A Phase II and Biomarker Study of Dual VEGF/PD-L1 Blockade in Neoadjuvant Setting in Resectable HCC Patients

总结 手术切除是治疗肝细胞癌（HCC）的有效方法。不幸的是，外科手术常常 早期复发（两年内高达50%），导致令人沮丧的结果。目前没有 批准的新辅助治疗方案，以诱导病理反应和降低复发率。 值得注意的是，HCC中宿主免疫的抑制是癌症建立和进展的标志。 程序性细胞死亡蛋白1（PD-1）是一种存在于T细胞上的免疫检查点受体， 肿瘤基质和癌细胞上的特异性配体（PD-L1、PD-L2）。在初步研究中， 分析了早期HCC术前免疫治疗后切除的HCC组织。我们发现了特定的集群 与有希望的反应相关，包括在治疗时频繁的病理完全反应。 手术（癌症免疫研究2019）。此外，我们证明PD-1阻断可以稳定肿瘤细胞， 血管，从而增强抗肿瘤免疫时，结合VEGF途径阻断， HCC的临床前模型（Hepatology 2020）。我们的目标是证明免疫细胞的重编程 HCC微环境的改变将为免疫治疗带来更大的益处。我们假设：1） 新辅助抗PD-L1/VEGF治疗是可行的，积极的，并将诱导病理完全缓解， HCC，和2）对新辅助抗PD-L1/VEGF治疗应答的HCC将具有增加的肿瘤内CD 8 + T细胞：Treg比率、循环细胞因子水平和成像上有利的代谢变化。我们将测试这些 2个特定目的的假设：目的1：评价抗PD-L1/VEGF联合治疗的安全性和疗效 在可切除的HCC患者中进行新辅助治疗。这项随机、多中心II期临床研究将 基于2：1随机化招募90例患者（新辅助atezo/bev = 60例，而前期手术= 30例） 有2个子目标：目标1a将评价安全性和病理学缓解率作为主要终点， atezo/bev组; Aim 1b将评价3年无复发生存率和OS作为次要终点 在atezo/bev组与对照组中的差异。目的2：确定抗肿瘤免疫的激活是否与 可切除的HCC患者在新辅助治疗背景下接受抗PD-L1/VEGF双重治疗后的持久应答， 通过研究组织、外周血和成像参数3个子目标。目的2a是分析免疫T- 在治疗前活组织检查和治疗后手术切除标本中的细胞簇，以评估CD 8 + T- 使用多重免疫荧光和单细胞RNA测序的细胞：Treg比率。目标2b是学习 组织免疫细胞、调节蛋白和血浆细胞因子的变化（多重蛋白阵列）， 探索可以预测反应的生物标志物特征。目标2c是评估 在治疗前和治疗后，使用PET MRI扫描观察肿瘤代谢活性的反应和变化。的影响 该项目的一个重要意义在于，它可能将免疫疗法在HCC中的作用从姑息性转变为治愈性。

SUMMARY Surgical resection is curative in hepatocellular carcinoma (HCC). Unfortunately, surgical cases often suffer from early recurrence (up to 50% in two years), which leads to dismal outcomes. Currently, there are no approved neoadjuvant therapy options to induce pathologic response and reduce the rate of recurrence. Notably, suppression of host immunity in HCC is a hallmark of cancer establishment and progression. Programmed cell death protein 1 (PD-1) is an immune checkpoint receptor present on T-cells that binds to specific ligands (PD-L1, PD-L2) on both tumor stroma and cancer cells. In preliminary studies, we have analyzed resected HCC tissues after preoperative immunotherapy in early HCC. We found specific clusters correlating with promising responses, including frequent pathologic complete responses at the time of surgery (Cancer Immunol Res 2019). In addition, we demonstrated that PD-1 blockade can stabilize tumor vasculature, thus enhancing anti-tumor immunity when combined with VEGF pathway blockade in preclinical models of HCC (Hepatology 2020). Our goal is to show that reprogramming of immune microenvironment in HCC will result in greater benefit for immunotherapy. We hypothesize that: 1) Neoadjuvant anti-PD-L1/VEGF therapy is feasible, active and will induce pathologic complete response in resectable HCCs, and 2) HCCs responding to neoadjuvant anti-PD-L1/VEGF therapy will have increased intratumoral CD8+ T-cell : Treg ratio, circulating cytokine levels, and favorable metabolic changes on imaging. We will test these hypotheses in 2 specific aims: Aim 1: To evaluate the safety and efficacy of anti-PD-L1/VEGF combination therapy in neoadjuvant setting in resectable HCC patients. This randomized, multi-site phase II clinical study will accrue 90 patients based on 2:1 randomization (neoadjuvant atezo/bev = 60, versus upfront surgery = 30) and has 2 sub-aims: Aim 1a will evaluate safety and pathologic response rate as the primary endpoints in the atezo/bev arm; Aim 1b will evaluate 3-year recurrence-free survival rate and OS as secondary endpoints in the atezo/bev arm versus control. Aim 2: To determine if activation of anti-tumor immunity correlates with durable responses after dual anti-PD-L1/VEGF therapy in neoadjuvant setting in resectable HCC patients, which has 3 sub-aims through studying tissue, peripheral blood, and imaging parameters. Aim 2a is to analyze immune T- cell clusters in pretreatment biopsies and posttreatment surgical resection specimens to evaluate CD8+ T- cell : Treg ratio using multiplexed immunofluorescence and single cell RNA sequencing. Aim 2b is to study changes in tissue immune cells, regulatory proteins, and plasma cytokines (multiplexed protein array) to explore a biomarker signature that may predict response. Aim 2c is to evaluate correlation between response and changes in tumor metabolic activity using PET MRI scan pre- and posttreatment. The impact of this project is that it may transform the role of immunotherapy in HCC from palliative to curative.