A randomized multicentre phase II trial comparing adjuvant therapy in patients with interferon alpha-2b and 5-FU alone or in combination with either external radiation treatment and cisplatin (CapRI) or radiation alone regarding event-free survival - CapRI-2

Case report: Long-term survival of a pancreatic cancer patient immunized with an SVN-2B peptide vaccine

A 62-year-old woman who underwent surgery to treat pancreatic cancer provided written, informed consent to undergo adjuvant therapy with gemcitabine, tegafur, and uracil. However, this was stopped after only 14 days due to Grade 4 neutropenia. She was then started on vaccine therapy with Survivin 2B peptide (SVN-2B) including IFA and INF-α. Although metastatic lung tumors were identified and resected at 82 months after surgery, the patient has remained free of new or relapsed disease for 12 years thereafter. Tetramer and ELISPOT assays revealed the continuous circulation of SVN-2B-restricted cytotoxic T-lymphocytes (CTLs) in her peripheral blood, and CTL clones had specific activity for SVN-2B at 12 years after surgery. The adverse effects of the peptide vaccination were tolerable and comprised low-grade headache, nausea, and fatigue. A prognosis beyond 10 years in the face of pancreatic cancer with distant metastasis is extremely rare. This experience might indicate the value of cancer vaccination therapy.

Clinical trials exploring the benefit of immunotherapy and radiation in cancer treatment: A review of the past and a look into the future

Cancer immunotherapy is rapidly redefining the standard of cancer care. The role of radiation therapy in eliciting antitumoral immune response is also being actively investigated in combination with various immunotherapeutic agents to exploit potential synergy between the 2 modalities. In this review, we summarize the rationale and results of past and ongoing clinical trials that combined the use of radiation therapy and immunogenic agents such as vaccines, cytokines, immune checkpoint inhibitors, costimulatory agonists, and myeloid activators.

Type I Interferon Receptor Expression in Human Pancreatic and Periampullary Cancer Tissue

OBJECTIVES

Interferons (IFNs) have several anticancer mechanisms. A number of clinical trials have been conducted regarding adjuvant IFN-α therapy in pancreatic cancer. Type I IFNs exert their effect via the type I IFN receptor (IFNAR-1, IFNAR-2c). The aims of the present study were to determine the type I IFN receptor expression in pancreatic and periampullary cancer tissues and to study its relation with clinicopathological factors.

METHODS

Receptor expression was determined by immunohistochemistry in paraffin-embedded cancer tissue of 47 pancreatic and 54 periampullary cancer patients.

RESULTS

The results demonstrated that 91.5% of the pancreatic tumors and 88.9% of the periampullary tumors showed expression of IFNAR-1, of which 23.4% and 13.0% were strongly positive, respectively. Regarding IFNAR-2c expression, 68.1% of the pancreatic tumors and 68.5% of the periampullary tumors were positive, of which 4.3% of the pancreatic tumors and none of the periampullary tumors had a strong expression. No statistically significant associations were found between type I IFN receptor expression and clinicopathological factors or survival.

CONCLUSIONS

Type I IFN receptors are expressed in pancreatic and periampullary cancer tissues although with great intertumoral and intratumoral variability. A small proportion of both tumors showed a strong expression of the IFNAR-1; only a very small percentage of the pancreatic tumors showed strong expression of the IFNAR-2c.

Phase I clinical study of multiple epitope peptide vaccine combined with chemoradiation therapy in esophageal cancer patients

Background

Chemoradiation therapy (CRT) has been widely used for unresectable esophageal squamous cell carcinoma (ESCC) patients. However, many patients develop local recurrence after CRT. In this study, we hypothesized that the immunotherapy by peptide vaccine may be effective for the eradication of minimal residual cancer cells after CRT. This study was conducted as a phase I clinical trial of multiple-peptide vaccine therapy combined with CRT on patients with unresectable ESCC.

Patients and methods

HLA-A*2402 positive 11 unresectable chemo-naïve ESCC patients were treated by HLA-A*2402-restricted multi-peptide vaccine combined with CRT. The peptide vaccine included the 5 peptides as follows; TTK protein kinase (TTK), up-regulated lung cancer 10 (URLC10), insulin-like growth factor–II mRNA binding protein 3 (KOC1), vascular endothelial growth factor receptor 1 (VEGFR1) and 2 (VEGFR2). CRT consisted of radiotherapy (60 Gy) with concurrent cisplatin (40 mg/m²) and 5-fluorouracil (400 mg/m²). Peptide vaccines mixed with incomplete Freund’s adjuvant were injected subcutaneously once a week on at least 8 occasions combined with CRT.

Results

Vaccination with CRT therapy was well-tolerated, and no severe adverse effects were observed. In the case of grade 3 toxicities, leucopenia, neutropenia, anemia and thrombocutopenia occurred in 54.5%, 27.3%, 27.3% and 9.1% of patients, respectively. Grade 1 local skin reactions in the injection sites of vaccination were observed in 81.8% of patients. The expressions of HLA class I, URLC10, TTK, KOC1, VEGFR1 and VEGFR2 antigens were observed in the tumor tissues of all patients. All patients showed peptide-specific cytotoxic T lymphocytes responses in at least one of the 5 kinds of peptide antigens during the vaccination. Six cases of complete response (CR) and 5 cases of progressive disease (PD) were observed after the 8^th vaccination. The 4 CR patients who continued the peptide vaccination experienced long consistent CR for 2.0, 2.9 4.5 and 4.6 years.

Conclusions

A combination therapy of multi-peptide vaccine with CRT can successfully be performed with satisfactory levels of safety, and application of this combination therapy may be an effective treatment for patients with unresectable ESCC.

Trial registration

ClinicalTrial.gov, number NCT00632333.

Influence of interferon-alpha combined with chemo (radio) therapy on immunological parameters in pancreatic adenocarcinoma

Prognosis of patients with carcinoma of the exocrine pancreas is particularly poor. A combination of chemotherapy with immunotherapy could be an option for treatment of pancreatic cancer. The aim of this study was to perform an immunomonitoring of 17 patients with pancreatic cancer from the CapRI-2 study, and tumor-bearing mice treated with combination of chemo (radio) therapies with interferon-2α. Low doses of interferon-2α led to a decrease in total leukocyte and an increase in monocyte counts. Furthermore, we observed a positive effect of interferon-2α therapy on the dendritic cells and NK (natural killer) cell activation immediately after the first injection. In addition, we recorded an increased amount of interferon-γ and IL-10 in the serum following the interferon-2α therapy. These data clearly demonstrate that pancreatic carcinoma patients also show an immunomodulatory response to interferon-2α therapy. Analysis of immunosuppressive cells in the Panc02 orthotopic mouse model of pancreatic cancer revealed an accumulation of the myeloid-derived suppressor cells in spleens and tumors of the mice treated with interferon-2α and 5-fluorouracil. The direct effect of the drugs on myeloid-derived suppressor cells was also registered in vitro. These data expose the importance of immunosuppressive mechanisms induced by combined chemo-immunotherapy.

Type I interferon-mediated pathway interacts with peroxisome proliferator activated receptor-γ (PPAR-γ): at the cross-road of pancreatic cancer cell proliferation

Pancreatic adenocarcinoma remains an unresolved therapeutic challenge because of its intrinsically refractoriness to both chemo- and radiotherapy due to the complexity of signaling and the activation of survival pathways in cancer cells. Recent studies have demonstrated that the combination of some drugs, targeting most of aberrant pathways crucial for the survival of pancreatic cancer cells may be a valid antitumor strategy for this cancer. Type I interferons (IFNs) may have a role in the pathogenesis and progression of pancreatic adenocarcinoma, but the limit of their clinical use is due to the activation of tumor resistance mechanisms, including JAK-2/STAT-3 pathway. Moreover, aberrant constitutive activation of STAT-3 proteins has been frequently detected in pancreatic adenocarcinoma. The selective targeting of these cell survival cascades could be a promising strategy in order to enhance the antitumor effects of type I IFNs. The activation of peroxisome proliferator-activated receptor γ (PPAR-γ), on the other hand, has a suppressive activity on STAT-3. In fact, PPAR-γ agonists negatively modulate STAT-3 through direct and/or indirect mechanisms in several normal and cancer models. This review provides an overview on the current knowledge about the molecular mechanisms and antitumor activity of these two promising classes of drugs for pancreatic cancer therapy. Finally, the synergistic antiproliferative activity of combined IFN-β and troglitazone treatment on pancreatic cancer cell lines, evaluated in vitro, and the consequent potential clinical applications will be discussed.

Pancreatic surgery: beyond the traditional limits

Pancreatic cancer is one of the five leading causes of cancer death for both males and females in the western world. More than 85 % pancreatic tumors are of ductal origin but the incidence of cystic tumors such as intrapapillary mucinous tumors (IPMN) or mucinous cystic tumors (MCN) and other rare tumors is rising. Complete surgical resection of the tumor is the mainstay of any curative therapeutic approach, however, up to 40 % of patients with potentially resectable pancreatic cancer are not offered surgery. This is despite 5-year survival rates of up to 40 % or even higher in selected patients depending on tumor stage and histology. Standard procedures for pancreatic tumors include the Kausch-Whipple- or pylorus-preserving Whipple procedure, and the left lateral pancreatic resection (often with splenectomy), and usually include regional lymphadenectomy. More radical or extended pancreatic operations are becoming increasingly utilised however and we examine the data available for their role. These operations include major venous and arterial resection, multivisceral resections and surgery for metastatic disease, or palliative pancreatic resection. Portal vein resection for local infiltration with or without replacement graft is now well established and does not deleteriously affect perioperative morbidity or mortality. Arterial resection, however, though often technically feasible, has questionable oncologic impact, is not without risk and is usually reserved for isolated cases. The value of extended lymphadenectomy is frequently debated; the recent level I evidence demonstrates no advantage. Multivisceral resections, i.e. tumors, often in the tail of the pancreas, with invasion of the colon or stomach or other surrounding tissues, while associated with an increased morbidity and a longer hospital stay, do however show comparable mortality-and survival rates to those without such infiltration and therefore should be performed if technically feasible. Routine resection for metastatic disease however does not seem to show any advantage over palliative treatment but may be an option in selected patients with easily removable metastases. In conclusion pancreatic surgery beyond the traditional limits is established in tumors infiltration the venous system and may be a considered approach in selected patients with locally infiltrating pancreatic cancer or metastasis.

Radiotherapy in the adjuvant management of pancreatic adenocarcinoma: is it helpful?

Curative-intent management for pancreatic adenocarcinoma requires gross total resection. Only 15-20% of patients are eligible for resection and of these only approximately 20% are long-term survivors. Adjuvant and neoadjuvant approaches have been, and are being, sought to improve upon surgical results. Radiotherapy has a role in the adjuvant management of many gastrointestinal malignancies and historically has also had a role in the adjuvant management of pancreatic adenocarcinoma. However, the role of radiotherapy in the management of pancreatic adenocarcinoma has been called into question. This review examines this controversy and the underlying issues and considers current efforts towards resolving them, as well as some likely future developments.

Pancreatic cancer: medical management (novel chemotherapeutics)

Pancreatic adenocarcinoma is the fourth leading cause of cancer death and has an extremely poor prognosis: The 5-year survival probability is less than 5% for all stages. The only chance for cure or longer survival is surgical resection; however, only 10% to 20% of patients have resectable disease. Although surgical techniques have improved, most who undergo complete resection experience a recurrence. Adjuvant systemic therapy reduces the recurrence rate and improves outcomes. There is a potential role for radiation therapy as part of treatment for locally advanced disease, although its use in both the adjuvant and neoadjuvant settings remains controversial. Palliative systemic treatment is the only option for patients with metastatic disease. To date, however, only the gemcitabine plus erlotinib combination, and recently the FOLFIRINOX regimen, have been associated with relatively small but statistically significant improvements in OS when compared directly with gemcitabine alone. Although several meta-analyses have suggested a benefit associated with combination chemotherapy, whether this benefit is clinically meaningful remains unclear, particularly in light of the enhanced toxicity associated with combination regimens. There is growing evidence that the exceptionally poor prognosis in PC is caused by the tumor's characteristic abundant desmoplastic stroma that plays a critical role in tumor cell growth, invasion, metastasis, and chemoresistance. Carefully designed clinical trials that include translational analysis will provide a better understanding of the tumor biology and its relation to the host stromal cells. Future directions will involve testing of new targeted agents, understanding the pharmacodynamics of our current targeted agents, searching for predictive and prognostic biomarkers, and exploring the efficacy of different combinations strategies.

Adjuvant chemotherapy, with or without postoperative radiotherapy, for resectable advanced pancreatic adenocarcinoma: continue or stop?

AIMS

The aim of the article is to perform a focused review of adjuvant chemotherapy with or without radiotherapy for the treatment of resectable pancreatic adenocarcinoma (PAC).

METHODS

We performed a Medline database search from 1965 to 2010 using the terms "adjuvant," "trial" and "pancreatic cancer".

RESULTS

Adding adjuvant chemotherapy to patients with resectable PAC was associated with significantly increased median overall survival (OS) (odds ratio[OR]: 1.98, p < 0.001), disease-free survival (DFS) (OR: 2.12, p < 0.001), two-year survival (OR: 1.38, p = 0.04) and five-year survival (OR: 2.16, p = 0.007) compared to surgery alone. There was no statistically significant difference observed with regard to OS (OR:0.99, p = 0.93), DFS (OR:0.99, p = 0.95), and two-year survival (OR: 0.90, p = 0.57) between adjuvant chemoradiotherapy and surgery alone. The further analysis showed that single agent gemcitabine was as active as combined chemotherapy or chemoradiation, which was reflected by an OR of 1.13 (p = 0.26) for OS and1.08 (p = 0.47) for DFS.

CONCLUSIONS

A significant benefit with regard to DFS and median OS for adjuvant chemotherapy after PAC resection was demonstrated by this analysis. These results do not support the use of adjuvant radiotherapy for PAC.

Adjuvant therapy for pancreatic cancer

Pancreatic cancer is a challenging malignancy to treat, as less than one-fifth of diagnosed cases are resectable, surgery is complex and postoperative recovery slow, treated patients tend to relapse and overall survival rates are low. It is one of the leading causes of cancer-related mortality. Adjuvant therapy has been employed in resectable disease, to target micrometastases and improve prognosis. Chemotherapy, chemoradiotherapy (chemoRT) and chemoradiotherapy (chemoRT) followed on by chemotherapy have been evaluated in randomised controlled trials. The European Study Group for Pancreatic Cancer (ESPAC)-1 and CONKO-001 trials clearly established the survival advantage of adjuvant chemotherapy with 5 fluorouracil (5FU) plus folinic acid and gemcitabine respectively over no chemotherapy. The ESPAC-3 (version 2) trial demonstrated equivalence between 5FU plus folinic acid and gemcitabine in terms of survival parameters, though gemcitabine had a better toxicity profile. The results of these key studies, together with smaller ones have been subjected to meta-analyses, with confirmation of improved survival with adjuvant systemic chemotherapy. The EORTC-40891 and ESPAC-1 trials found no survival advantage with adjuvant chemoRT compared to observation, and this has been reflected in a subsequent meta-analysis. The popularisation of chemoRT, with follow on chemotherapy (versus observation) was based on the small underpowered GITSG trial. The ESPAC-1 trial was unable to find a survival benefit for chemoRT, with follow on chemotherapy compared to observation. The RTOG-9704 trial assessed chemoRT with follow on chemotherapy in both arms and found no difference between survival in the gemcitabine and 5FU arms. There has never been a published head-to-head randomised comparison of adjuvant chemotherapy to chemoRT, with follow on chemotherapy. Ongoing randomised trials are looking into adjuvant combination chemotherapy, chemotherapy with follow on chemoRT, and neoadjuvant therapy. Novel agents continue to be assessed in early phase trials with a major emphasis on predictive and prognostic biomarkers. Based on the available evidence, adjuvant chemotherapy with gemcitabine or 5FU/folinic acid is the current recommended gold standard in the management of resected pancreatic cancer.

Evolution of systemic therapy for advanced pancreatic cancer

The prognosis for advanced pancreatic cancer remains poor and successful drug development in this disease continues to be a major challenge. In the last decade the approach to drug development in pancreatic cancer has included a focus on combinations of cytotoxic agents. While some promising results were seen in Phase II studies, none of the Phase III trials of cytotoxic combinations were able to demonstrate an improvement in overall survival over that seen with the single-agent gemcitabine. Newer studies have assessed the efficacy of 'targeted' agents that inhibit pathways thought to be important in the development, growth, invasion and metastasis of pancreatic cancer. Although some agents had promising activity in preclinical studies, none has made a major impact in the clinic. There has been some success with the addition of the EGF receptor tyrosine kinase inhibitor erlotinib to gemcitabine, which was the first combination to achieve an overall survival benefit compared with gemcitabine alone in a Phase III trial. Future directions for drug development in pancreatic cancer will mainly involve testing new targeted agents, although some cytotoxic combinations are currently in Phase III testing. There is a need to better understand the biology of the disease and incorporate this into trials in an attempt to search for predictive and prognostic markers that will aid in drug development. Control of pancreatic cancer will require combinations of targeted agents, probably individualized based on tumor genetics. We are just beginning to explore the efficacy of combining targeted agents in the clinic.

Curative radiation therapy for pancreatic malignancies

Surgery is generally considered as the only curative therapy for pancreatic cancer; however, even with optimal surgery, long-term cure is achieved in very few patients, thus highlighting the need for adjuvant therapies. Radiation therapy, usually in combination with chemotherapy, plays a role in the setting of unresectable, nonmetastatic pancreatic cancer. Its role in the adjuvant setting remains controversial and as yet undefined. This article reviews the role of radiation therapy in the adjuvant and definitive settings, and describes recent improvements in the delivery of radiotherapy that allow for improved dose delivery with decreased toxicity.

Adjuvant and neoadjuvant therapy in curable pancreatic cancer

Pancreatic cancer is the tenth most common cancer in the United States and the fourth leading cause of cancer death. Afflicting approximately 37,000 Americans yearly, more than 80% of patients are unresectable and, therefore, incurable at the time of their diagnosis. Although surgical resection offers the only opportunity for cure, it remains largely unsuccessful; most patients who are candidates for surgical resection relapse and die in fewer than 5 years. This mortality leaves a 5-year overall survival of about 4% for patients diagnosed with pancreatic cancer. Perhaps the most daunting realization for physicians involved in the management of this disease is the understanding that these numbers have not changed in more than 30 years. As surgery remains the foundation of curative therapy for pancreatic cancer, this article reviews the data on adjuvant chemotherapy and adjuvant chemotherapy with radiotherapy as efforts to boost cure rates.