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

摘要 手术切除是治疗肝细胞癌的有效方法。不幸的是，外科病例经常遭受 早期复发(两年内高达50%)，这会导致悲惨的结局。目前，没有 批准的新辅助治疗方案可诱导病理反应并降低复发率。 值得注意的是，在肝细胞癌中抑制宿主免疫是癌症发生和发展的一个标志。 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，与 肿瘤间质和癌细胞上的特异性配体(PD-L1、PD-L2)。在初步研究中，我们有 分析早期肝细胞癌术前免疫治疗后切除的肝细胞癌组织。我们发现了特定的星团 与有希望的反应相关，包括在以下情况下的频繁病理完全反应 外科手术(癌症免疫研究报告2019)。此外，我们还证明了PD-1阻滞剂可以稳定肿瘤 血管生成，从而增强抗肿瘤免疫当与血管内皮生长因子途径阻断时 肝细胞癌的临床前模型(肝病学2020)。我们的目标是证明免疫系统的重新编程 肝细胞癌的微环境将为免疫治疗带来更大的益处。我们假设：1) 新辅助抗PD-L1/血管内皮生长因子治疗是可行的、有效的，并将在可切除的肿瘤中诱导病理完全反应 2)对新佐剂抗PD-L1/血管内皮生长因子治疗有反应的肝癌细胞将增加肿瘤内CD8+ T细胞：Treg比率，循环细胞因子水平，以及影像上有利的代谢变化。我们将测试这些 两个特定目标的假设：目的1：评价抗PD-L1/VEGF联合治疗的安全性和有效性 在可切除的肝细胞癌患者的新辅助治疗中。这项随机、多部位的II期临床研究将 根据2：1随机分组(新辅助剂ATEZO/BEV=60，与前期手术=30)，累积90名患者 有两个子目标：目标1a将评估安全性和病理应答率作为#年的主要终点 Atezo/Bev ARM；Aim 1b将评估3年无复发存活率和OS作为次要终点 在Tatezo/Bev手臂和控制臂之间。目的2：确定抗肿瘤免疫的激活是否与 在可切除的肝细胞癌患者中，双重抗PD-L1/VEGF治疗在新辅助环境下的持久反应 通过对组织、外周血和影像参数的研究，分3个目标。目标2a是为了分析免疫T- 术前活检和术后手术切除标本中的细胞团评估CD8+T- 细胞：Treg比率采用多重免疫荧光和单细胞RNA测序。目标2b是为了研究 组织免疫细胞、调节蛋白和血浆细胞因子(多路蛋白阵列)的变化 探索一种可以预测反应的生物标志物签名。目标2c是评估 治疗前后PET MRI扫描对肿瘤代谢活性的影响及变化。其影响 这一项目的意义在于，它可能会将免疫治疗在肝癌中的作用从姑息治疗转变为治愈。

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.