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Passaro A, Brahmer J, Antonia S, Mok T, Peters S. Managing Resistance to Immune Checkpoint Inhibitors in Lung Cancer: Treatment and Novel Strategies. J Clin Oncol 2022; 40:598-610. [PMID: 34985992 DOI: 10.1200/jco.21.01845] [Citation(s) in RCA: 96] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
A proportion of patients with lung cancer experience long-term clinical benefit with immune checkpoint inhibitors (ICIs). However, most patients develop disease progression during treatment or after treatment discontinuation. Definitions of immune resistance are heterogeneous according to different clinical and biologic features. Primary resistance and acquired resistance, related to tumor-intrinsic and tumor-extrinsic mechanisms, are identified according to previous response patterns and timing of occurrence. The clinical resistance patterns determine differential clinical approaches. To date, several combination therapies are under development to delay or prevent the occurrence of resistance to ICIs, including the blockade of immune coinhibitory signals, the activation of those with costimulatory functions, the modulation of the tumor microenvironment, and the targeting T-cell priming. Tailoring the specific treatments with distinctive biologic resistance mechanisms would be ideal to improve the design and results of clinical trial. In this review, we reviewed the available evidence on immune resistance mechanisms, clinical definitions, and management of resistance to ICIs in lung cancer. We also reviewed data on novel strategies under investigation in this setting.
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Affiliation(s)
- Antonio Passaro
- Division of Thoracic Oncology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Julie Brahmer
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | | | - Tony Mok
- State Key Laboratory in Translational Oncology, Department of Clinical Oncology Chinese University of Hong Kong, Hong Kong, P.R. China
| | - Solange Peters
- Department of Oncology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
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Bosch-Barrera J, Verdura S, Ruffinelli JC, Carcereny E, Sais E, Cuyàs E, Palmero R, Lopez-Bonet E, Hernández-Martínez A, Oliveras G, Buxó M, Izquierdo A, Morán T, Nadal E, Menendez JA. Silibinin Suppresses Tumor Cell-Intrinsic Resistance to Nintedanib and Enhances Its Clinical Activity in Lung Cancer. Cancers (Basel) 2021; 13:4168. [PMID: 34439322 PMCID: PMC8394850 DOI: 10.3390/cancers13164168] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 08/13/2021] [Indexed: 12/28/2022] Open
Abstract
The anti-angiogenic agent nintedanib has been shown to prolong overall and progression-free survival in patients with advanced non-small-cell lung cancer (NSCLC) who progress after first-line platinum-based chemotherapy and second-line immunotherapy. Here, we explored the molecular basis and the clinical benefit of incorporating the STAT3 inhibitor silibinin-a flavonolignan extracted from milk thistle-into nintedanib-based schedules in advanced NSCLC. First, we assessed the nature of the tumoricidal interaction between nintedanib and silibinin and the underlying relevance of STAT3 activation in a panel of human NSCLC cell lines. NSCLC cells with poorer cytotoxic responses to nintedanib exhibited a persistent, nintedanib-unresponsive activated STAT3 state, and deactivation by co-treatment with silibinin promoted synergistic cytotoxicity. Second, we tested whether silibinin could impact the lysosomal sequestration of nintedanib, a lung cancer cell-intrinsic mechanism of nintedanib resistance. Silibinin partially, but significantly, reduced the massive lysosomal entrapment of nintedanib occurring in nintedanib-refractory NSCLC cells, augmenting the ability of nintedanib to reach its intracellular targets. Third, we conducted a retrospective, observational multicenter study to determine the efficacy of incorporating an oral nutraceutical product containing silibinin in patients with NSCLC receiving a nintedanib/docetaxel combination in second- and further-line settings (n = 59). Overall response rate, defined as the combined rates of complete and partial responses, was significantly higher in the study cohort receiving silibinin supplementation (55%) than in the control cohort (22%, p = 0.011). Silibinin therapy was associated with a significantly longer time to treatment failure in multivariate analysis (hazard ratio 0.43, p = 0.013), despite the lack of overall survival benefit (hazard ratio 0.63, p = 0.190). Molecular mechanisms dictating the cancer cell-intrinsic responsiveness to nintedanib, such as STAT3 activation and lysosomal trapping, are amenable to pharmacological intervention with silibinin. A prospective, powered clinical trial is warranted to confirm the clinical relevance of these findings in patients with advanced NSCLC.
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Affiliation(s)
- Joaquim Bosch-Barrera
- Medical Oncology, Catalan Institute of Oncology, Dr. Josep Trueta Hospital of Girona, 17007 Girona, Spain; (E.S.); (A.H.-M.); (A.I.)
- Department of Medical Sciences, Medical School, University of Girona, 17003 Girona, Spain
- Girona Biomedical Research Institute (IDIBGI), 17190 (Salt) Girona, Spain; (S.V.); (E.C.); (M.B.)
| | - Sara Verdura
- Girona Biomedical Research Institute (IDIBGI), 17190 (Salt) Girona, Spain; (S.V.); (E.C.); (M.B.)
| | - José Carlos Ruffinelli
- Medical Oncology Department, Catalan Institute of Oncology, Hospital Duran i Reynals, 08908 L’Hospitalet de Llobregat, Spain; (J.C.R.); (R.P.); (E.N.)
| | - Enric Carcereny
- Medical Oncology Department, Catalan Institute of Oncology, Hospital Germans Trias i Pujol, 08916 Badalona, Spain; (E.C.); (T.M.)
- B-ARGO Group (Badalona Applied Research Group in Oncology), Germans Trias i Pujol Research Institute (IGTP), 08916 Badalona, Spain
| | - Elia Sais
- Medical Oncology, Catalan Institute of Oncology, Dr. Josep Trueta Hospital of Girona, 17007 Girona, Spain; (E.S.); (A.H.-M.); (A.I.)
| | - Elisabet Cuyàs
- Girona Biomedical Research Institute (IDIBGI), 17190 (Salt) Girona, Spain; (S.V.); (E.C.); (M.B.)
| | - Ramon Palmero
- Medical Oncology Department, Catalan Institute of Oncology, Hospital Duran i Reynals, 08908 L’Hospitalet de Llobregat, Spain; (J.C.R.); (R.P.); (E.N.)
| | - Eugeni Lopez-Bonet
- Department of Anatomical Pathology, Dr. Josep Trueta Hospital of Girona, 17007 Girona, Spain; (E.L.-B.); (G.O.)
| | - Alejandro Hernández-Martínez
- Medical Oncology, Catalan Institute of Oncology, Dr. Josep Trueta Hospital of Girona, 17007 Girona, Spain; (E.S.); (A.H.-M.); (A.I.)
| | - Gloria Oliveras
- Department of Anatomical Pathology, Dr. Josep Trueta Hospital of Girona, 17007 Girona, Spain; (E.L.-B.); (G.O.)
| | - Maria Buxó
- Girona Biomedical Research Institute (IDIBGI), 17190 (Salt) Girona, Spain; (S.V.); (E.C.); (M.B.)
| | - Angel Izquierdo
- Medical Oncology, Catalan Institute of Oncology, Dr. Josep Trueta Hospital of Girona, 17007 Girona, Spain; (E.S.); (A.H.-M.); (A.I.)
- Department of Medical Sciences, Medical School, University of Girona, 17003 Girona, Spain
- Hereditary Cancer Program, Epidemiology Unit and Girona Cancer Registry, Oncology Coordination Plan, Catalan Institute of Oncology-Girona Biomedical Research Institute (IDIBGI), 17007 Girona, Spain
| | - Teresa Morán
- Medical Oncology Department, Catalan Institute of Oncology, Hospital Germans Trias i Pujol, 08916 Badalona, Spain; (E.C.); (T.M.)
- B-ARGO Group (Badalona Applied Research Group in Oncology), Germans Trias i Pujol Research Institute (IGTP), 08916 Badalona, Spain
| | - Ernest Nadal
- Medical Oncology Department, Catalan Institute of Oncology, Hospital Duran i Reynals, 08908 L’Hospitalet de Llobregat, Spain; (J.C.R.); (R.P.); (E.N.)
| | - Javier A. Menendez
- Girona Biomedical Research Institute (IDIBGI), 17190 (Salt) Girona, Spain; (S.V.); (E.C.); (M.B.)
- Program against Cancer Therapeutic Resistance (ProCURE), Metabolism & Cancer Group, Catalan Institute of Oncology, 17190 (Salt) Girona, Spain
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