A Phase II Clinical Trial in Newly Diagnosed Glioblastoma Patients Treated with WP1066 and Radiation

总结 脑肿瘤微环境（TME）主要由髓样细胞浸润所支配，其中大多数是脑驻留细胞 小胶质细胞和浸润性胶质母细胞瘤相关髓样细胞（GAM）。尽管如此，大多数临床试验 胶质母细胞瘤已被导向基于T细胞的免疫疗法，这未能影响大多数人的结果。 患者目标是基于GAMS的再教育来靶向胶质母细胞瘤，以实现免疫清除 这个临床试验。信号转导子和转录激活子3（STAT 3）是这两个信号转导子和转录激活子的负调节子。 先天性和适应性免疫，并且该途径在TME中显著上调。我们先前已经 在I期临床试验的背景下，开发并测试了第一种人体血脑屏障渗透剂， STAT 3分子抑制剂，命名为WP 1066。第一阶段试验结果表明，WP 1066是良好的 耐受，并抑制免疫细胞中的STAT 3靶点。作为单一疗法，WP 1066治疗具有 在多项临床前研究中证明了刺激强大的抗肿瘤反应的能力， 放射治疗是新诊断的胶质母细胞瘤的标准治疗， 增加肿瘤免疫原性。治疗肿瘤的无偏纳米线分析显示， 在TME中的抗原呈递。对于这里提出的研究，我们希望 将我们的临床前发现扩展到新诊断的胶质母细胞瘤患者。在这项临床试验中，我们将测试 假设WP1066与辐射一起施用将诱导T细胞-树突状细胞簇相互作用， 胶质母细胞瘤微环境，这种诱导，反过来，将增加无进展生存期（PFS）， 胶质母细胞瘤患者。在具体的目标1中，我们进行了一项II期试验，其中有一个扩展队列用于联合治疗。 WP1066和放射治疗在新诊断的MGMT未甲基化胶质母细胞瘤患者中的作用。在队列1中， 诊断为MGMT未甲基化的IDH 1野生型胶质母细胞瘤患者将用8 mg/kg的WP 1066治疗 同时接受每日剂量为2戈伊的标准护理放射治疗。PFS将用于确定是否有 是治疗获益的指标。在队列2中，将对未实现大体全切除的患者进行 用放射和WP 1066的组合治疗，目的是获得治疗的肿瘤，如果手术治疗， 存在易受损伤的病变。这样的组织将允许分析TME免疫活化和簇集。 目标2中的相互作用、药物浓度和靶点参与。Aim 2还将使用纵向纹理MRI 通过使用我们的STAT 3特异性多重免疫分析TME中的相关炎症反应 荧光板和互补的离体流式细胞术和纳米线分析。STAT 3靶点抑制， 包括特异性免疫细胞群内的免疫细胞的免疫学特性将通过使用多重组来确定， 还将告知关于肿瘤中簇相互作用的诱导。WP 1066的HPLC定量 增强和非增强肿瘤中的浓度将用于确定药物药代动力学。在 目的3，我们将阐明TME中哪些人GAM触发T细胞活化，以及这种活化是否被TME改变。 STAT 3抑制。

SUMMARY The brain tumor microenvironment (TME) is dominated by myeloid cell infiltrates which are mostly brain resident microglia and infiltrating glioblastoma-associated myeloid cells (GAMs). Despite this fact, most clinical trials for glioblastoma have been directed to T cell-based immunotherapies, which have failed to impact outcome for most patients. Targeting glioblastoma based on re-education of GAMS to enable immunological clearance is the goal of this clinical trial. The signal transducer and activator of transcription 3 (STAT3) is a negative regulator of both innate and adaptive immunity and this pathway is markedly up regulated in the TME. We have previously developed and tested, in the context of Phase I clinical trials, a first-in-man blood-brain-barrier penetrant small molecule inhibitor of STAT3, designated WP1066. The Phase I trial results have shown that WP1066 is well tolerated and is inhibiting the STAT3 target in immune cells. As a monotherapy, WP1066 treatment has demonstrated the ability to stimulate robust anti-tumor response in multiple preclinical studies that is further enhanced with radiation therapy, which is standard of care for newly diagnosed glioblastoma and is known to increase tumor immunogenicity. Unbiased nanostring analysis of treated tumors revealed that activation of antigen presentation in the TME with the combination treatment. For the research proposed here we want to extend our preclinical findings to newly diagnosed glioblastoma patients. In this clinical trial, we will test the hypothesis that the administration of WP1066 with radiation will induce T cell-dendritic cell cluster interactions in the glioblastoma microenvironment, and this induction, in turn, will increase progression free survival (PFS) for glioblastoma patients. In specific Aim 1, we conduct a Phase II trial with an expansion cohort for the combination of WP1066 and radiation in newly diagnosed MGMT unmethylated glioblastoma patients. In cohort 1, newly diagnosed MGMT unmethylated, IDH1 wild-type glioblastoma patients will be treated with 8 mg/kg of WP1066 while undergoing standard-of-care radiation therapy at a daily dose of 2 Gy. PFS will be used to ascertain if there is indication of treatment benefit. In cohort 2, patients for whom gross total resection was not achieved will be treated with the combination of radiation and WP1066 with the intent of obtaining treated tumor, if a surgically amenable lesion is present. Such tissue would allow for analysis of TME immune activation and cluster interactions, drug concentrations and target engagement in Aim 2. Aim 2 will also use longitudinal textural MRI analysis to correlate inflammatory responses in the TME by using our STAT3-specific multiplex immune fluorescent panel and complementary ex vivo flow cytometry and nanostring profiling. STAT3 target inhibition, including within specific immune cell populations, will be ascertained through use of the multiplex panel, which will also inform regarding the induction of cluster interactions in the tumor. HPLC quantification of WP1066 concentrations in both enhancing and non-enhancing tumor will be used to determine drug pharmacokinetics. In Aim 3, we will clarify which human GAMs in the TME trigger T cell activation, and if such activation is altered by STAT3 inhibition.