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Tintelnot J, Stein A, Al-Batran SE, Ettrich T, Götze T, Grün B, Haag GM, Heuer V, Hofheinz RD, Homann N, Bröring TS, Cruz MS, Kurreck A, Lorenzen S, Moosmann N, Müller C, Schuler M, Siegler G, Binder M, Gökkurt E. Pembrolizumab and trastuzumab in combination with FLOT in the perioperative treatment of HER2-positive, localized esophagogastric adenocarcinoma-a phase II trial of the AIO study group (AIO STO 0321). Front Oncol 2023; 13:1272175. [PMID: 37909020 PMCID: PMC10615128 DOI: 10.3389/fonc.2023.1272175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/15/2023] [Indexed: 11/02/2023] Open
Abstract
Background Esophagogastric adenocarcinoma (EGA) presents a substantial global health challenge as the number of cases continues to rise. The current standard approach for treating localized EGA involves a combination of triplet chemotherapy, which consists of a platinum compound, a fluoropyrimidine, and a taxane (known as FLOT), followed by surgery. In cases of metastatic EGA with HER2-positive status or in certain studies with localized EGA, the use of HER2-targeted antibodies such as trastuzumab has shown improved responses. Recently, the addition of programmed cell death protein 1 (PD-1) inhibitors, such as pembrolizumab, when combined with 5-FU, platinum-based chemotherapy, and trastuzumab, has demonstrated significant enhancements in response rates for HER2-positive metastatic EGA. However, there is currently insufficient evidence regarding this treatment approach in localized HER2-positive disease. Methods The PHERFLOT study is an open-label, single-arm, multicenter, exploratory phase II trial designed to assess the efficacy, safety, and tolerability of perioperative pembrolizumab, FLOT, and trastuzumab in patients with previously untreated localized HER2-positive EGA. In total, 30 patients will be recruited. The co-primary end points are pathological complete response rate and disease-free survival rate after 2 years. Secondary objectives include safety and tolerability, efficacy in terms of progression-free survival and objective response rate and translational markers, such as blood-based signatures (e.g., immune repertoire changes or emergence of anti-HER2 resistance variants) or microbiota signatures that may correlate with immune activation and therapy response. Discussion Recent evidence from phase II clinical trials demonstrated improved efficacy through the addition of trastuzumab to perioperative FLOT. Furthermore, in advanced or metastatic EGA, the combination of trastuzumab, FLOT, and the PD1-inhibitor pembrolizumab significantly improved treatment response. The PHERFLOT study aims to assess the efficacy and safety of this treatment approach in HER2-positive-localized EGA, potentially identifying a promising new perioperative regimen for localized EGA, which then needs to be confirmed within a randomized trial. Furthermore, the accompanying translational program of the study might help to improve the stratification of suitable patients and to identify potential translational targets for future clinical trials. Clinical trial registration https://clinicaltrials.gov, identifier NCT05504720.
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Affiliation(s)
- Joseph Tintelnot
- ll. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander Stein
- Hematology-Oncology Practice Eppendorf (HOPE), Hamburg, Germany
| | | | - Thomas Ettrich
- l. Department of Medicine, University Hospital Ulm, Ulm, Germany
| | - Thorsten Götze
- Institute of Clinical Cancer Research, Krankenhaus Nordwest, Frankfurt, Germany
| | - Barbara Grün
- Department of Medical Oncology, University Medical Center Heidelberg, Heidelberg, Germany
| | - Georg Martin Haag
- Department of Medical Oncology, University Medical Center Heidelberg, Heidelberg, Germany
| | - Vera Heuer
- Department of Oncology, St. Anna Hospital Herne, Herne, Germany
| | | | - Nils Homann
- ll. Medical Department, Klinikum Wolfsburg, Wolfsburg, Germany
| | | | - Mariana Santos Cruz
- ll. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Annika Kurreck
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Hematology, Oncology, and Cancer Immunology, Berlin, Germany
| | - Sylvie Lorenzen
- Rechts der Isar Hospital, Technical University of Munich, Munich, Germany
| | - Nicolas Moosmann
- Department of Oncology and Hematology, Barmherzige Brüder Regensburg Hospital, Regensburg, Germany
| | - Christian Müller
- Department of Hematology and Oncology, Klinik Essen-Mitte, Essen, Germany
| | - Markus Schuler
- Onkologischer Schwerpunkt am Oskar-Helene-Heim, Berlin, Germany
| | - Gabriele Siegler
- Department of Internal Medicine V, Hematology/Oncology, Hospital Nürnberg Nord/Paracelsus Medical University, Nürnberg, Germany
| | - Mascha Binder
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Eray Gökkurt
- Hematology-Oncology Practice Eppendorf (HOPE), Hamburg, Germany
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Aisa A, Weng S, Li X, Zhang D, Yuan Y. Immune Checkpoint Inhibitors combined with HER-2 targeted therapy in HER-2 positive Gastroesophageal cancer. Crit Rev Oncol Hematol 2022; 180:103864. [DOI: 10.1016/j.critrevonc.2022.103864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/25/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022] Open
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Högner A, Moehler M. Immunotherapy in Gastric Cancer. Curr Oncol 2022; 29:1559-1574. [PMID: 35323331 PMCID: PMC8946975 DOI: 10.3390/curroncol29030131] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/25/2022] [Accepted: 02/28/2022] [Indexed: 12/30/2022] Open
Abstract
Immune checkpoint inhibition is a new standard of targeted therapy in the treatment of advanced or metastatic gastric cancer (GC) and is represented in various combinations with and without chemotherapy in every therapy line within clinical trials. In advanced adenocarcinoma of GC, gastroesophageal junction cancer (GEJC) and esophageal cancer (EC), the combination of nivolumab and chemotherapy in first-line therapy improves overall survival (OS) in PD-L1 (programmed cell death protein 1)-positive patients with approval in Europe (PD-L1 CPS (combined positivity score) ≥ 5), USA and Taiwan (CHECKMATE-649) and pembrolizumab plus chemotherapy for GEJC and EC in Europe (CPS ≥ 10) and the USA (KEYNOTE-590). Furthermore, pembrolizumab plus trastuzumab and chemotherapy show clear benefits in OS and are approved as first-line treatment of Her2 (human epidermal growth factor receptor-2)-positive tumors in the USA (KEYNOTE-811). Nivolumab demonstrates superior OS regardless of PD-L1 expression in third-line therapy with approval in Japan (ATTRACTION-02) and pembrolizumab prolonged the duration of response in PD-L1 positive patients with approval in the USA in PD-L1 CPS ≥ 1 patients (KEYNOTE-059). This review reflects the rationale and current results of phase II and III clinical trials investigating various immune checkpoint inhibitors targeting PD-L1/1 and CTLA (anticytotoxic T-lymphocyte-associated antigen)-4 in combination with and without chemotherapy and Her2-targeted therapy in GC.
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Affiliation(s)
- Anica Högner
- Campus Virchow-Klinikum, Medizinische Klinik m.S. Hämatologie, Onkologie und Tumorimmunologie, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany;
| | - Markus Moehler
- Universitätsmedizin der Johannes Gutenberg-Universität Mainz, 55131 Mainz, Germany
- Correspondence:
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Tintelnot J, Goekkurt E, Binder M, Thuss-Patience P, Lorenzen S, Knorrenschild JR, Kretzschmar A, Ettrich T, Lindig U, Jacobasch L, Pink D, Al-Batran SE, Hinke A, Hegewisch-Becker S, Nilsson S, Bokemeyer C, Stein A. Ipilimumab or FOLFOX with Nivolumab and Trastuzumab in previously untreated HER2-positive locally advanced or metastatic EsophagoGastric Adenocarcinoma - the randomized phase 2 INTEGA trial (AIO STO 0217). BMC Cancer 2020; 20:503. [PMID: 32487035 PMCID: PMC7268753 DOI: 10.1186/s12885-020-06958-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 05/13/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Esophagogastric adenocarcinoma (EGA) currently represents a main cause of cancer related death. Despite an intensified treatment for locally advanced or metastatic EGA with a doublet chemotherapy consisting of a platinum compound and a fluoropyrimidine in combination with trastuzumab for HER2-positive disease or in selected cases with docetaxel, survival remains poor. Recently, immune-oncology based strategies relevantly improved the treatment of different solid tumors and showed some promise in late or later stage trials in EGA. Notably, the combination of immunotherapy with trastuzumab to enhance anti-tumor immunity through activation of innate and adaptive immunity was beneficial in preclinical studies or clinical studies in breast cancer. METHODS The INTEGA study is an open-label, randomized, multicenter, exploratory phase II trial designed to assess clinical performance, safety and tolerability of ipilimumab or 5-FU/folinic acid and oxaliplatin (FOLFOX) in combination with nivolumab and trastuzumab in patients with previously untreated HER2-positive, locally advanced or metastatic EGA. The primary objective is to determine the clinical performance of ipilimumab or FOLFOX in combination with nivolumab and trastuzumab in terms of overall survival. Secondary objectives are safety and tolerability, efficacy in terms of progression-free survival and objective response rate and blood-based signatures (e.g. immune response or suppression of anti-HER2 resistance) that may correlate with treatment response. DISCUSSION Recent evidence from the phase II NCT02954536 study (oxaliplatin, capecitabine, trastuzumab and pembrolizumab) suggests the clinical feasibility of combining chemotherapy, trastuzumab and checkpoint inhibition in EGA. However, evidence for a chemotherapy-free regimen is also mounting in HER2-positive disease (NCT02689284) i.e. margetuximab and Pembrolizumab. Both studies excelled with high overall response rates and manageable toxicities. The INTEGA study aims to comparatively assess these results and select a promising new 1st line regimen which then needs to be confirmed in a randomized phase III trial. Further, the translational part of the study might help to better stratify patients and tailor treatment of either arm. TRIAL REGISTRATION NCT03409848 24.01.2018.
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Affiliation(s)
- Joseph Tintelnot
- Department of Internal Medicine II (Oncology Center), University Medical Center Hamburg-Eppendorf, Hubertus Wald Tumorzentrum/UCCH, Martinistr. 52, 20246, Hamburg, Germany
| | - Eray Goekkurt
- Department of Internal Medicine II (Oncology Center), University Medical Center Hamburg-Eppendorf, Hubertus Wald Tumorzentrum/UCCH, Martinistr. 52, 20246, Hamburg, Germany
- Hematology-Oncology Practice Hamburg (HOPE), Hamburg, Germany
| | - Mascha Binder
- University Hospital Halle-Wittenberg, Halle, Germany
| | | | - Sylvie Lorenzen
- Rechts der Isar Hospital, Technical University of Munich, Munich, Germany
| | | | | | | | | | | | - Daniel Pink
- Helios Clinic Bad Saarow, Bad Saarow, Germany and University Medicine Greifswald, Greifswald, Germany
| | | | | | | | - Sven Nilsson
- Department of Internal Medicine II (Oncology Center), University Medical Center Hamburg-Eppendorf, Hubertus Wald Tumorzentrum/UCCH, Martinistr. 52, 20246, Hamburg, Germany
| | - Carsten Bokemeyer
- Department of Internal Medicine II (Oncology Center), University Medical Center Hamburg-Eppendorf, Hubertus Wald Tumorzentrum/UCCH, Martinistr. 52, 20246, Hamburg, Germany
| | - Alexander Stein
- Department of Internal Medicine II (Oncology Center), University Medical Center Hamburg-Eppendorf, Hubertus Wald Tumorzentrum/UCCH, Martinistr. 52, 20246, Hamburg, Germany.
- Hematology-Oncology Practice Hamburg (HOPE), Hamburg, Germany.
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Selim JH, Shaheen S, Sheu WC, Hsueh CT. Targeted and novel therapy in advanced gastric cancer. Exp Hematol Oncol 2019; 8:25. [PMID: 31632839 PMCID: PMC6788003 DOI: 10.1186/s40164-019-0149-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 09/28/2019] [Indexed: 12/14/2022] Open
Abstract
The systemic treatment options for advanced gastric cancer (GC) have evolved rapidly in recent years. We have reviewed the recent data of clinical trial incorporating targeted agents, including inhibitors of angiogenesis, human epidermal growth factor receptor 2 (HER2), mesenchymal-epithelial transition, epidermal growth factor receptor, mammalian target of rapamycin, claudin-18.2, programmed death-1 and DNA. Addition of trastuzumab to platinum-based chemotherapy has become standard of care as front-line therapy in advanced GC overexpressing HER2. In the second-line setting, ramucirumab with paclitaxel significantly improves overall survival compared to paclitaxel alone. For patients with refractory disease, apatinib, nivolumab, ramucirumab and TAS-102 have demonstrated single-agent activity with improved overall survival compared to placebo alone. Pembrolizumab has demonstrated more than 50% response rate in microsatellite instability-high tumors, 15% response rate in tumors expressing programmed death ligand 1, and non-inferior outcome in first-line treatment compared to chemotherapy. This review summarizes the current state and progress of research on targeted therapy for advanced GC.
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Affiliation(s)
- Julie H. Selim
- School of Pharmacy, Loma Linda University, Loma Linda, CA 92350 USA
| | - Shagufta Shaheen
- Division of Oncology, Stanford Cancer Center, Stanford, CA 94304 USA
| | - Wei-Chun Sheu
- Department of Internal Medicine, Richmond University Medical Center, Staten Island, NY 10310 USA
| | - Chung-Tsen Hsueh
- Division of Medical Oncology and Hematology, Department of Medicine, Loma Linda University, 11175 Campus Street, CSP 11015, Loma Linda, CA 92354 USA
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Shahjehan F, Kamatham S, Kasi PM. Role of Circulating Tumor DNA in Gastrointestinal Cancers: Update From Abstracts and Sessions at ASCO 2018. Front Oncol 2019; 9:358. [PMID: 31139561 PMCID: PMC6519295 DOI: 10.3389/fonc.2019.00358] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 04/17/2019] [Indexed: 11/13/2022] Open
Abstract
Background: The promising aspect of circulating tumor DNA (ctDNA) is its rapid turnaround and non-invasive nature. According to the American Society of Clinical Oncology (ASCO) and College of American Pathologists joint ctDNA review published in March 2018, there is not sufficient evidence to support the use of ctDNA in practice for GI cancers. However, there were numerous studies presented at ASCO Annual Meeting supporting its value. We aimed to summarize on its role in the management of gastrointestinal cancers based on the studies presented recently, and future directions. Methods: We limited our search to keywords "ctDNA," "circulating tumor DNA," "cell-free DNA (cfDNA)" and/or "liquid biopsy," at the 2018 ASCO Annual Meeting library abstracts and presentations. Results: There were 35 studies that revolved around ctDNA as a diagnostic tool, prognostic marker and/or a measure of tumor heterogeneity in gastrointestinal cancers. Depending on the assay used, the results of several studies showed that ctDNA was able to identify relevant mutations or fusions including RAS, HER2/Neu, BRAF, MET, BRCA2, APC, TP53, ALK, ROS1, PTEN, and NF1. The prognosis in terms of tumor mutation burden, objective response rate, metastasis and survival were also estimated by various studies based on ctDNA. The findings showed that higher baseline ctDNA levels and/or increased number of mutations detected in ctDNA were associated with poor survival and multi-site metastasis. Right-sided colon cancer was associated with higher number of mutations in ctDNA than left-sided colon and rectal cancers. Similarly, tubular adenocarcinoma subtype of gastric cancer was more likely to have higher ctDNA levels than signet-ring cell subtype. The feasibility of assessing response to therapy and residual metastatic disease by using ctDNA which was otherwise not detected on imaging was also presented. Conclusions: The studies presented at ASCO 2018 report on the many ways ctDNA is of value in patients with gastrointestinal malignancies. Experts and discussants at the meeting argued that this may well indeed be ready for prime time for certain GI malignancies including colorectal cancers, especially in the metastatic setting. These findings alongside ongoing studies showing its feasibility into practice would likely lead to revision of the current guidelines for metastatic GI cancers.
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Affiliation(s)
- Faisal Shahjehan
- Division of Hematology, Oncology, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Saivaishnavi Kamatham
- Division of Hematology, Oncology, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Pashtoon Murtaza Kasi
- Division of Hematology, Oncology, University of Iowa Health Care, Iowa City, IA, United States
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Stein A, Thuss-Patience P. Immunotherapy in Esophagogastric Adenocarcinoma. Visc Med 2019; 35:12-16. [PMID: 31312645 PMCID: PMC6597905 DOI: 10.1159/000497292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 01/28/2019] [Indexed: 01/14/2023] Open
Abstract
Immunotherapy, particular PD-1/L1 inhibition, is a relevant treatment approach in esophagogastric adenocarcinoma. To date, single-agent activity is limited to the chemotherapy refractory setting and molecularly defined subgroups. Currently, ongoing trials, which are likely to relevantly change the landscape of treatment for this disease in the next years, evaluate different combination approaches with chemotherapy and/or molecular targeted agents in different disease settings. The German AIO study group has launched several combination trials in the perioperative, first-line, and advanced disease setting to further define the role of immunotherapy in esophagogastric adenocarcinoma.
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Affiliation(s)
- Alexander Stein
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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