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Badran YR, Zou F, Durbin SM, Dutra BE, Abu-Sbeih H, Thomas AS, Altan M, Thompson JA, Qiao W, Leet DE, Lai PY, Horick NK, Postow MA, Faleck DM, Wang Y, Dougan M. Concurrent immune checkpoint inhibition and selective immunosuppressive therapy in patients with immune-related enterocolitis. J Immunother Cancer 2023; 11:e007195. [PMID: 37349130 PMCID: PMC10314704 DOI: 10.1136/jitc-2023-007195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 06/24/2023] Open
Abstract
PURPOSE Immune checkpoint inhibitor (ICI) therapy is often suspended because of immune-related enterocolitis (irEC). We examined the effect of resumption of ICIs with or without concurrent selective immunosuppressive therapy (SIT) on rates of symptom recurrence and survival outcomes. METHODS This retrospective, multicenter study examined patients who were treated with ICI and developed irEC requiring SIT (infliximab or vedolizumab) for initial symptom control or to facilitate steroid tapering between May 2015 and June 2020. After symptom resolution, patients were restarted either on ICI alone or on concurrent ICI and SIT at the discretion of the treating physicians. The associations between irEC recurrence and treatment group were assessed via univariate analyses and multivariate logistic regression. Cox proportional hazards model was used for survival analysis. RESULTS Of the 138 included patients who required SIT for initial irEC symptom control, 61 (44.2%) patients resumed ICI without concurrent SIT (control group) and 77 (55.8%) patients resumed ICI therapy with concurrent SIT: 33 with infliximab and 44 with vedolizumab. After symptom resolution, patients in the control group were more commonly restarted on a different ICI regimen (65.6%) compared with those receiving SIT (31.2%) (p<0.001). The total number of ICI doses administered after irEC resolution and ICI resumption was similar in both groups (four to five doses). Recurrence of severe colitis or diarrhea after ICI resumption was seen in 34.4% of controls compared with 20.8% of patients receiving concurrent SIT. Concurrent SIT was associated with reduced risk of severe irEC recurrence after ICI resumption in a multivariate logistic regression model (OR 0.34; 95% CI 0.13 to 0.92; p=0.034). There was no difference in survival outcomes between patients in the control group and patients concurrently treated with SIT. CONCLUSION After resolution of irEC symptoms, reinitiation of ICI with concurrent SIT is safe, reduces severe irEC recurrence, and has no negative impact on survival outcomes.
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Affiliation(s)
- Yousef R Badran
- Division of Gastroenterology, Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Fangwen Zou
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China
| | - Sienna M Durbin
- Harvard Medical School, Boston, MA, USA
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Barbara E Dutra
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Hamzah Abu-Sbeih
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Anusha S Thomas
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mehmet Altan
- Department of Thoracic, Head & Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - John A Thompson
- Department of Medicine, Division of Oncology, Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, University of Washington, Seattle, Washington, USA
| | - Wei Qiao
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Donna E Leet
- Harvard Medical School, Boston, MA, USA
- Department of Internal Medicine, University of California San Francisco, San Francisco, California, USA
| | - Po-Ying Lai
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Nora K Horick
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Michael A Postow
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical Center, New York, New York, USA
| | - David M Faleck
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical Center, New York, New York, USA
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Dougan
- Division of Gastroenterology, Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
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Ventre KS, Roehle K, Bello E, Bhuiyan AM, Biary T, Crowley SJ, Bruck PT, Heckler M, Lenehan PJ, Ali LR, Stump CT, Lippert V, Clancy-Thompson E, Conce Alberto WD, Hoffman MT, Qiang L, Pelletier M, Akin JJ, Dougan M, Dougan SK. cIAP1/2 Antagonism Induces Antigen-Specific T Cell-Dependent Immunity. J Immunol 2023; 210:991-1003. [PMID: 36881882 PMCID: PMC10036868 DOI: 10.4049/jimmunol.2200646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/24/2023] [Indexed: 03/09/2023]
Abstract
Checkpoint blockade immunotherapy has failed in pancreatic cancer and other poorly responsive tumor types in part due to inadequate T cell priming. Naive T cells can receive costimulation not only via CD28 but also through TNF superfamily receptors that signal via NF-κB. Antagonists of the ubiquitin ligases cellular inhibitor of apoptosis protein (cIAP)1/2, also called second mitochondria-derived activator of caspases (SMAC) mimetics, induce degradation of cIAP1/2 proteins, allowing for the accumulation of NIK and constitutive, ligand-independent activation of alternate NF-κB signaling that mimics costimulation in T cells. In tumor cells, cIAP1/2 antagonists can increase TNF production and TNF-mediated apoptosis; however, pancreatic cancer cells are resistant to cytokine-mediated apoptosis, even in the presence of cIAP1/2 antagonism. Dendritic cell activation is enhanced by cIAP1/2 antagonism in vitro, and intratumoral dendritic cells show higher expression of MHC class II in tumors from cIAP1/2 antagonism-treated mice. In this study, we use in vivo mouse models of syngeneic pancreatic cancer that generate endogenous T cell responses ranging from moderate to poor. Across multiple models, cIAP1/2 antagonism has pleiotropic beneficial effects on antitumor immunity, including direct effects on tumor-specific T cells leading to overall increased activation, increased control of tumor growth in vivo, synergy with multiple immunotherapy modalities, and immunologic memory. In contrast to checkpoint blockade, cIAP1/2 antagonism does not increase intratumoral T cell frequencies. Furthermore, we confirm our previous findings that even poorly immunogenic tumors with a paucity of T cells can experience T cell-dependent antitumor immunity, and we provide transcriptional clues into how these rare T cells coordinate downstream immune responses.
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Affiliation(s)
- Katherine S. Ventre
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA
| | - Kevin Roehle
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA
- Department of Immunology, Harvard Medical School, Boston, MA
- Novartis Institute for Biomedical Research, Cambridge, MA
| | - Elisa Bello
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Aladdin M. Bhuiyan
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Tamara Biary
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Stephanie J. Crowley
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA
| | - Patrick T. Bruck
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA
| | - Max Heckler
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA
- Department of Immunology, Harvard Medical School, Boston, MA
| | - Patrick J. Lenehan
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA
- Department of Immunology, Harvard Medical School, Boston, MA
| | - Lestat R. Ali
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Courtney T. Stump
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA
- Department of Immunology, Harvard Medical School, Boston, MA
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Victoria Lippert
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA
| | - Eleanor Clancy-Thompson
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA
- Department of Immunology, Harvard Medical School, Boston, MA
| | - Winiffer D. Conce Alberto
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA
- Department of Immunology, Harvard Medical School, Boston, MA
| | - Megan T. Hoffman
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA
- Department of Immunology, Harvard Medical School, Boston, MA
| | - Li Qiang
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA
- Department of Immunology, Harvard Medical School, Boston, MA
| | - Marc Pelletier
- Novartis Institute for Biomedical Research, Cambridge, MA
| | - James J. Akin
- Novartis Institute for Biomedical Research, Cambridge, MA
| | - Michael Dougan
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Stephanie K. Dougan
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA
- Department of Immunology, Harvard Medical School, Boston, MA
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