/19/2020] [Accepted: 03/20/2020] [Indexed: 02/08/2023]
Abstract
Pancreatic adenocarcinoma (PAC) is associated with extremely poor prognosis and remains a lethal malignancy. The main cure for PAC is surgical resection. Further treatment modalities, such as surgery, chemotherapy, radiotherapy and other locoregional therapies provide low survival rates. Currently, many clinical trials seek to assess the efficacy of immunotherapeutic strategies in PAC, including immune checkpoint inhibitors, cancer vaccines, adoptive cell transfer, combinations with other immunotherapeutic agents, chemoradiotherapy or other molecularly targeted agents; however, none of these studies have shown practice changing results. There seems to be a synergistic effect with increased response rates when a combinatorial approach of immunotherapy in conjunction with other modalities is being exploited. In this review, we illustrate the current role of immunotherapy in PAC.
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Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | | | - Christo Kole
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Panagiota Economopoulou
- Department of Internal Medicine, Section of Medical Oncology, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Evangelos Koustas
- Molecular Oncology Unit, Department of Biological Chemistry, National and Kapodistrian University of Athens, Athens, Greece
| | - Efthymios Gkotsis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Dimitrios Ziogas
- First Department of Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Amanda Psyrri
- Department of Internal Medicine, Section of Medical Oncology, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Michalis V Karamouzis
- Molecular Oncology Unit, Department of Biological Chemistry, National and Kapodistrian University of Athens, Athens, Greece
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92
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Lee JW, Beatty GL. Inflammatory networks cultivate cancer cell metastasis to the liver. Cell Cycle 2020; 19:642-651. [PMID: 32053029 PMCID: PMC7145328 DOI: 10.1080/15384101.2020.1728013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 12/28/2019] [Accepted: 02/06/2020] [Indexed: 02/08/2023] Open
Abstract
The liver is the most frequent site of metastatic spread in malignancies that arise from the digestive system, including pancreatic ductal adenocarcinoma (PDAC). Metastasis to the liver is a major cause of morbidity and mortality in cancer patients, yet mechanisms that govern this process remain poorly understood. Until recently, liver tropism of metastasis was believed to be driven by mechanical factors that direct the passive flow of circulating cancer cells to the liver. However, emerging evidence now shows that liver metastasis is a dynamic process that is, at least in part, dependent on the formation of a "pro-metastatic niche". Key features of this niche are myeloid cells and fibrosis that support cancer cell colonization and growth. Inflammatory responses that are mounted early during primary tumor development are critical for the recruitment of myeloid cells and the deposition of extracellular matrix (ECM) proteins within the liver. Intriguingly, the inflammatory processes that direct the formation of a pro-metastatic niche share remarkable resemblance to mechanisms of liver injury and regeneration, suggesting that cancer co-opts physiological liver functions to support metastasis. Therefore, therapeutic strategies that target key elements of liver inflammation that form the basis of a pro-metastatic niche may lead to effective treatments for metastatic cancer.
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Affiliation(s)
- Jae W. Lee
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory L. Beatty
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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93
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Juergens RA, Hao D, Ellis PM, Tu D, Mates M, Kollmannsberger C, Bradbury PA, Tehfe M, Wheatley-Price P, Robinson A, Bebb G, Laskin J, Goffin J, Hilton J, Tomiak A, Hotte S, Goss GD, Brown-Walker P, Sun X, Tsao MS, Cabanero M, Gauthier I, Song X, Dennis PA, Seymour LK, Smoragiewicz M, Laurie SA. A phase IB study of durvalumab with or without tremelimumab and platinum-doublet chemotherapy in advanced solid tumours: Canadian Cancer Trials Group Study IND226. Lung Cancer 2020; 143:1-11. [PMID: 32169783 DOI: 10.1016/j.lungcan.2020.02.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/10/2020] [Accepted: 02/22/2020] [Indexed: 12/24/2022]
Abstract
This multicenter phase Ib study aimed to establish a recommended phase II dose for durvalumab (Du) ± tremelimumab (Tr) in combination with standard platinum-doublet chemotherapy. Eligible patients were enrolled into one of six dose levels (DL) of Du ± Tr which included concomitant treatment with standard platinum-doublet regimens; (pemetrexed, gemcitabine, etoposide, (each with cisplatin or carboplatin) or nab-paclitaxel (with carboplatin)). Dose escalation was according to a Rolling Six type design. Both weight-based and fixed dosing of Du and Tr were explored. Du was continued until progression. Tr dosing was finite (up to 6 doses) with increasing dose and/or frequency by DL. 136 patients were enrolled. The majority of drug-related adverse events (AEs) were ≤ grade 2 and attributable to chemotherapy. AEs considered related to immunotherapy were mainly ≤ grade 2; the most frequent (occurring ≥10 %) were colitis/diarrhea, skin, and thyroid dysfunction. Seven patients had DLTs including pneumonitis, myocarditis, diarrhea, encephalitis, motor neuropathy, and enterocolitis. There were 2 treatment-related deaths. Tr and Du exposures did not appear affected by chemotherapy. Among the 73 non-small cell lung cancer (NSCLC) patients treated, the objective response rate was 51 % (95 %CI = 38.7-62.6 %) with a median progression-free and overall survival of 6.5 months (95 % CI = 5.5-9.4 months) and 19.8 months (95 % CI = 14.8 months - not yet reached) respectively. Anti-tumour activity was observed across PD-L1 subtypes. Du 1500 mg q3w and Tr 75 mg q3wx5 can be safely combined with platinum-doublet chemotherapy. Efficacy among NSCLC patients appears comparable to results from other immunotherapy and chemotherapy combination trials. NCT02537418.
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Affiliation(s)
| | - Desiree Hao
- Tom Baker Cancer Center, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Peter M Ellis
- Juravinski Cancer Center, McMaster University, Hamilton, ON, Canada
| | - Dongsheng Tu
- Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Mihaela Mates
- Cancer Center of Southeastern Ontario, Kingston, Ontario, Canada
| | | | | | | | - Paul Wheatley-Price
- The Ottawa Hospital Cancer Centre, Division of Medical Oncology, Ottawa, ON, Canada
| | - Andrew Robinson
- Cancer Center of Southeastern Ontario, Kingston, Ontario, Canada
| | - Gwyn Bebb
- Tom Baker Cancer Center, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Janessa Laskin
- British Columbia Cancer Agency - Vancouver Cancer Center, Vancouver, British Columbia, Canada
| | - John Goffin
- Juravinski Cancer Center, McMaster University, Hamilton, ON, Canada
| | - John Hilton
- The Ottawa Hospital Cancer Centre, Division of Medical Oncology, Ottawa, ON, Canada
| | - Anna Tomiak
- Cancer Center of Southeastern Ontario, Kingston, Ontario, Canada
| | - Sebastien Hotte
- Juravinski Cancer Center, McMaster University, Hamilton, ON, Canada
| | - Glenwood D Goss
- The Ottawa Hospital Cancer Centre, Division of Medical Oncology, Ottawa, ON, Canada
| | | | - Xiaoqun Sun
- Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | | | | | - Isabelle Gauthier
- Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Xuyang Song
- Global Medicines Development, AstraZeneca, Gaithersburg, Maryland, USA
| | - Phillip A Dennis
- Global Medicines Development, AstraZeneca, Gaithersburg, Maryland, USA
| | - Lesley K Seymour
- Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada.
| | | | - Scott A Laurie
- The Ottawa Hospital Cancer Centre, Division of Medical Oncology, Ottawa, ON, Canada
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Sarantis P, Koustas E, Papadimitropoulou A, Papavassiliou AG, Karamouzis MV. Pancreatic ductal adenocarcinoma: Treatment hurdles, tumor microenvironment and immunotherapy. World J Gastrointest Oncol 2020; 12:173-181. [PMID: 32104548 PMCID: PMC7031151 DOI: 10.4251/wjgo.v12.i2.173] [Citation(s) in RCA: 183] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 11/28/2019] [Accepted: 12/15/2019] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal diseases, with an average 5-year survival rate of less than 10%. Unfortunately, the majority of patients have unresectable, locally advanced, or metastatic disease at the time of diagnosis. Moreover, traditional treatments such as chemotherapy, surgery, and radiation have not been shown to significantly improve survival. Recently, there has been a swift increase in cancer treatments that incorporate immunotherapy-based strategies to target all the stepwise events required for tumor initiation and progression. The results in melanoma, non-small-cell lung cancer and renal cell carcinoma are very encouraging. Unfortunately, the application of checkpoint inhibitors, including anti-CTLA4, anti-PD-1, and anti-PD-L1 antibodies, in pancreatic cancer has been disappointing. Many studies have revealed that the PDAC microenvironment supports tumor growth, promotes metastasis and consists of a physical barrier to drug delivery. Combination therapies hold great promise for enhancing immune responses to achieve a better therapeutic effect. In this review, we provide an outline of why pancreatic cancer is so lethal and of the treatment hurdles that exist. Particular emphasis is given to the role of the tumor microenvironment, and some of the latest and most promising studies on immunotherapy in PDAC are also presented.
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Affiliation(s)
- Panagiotis Sarantis
- Molecular Oncology Unit, Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Evangelos Koustas
- Molecular Oncology Unit, Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Adriana Papadimitropoulou
- Center of Basic Research, Biomedical Research Foundation of the Academy of Athens, Athens 11527, Greece
| | - Athanasios G Papavassiliou
- Molecular Oncology Unit, Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Michalis V Karamouzis
- Molecular Oncology Unit, Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens 11527, Greece
- First Department of Internal Medicine, “Laiko” General Hospital, Medical School, National and Kapodistrian University of Athens, Athens 11527, Greece
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95
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The IGF-II-Insulin Receptor Isoform-A Autocrine Signal in Cancer: Actionable Perspectives. Cancers (Basel) 2020; 12:cancers12020366. [PMID: 32033443 PMCID: PMC7072655 DOI: 10.3390/cancers12020366] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 01/31/2020] [Accepted: 02/02/2020] [Indexed: 12/18/2022] Open
Abstract
Insulin receptor overexpression is a common event in human cancer. Its overexpression is associated with a relative increase in the expression of its isoform A (IRA), a shorter variant lacking 11 aa in the extracellular domain, conferring high affinity for the binding of IGF-II along with added intracellular signaling specificity for this ligand. Since IGF-II is secreted by the vast majority of malignant solid cancers, where it establishes autocrine stimuli, the co-expression of IGF-II and IRA in cancer provides specific advantages such as apoptosis escape, growth, and proliferation to those cancers bearing such a co-expression pattern. However, little is known about the exact role of this autocrine ligand–receptor system in sustaining cancer malignant features such as angiogenesis, invasion, and metastasis. The recent finding that the overexpression of angiogenic receptor kinase EphB4 along with VEGF-A is tightly dependent on the IGF-II/IRA autocrine system independently of IGFIR provided new perspectives for all malignant IGF2omas (those aggressive solid cancers secreting IGF-II). The present review provides an updated view of the IGF system in cancer, focusing on the biology of the autocrine IGF-II/IRA ligand–receptor axis and supporting its underscored role as a malignant-switch checkpoint target.
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96
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Uemura S, Wang L, Tsuda M, Suzuka J, Tanikawa S, Sugino H, Nakamura T, Mitsuhashi T, Hirano S, Tanaka S. Signaling adaptor protein Crk is involved in malignant feature of pancreatic cancer associated with phosphorylation of c-Met. Biochem Biophys Res Commun 2020; 524:378-384. [PMID: 32005519 DOI: 10.1016/j.bbrc.2020.01.105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/19/2020] [Indexed: 02/06/2023]
Abstract
Signaling adaptor protein Crk has been shown to play an important role in various human cancers. Crk links tyrosine kinases and guanine nucleotide exchange factors (GEFs) such as C3G and Dock180 to activate small G-proteins Rap and Rac, respectively. In pancreatic cancer, various molecular targeted therapies have provided no significant therapeutic benefit for the patients so far due to constitutive activation of KRAS by frequent KRAS mutation. Therefore, the establishment of novel molecular targeted therapy in KRAS-independent manner is required. Here, we investigated a potential of Crk as a therapeutic target in pancreatic cancer. Immunohistochemistry on human pancreatic cancer specimens revealed that the patients with high expression of Crk had a worse prognosis than those with low expression. We established Crk-knockdown pancreatic cancer cells by siRNA using PANC-1, AsPC-1, and MIA PaCa-2 cells, which showed decreased cell proliferation, invasion, and adhesion. In Crk-knockdown pancreatic cancer cells, the decrease of c-Met phosphorylation was observed. In the orthotopic xenograft model, Crk depletion prolonged survival of mice significantly. Thus, signaling adaptor protein Crk is involved in malignant potential of pancreatic cancer associated with decrease of c-Met phosphorylation, and Crk can be considered to be a potential therapeutic molecular target.
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Affiliation(s)
- Satoko Uemura
- Department of Cancer Pathology, Hokkaido University Graduate School of Medicine, Sapporo, Japan; Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Lei Wang
- Department of Cancer Pathology, Faculty of Medicine, Hokkaido University, Sapporo, Japan; Global Station for Soft Matter (GSS), Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Sapporo, Japan
| | - Masumi Tsuda
- Department of Cancer Pathology, Faculty of Medicine, Hokkaido University, Sapporo, Japan; Global Station for Soft Matter (GSS), Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Sapporo, Japan; World Premier International Research Center Initiative, Institute for Chemical Reaction Design and Discovery (WPI-ICReDD), Hokkaido University, Sapporo, Japan
| | - Jun Suzuka
- Department of Cancer Pathology, Faculty of Medicine, Hokkaido University, Sapporo, Japan; Global Station for Soft Matter (GSS), Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Sapporo, Japan
| | - Satoshi Tanikawa
- Department of Cancer Pathology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Hirokazu Sugino
- Department of Cancer Pathology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Tomoko Mitsuhashi
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Shinya Tanaka
- Department of Cancer Pathology, Faculty of Medicine, Hokkaido University, Sapporo, Japan; Global Station for Soft Matter (GSS), Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Sapporo, Japan; World Premier International Research Center Initiative, Institute for Chemical Reaction Design and Discovery (WPI-ICReDD), Hokkaido University, Sapporo, Japan.
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97
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Rodriguez-Pascual J, Ayuso-Sacido A, Belda-Iniesta C. Drug resistance in cancer immunotherapy: new strategies to improve checkpoint inhibitor therapies. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2019; 2:980-993. [PMID: 35582274 PMCID: PMC9019209 DOI: 10.20517/cdr.2019.61] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/05/2019] [Accepted: 09/27/2019] [Indexed: 12/12/2022]
Abstract
Recent advances in pharmacological immune modulation against tumor cells has dramatically changed the paradigm of cancer treatment. Checkpoint inhibitor therapy is a form of cancer immunotherapy already in clinical setting but also under active basic and clinical investigation. Nevertheless, some patients are primary unresponsive or develop ulterior resistance to these family of drugs. This review aims to update the basic molecular mechanism of resistance as well as the current strategies for checkpoint inhibitor selection in order to propose new approaches to individualize the use of these novel therapies.
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98
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Liu Y, Liu Z, Zeng X, Bai C, Chen L, Lin S, Tian X. Fatal myositis and spontaneous haematoma induced by combined immune checkpoint inhibitor treatment in a patient with pancreatic adenocarcinoma. BMC Cancer 2019; 19:1193. [PMID: 31805889 PMCID: PMC6896742 DOI: 10.1186/s12885-019-6372-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 11/18/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have achieved unprecedented success in cancer treatment over the past decade. The application of ICIs hasled to the discovery of various types of immune-related adverse events (irAEs). Here, we report a case of fatal myositis and spontaneous haematoma following concurrent treatment of nivolumab and ipilimumab for pancreatic adenocarcinoma. CASE PRESENTATION A 71-year-old gentleman with pancreatic adenocarcinoma underwent the Whipple procedure in September 2014. The patient received 8 cycles of adjuvant chemotherapy with gemcitabineand achieved a complete responsein April 2015. Treatment with the PD-1 inhibitor nivolumab was started due to suspected tumour recurrence in November 2015. In August 2016, the CTLA-4 inhibitor ipilimumab was added to nivolumab for 2 cycles. Eight weeks after the last dose, the patient developed severe myositis complicated with spontaneous haematomain skeletalmuscle. Pathology of the skeletal muscle autopsy revealed lymphocytic infiltration. Intense immunosuppressive therapy, including high-dose corticosteroids and methotrexate, resulted in clinical success in the treatment of myositis. However, the patient died of cancer recurrence. CONCLUSION Myositis due to immunotherapy can be a fatal adverse event of ICIs, which requires close monitoring and cautious management.
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Affiliation(s)
- Yuan Liu
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Zhi Liu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Xuejun Zeng
- Department of General Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Chunmei Bai
- Department of Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Lin Chen
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Songbai Lin
- Department of international Medical Service, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Xinlun Tian
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, #1 Shuaifuyuan, Wangfujing, Beijing, 100730 China
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99
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Kamath SD, Kalyan A, Kircher S, Nimeiri H, Fought AJ, Benson A, Mulcahy M. Ipilimumab and Gemcitabine for Advanced Pancreatic Cancer: A Phase Ib Study. Oncologist 2019; 25:e808-e815. [PMID: 31740568 DOI: 10.1634/theoncologist.2019-0473] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/16/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) remains resistant to chemotherapy and immunotherapy individually because of its desmoplastic stroma and immunosuppressive tumor microenvironment. Synergizing cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) immune checkpoint blockade with chemotherapy could overcome these barriers. Here we present results of a phase Ib trial combining ipilimumab and gemcitabine in advanced PDAC. MATERIALS AND METHODS This was a single-institution study with a 3 + 3 dose-escalation design. The primary objective was to determine the maximum tolerated dose (MTD). Secondary objectives included determining the toxicity profile, objective response rate (ORR), median progression-free survival (PFS), and overall survival (OS). RESULTS Twenty-one patients were enrolled, 13 during dose escalation and 8 at the MTD. The median age was 66 years, 62% were female, 95% had stage IV disease, and 67% had received at least one prior line of therapy. The primary objective to establish the MTD was achieved at doses of ipilimumab 3 mg/kg and gemcitabine 1,000 mg/m2 . The most common grade 3 or 4 adverse events were anemia (48%), leukopenia (48%), and neutropenia (43%). The ORR was 14% (3/21), and seven patients had stable disease. Median response duration for the three responders was 11 months, with one response duration of 19.8 months. Median PFS was 2.78 months (95% confidence interval [CI], 1.61-4.83 months), and median OS was 6.90 months (95% CI, 2.63-9.57 months). CONCLUSION Gemcitabine and ipilimumab is a safe and tolerable regimen for PDAC with a similar response rate to gemcitabine alone. As in other immunotherapy trials, responses were relatively durable in this study. IMPLICATIONS FOR PRACTICE Gemcitabine and ipilimumab is a safe and feasible regimen for treating advanced pancreatic cancer. Although one patient in this study had a relatively durable response of nearly 20 months, adding ipilimumab to gemcitabine does not appear to be more effective than gemcitabine alone in advanced pancreatic cancer.
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Affiliation(s)
- Suneel D Kamath
- Division of Hematology and Oncology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
| | - Aparna Kalyan
- Division of Hematology and Oncology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Developmental Therapeutics Program, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
| | - Sheetal Kircher
- Division of Hematology and Oncology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
| | - Halla Nimeiri
- Division of Hematology and Oncology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
| | - Angela J Fought
- Division of Biostatistics, Department of Preventative Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Al Benson
- Division of Hematology and Oncology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
| | - Mary Mulcahy
- Division of Hematology and Oncology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
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100
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Lai E, Puzzoni M, Ziranu P, Pretta A, Impera V, Mariani S, Liscia N, Soro P, Musio F, Persano M, Donisi C, Tolu S, Balconi F, Pireddu A, Demurtas L, Pusceddu V, Camera S, Sclafani F, Scartozzi M. New therapeutic targets in pancreatic cancer. Cancer Treat Rev 2019; 81:101926. [PMID: 31739115 DOI: 10.1016/j.ctrv.2019.101926] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/03/2019] [Accepted: 11/04/2019] [Indexed: 02/07/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is associated with poor survival. Of all newly diagnosed patients, only about 20% can benefit from a potentially curative surgical resection, the remaining 80% presenting with unresectable locally advanced (LAPC) or metastatic (MPC) disease. Currently, there are limited therapeutic options for LAPC and MPC patients. Furthermore, despite intensive research efforts to better understand the molecular bases of PDAC and the biological relevance of its tumor microenvironment, treatments still largely consist of classical cytotoxic chemotherapy agents. Several studies of genetic and epigenetic sequencing have demonstrated the existence of 4 molecular PDAC subtypes, with heterogeneous genetic characteristics and different biological behaviour: squamous, pancreatic progenitor, immunogenic and aberrantly differentiated endocrine exocrine (ADEX). These distinct subtypes derive from alterations at multiple levels. Apart from the DNA repair pathway, however, none of these has so far been validated as a clinically relevant therapeutic target. Also, PDAC is unique from an immunological perspective and many studies have recently tried to elucidate the role of intratumoral effector T-cells, RAS oncogene, immunosuppressive leukocytes and desmoplastic reaction in maintaining the immunological homeostasis of this disease. However, there still remains much to be learned about the mechanisms whereby the pancreatic immune microenvironment promotes immune escape of cancer cells. Furthermore, while therapies targeting the stroma as well as immunotherapies hold promise for the future, these are not yet standard of care. This review aims to outline the state-of-the-art of LAPC and MPC treatment, highlighting data on the target therapies failure and current ongoing clinical trials on new promising therapeutic strategies.
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Affiliation(s)
- Eleonora Lai
- Medical Oncology Unit, University Hospital and University of Cagliari, Cagliari, Italy.
| | - Marco Puzzoni
- Medical Oncology Unit, University Hospital and University of Cagliari, Cagliari, Italy.
| | - Pina Ziranu
- Medical Oncology Unit, University Hospital and University of Cagliari, Cagliari, Italy.
| | - Andrea Pretta
- Medical Oncology Unit, Sapienza University of Rome - University Hospital and University of Cagliari, Cagliari, Italy.
| | - Valentino Impera
- Medical Oncology Unit, Sapienza University of Rome - University Hospital and University of Cagliari, Cagliari, Italy.
| | - Stefano Mariani
- Medical Oncology Unit, University Hospital and University of Cagliari, Cagliari, Italy.
| | - Nicole Liscia
- Medical Oncology Unit, Sapienza University of Rome - University Hospital and University of Cagliari, Cagliari, Italy.
| | - Paolo Soro
- Medical Oncology Unit, University Hospital and University of Cagliari, Cagliari, Italy.
| | - Francesca Musio
- Medical Oncology Unit, University Hospital and University of Cagliari, Cagliari, Italy.
| | - Mara Persano
- Medical Oncology Unit, University Hospital and University of Cagliari, Cagliari, Italy.
| | - Clelia Donisi
- Medical Oncology Unit, University Hospital and University of Cagliari, Cagliari, Italy.
| | - Simona Tolu
- Medical Oncology Unit, Sapienza University of Rome - University Hospital and University of Cagliari, Cagliari, Italy.
| | - Francesca Balconi
- Medical Oncology Unit, University Hospital and University of Cagliari, Cagliari, Italy.
| | - Annagrazia Pireddu
- Medical Oncology Unit, Sapienza University of Rome - University Hospital and University of Cagliari, Cagliari, Italy.
| | - Laura Demurtas
- Medical Oncology Unit, University Hospital and University of Cagliari, Cagliari, Italy.
| | - Valeria Pusceddu
- Medical Oncology Unit, University Hospital and University of Cagliari, Cagliari, Italy.
| | - Silvia Camera
- Medical Oncology Unit, Sapienza University of Rome - University Hospital and University of Cagliari, Cagliari, Italy.
| | | | - Mario Scartozzi
- Medical Oncology Unit, University Hospital and University of Cagliari, Cagliari, Italy.
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