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Martínez-Galán J, Jiménez-Luna C, Rodriguez I, Maza E, García-Collado C, Rodríguez-Fernández A, López-Hidalgo JL, Caba O. Metastatic pancreatic and lung cancer patient in complete remission following immunotherapy: A case report and review of literature. World J Gastrointest Oncol 2024; 16:2233-2240. [PMID: 38764840 PMCID: PMC11099454 DOI: 10.4251/wjgo.v16.i5.2233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/09/2024] [Accepted: 03/13/2024] [Indexed: 05/09/2024] Open
Abstract
BACKGROUND Metastatic pancreatic ductal adenocarcinoma (PDAC) is a lethal malignancy with dispiriting survival data. Immunotherapy is a promising approach to many cancer types, but achieves poor outcomes in advanced PDAC due to its immunosuppressive tumor microenvironment. We describe a case of metastatic PDAC effectively treated with pembrolizumab. CASE SUMMARY We report the case of a 67-year-old woman with unresectable locally advanced PDAC, treated with gemcitabine plus nab-paclitaxel followed by radiotherapy plus capecitabine. At nine months, pancreatic tumor progression was observed at the level of the hepatic hilum with the appearance of a new pulmonary nodule suggestive of a second primary, confirmed by left lung biopsy. Systemic immunotherapy was then initiated with pembrolizumab, an immune checkpoint inhibitor targeting programmed cell death protein-1 that covers the two tumor types. The patient showed a complete metabolic response that was maintained throughout the treatment. The patient continues to be disease-free at 5.6 years since the start of immunotherapy. CONCLUSION These results suggest that the administration of pembrolizumab after chemoradiotherapy has a beneficial effect in patients with metastatic PDAC. To our knowledge, this is the first reported case of a patient with metastatic PDAC and metastatic lung cancer showing such a long-lasting complete response after pembrolizumab treatment without curative surgery. Further studies are required to determine biomarkers that identify PDAC patients most likely to benefit from this immunotherapy.
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Affiliation(s)
- Joaquina Martínez-Galán
- Department of Medical Oncology, Virgen de las Nieves University Hospital, Granada 18014, Spain
- Instituto de Investigación Biosanitaria, Ibs. Granada, Granada 18012, Spain
| | - Cristina Jiménez-Luna
- Instituto de Investigación Biosanitaria, Ibs. Granada, Granada 18012, Spain
- Institute of Biopathology and Regenerative Medicine (IBIMER), University of Granada, Granada 18016, Spain
| | - Isabel Rodriguez
- Department of Medical Oncology, Virgen de las Nieves University Hospital, Granada 18014, Spain
- Instituto de Investigación Biosanitaria, Ibs. Granada, Granada 18012, Spain
| | - Elisabeth Maza
- Department of Medical Oncology, Virgen de las Nieves University Hospital, Granada 18014, Spain
- Instituto de Investigación Biosanitaria, Ibs. Granada, Granada 18012, Spain
| | - Carlos García-Collado
- Instituto de Investigación Biosanitaria, Ibs. Granada, Granada 18012, Spain
- Pharmacogenetics Unit, Virgen de las Nieves University Hospital, Granada 18014, Spain
| | - Antonio Rodríguez-Fernández
- Instituto de Investigación Biosanitaria, Ibs. Granada, Granada 18012, Spain
- Department of Medicina Nuclear, Virgen de las Nieves University Hospital, Granada 18014, Spain
| | - Javier Luis López-Hidalgo
- Instituto de Investigación Biosanitaria, Ibs. Granada, Granada 18012, Spain
- Department of Anatomía Patológica, Virgen de las Nieves University Hospital, Granada 18014, Spain
| | - Octavio Caba
- Instituto de Investigación Biosanitaria, Ibs. Granada, Granada 18012, Spain
- Institute of Biopathology and Regenerative Medicine (IBIMER), University of Granada, Granada 18016, Spain
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Gao Z, Azar J, Zhu H, Williams-Perez S, Kang SW, Marginean C, Rubinstein MP, Makawita S, Lee HS, Camp ER. Translational and oncologic significance of tertiary lymphoid structures in pancreatic adenocarcinoma. Front Immunol 2024; 15:1324093. [PMID: 38361928 PMCID: PMC10867206 DOI: 10.3389/fimmu.2024.1324093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/11/2024] [Indexed: 02/17/2024] Open
Abstract
Pancreatic adenocarcinoma (PDAC) is an aggressive tumor with poor survival and limited treatment options. PDAC resistance to immunotherapeutic strategies is multifactorial, but partially owed to an immunosuppressive tumor immune microenvironment (TiME). However, the PDAC TiME is heterogeneous and harbors favorable tumor-infiltrating lymphocyte (TIL) populations. Tertiary lymphoid structures (TLS) are organized aggregates of immune cells that develop within non-lymphoid tissue under chronic inflammation in multiple contexts, including cancers. Our current understanding of their role within the PDAC TiME remains limited; TLS are complex structures with multiple anatomic features such as location, density, and maturity that may impact clinical outcomes such as survival and therapy response in PDAC. Similarly, our understanding of methods to manipulate TLS is an actively developing field of research. TLS may function as anti-tumoral immune niches that can be leveraged as a therapeutic strategy to potentiate both existing chemotherapeutic regimens and potentiate future immune-based therapeutic strategies to improve patient outcomes. This review seeks to cover anatomy, relevant features, immune effects, translational significance, and future directions of understanding TLS within the context of PDAC.
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Affiliation(s)
- Zachary Gao
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Joseph Azar
- The Pelotonia Institute for Immuno-Oncology, Ohio State University Comprehensive Cancer Center, Columbus, OH, United States
| | - Huili Zhu
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Sophia Williams-Perez
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Sung Wook Kang
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, United States
- Systems Onco-Immunology Laboratory, David J. Sugarbaker Division of Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Celia Marginean
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Mark P. Rubinstein
- The Pelotonia Institute for Immuno-Oncology, Ohio State University Comprehensive Cancer Center, Columbus, OH, United States
| | - Shalini Makawita
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Hyun-Sung Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, United States
- Systems Onco-Immunology Laboratory, David J. Sugarbaker Division of Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - E. Ramsay Camp
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, United States
- Baylor College of Medicine, Michael E. DeBakey VA Medical Center, Houston, TX, United States
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Quintanilha JC, Storandt MH, Graf RP, Li G, Keller R, Lin DI, Ross JS, Huang RS, Schrock AB, Oxnard GR, Chakrabarti S, Mahipal A. Tumor Mutational Burden in Real-World Patients With Pancreatic Cancer: Genomic Alterations and Predictive Value for Immune Checkpoint Inhibitor Effectiveness. JCO Precis Oncol 2023; 7:e2300092. [PMID: 37410975 PMCID: PMC10581638 DOI: 10.1200/po.23.00092] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/05/2023] [Accepted: 05/26/2023] [Indexed: 07/08/2023] Open
Abstract
PURPOSE Pancreatic ductal adenocarcinoma (PDAC) is largely considered a nonimmunogenic malignancy; however, approximately 1%, of patients may have tumors with deficient mismatch repair, high microsatellite instability, or high tumor mutational burden (TMB ≥10 mutations/Mb), which may be predictive of response to immune checkpoint inhibitor (ICI) therapy. We sought to analyze outcomes of patients with high-TMB and pathogenic genomic alterations observed in this population. METHODS This study included patients with PDAC who underwent comprehensive genomic profiling (CGP) at Foundation Medicine (Cambridge, MA). Clinical data were obtained from a US-wide real-world clinicogenomic pancreatic database. We report genomic alterations in those with high and low TMB, and compare outcomes on the basis of receipt of single-agent ICI or therapy regimens not containing ICI. RESULTS We evaluated 21,932 patients with PDAC who had tissue CGP data available, including 21,639 (98.7%) with low-TMB and 293 (1.3%) with high-TMB. Among patients with high-TMB, a greater number of alterations were observed in BRCA2, BRAF, PALB2, and genes of the mismatch repair pathway, whereas fewer alterations were observed in KRAS. Among patients who received an ICI (n = 51), those with high-TMB had more favorable median overall survival when compared with the low-TMB subset (25.7 v 5.2 months; hazard ratio, 0.32; 95% CI, 0.11 to 0.91; P = .034). CONCLUSION Longer survival was observed in patients with high-TMB receiving ICI compared with those with low-TMB. This supports the role of high-TMB as a predictive biomarker for efficacy of ICI therapy in PDAC. Additionally, we report higher rates of BRAF and BRCA2 mutations and lower rates of KRAS mutation among patients with PDAC and high-TMB, which to our knowledge, is a novel finding.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Sakti Chakrabarti
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Amit Mahipal
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
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Storandt MH, Tran N, Martin N, Jatoi A. Pembrolizumab near the end of life in patients with metastatic pancreatic cancer: a multi-site consecutive series to examine survival and patient treatment burden. Cancer Immunol Immunother 2023:10.1007/s00262-023-03397-4. [PMID: 36872382 DOI: 10.1007/s00262-023-03397-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/03/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Pembrolizumab confers minimal benefit to most patients with pancreas cancer. We explored survival and patient treatment burden (for example, death within 14 days of therapy) in a subgroup who had early access to pembrolizumab . METHODS This multisite study examined consecutive pancreas cancer patients, who received pembrolizumab from 2004 through 2022. Median overall survival of > 4 months was to be deemed favorable. Patient treatment burden and medical record quotations are presented descriptively. RESULTS Forty-one patients (median age 66 years; range 36, 84) are included. Fifteen (37%) had dMMR, MSI-H, TMB-H, or Lynch syndrome; and 23 (56%) received concurrent therapy. The median overall survival was 7.2 months (95% confidence interval (CI): 5.2, 12.7 months); 29 were deceased at the time of reporting. Patients with dMMR, MSI-H, TMB-H, or Lynch syndrome had a lower risk of death: hazard ratio (HR): 0.29 (95% CI: 0.12, 0.72); p = 0.008. Medical record phrases ("brilliant response") aligned with the above. One patient died within 14 days of therapy, and one was in an intensive care unit within 30 days of death. Fifteen patients enrolled in hospice; four of these died < 3 days later. CONCLUSIONS These unexpectedly favorable findings underscore the need for healthcare providers-including palliative care providers-to knowledgeably guide patients about cancer therapy even near the end of life.
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Affiliation(s)
| | - Nguyen Tran
- Department of Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Nichole Martin
- Department of Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Aminah Jatoi
- Department of Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Buhe H, Ma JX, Ye FZ, Song CY, Chen XY, Liu Y, Lin H, Han X, Ma LX, Saiyin H. IDO-1 inhibitor INCB24360 elicits distant metastasis of basal extruded cancer cells in pancreatic ductal adenocarcinoma. Acta Pharmacol Sin 2022; 44:1277-1289. [DOI: 10.1038/s41401-022-01035-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 11/20/2022] [Indexed: 12/15/2022] Open
Abstract
AbstractNeoplastic cells of non-immunogenic pancreatic ductal adenocarcinoma (PDAC) express indoleamine 2,3-dioxygenase 1 (IDO-1), an immunosuppressive enzyme. The metabolites of IDO-1 in cancers provide one-carbon units that annihilate effector T cells, and recruit immunosuppressive cells. In this study we investigated how IDO-1 affected the neoplastic cell behaviors in PDACs. Using multiple markers co-labeling method in 45-µm-thick tissue sections, we showed that IDO-1 expression was uniquely increased in the neoplastic cells extruded from ducts’ apical or basal domain, but decreased in lymph metastatic cells. IDO-1+ extruding neoplastic cells displayed increased vimentin expression and decreased cytokeratin expression in PDACs, characteristics of epithelial-mesenchymal transition (EMT). However, IDO-1 expression was uncorrelated with immunosuppressive infiltrates and clinicopathological characteristics of grim outcome. We replicated basal extrusion with EMT in murine KPIC PDAC organoids by long-term IFN-γ induction; application of IDO-1 inhibitor INCB24360 or 1-MT partially reversed basal extrusion coupled EMT. Ido-1 deletion in KPIC cells deprived its tumorigenicity in immunocompetent mice, decreased cellular proliferation and macropinocytic ability, and increased immunogenicity. KPIC organoids with IFN-γ-induced basal extrusion did not accelerate distant metastasis, whereas inhibition IFN-γ-induced IDO-1 with INB24360 but not 1-MT in KPIC organoids elicited liver metastasis of subcutaneous KPIC organoid tumors, suggesting that lower IDO-1 activity accelerated distant metastasis, whereas IDO-1 was indispensable for tumorigenicity of PDAC cells and supports the survival of extruding cells.
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