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Fonkoua LAK, Chakrabarti S, Sonbol MB, Kasi PM, Starr JS, Liu AJ, Nevala WK, Maus RL, Bois MC, Pitot HC, Chandrasekharan C, Ross HJ, Wu TT, Graham RP, Villasboas JC, Weiss M, Foster NR, Markovic SN, Dong H, Yoon HH. Outcomes on anti-VEGFR-2/paclitaxel treatment after progression on immune checkpoint inhibition in patients with metastatic gastroesophageal adenocarcinoma. Int J Cancer 2021; 149:378-386. [PMID: 33739449 PMCID: PMC8488901 DOI: 10.1002/ijc.33559] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/25/2021] [Accepted: 02/22/2021] [Indexed: 12/30/2022]
Abstract
Through our involvement in KEYNOTE-059, we unexpectedly observed durable responses in two patients with metastatic gastroesophageal adenocarcinoma (mGEA) who received ramucirumab (anti-VEGFR-2)/paclitaxel after immune checkpoint inhibition (ICI). To assess the reproducibility of this observation, we piloted an approach to administer ramucirumab/paclitaxel after ICI in more patients, and explored changes in the immune microenvironment. Nineteen consecutive patients with mGEA received ICI followed by ramucirumab/paclitaxel. Most (95%) did not respond to ICI, yet after irRECIST-defined progression on ICI, all patients experienced tumor size reduction on ramucirumab/paclitaxel. The objective response rate (ORR) and progression-free survival (PFS) on ramucirumab/paclitaxel after ICI were higher than on the last chemotherapy before ICI in the same group of patients (ORR, 58.8% vs 11.8%; PFS 12.2 vs 3.0 months; respectively). Paired tumor biopsies examined by imaging mass cytometry showed a median 5.5-fold (range 4-121) lower frequency of immunosuppressive forkhead box P3+ regulatory T cells with relatively preserved CD8+ T cells, post-treatment versus pre-treatment (n = 5 pairs). We then compared the outcomes of these 19 patients with a separate group who received ramucirumab/paclitaxel without preceding ICI (n = 68). Median overall survival on ramucirumab/paclitaxel was longer with (vs without) immediately preceding ICI (14.8 vs 7.4 months) including after multivariate analysis, as was PFS. In our small clinical series, outcomes appeared improved on anti-VEGFR-2/paclitaxel treatment when preceded by ICI, in association with alterations in the immune microenvironment. However, further investigation is needed to determine the generalizability of these data. Prospective clinical trials to evaluate sequential treatment with ICI followed by anti-VEGF(R)/taxane are underway.
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Affiliation(s)
- Lionel A. Kankeu Fonkoua
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
- Department of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Sakti Chakrabarti
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
- Department of Oncology, Medical College of Wisconsin, Wauwatosa, Wisconsin
| | | | - Pashtoon M. Kasi
- Department of Oncology, Mayo Clinic, Jacksonville, Florida
- Department of Oncology, University of Iowa, Iowa City, Iowa
| | - Jason S. Starr
- Department of Oncology, Mayo Clinic, Jacksonville, Florida
| | - Alex J. Liu
- Department of Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Rachel L. Maus
- Department of Immunology, Mayo Clinic, Rochester, Minnesota
| | - Melanie C. Bois
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Henry C. Pitot
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Helen J. Ross
- Department of Oncology, Mayo Clinic, Phoenix, Arizona
| | - Tsung-Teh Wu
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Rondell P. Graham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Jose C. Villasboas
- Department of Hematology, Mayo Clinic, Rochester, Minnesota
- Department of Immune Monitoring Core, Mayo Clinic, Rochester, Minnesota
| | | | - Nathan R. Foster
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Svetomir N. Markovic
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
- Department of Immunology, Mayo Clinic, Rochester, Minnesota
| | - Haidong Dong
- Department of Immunology, Mayo Clinic, Rochester, Minnesota
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | - Harry H. Yoon
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
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