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Zakharia Y, McWilliams RR, Rixe O, Drabick J, Shaheen MF, Grossmann KF, Kolhe R, Pacholczyk R, Sadek R, Tennant LL, Smith CM, Kennedy EP, Link CJ, Vahanian NN, Yu J, Shen SS, Brincks EL, Rossi GR, Munn D, Milhem M. Phase II trial of the IDO pathway inhibitor indoximod plus pembrolizumab for the treatment of patients with advanced melanoma. J Immunother Cancer 2021; 9:jitc-2020-002057. [PMID: 34117113 PMCID: PMC8202104 DOI: 10.1136/jitc-2020-002057] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 12/23/2022] Open
Abstract
Background The indoleamine 2,3-dioxygenase (IDO) pathway is a key counter-regulatory mechanism that, in cancer, is exploited by tumors to evade antitumor immunity. Indoximod is a small-molecule IDO pathway inhibitor that reverses the immunosuppressive effects of low tryptophan (Trp) and high kynurenine (Kyn) that result from IDO activity. In this study, indoximod was used in combination with a checkpoint inhibitor (CPI) pembrolizumab for the treatment for advanced melanoma. Methods Patients with advanced melanoma were enrolled in a single-arm phase II clinical trial evaluating the addition of indoximod to standard of care CPI approved for melanoma. Investigators administered their choice of CPI including pembrolizumab (P), nivolumab (N), or ipilimumab (I). Indoximod was administered continuously (1200 mg orally two times per day), with concurrent CPI dosed per US Food and Drug Administration (FDA)-approved label. Results Between July 2014 and July 2017, 131 patients were enrolled. (P) was used more frequently (n=114, 87%) per investigator’s choice. The efficacy evaluable population consisted of 89 patients from the phase II cohort with non-ocular melanoma who received indoximod combined with (P). The objective response rate (ORR) for the evaluable population was 51% with confirmed complete response of 20% and disease control rate of 70%. Median progression-free survival was 12.4 months (95% CI 6.4 to 24.9). The ORR for Programmed Death-Ligand 1 (PD-L1)-positive patients was 70% compared with 46% for PD-L1-negative patients. The combination was well tolerated, and side effects were similar to what was expected from single agent (P). Conclusion In this study, the combination of indoximod and (P) was well tolerated and showed antitumor efficacy that is worth further evaluation in selected patients with advanced melanoma.
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Affiliation(s)
- Yousef Zakharia
- University of Iowa Holden Comprehensive Cancer Center, Iowa City, Iowa, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jiayi Yu
- NewLink Genetics Corp, Ames, Iowa, USA
| | - Steven S Shen
- University of Minnesota Institute for Health Informatics, Minneapolis, Minnesota, USA
| | | | | | - David Munn
- Augusta University, Augusta, Georgia, USA
| | - Mohammed Milhem
- University of Iowa Holden Comprehensive Cancer Center, Iowa City, Iowa, USA
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Caforio M, Sorino C, Caruana I, Weber G, Camera A, Cifaldi L, De Angelis B, Del Bufalo F, Vitale A, Goffredo BM, De Vito R, Fruci D, Quintarelli C, Fanciulli M, Locatelli F, Folgiero V. GD2 redirected CAR T and activated NK-cell-mediated secretion of IFNγ overcomes MYCN-dependent IDO1 inhibition, contributing to neuroblastoma cell immune escape. J Immunother Cancer 2021; 9:jitc-2020-001502. [PMID: 33737337 PMCID: PMC7978286 DOI: 10.1136/jitc-2020-001502] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 12/31/2022] Open
Abstract
Immune escape mechanisms employed by neuroblastoma (NB) cells include secretion of immunosuppressive factors disrupting effective antitumor immunity. The use of cellular therapy to treat solid tumors needs to be implemented. Killing activity of anti-GD2 Chimeric Antigen Receptor (CAR) T or natural killer (NK) cells against target NB cells was assessed through coculture experiments and quantified by FACS analysis. ELISA assay was used to quantify interferon-γ (IFNγ) secreted by NK and CAR T cells. Real Time PCR and Western Blot were performed to analyze gene and protein levels modifications. Transcriptional study was performed by chromatin immunoprecipitation and luciferase reporter assays on experiments of mutagenesis on the promoter sequence. NB tissue sample were analyzed by IHC and Real Time PCR to perform correlation study. We demonstrate that Indoleamine-pyrrole 2,3-dioxygenase1 (IDO1), due to its ability to convert tryptophan into kynurenines, is involved in NB resistance to activity of immune cells. In NB, IDO1 is able to inhibit the anti-tumor effect displayed by of both anti-GD2 CAR (GD2.CAR) T-cell and NK cells, mainly by impairing their IFNγ production. Furthermore, inhibition of MYCN expression in NB results into accumulation of IDO1 and consequently of kynurenines, which negatively affect the immune surveillance. Inverse correlation between IDO1 and MYCN expression has been observed in a wide cohort of NB samples. This finding was supported by the identification of a transcriptional repressive role of MYCN on IDO1 promoter. The evidence of IDO1 involvement in NB immune escape and its ability to impair NK and GD2.CAR T-cell activity contribute to clarify one of the possible mechanisms responsible for the limited efficacy of these immunotherapeutic approaches. A combined therapy of NK or GD2.CAR T-cells with IDO1 inhibitors, a class of compounds already in phase I/II clinical studies, could represent a new and still unexplored strategy capable to improve long-term efficacy of these immunotherapeutic approaches.
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Affiliation(s)
- Matteo Caforio
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy.,Departement of Biochemical Sciences "A Rossi Fanelli", Sapienza University of Rome, Rome, Italy
| | - Cristina Sorino
- SAFU Laboratory, Department of Research, Advanced Diagnostic, and Technological Innovation, Istituto Regina Elena Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy, Italy
| | - Ignazio Caruana
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Gerrit Weber
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Antonio Camera
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Loredana Cifaldi
- Academic Department of Pediatrics (DPUO), IRCCS Bambino Gesù Children's Hospistal, Rome, Italy.,Department of Clical Sciences and Translational Medicine, University of Tor Vergata, Rome, Italy
| | - Biagio De Angelis
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Francesca Del Bufalo
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Alessia Vitale
- Division of Metabolism and Research Unit of Metabolic Biochemistry, IRCCS Bambino gesù Children's Hospital, Rome, Italy
| | - Bianca Maria Goffredo
- Division of Metabolism and Research Unit of Metabolic Biochemistry, IRCCS Bambino gesù Children's Hospital, Rome, Italy
| | - Rita De Vito
- Department of Laboratories, Pathology Unit, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Doriana Fruci
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Concetta Quintarelli
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy.,Departyment of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Maurizio Fanciulli
- SAFU Laboratory, Department of Research, Advanced Diagnostic, and Technological Innovation, Istituto Regina Elena Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy, Italy
| | - Franco Locatelli
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy.,Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Valentina Folgiero
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
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