Adjuvant immunotherapy for non-small cell lung cancer

描述(申请人提供)：临床IB期、IIA/B期和IIIA期非小细胞肺癌(NSCLC)患者的5年生存率很低，从15%到40%不等。一项国际合作研究的初步结果表明，尽管有很高比例的患者(23%)经历了严重的4级毒性反应，但通过术后化疗和/或放射治疗患者的存活率可能会提高(约5%)。需要更具肿瘤特异性和毒性较低的辅助治疗。我们认为，树突状细胞(DC)在体外负载来自患者自身照射的自体肿瘤的抗原，并在干扰素-γ(干扰素-γ)和灭活/甲醛固定(BCG)的组合下成熟，可以在佐剂环境下安全地诱导抗肿瘤免疫状态，延长无肿瘤生存时间。将进行I期临床试验，以评估这种形式的DC疫苗对选择的临床IB、IIA/B或IIIA非小细胞肺癌术后患者的安全性和耐受性。肿瘤细胞产生免疫抑制因子，抑制宿主免疫，提高肿瘤存活率。切除原发肿瘤可以减少这些因素，暂时恢复免疫反应。肿瘤切除还可以减轻肿瘤负担，降低肿瘤变异体逃脱免疫检测的风险。因此，在术后期间治疗患者为使用抗肿瘤疫苗提供了一个最佳窗口。DC前体细胞将通过白细胞分离获得，并在体外用GM-CSF和IL-4进行分化。自体肿瘤将在患者的初级肿瘤切除过程中收获，并使用一种新的免疫耗竭方案进行纯化。利用患者自身的肿瘤，树突状细胞将被加载一套完整的肿瘤抗原，能够诱导CD4和CD8T细胞反应。在抗原负载后，DC将被卡介苗和干扰素-γ处理，以增强IL-12的产生、共刺激活性和T细胞激活能力。在手术康复后，DC疫苗将连续三个月每月皮内注射一次。共有12-15名患者将在两个队列中接受治疗，一个队列每次接种2×106 DC，第二个队列每次接种6×106 DC。除了标准的毒性、耐受性和临床结果外，血清细胞因子(IL-10、血管内皮生长因子、转化生长因子-β)和细胞亚群(DC1、DC2、T抑制因子)的变化将被用来监测肿瘤相关免疫抑制的变化；对PPD的皮试反应、卡介苗特异性T细胞增殖和细胞内细胞因子对负载卡介苗的DC的反应将被用来监测对疫苗的反应；T细胞增殖和细胞内细胞因子对肿瘤负载的树突状细胞的反应将被用来监测肿瘤特异性免疫的发展。患者将接受为期1年的随访。疫苗是安全的证据、可行的制造过程的文件记录以及疫苗特异性免疫反应的证据将提供所需的信息，以支持关注临床结果和存活率的后续临床试验。

DESCRIPTION (provided by applicant): Patients with clinical stage IB, IIA/B and IIIA non-small cell lung cancer (NSCLC) have poor 5-year survival rates that range from 15-40%. Preliminary results from an international cooperative study suggest that survival might be improved (approximately 5%) by treating patients with post-operative chemotherapy and/or radiation, although a high percentage of patients (23%) experienced serious Grade 4 toxicity. Adjuvant therapies that are more tumor-specific and less toxic are needed. We propose that dendritic cells (DC) loaded ex vivo with antigens from the patient's own irradiated autologous tumor, and matured with a combination of interferon-gamma (IFN-gamma) and inactivated/formaldehyde-fixed (BCG), can be used to safely induce a state of anti-tumor immunity and prolong tumor-free survival in the adjuvant setting. A Phase I clinical trial will be carried out to evaluate the safety and tolerability of administering this form of DC vaccine to postoperative patients with selected clinical stage IB, IIA/B or IIIA NSCLC. Tumor cells produce immunosuppressive factors that can suppress host immunity and enhance tumor survival. Resection of the primary tumor reduces these factors and temporarily restores immune responsiveness. Tumor resection also reduces tumor burden, reducing the risk that tumor variants will escape immune detection. As such, treating patients in the postoperative period provides an optimal window for employing anti-tumor vaccines. DC precursors will be harvested by leukapheresis and differentiated ex vivo with GM-CSF and IL-4. Autologous tumor will be harvested during the patient's primary tumor resection and purified using a novel immunodepletion protocol. Using the patient's own tumor, DC will be loaded with a full repertoire of tumor antigens capable of inducing both CD4 and CD8 T cell responses. After antigen loading, DC will be treated with BCG and IFN-gamma to enhance IL-12 production, co-stimulatory activity and capacity for T cell activation. The DC vaccine will then be administered as a monthly intradermal injection for three consecutive months following recovery from surgery. A total of 12-15 patients will be treated in two cohorts, one receiving 2 x 106 DC per immunization and the second receiving 6 x 106 DC per immunization. In addition to standard toxicity, tolerability and clinical outcomes, changes in serum cytokines (IL-10, VEGF, TGF-beta) and cell subsets (DC1, DC2, T suppressor) will be used to monitor changes in tumor-related immunosuppression; skin-test reactions to PPD, BCG-specific T cell proliferation and intracellular cytokine responses to DC loaded with BCG will be used to monitor responses to the vaccine; and T cell proliferation and intracellular cytokine responses to tumor-loaded DC will be used to monitor the development of tumor-specific immunity. Patients will be followed for a total of 1 year. Evidence that the vaccine is safe, documentation of a feasible manufacturing process, and evidence of vaccine-specific immune responses will provide the information required to support subsequent clinical trials focused on clinical outcomes and survival.