A phase Ib study of TQB2450 plus anlotinib in patients with advanced triple-negative breast cancer

Immunotherapy in breast cancer: current landscape and emerging trends

Breast cancer remains one of the most prevalent malignancies worldwide, underscoring an urgent need for innovative therapeutic strategies. Immunotherapy has emerged as a transformative frontier in this context. In triple-negative breast cancer (TNBC), the combination of immunotherapy based on PD-1/PD-L1 immune checkpoint inhibitors (ICIs) with chemotherapy has proven efficacious in both early and advanced clinical trials. These encouraging results have led to the approval of ICIs for TNBC, opening up new therapeutic avenues for challenging-to-treat patient populations. Furthermore, a multitude of ongoing trials are actively investigating the efficacy of immunotherapy-based combinations, including ICIs in conjunction with chemotherapy, targeted therapy and radiation therapy, as well as other novel strategies such as bispecific antibodies, CAR-T cells and cancer vaccines across all breast cancer subtypes, including HR-positive/HER2-negative and HER2-positive disease. This review provides a comprehensive overview of current immunotherapeutic approaches in breast cancer, highlighting pivotal findings from recent clinical trials and the potential impact of these advancements on patient outcomes.

Combination of anlotinib with immunotherapy enhanced both anti-angiogenesis and immune response in high-grade serous ovarian cancer

Background

High-grade serous ovarian cancer (HGSOC) poses significant treatment challenges due to frequent recurrence and resistance to conventional therapies. Combination of anlotinib with immunotherapy have showed promise in various cancers, but its impact on HGSOC remains to be fully elucidated.

Methods

A retrospective analysis was performed on 36 HGSOC patients treated with anlotinib-based therapies, including both monotherapy and combination treatment with anti-PD-L1/anti-PD-1 antibody (aPD-L1/aPD-1). Peripheral blood mononuclear cell-derived patient-derived xenograft (PBMC-PDX) model was established from drug-resistant recurrent HGSOC patient-derived tumor cells, and single-cell RNA sequencing (scRNA-seq) was conducted to dissect the TME following treatment with anlotinib, anlotinib + aPD-L1 and anlotinib + aPD-1.

Results

Clinical analysis revealed a disease control rate (DCR) of 71.43% for anlotinib monotherapy, which improved to 100% when combined with aPD-L1/aPD-1. In PBMC-PDX models, treatment evaluation showed that anlotinib decreased tumor volume, an effect further enhanced by its combination with aPD-L1. scRNA-seq analysis demonstrated that anlotinib reduced the proportions of myofibroblastic cancer-associated fibroblasts and ESM1+ endothelial cells, resulting in decreased angiogenesis. The combination of anlotinib and aPD-L1 further amplified these effects, promoting CD8+ T cell infiltration and reversing T cell exhaustion, whereas anlotinib + aPD-1 showed limited efficacy in this regard. Additionally, anlotinib + immunotherapy induced a shift toward M1 polarization of myeloid cells, enhanced anti-tumor activity, and inhibited immune escape. Cell-cell communication analysis revealed reduced APP-CD74 signaling and increased CD99-CD99 signaling, which might contribute to immune activation.

Conclusion

The combination of anlotinib and aPD-L1 effectively modulates the HGSOC tumor microenvironment by inhibiting angiogenesis, enhancing immune infiltration, and reversing T cell exhaustion.

Efficacy and safety of TQB2450 combined with anlotinib as maintenance therapy for LS-SCLC after definitive concurrent or sequential chemoradiotherapy: a prospective phase Ib study

PURPOSE

There is a significant unmet need in treating patients with limited-stage small-cell lung cancer (LS-SCLC). The ETER701 study showed that Benmelstobart (TQB2450, an anti-PD-L1 antibody) combined with Anlotinib and chemotherapy achieved the longest progression-free survival (PFS) and overall survival (OS) as a first-line therapy in patients with extensive-stage small cell lung cancer (ES-SCLC). This suggests that TQB2450 and Anlotinib represent a promising treatment combination for LS-SCLC. This prospective study aimed to evaluate the efficacy and safety of TQB2450 combined with Anlotinib as maintenance therapy for LS-SCLC following concurrent or sequential chemoradiotherapy (CCRT or SCRT).

METHODS

Patients who did not show disease progression after chemoradiotherapy were enrolled. They received TQB2450 and Anlotinib every 3 weeks for up to 24 months. TQB2450 was intravenously administered at a dose of 1200 mg every 3 weeks. Anlotinib was initiated at a dose of 8 mg daily for days 1-14; if well tolerated, the dose was increased to 10 mg. Adverse events (AEs) were recorded using electronic data capture system. The trial was registered at the ClinicalTrials.gov (NCT05942508, 06/07/2023).

RESULTS

Fifteen patients were enrolled in the study between May 31, 2023 and October 13, 2023. As of October 31, 2024, the median follow-up time was 15.13 months. The 12-month PFS rate was 86.7% (95% CI, 71.1-100.0), and the OS rate at 12 months was 100%. The disease control rate was 100%. AEs were reported in 13 patients (86.67%), with fatigue being the most common treatment related AE (40.00%). And two SAEs were observed (elevation in cardiac troponin T and cerebral infarction), which were determined to be unlikely unrelated to the trial drugs. Radiation pneumonitis (RP) occurred in three patients, all classified as grade 2, and one patient developed grade 1 immune-related pneumonitis. No grade 5 AEs occurred, and no patients withdrew from the study due to AEs.

CONCLUSIONS

TQB2450 combined with Anlotinib showed promising efficacy and well tolerance in patients with LS-SCLC following first-line treatment. A randomized, double-blind, placebo-controlled Phase III clinical study (ClinicalTrials.gov Identifier: NCT06469879) is being conducted to further explore the efficacy and safety of TQB2450 combined with Anlotinib as maintenance therapy after definitive CCRT or SCRT for LS-SCLC.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05942508. Date of registration: 7 June 2023.

Real‑world evaluation of the efficacy of immune checkpoint inhibitors in the treatment of metastatic breast cancer

The present study aimed to assess the efficacy and safety of immune checkpoint inhibitor (ICI)-based therapy in patients with metastatic breast cancer (MBC). Therefore, eligible patients with histologically confirmed MBC, treated with ICI-based therapy, were enrolled. The primary endpoint was progression-free survival (PFS) and the secondary endpoints included objective response rate (ORR), disease control rate (DCR), overall survival (OS) and safety. A total of 90 patients with MBC, treated with ICI-based therapy, with different treatment lines, were included in the present study. The median age was 50 years (range, 27-76). The predominant tumor subtypes were triple negative (53.3%) and luminal (31.1%) breast cancer. The majority of patients (61.1%) were heavily pretreated (lines of treatment, ≥3). Approximately half of the patients (46.7%) had ≥3 metastatic sites. The overall ORR was 36.7% (33/90 patients), while a DCR of 78.9% (71/90 patients) was also recorded. With a median follow-up of 16.0 months, the median PFS and OS were 4.9 months [95% confidence interval (CI), 3.8-6.1] and 13.9 months (95% CI, 9.5-18.2), respectively. Patients treated with ICIs as first-line therapy exhibited notable improvement, with a median PFS of 11.0 months (95% CI, 6.0-16.0) and a median OS of 24.3 months (95% CI, 11.4-37.2). In addition, the pretreatment blood platelet-to-lymphocyte ratio was an independent risk factor for PFS [hazard ratio (HR)=2.406; 95% CI, 1.325-4.370; P=0.004] and OS (HR=2.376; 95% CI, 1.059-5.328; P=0.036). The most common adverse events were nausea (44.4%), neutropenia (42.0%) and alanine aminotransferase/aspartate aminotransferase elevation (22.2%). Furthermore, three (3.3%) patients developed grade 1/2 immuno-related toxicity and recovered after supportive care. Overall, the present study suggested that the ICI-based therapy exhibited encouraging clinical outcomes with manageable toxicity in patients with MBC in real-world settings, with the most favorable efficacy in first-line treatment.

Integrating immunotherapy with conventional treatment regime for breast cancer patients- an amalgamation of armamentarium

Immunotherapy stands as the frontrunner in treatment strategies imparting efficient remission in various types of cancer. In fact, emerging breakthroughs with immune checkpoint inhibitors (ICI) in a spectrum of cancers have evoked interest in research related to the potential effects of immunotherapy in breast cancer patients. A major challenge with breast cancer is the molecular heterogeneity that limits the efficacy of many therapeutic regimes. Clinical trials have shown favorable clinical outcomes with immunotherapeutic options in some subtypes of breast cancer. However, ICI monotherapy may not be sufficient for all breast cancer patients, emphasizing the need for combinatorial approaches. Ongoing research is focused on untangling the interplay of ICI with established as well as novel anticancer therapeutic regimens in preclinical models of breast cancer. Our review will analyze the existing research regarding the mechanisms and clinical impact of immunotherapy for the treatment of breast cancer. We shall evaluate the role of immune cell modulation for improved therapeutic response in breast cancer patients. This review will provide collated evidences about the current clinical trials that are testing out the implications of immunotherapy in conjunction with traditional treatment modalities in breast cancer and summarize the potential future research directions in the field. In addition, we shall underline the recent findings related to microbiota modulation as a key regulator of immune therapy response in cancer patients and its plausible applications in breast cancer.

Narrative review on efficacy and safety of anti-angiogenesis in combination with immunotherapy in the treatment of breast cancer

Background and Objective

Breast cancer was the second frequently diagnosed cancer in 2022 among all cancers. Besides classical chemotherapy and radiation, immunotherapy and targeted therapy are both identical treatment options for patients with advanced breast cancer. Immunotherapy is a therapeutic approach to control and eliminate tumors by restarting and maintaining the tumor-immunity cycle and restoring the body's normal anti-tumor immune response. Immunotherapy alone or in combination with other therapies has been shown to be clinically beneficial in a variety of solid tumors with a manageable safety profile. However, immunotherapy alone cannot fully satisfy the therapeutic needs for patients with breast cancer. Therefore, there is an urgent need for immunotherapy to be combined with other therapeutic approaches to increase treatment efficacy.

Methods

We systematically searched PubMed database for relevant studies published over the past 5 years. Articles were screened for eligibility and key data extracted.

Key Content and Findings

We assess the current breast cancer treatment landscape, summarizing efficacy and safety of recent immunotherapy, chemotherapy combined with immunotherapy, immunotherapy combined with anti-angiogenic therapy. In the treatment of breast cancer, aiming to promote further research and applications of this novel treatment regimen in patients with breast cancer. Since anti-angiogenic therapy can reprogramme the tumor immune microenvironment, immunotherapy in combination with anti-angiogenic therapy might have a synergistic effect, igniting a new hope for immunotherapy for breast cancer patients. The review's conclusions offer insightful information on the state of breast cancer treatment today. In the end, improving clinical practice and pertinent research for immunotherapy combination therapy will contribute to bettering patient outcomes, raising quality of life, and creating more potent treatments.

Conclusions

This review emphasizes the potential of immunotherapy combinations, especially with anti-angiogenic therapeutic regimens, as a viable strategy for the treatment of breast cancer through a thorough study of the literature. To improve treatment approaches, lessen side effects for patients, and find trustworthy biomarkers to forecast response to immunotherapy combo medicines, further research is necessary.

Case report: outcome of anlotinib treatment in breast cancer patient with brain metastases

Brain metastases (BM) represent a common and severe complication of breast cancer (BC), emerging in approximately 10%-16% of all BC patients. The prevalent approach for treating BC patients with BM encompasses a multimodal strategy, combining surgery, whole brain radiation therapy, and stereotactic radiosurgery. Yet, a concrete guideline for localized treatment strategies remains elusive, while systemic treatments like small-molecule-targeted therapy and immunotherapy are still in the clinical trial phase. This case study presents a significant clinical response to anlotinib treatment in a patient with estrogen receptor-negative, progesterone receptor-positive, and human epidermal growth factor receptor 2 (HER2)-positive breast cancer, complicated by BM. After the standard first-line treatment including albumin-bound paclitaxel, trastuzumab and pertuzumab, and a second-line treatment involving pyrotinib, capecitabine, and radiotherapy did not produce the desired results, the patient was then administered anlotinib in combination with pyrotinib and letrozole as a third-line treatment, which led to a partial response (PR). The findings suggest that anti-angiogenic therapy, specifically anlotinib, could be regarded as a promising therapeutic option for BC patients with BM.

Analysis of the Value of Quantitative Features in Multimodal MRI Images to Construct a Radio-Omics Model for Breast Cancer Diagnosis

Objective

To analyze the diagnostic value of quantitative features in multimodal magnetic resonance imaging (MRI) images to construct a radio-omics model for breast cancer.

Methods

Ninety-five patients with breast-related diseases from January 2020 to January 2021 were grouped into the benign group (n=57) and malignant group (n=38) according to the pathological findings. All cases were randomized as the training group (n=66) and validation group (n=29) in a 7:3 ratio based on the examination time. All subjects were examined by T1-weighted imaging (T1WI), T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), dynamic contrast enhancement (DCE), and apparent diffusion coefficient (ADC) multimodality MRI. The MRI findings were analyzed against pathological findings. A diagnostic breast cancer radiomics model was constructed. The diagnostic efficacy of the model in the validation group was analyzed, and the diagnostic efficacy was analyzed via the ROC curve.

Results

Fibroadenoma accounted for 49.12% of benign breast diseases, and invasive ductal carcinoma accounted for 73.68% of malignant breast diseases. The sensitivity of T1WI, T2WI, DWI, ADC, and DCE in diagnosing breast cancer was 61.14%, 66.67%, 73.30%, 78.95%, and 85.96%, using the four-fold table method. The area under the curves (AUCs) of T1WI, T2WI, DWI, ADC, and DCE for diagnosing breast cancer were 0.715, 0.769, 0.785, 0.835, and 0.792, respectively. The AUCs of plain scan, diffuse, enhanced, plain scan + diffuse, plain scan + enhanced, enhanced + diffuse, and plain scan + enhanced + diffuse for diagnosing breast cancer were 0.746, 0.798, 0.816, 0.839, 0.890, 0.906, and 0.927, respectively.

Conclusion

The construction of a radio-omics model by quantitative features in multimodal MRI images was valuable in the diagnosis of breast cancer. The value of radio-omics models such as plain scan + enhanced + diffuse was higher than the other models in diagnosing breast cancer and could be widely applied in clinical practice.

Safety and efficacy of anlotinib combined with taxane and lobaplatin in neoadjuvant treatment of clinical stage II/III triple-negative breast cancer in China (the neoALTAL trial): a single-arm, phase 2 trial

Background

Anlotinib is a new type of tyrosine kinase inhibitor that targets vascular endothelial growth factor receptors 1/2/3, platelet-derived growth factor receptors α/β, and fibroblast growth factor receptors 1-4 and c-Kit, with a broad spectrum of inhibitory effects on tumor angiogenesis and growth. It has been proven effective in HER2-negative metastatic breast cancer, but its efficacy in early-stage triple-negative breast cancer (TNBC) is unknown. This phase 2 study aims to evaluate the efficacy and safety of adding anlotinib to neoadjuvant chemotherapy in patients with TNBC.

Methods

Patients with clinical stage II/III TNBC were treated with 5 cycles of anlotinib (12 mg, d1-14, q3w) plus 6 cycles of taxanes (docetaxel 75 mg/m2 ,d1, q3w or nab-paclitaxel 125 mg/m2, d1 and d8, q3w) and lobaplatin (30 mg/m2, d1, q3w), followed by surgery. The primary endpoint was pathological complete response (pCR; ypT0/is ypN0) and the secondary endpoints include breast pCR (bpCR), axillary pCR (apCR), residual cancer burden (RCB), objective response rate (ORR), survival, and safety. Exploratory endpoints were efficacy biomarkers based on Fudan University Shanghai Cancer Center Immunohistochemical (FUSCC IHC) classification for TNBC and next-generation sequencing (NGS) of DNA from tumor tissue and blood samples of patients with 425-gene panel. This trial is registered with www.chictr.org.cn (ChiCTR2100043027).

Findings

From Jan 2021 to Aug 2022, 48 patients were assessed and 45 were enrolled. All patients received at least one dose of study treatment and underwent surgery. The median age was 48.5 years (SD: 8.7), 71% were nodal involved, and 20% had stage III. In the intention-to-treat population, 26 out of 45 patients achieved pCR (57.8%; 90% CI, 44.5%-70.3%), and 39 achieved residual cancer burden class 0-I (86.7%; 95% CI, 73.2%-94.9%). The bpCR and apCR rate were 64.4% (29/45) and 71.9% (23/32), respectively. No recurrence or metastasis occurred during the short-term follow-up. Based on the FUSCC IHC-based subtypes, the pCR rates were 68.8% (11/16) for immunomodulatory subtype, 58.3% (7/12) for basal-like immune-suppressed subtype and 33.3% (4/12) for luminal androgen receptor subtype, respectively. NGS revealed that the pCR were 77% (10/13) and 50% (14/28) in MYC-amplified and wild-type patients, respectively, and 78% (7/9) and 53% (17/32) in gBRCA1/2-mutated and wild-type patients, respectively. The median follow-up time of the study was 14.9 months (95% CI: 13.5-16.3 months). There was no disease progression or death during neoadjuvant therapy. No deaths occurred during postoperative follow-up. In the safety population (N = 45), Grade 3 or 4 treatment emergent adverse events occurred in 29 patients (64%), and the most common events were neutropenia (38%), leukopenia (27%), thrombocytopenia (25%), anemia (13%), and hypertension (13%), respectively.

Interpretation

The addition of anlotinib to neoadjuvant chemotherapy showed manageable toxicity and encouraging antitumor activity for patients with clinical stage II/III TNBC.

Funding

Chongqing Talents Project, Chongqing Key Project of Technology Innovation and Application Development and Chongqing Outstanding Youth Natural Science Foundation.

Potential therapeutic targets of the JAK2/STAT3 signaling pathway in triple-negative breast cancer

Triple-negative breast cancer (TNBC) poses a significant clinical challenge due to its propensity for metastasis and poor prognosis. TNBC evades the body's immune system recognition and attack through various mechanisms, including the Janus Kinase 2 (JAK2)/signal transducer and activator of transcription 3 (STAT3) signaling pathway. This pathway, characterized by heightened activity in numerous solid tumors, exhibits pronounced activation in specific TNBC subtypes. Consequently, targeting the JAK2/STAT3 signaling pathway emerges as a promising and precise therapeutic strategy for TNBC. The signal transduction cascade of the JAK2/STAT3 pathway predominantly involves receptor tyrosine kinases, the tyrosine kinase JAK2, and the transcription factor STAT3. Ongoing preclinical studies and clinical research are actively investigating this pathway as a potential therapeutic target for TNBC treatment. This article comprehensively reviews preclinical and clinical investigations into TNBC treatment by targeting the JAK2/STAT3 signaling pathway using small molecule compounds. The review explores the role of the JAK2/STAT3 pathway in TNBC therapeutics, evaluating the benefits and limitations of active inhibitors and proteolysis-targeting chimeras in TNBC treatment. The aim is to facilitate the development of novel small-molecule compounds that target TNBC effectively. Ultimately, this work seeks to contribute to enhancing therapeutic efficacy for patients with TNBC.

TORCHLIGHT trial, brightening the life of more patients with advanced triple-negative breast cancer

Toripalimab (JS001) is a monoclonal antibody against programmed cell death-1 (PD-1), independently developed by Shanghai Junshi Biosciences Co., LTD, which is the first domestic original PD-1 inhibitor approved in China. TORCHLIGHT is the first phase III trial of PD-1 inhibitor combined chemotherapy in advanced triple-negative breast cancer (TNBC) in China, evaluating the efficacy and safety of toripalimab plus nab-paclitaxel as first- or second-line therapy. Nab-paclitaxel has significant advantages over other chemotherapy drugs, as paclitaxel nanoparticles combine with natural albumin to increase drug delivery and bioavailability of paclitaxel. Firstly, nab-paclitaxel has a higher therapy response; Secondly, albumin carries paclitaxel out of the blood circulation faster, reducing the damage to normal tissues, ensuring the survival of more normal immune cells and exerting immune efficacy. Finally, nab-paclitaxel does not cause allergic reactions caused by organic solvents and does not require glucocorticoid pretreatment, avoiding immune suppression and ensuring the maximum efficacy of immune checkpoint inhibitors (ICIs). In TORCHLIGHT trial, 95% of subjects were on the first line treatment, with only 5% being on the second line, and 56% patients were programmed death-ligand 1 (PD-L1) positive in total population. It achieved the survival benefits of progression-free survival (PFS) and overall survival (OS) dual efficacy end points, which stood out among numerous ICIs in advanced TNBC. TORCHLIGHT trial, as the name of it, like a torch to more patients with advanced TNBC, lighting up their lives. We described the design background of TORCHLIGHT trial and reviewed primary trials of PD-1 or PD-L1 inhibitor in advanced TNBC both domestically and internationally.

Hypoxia: syndicating triple negative breast cancer against various therapeutic regimens

Triple-negative breast cancer (TNBC) is one of the deadliest subtypes of breast cancer (BC) for its high aggressiveness, heterogeneity, and hypoxic nature. Based on biological and clinical observations the TNBC related mortality is very high worldwide. Emerging studies have clearly demonstrated that hypoxia regulates the critical metabolic, developmental, and survival pathways in TNBC, which include glycolysis and angiogenesis. Alterations to these pathways accelerate the cancer stem cells (CSCs) enrichment and immune escape, which further lead to tumor invasion, migration, and metastasis. Beside this, hypoxia also manipulates the epigenetic plasticity and DNA damage response (DDR) to syndicate TNBC survival and its progression. Hypoxia fundamentally creates the low oxygen condition responsible for the alteration in Hypoxia-Inducible Factor-1alpha (HIF-1α) signaling within the tumor microenvironment, allowing tumors to survive and making them resistant to various therapies. Therefore, there is an urgent need for society to establish target-based therapies that overcome the resistance and limitations of the current treatment plan for TNBC. In this review article, we have thoroughly discussed the plausible significance of HIF-1α as a target in various therapeutic regimens such as chemotherapy, radiotherapy, immunotherapy, anti-angiogenic therapy, adjuvant therapy photodynamic therapy, adoptive cell therapy, combination therapies, antibody drug conjugates and cancer vaccines. Further, we also reviewed here the intrinsic mechanism and existing issues in targeting HIF-1α while improvising the current therapeutic strategies. This review highlights and discusses the future perspectives and the major alternatives to overcome TNBC resistance by targeting hypoxia-induced signaling.