Targ Oncol DOI 10.1007/s11523-014-0337-6

ORIGINAL RESEARCH

Dose-finding/phase II trial: bevacizumab, immunotherapy, and chemotherapy (BIC) in metastatic renal cell cancer (mRCC). Antitumor effects and variations of circulating T regulatory cells (Treg) M. Donini & S. Buti & S. Lazzarelli & R. Bozzetti & L. Rivoltini & C. Camisaschi & C. Castelli & A. Bearz & C. Simonelli & G. Lo Re & R. Mattioli & C. Caminiti & R. Passalacqua & GOIRC (Italian Oncology Group for Clinical Research)

Received: 9 January 2014 / Accepted: 29 August 2014 # Springer International Publishing Switzerland 2014

Abstract The aim of this study was to explore the efficacy and toxicities of a combined regimen of bevacizumab plus immunotherapy and chemotherapy (BIC) and the circulating T regulatory cells (Treg) in metastatic renal cell cancer (mRCC). Nephrectomized mRCC patients were enrolled into a multicenter single-arm dose-finding study with five escalated dose From the GOIRC (Italian Oncology Group for Clinical Research) M. Donini (*) : S. Buti : S. Lazzarelli : R. Bozzetti : R. Passalacqua Oncology Division, Azienda Istituti Ospitalieri di Cremona, Viale Concordia 1, 26100 Cremona, Italy e-mail: [email protected] S. Buti Oncology Unit, Azienda Ospedaliero-universitaria di Parma, Parma, Italy L. Rivoltini : C. Camisaschi : C. Castelli Unit of Immunotherapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy A. Bearz : C. Simonelli Oncology Division, Centro di Riferimento Oncologico, Aviano, Pordenone, Italy C. Simonelli Clinical Research Menarini Ricerche, Florence, Italy G. Lo Re Oncology Division, Azienda Ospedaliera Santa Maria degli Angeli, Pordenone, Italy

levels of chemotherapy with intravenous gemcitabine and 5fluorouracil associated with fixed intravenous doses of bevacizumab, subcutaneous low doses of interleukin-2, and interferon-α-2a. An expanded cohort (phase II study) was treated at the recommended dose for additional safety and efficacy information according to minimax Simon two-stage design. Blood samples for Treg were collected and evaluated by fluorescence-activated cell sorting (FACS) analysis on cycle 1. Fifty-one patients were entered to receive one of five dose levels. Median age was 58 years (male 67 %, pretreated 49 %): 15 patients were low risk according to Memorial SloanKettering Cancer Center (MSKCC) criteria, while 27 and nine were respectively intermediate- and high-risk patients. More frequent grade 3 and 4 toxicities included nonfebrile neutropenia, thrombocytopenia, and fever. Among patients evaluable for response (49), 29.5 % had partial response and 37 % stable disease. Overall median time to progression and median overall survival were 8.8 and 22.67 months, respectively. We observed a rapid increase in the percentage of Treg after immunotherapy and a reduction after bevacizumab only in patient who obtained a partial response or stable disease. The BIC was feasible, well tolerated, and shown interesting activity. Further studies are needed to explore if Treg could have a role in clinical response in mRCC treated with bevacizumab. Keywords Bevacizumab . Immunotherapy . Chemotherapy . Renal cell cancer . Treg

R. Mattioli Oncology Unit, Azienda Ospedaliera Santa Croce, Fano, Italy

Introduction

C. Caminiti Research and Innovation Unit, Azienda Ospedaliero-universitaria di Parma, Parma, Italy

At the time this study was planned (autumn 2005), immunotherapy (IT) with IFN-α had been extensively studied in the

Targ Oncol

treatment of metastatic renal cell carcinoma (mRCC), both as monotherapy and in combination with IL-2 or/and chemotherapy (CT) [1, 2]. CT was rarely used against mRCC, and it was employed only for progressing, unresponsive patients [1, 2]. The few published trial showed at the best a response rate (RR) of 10–15 %, with the combination of gemcitabine and 5fluorouracil representing the best regimen [3, 4]. In a previous analysis of a series of mRCC patients treated with the combination of chemotherapy (gemcitabine+5-fluorouracil) plus IT (low doses IL-2+IFN-α), we described a modest but definite activity of this combination with a good disease control rate and tolerability [3]. The rationale for combining CT with antivascular endothelial growth factor (VEGF) drugs is based on preclinical data showing that anti-VEGF therapy normalizes tumor vascularization and improves the distribution of CT agents to tumoral cells [5] and also on the results of clinical trials in other tumors [6]. On the basis of these results, we conducted this study using drugs with different mechanisms of action against mRCC in order to overcome single drug resistance and improve efficacy. This was the first study investigating CT-IT combined with bevacizumab (called BIC). Data of the dose-finding of this study were yet published [7]. An expanded cohort (phase II study) was treated at the recommended doses to assess further tolerability and efficacy of the combination. Furthermore, we know that IL-2 is an essential cytokine for development and expansion of regulatory T cells, also with moderate to lower dose [8]. Treg are a subset of CD4+ T cells that constitutively express the IL-2 receptor CD25, but the lineage-defining and master regulator is dictated by expression of the forkhead box P3 transcription factor (Foxp3) [9]. These cells have immunosuppressive properties and have a critical role in maintaining self-tolerance and homeostasis [10]. Depletion of Treg in vivo enhances antitumor immunity and facilitates tumor rejection. Moreover, there are some evidence that tumor cells can directly convert CD4+CD25T cells into Treg [11]. We do not know their role in clinical response. We observed the variations of peripheral Treg during the first cycle of therapy.

Patients and methods Patients Eligible patients were prior presented in published phase I study (nephrectomized, pretreated, or not, metastatic patients with measurable lesions per Response Evaluation Criteria in Solid Tumors version 1.0 (RECIST) [12], with an histological diagnosis of clear cell renal cancer; age of ≥18 years; Eastern Cooperative Oncology Group performance status (PS) of 0–1, an adequate bone marrow, hepatic, and renal function and

signed informed consent). Among the exclusion criteria are the following: cerebral metastases untreated by surgery or radiotherapy; a history of inflammatory intestinal disease and/or acute/subacute intestinal occlusion; a severe wound or ulcer that will not heal; evidence of hemorrhagic diathesis or coagulopathy; arterial hypertension uncontrolled by medical therapy; significant cardiovascular disease ongoing or in the previous 6 months; and major surgery, within the 28 days preceding the study treatment [7]. Study design This was a multicentre single-arm dose-finding/phase II study involving four Italian centers; the study was sponsored by the Gruppo Oncologico Italiano di Ricerca Clinica (GOIRC), with a research grant by the Roche and approved by the centers’ local Ethic Committees before the enrollment of the first patient. The study was registered at the EudraCT Identifier (2005-005670-71). In the dose-finding portion, five incremental doses of the chemotherapeutic drugs (gemcitabine and 5-fluorouracil) were used to determine the maximum dose tolerated (MTD) [7]. In the phase II portion, an additional cohort was treated at the recommended dose level, as established in dose-finding portion, to assess safety and feasibility further. Treatment Each treatment cycle lasted 28 days. Details of the doseescalation plan have been previously reported: maximum tolerated dose (MTD) was not achieved and we used for phase II portion the fifth level of dose [7]: gemcitabine (Gemzar, Eli Lilly, Indianapolis, IN, USA) was administered at the recommended dose of 1,000 mg/m2 intravenously (i.v.) over 1 h, before the administration of 5-fluorouracil; undiluted 5fluorouracil (Fluorouracile, Teva Pharma Italia, Milan, Italy) was administered at the recommended dose of 600 mg/m2 exclusively as an i.v. bolus over 1–2 min. This CT was administered with antiemetic i.v. premedication (5-HT3 receptor antagonists), on days 1 and 8 and continued until the onset of progression of disease (PD) or unacceptable toxicity, up to a maximum of six cycles. Bevacizumab (Avastin, Roche, Basel, Switzerland) was administered every 2 weeks (on days 1 and 15) at a dose of 10 mg/kg in an i.v. infusion lasting from 30 to 90 min, after the CT. IL-2 (Proleukin, Chiron, Amsterdam, the Netherlands) was administered s.c. at a dose of 1,000,000 IU/m2 twice a day (every 12 h) on days 8, 9, 15, and 16, and once a day from day 10 to day 12 and from day 17 to day 19. IFN-α (IFN-α-2a: Roferon-A, Roche, Basel, Switzerland) was administered s.c. at a dose of 3,000,000 IU, once a day in the evening on days 10, 12, 17, and 19. This IT and bevacizumab were

Targ Oncol

administered also after the completion of the six cycles (maintenance), until the onset of PD or unacceptable toxicity, unless the investigator or patient decided otherwise. If a patient’s weight changed by >10 % during the treatment, the doses had to be recalculated. Patients were evaluated for adverse events based on the National Cancer Institute Common Toxicity Criteria, version 3 [13]. If occurrence of grade 2–4 adverse events, the protocol laid down preestablished criteria for reducing the CT and IT doses by up to 50 % of the initial dose and on a maximum of two occasions; it also laid down precise criteria for postponing treatment. Study assessment Response was assessed every 12 weeks during treatment (or earlier if there was a clinical suspicion of PD) by RECIST [12]. Disease control rate (DCR) was defined as RR plus disease stabilization rate. If patients leaving the study for any reason other than PD, tumor assessments continued to be made every 3 months until a finding of PD. Statistics All safety and efficacy end points were analyzed on the basis of available data. After completion of the dose-finding portion of this study [7], the phase II portion was carried out according to minimax Simon two-stage design. Following this approach, we chose the lower activity (p0) of 0.12 and target activity level (p1) of 0.32. A maximum of 25 assessable patients would be needed to guarantee 80 % power under a [alpha]level of 5 %. The first stage was designed to accrue 15 patients: if a number of patients ≤1/15 had responded, the study would be closed and the regimen would be rejected as inactive. Instead if more than 1/15 had responded, an additional ten patients had to be enrolled (second stage). In this final stage, the regimen would be rejected as unable to add efficacy to a schedule with cytokines only, if a number of patients ≤5/25 had responded. The RR and toxicity were estimated using all of the enrolled patients (intention-to-treat analysis). Overall survival (OS) was calculated from the date of randomization to death. Time to progression (TTP) was defined as the time between randomization and the date of disease progression or death. Patients still alive or not yet in PD were considered censored. The Kaplan-Meier method was used to estimate the trend of TTP and OS, and two-sided p values were recorded for all of the analyses, which were made using STATA Statistics software vs 9.2. Treg For consenting patients, blood samples for measurements of Treg were obtained by fluorescence-activated cell sorting

(FACS) analysis on days 1, 8, 15, 22, and 29 of cycle 1 and day 29 of cycle 2, identified as CD4+CD25highFoxP3+ in peripheral blood mononuclear cells (PBMCs) isolated from whole blood using Ficoll-Paque method.

Results Patient characteristics The study overall enrolled 51 patients from February 2006 and January 2009, 25 of whom (49 %) had been previously treated and 26 (51 %) were naïve. In the dose-finding portion of this study, which has already been published, 27 patients were enrolled [7]. Thirty patients were treated at the recommended dose level including both those in dose-finding (six patients) and in phase II portion (24 patients). Table 1 shows the general characteristics of the patients. Summary of treatment and adverse events The MTD had not been reached, dose level 5 (gemcitabine 1,000 mg/m2 and 5-fluorouracil 600 mg/m2) was defined the recommended dose to be combined with low-dose IT and bevacizumab in subsequent phase II studies [7]. All patients enrolled received at least one cycle of therapy. The median follow-up was 33.7 months (IC 95 % 26.8–35.4). The median number of cycles of chemotherapy was 6 (range 1–7). The median number of bevacizumab infusions was 12 (range 2–64). All patients were evaluated for toxicity. No allergic reaction was recorded. Table 2 shows all of the adverse events of any grade recorded throughout the study. All of these were reversible after a dose reduction or delayed administration. The most frequently recorded grade 3–4 toxicities were neutropenia (58 %), febrile neutropenia (2 %), thrombocytopenia (31 %), and fever (20 %); 25 patients (49 %) had to postpone treatment due to adverse events, while patients for which doses were reduced at least once due to toxicities were respectively 37 (72 %) for IT and 39 (76 %) for CT. All of the dose postponements and reductions were made in accordance with the preestablished protocol criteria. One patients interrupted treatment due to adverse events (grade 3–4 proteinuria). During the IT, most of the patients developed a hard and often pruritic or painful erythematous lesion at the IL-2 injection site, as well as constitutional symptoms such as fever, shivers, mild malaise, and asthenia that regressed upon taking oral paracetamol 500–1,000 mg and in any case within 24 h of the injection; the incidence and grade of this IT-related toxicity tended to decrease during the subsequent cycles. No clearly treatment-related deaths were recorded.

Targ Oncol Table 1 Main patients’ characteristics Characteristics

No. of patients No. of patients evaluable for toxicity No. of patients evaluable for response Gender Male Female Age (years) Median Range Risk group MSKCC 2002 Low Intermediate High ECOG PS 0 1 2a Previous treatment IT CT Metastatic sites Lung Lymph nodes Bone Liver Local relapse Brain (treated)b >1 metastatic sites

Table 2 All-grade adverse events All patients

Pretreated

Toxicity

No.

%

No.

%

51 51 49

100 96

25 25 23

49 100 92

34 17

67 33

15 10

40 60

58 28–80

56 28–79

15 29 27 53 9 18

10 13 2

40 52 8

42 8

82 16

21 4

84 16

1

2

0

0

12 10

23 20

12 10

23 20

38 24 20 17 6 3 43

74 47 39 33 12 6 84

22 13 11 11 1 3 24

88 52 44 44 4 12 96

ECOG PS Eastern Cooperative Oncology Group performance status, MSKCC Memorial Sloan-Kettering Cancer Center risk score [24] a

Protocol deviation

b

All of the metastases were treated with radiotherapy or were surgically removed

Response Phase II results showed a DCR of 68 % (32 % PR; 36 % SD; 32 % PD); median TTP was 8.2 months (confidence interval (CI) 95 % 4.4–11.9) and median OS was 18.4 months (CI 95 % 10.5–26.2). All patients were evaluable for response. Overall population results showed a DCR of 66 %: 15 (29.5 %) patients obtained partial response (PR), 19 (37 %) stable disease (SD), and 15 (29.5 %) had a progression disease (PD). Two of the overall 51 patients enrolled were not evaluable for response: one patient because of toxicity (he discontinued therapy during second cycle due to grade 3 proteinuria) and one patient because of a protocol violation

Grade 1

2

3

4

Leukopenia Neutropenia Febrile neutropenia Thrombocytopenia Anemia Hypertransaminasemia Mucositis Nausea/vomiting Diarrhea Constipation Arterial hypertension Proteinuria Renal failure Macro-hematuria

6% 6% – 31 % 25 % 10 % 18 % 39 % 10 % 14 % 12 % 12 % 7% 8%

8% 18 % – 14 % 6% 18 % 4% 8% 12 % – 16 % 10 % 2% 2%

10 % 25 % – 27 % 4% 8% – 4% – – 8% 6% 2% –

2 33 2 4

Epistaxis Dyspnea Hemoptoe Fever Neurotoxicity Asthenia Anorexia Skin toxicity Cardiac toxicity Othera

47 5 10 25 6 18 17 20 6

% % % % % % % % %

6% 5% – 35 % 2% 16 % 7% 10 % 4%

– – % % – % % – %

– – – 6% 2% – – – –

24 %

19 %

17 %

6%

2 14 10 2 2

% % % % – – – – – – – 2% – –

Grades are according to National Cancer Institute Toxicity Criteria, version 3 [22]. Each adverse event was counted once (any cycle; highest grade) for each patient a

Pain, headache, myalgia, cough, mood depression, alopecia, hypoalbuminemia, thrombophlebitis, arthralgia, hypotension, deep vein thrombosis

of exclusion criteria (he was enrolled while he was responding to a previous treatment). Among the 49 evaluable patients, approximately half was pretreated and 82 % patients belonged to intermediate-low-risk groups, according to Memorial Sloan-Kettering Cancer Center (MSKCC) risk [14] (Tables 3 and 4). Response rate (RR) was better in patients with intermediate risk MSKCC [14], even though DCR was better in patient with low risk, without any statistically significant difference (Table 3). Even though we are aware, we are talking about a little number of patients, similar data, of RR and DCR were confirmed also considering only naïve patients: we describe a RR of 38 % and a DCR that reach 80 % (Table 4). Furthermore, no statistically significant differences in DCR were found in pretreated and naïve (52 vs 80 %; χ2 test=6.27; p=0.106) (Table 4). The median response duration was 8.5 months (IC 95 % 5–11.3). Median TTP, calculated on all 51 patients, was 8.8 months (CI 95 % 5.0–9.33) (Fig. 1).

Targ Oncol Table 3 Efficacy results according to MSKCC risk class MSKCC risk class No. of patients Efficacy results

Low Intermediate High Total

15 27 9 51

PR (%)

CR (%) SD (%)

PD (%)

DCR (%)

NV (%) TTP (months)

OS (months)

3 (20 %) 11 (41 %) 1 (11 %) 15 (29.5 %)

0 (0 0 (0 0 (0 0 (0

1 (6 %) 10 (37 %) 4 (44 %) 15 (29.5 %)

13 (87 %) 16 (69 %) 5 (55 %) 34 (66 %)

1 (7 1 (4 0 (0 2 (4

32.3 (15.5- .) 18.3 (9.56–29.7) 12.8 (4.46–32) 22.67 (15.2–29.7)

%) %) %) %)

10 (67 %) 5 (18 %) 4 (44 %) 19 (37 %)

%) %) %) %)

11.6 (8.76- .) 6.4 (2.83–10.33) 8.1 (2.56–9.93) 8.8 (5–9.33)

PR partial response, CR complete response SD stable disease, PD progressive disease, DCR disease control rate (response rate+stable disease rate), NV not evaluable, TTP time to progression, OS overall survival

TTP was better in low-risk patients (Table 4 and Fig. 1b) than in the other groups, with a statistically significant difference [log rank (Mantel-Cox) test p=0.027]. Furthermore, no difference in TTP between pretreated and naïve patients was found (Table 3 and Fig. 1c). Median OS was 22.67 months (CI 95 % 15.2–29.7), with 84 % of the patients still alive after 6 months and 70 % after 1 year (Fig. 2b). Median OS was better in low-risk patients (Table 4 and Fig. b) than in the other groups, but without statistically significant differences [log rank (Mantel-Cox) test p=0.138]. No difference in OS between pretreated and naïve patients was found (Table 3 and Fig. 2c). Treg variations Blood samples for Treg were available for 28 patients. We observed a rapid increase in the percentage of Treg in 2 weeks after treatment with IL-2 and IFN-α, from day 8 to day 22. In addiction, we also observed a different trend of Treg on day 22 between responsive and nonresponsive patients: Treg seems not to increase, after bevacizumab (on day 22), in patients who obtained a PR or SD, while in nonresponsive patients, the increment of Treg was constant (Fig. 3).

Discussion The progress in the care of patients with mRCC has greatly changed the therapeutic horizon: at least eight randomized studies have shown that the antiangiogenic agents sunitinib,

sorafenib, bevacizumab (combined with IFN-α), pazopanib, axitinib, and the mTOR inhibitors temsirolimus and everolimus are able to modify the natural history of the disease [15–22]. First-line bevacizumab combined with IFN-α has proved to be superior to IFN-α alone in terms of RR and progression-free survival in two randomized phase III studies [17, 18]. Immunotherapy with cytokines is currently used for selected patients: in Motzer’s sunitinib study, median OS had not been reached with treatment in the favorable-risk group (at 12 months, 91 % of patients in the sunitinib group were alive compared with 92 % of patients in the IFN-α group; and at 2 years, 72 vs 76 %, respectively, were alive) and this is also proved by the fact that in the present study, more than 35 % of patients were treated with cytokines in first line [23]; in the study with pazopanib [19] and with axitinib [20], up to 47 and 35 % of patients, respectively, were pretreated with cytokines. Recently a phase II trial of bevacizumab with high doses IL-2 was also published [24]. Furthermore, even if mRCC is considered to be unresponsive or poorly responsive to CT [25], with an RR that is generally less than 10 %, various studies have found that the activity of combined gemcitabine and 5-fluorouracil [6, 7] or gemcitabine and capecitabine [26–28] is interesting. A good activity of chemotherapy has been described by our group in patients with mRCC progressing to a regimen of low doses of IL-2+IFN-α [3]. Several studies also showed activity of chemotherapy alone or in combination with target therapy. We also underline that in many phase III studies recently published, among the list of the treatment received after or before

Table 4 Efficacy results in naïve and pretreated patients Treatment

Naïve Pretreated Total

No. of patients

26 25 51

Efficacy results PR (%)

CR (%)

SD (%)

PD (%)

DCR (%)

NV (%)

TTP (months)

OS (months)

10 (38` %) 5 (20 %) 15 (29.5 %)

0 (0 %) 0 (0 %) 0 (0 %)

11 (42 %) 8 (32 %) 19 (37 %)

5 (19 %) 10 (40 %) 15 (29.5 %)

21 (80 %) 13 (52 %) 34 (66 %)

0 (0 %) 2 (8 %) 2 (4 %)

9.53 (6.43–11.56) 6.1 (2.83–9.63) 8.8 (5–9.33)

22.6 (12.1–32) 23.36 (12.8- .) 22.67 (15.2–29.7)

PR partial response, CR complete response, SD stable disease, PD progressive disease, DCR, disease control rate (response rate+stable disease rate), NV not evaluable, TTP time to progression, OS overall survival

Targ Oncol Fig. 1 a Time to progression for all patients. b Time to progression according to MSKCC risk class. c Time to progression in pretreated and naïve patients

a Time to progression for all patients

b Time to progression according to MSKCC risk class

Good risk; ----- Intermediate risk; …… Poor risk.

c Time to progression in pretreated and naïve patients

----- pretreated;

naïve.

Targ Oncol Fig. 2 a Overall survival for all patients. b Overall survival according to MSKCC risk class. c Overall survival in pretreated and naïve patients

Targ Oncol Fig. 3 Decrease of Treg cells (CD4+CD25hi Foxp3+) in responding (red line) or progressing patients (green line) (first cycle of treatment)

the agents of the protocols, the chemotherapy was often mentioned. [26–29]. The combination of CT with anti-VEGF drugs was supported by the capacity of the latter to normalize tumor vasculature, thus improving the distribution of the CT agents to tumor cells [8]. To our knowledge, this is the first study that has explored the toxicity, feasibility, and efficacy of the combination of bevacizumab, IT, and CT in mRCC. The aim of combining three different drugs is to look for a regimen with a broader range of activity against various mRCC patients with different risk factors: low, intermediate, and high. Target activity level (p1) of 0.32, which included an increase of 20 % of the combined regimen activity to only IT, was obtained for phase II portion. This RR roughly corresponds to the sum of the individual RRs obtained in clinical trials of IT (IL-2 and IFN-α; RR 12 %) [9], CT (gemcitabine and 5-fluorouracil, RR 8 %) [6], and bevacizumab (RR 10 %) [10] as first- or second-line treatment, and so, it seems probable this combination has additive activity and not synergic. Unexpectedly, we did not record any CR, even though these are described both with IT and CT [3–6, 30, 31]. That could be justified by the relative short treatment with IT (only 2 weeks for every cycle) and by the number of dose reduction or delay. The overall rate of PR ranged from 11 to 41 % between the three risk groups MSKCC [14], even though DCR was clearly better (87 %) in patients with low risk, which also had a longer TTP (with statistical significance) and OS (Table 3) than in patients with intermediate or high risk.

This regimen was efficacy in all MSKCC groups, in pretreated and naïve patients, with a overall RR similar to RR obtained with sunitinib in first line (PR 31 %, and only 6.5 % of patients with high-risk MSKCC) [15], superior to RR obtained with sorafenib in second line (PR 10 %, in only patients with low or intermediate MSKCC risk) [16] and also similar to RR obtained in two important randomized studies: 25–31 % by the association between bevacizumab and IFN-α as first line [17, 18]. The high-risk population has less chance to be cured with the currently available target therapies, and new strategies are urgent. It is interesting underline that in our casistic 18 % (Table 3) of overall patients and 27 % (Table 3) of naïve patients was high-risk MSKCC, and in this group, DCR was relevant: 55 % with 11 % of PR for overall population and 71 % with 15 of PR from naïve patients vs a 32 % with 9 % of PR obtained with temsirolimus as first line in a randomized phase III trial that included only intermediate- and high-risk patients [21]. Concerning to toxicity, this regimen can be considered safe even though not irrelevant. There were no overlapping toxicities among the three classes of drugs. The recorded grade 3–4 hematological toxicity was little greater than expected, probably because the low rate i.v. infusion (over 1 h) of gemcitabine that is known to be more toxic [32] and because the therapeutic schedule meant that the patients also underwent blood tests on day 15, when granulocyte neutrophil and platelet counts are at their nadir. The incidence of grade 3– 4 nonhematological adverse events certainly attributable to the

Targ Oncol

treatment was low (except for IT-induced fever). Generally, the treatment was quite well tolerated. Even if all the comparison with literature data mentioned cannot demonstrate something because indirect and because of their heterogeneity, on the basis of our results, it is possible to say that BIC regimen showed an interesting activity, independently from pretreatment and risk groups. We also showed that, even if a bit complicated and not cheap, it was feasible and quite well tolerated. Further randomized phase IIb-III studies are needed to test BIC or simpler CT and bevacizumab combination efficacy vs other standard target therapies in selected patients (high risk). The increase of Treg after immunotherapy was expected: IL-2 on the one hand stimulates cytotoxic lymphocytes and natural killer cells and induces clinical response [8]; on the other hand, it is required for the generation and maintenance of Treg [33], even though this dual and seeming paradoxal role is not yet well clarified. Several studies on animal models have proved that the tumor immunosurveillance can be increased when CD4+CD25+ Treg is inhibited or depleted [34]. At our knowledge for the first time, we observed a different trend in Treg after bevacizumab combined with IL-2 and IFN-α administration in patients with different clinical responses. Previous studies demonstrated that higher levels of VEGF directly inhibit dendritic cells differentiation and maturation and have been implicated in the T-helper2 response observed in cancer patients [35]. In mouse models, overexpression of tumor VEGF results in increased numbers of Treg and VEGF blockade combined with immunotherapy results in enhanced antitumour activity associated with decreases in Treg [36]. High levels of VEGF in patients with RCC have correlated with a lack of clinical response to IL-2 and decrease overall survival [37]. The clinical significance of our finding will require further study. We only can hypothesize a possible role of Treg in the determination of clinical outcome in patients with mRCC treated with IT+bevacizumab. If confirmed by other studies, Treg could be helpful to select nonresponsive patients. Acknowledgments The study was sponsored by the Italian Oncology Group for Clinical Research (GOIRC), with a financial support by the Roche. Conflict of interest The authors have declared no conflicts of interest.

References 1. Lilleby W, Fossa SD (2005) Chemotherapy in metastatic renal cell cancer. World J Urol 23:175–179 2. Amato RJ (2005) Renal cell carcinoma: review of novel singleagent therapeutics and combination regimens. Ann Oncol 16(7–1516):7–15

3. Buti S, Brighenti M, Bongiovanni C et al (2007) Role of chemotherapy with gemcitabine plus 5-fluorouracil and chemoimmunotherapy in metastatic renal cell cancer. J Immunother 30:780–786 4. Buzaid AC, Todd MB (1989) Therapeutic options in renal cell carcinoma. Semin Oncol 16(1):12–19 5. Jain RK (2005) Normalization of tumor vasculature: an emerging concept in antiangiogenic therapy. Science 307:58–62 6. Motl S (2005) Bevacizumab in combination chemotherapy for colorectal and other cancers. Am J Health Syst Pharm 62:1021–1032 7. Buti S, Lazzarelli S, Chiesa MD et al (2010) Dose-finding trial of a combined regimen with Bevacizumab, immunotherapy, and chemotherapy in patients with metastatic renal cell cancer: an Italian oncology group for clinical research (GOIRC) study. J Immunother 33(7): 735–741 8. Aoyamaa A, Klarina D, Yamadaa Y et al. Low-dose IL-2 for in vivo expansion of CD4+ and CD8+ regulatory T cells in nonhuman primates. American Journal of Transplantation Brief Communication doi: 10.1111/j.1600-6143.2012.04133.x 9. Rowe JH, Ertelt JM, Way SS (2012) Foxp3+ regulatory T cells, immune stimulation and host defence against infection. Immunology 136(1):1–10 10. Xia Liu, Xun Xu, Xin Lin et al. PTD-hFOXP3 protein acts as an immune regulator to convert human CD4+CD25- T cells to regulatory T-like cells. Journal of cellular biochemistry. doi:10.1002/jcb. 24255 11. Liu VC, Wong LY, Jang T et al (2007) Tumor evasion of the immune system by converting CD4+CD25- T cells into CD4+CD25+ T regulatory cells: role of tumor-derived TGF-beta. J immunol 1 178(5):2883–2892 12. Therasse P, Arbuck SG, Eisenhauer EA et al (2000) New guidelines to evaluate the response to treatment in solid tumors: European organization for research and treatment of cancer, national cancer institute of the United States, national cancer institute of Canada. J Natl Cancer Inst 92:205–216 13. NCI Common Terminology Criteria for Adverse Events v3.0 (CTCAE) Publish Date: December 12, 2003. http://ctep.cancer.gov/ reporting/ctc.html. 14. Motzer RJ, Mazumdar M, Bacik J et al (1999) Survival and prognostic stratification of 670 patients with advanced renal cell carcinoma. J Clin Oncol 17(8):2530–2540 15. Motzer RJ, Hutson TE, Tomczak P et al (2007) Sunitinib versus interferon alfa in metastatic renal-cell carcinoma. N Engl J Med 356: 115–124 16. Escudier B, Eisen T, Stadlre WM et al (2007) Sorafenib in advanced clear-cell renal-cell carcinoma. N Engl J Med 356:125–134 17. Escudier B, Pluzanska A, Koralewski P et al (2007) Bevacizumab plus interferon alfa-2a for treatment of metastatic renal cell carcinoma: a randomised, double-blind phase III trial. Lancet 370:2103–2111 18. Rini BI, Halabi S, Rosenberg JE et al (2008) Bevacizumab plus interferon alfa compared with interferon alfa monotherapy in patients with metastatic renal cell carcinoma: CALGB 90206. J Clin Oncol 26:5422–5428 19. Sternberg CN, Davis ID, Mardiak J et al (2010) Pazopanib in locally advanced or metastatic renal cell carcinoma: results of a randomized phase III trial. J Clin Oncol 28:1061–1068 20. Rini B, Escudier B, Tomczak P et al (2011) Comparative effectiveness of axitinib versus sorafenib in advanced renal cell carcinoma (AXIS): a randomized phase 3 trial. Lancet 2011 378(9807):1931– 1939. doi:10.1016/S0140-6736(11)61613-9 21. Hudes G, Carducci M, Tomczak P et al (2007) Temsirolimus, interferon alfa, or both for advanced renal cell carcinoma. N Engl J Med 356:2271–2281 22. Motzer RJ, Escudier B, Oudard S et al (2008) Efficacy of everolimus in advanced renal cell carcinoma: a double-blind, randomised, placebo-cont rolled phase III trial. Lancet 372:449–456

Targ Oncol 23. Motzer RJ, Hutson TE, Tomczak P et al (2009) Overall survival and updated results for sunitinib compared with interferon alpha in patients with metastatic renal cell carcinoma. J Clin Oncol 27(22): 3584–3590 24. Dandamudi UB, Ghebremichael M, Sosman JA et al (2013) A phase II study of Bevacizumab and high-dose interleukin-2 in patients with metastatic renal cell carcinoma: a cytokine working group (CWG) study. J Immunother 36(9):490–495. doi:10.1097/CJI. 0000000000000003 25. Cameron RB, McIntosh JK, Rosenberg SA (1988) Synergic antitumor effects of combination immunotherapy with recombinant interleukin-2 and a recombinant hybrid alpha-interferon in the treatment of established murine hepatic metastases. Cancer Res 48: 5810–5817 26. Rini BI, Weinberg V, Small EJ (2005) A phase I trial of fixed dose rate gemcitabine and capecitabine in metastatic renal cell carcinoma. Cancer 103:553–558 27. Tannir NM, Thall PF, Ng CS et al (2008) A phase II trial of gemcitabine plus capecitabine for metastatic renal cell cancer previously treated with immunotherapy and targeted agents. J Urol 180: 867–872 28. Soga N, Yamada Y, Nishikawa K et al (2009) Gemcitabine and capecitabine chemotherapy in Japanese patients with immunotherapy-resistant renal cell carcinoma. Int J Urol 16:576–579 29. Buti S, Bersanelli M, Sikokis A et al (2013) Chemotherapy in metastatic renal cell carcinoma today? A systemic review. AntiCancer Drugs 24(6):535–554. doi:10.1097/CAD.0b013e3283609ec1

30. Stadler WM (1995) Low-dose interleukin-2 in the treatment of metastatic renal-cell carcinoma. Semin Oncol 22:67–73 31. Vogelzang NJ, Lipton A, Figlin RA (1993) Subcutaneous interleukin-2 plus interferon alfa-2a in metastatic renal cancer: an outpatient multicenter trial. J Clin Oncol 11:1809–1816 32. Tempero M, Plunkett W, Ruiz Van Haperen VW et al (2003) Randomized phase II comparison of dose-intense gemcitabine: thirty-minute infusion and fixed dose rate infusion in patients with pancreatic adenocarcinoma. J Clin Oncol 21:3402–3408 33. Ahmadzadeh M, Rosenberg SA (2006) IL-2 administration increases CD4+CD25highFOXP3+ regulatory T cells in cancer patients. Blood 107:2409–2414 34. Guangxian Liu, Wuwei Yang, Mei Guo et al. Effective modulation of CD4+CD25+high regulatory T and NK cells in malignant patients by combination of interferon-a and interleukin-2. Cancer Immunol Immunother doi 10.1007/s00262-012-1297-2 35. Sanarico N, Ciamarella A, Sacchi A et al (2006) Human monocytederived dendritic-cells differentiated in the presence of IL-2 produce proinflammatory cytokines and prime Th1 immune response. J Leukoc Biol 80:555–562 36. Yamazaki S, Steinman RM (2009) Dendritic cells as controllers of antigen-specific Foxp3+ regulatory T cells. J Dermatol Sci 54: 69–75 37. Sabbatino M, Kim-Schulze S, Panelli MC et al (2009) Serum vascular endothelial growth factor and fibronectin predict clinical response to high-dose interleukin-2 therapy. JCO 27:2645–2652

phase II trial: bevacizumab, immunotherapy, and chemotherapy (BIC) in metastatic renal cell cancer (mRCC). Antitumor effects and variations of circulating T regulatory cells (Treg).

The aim of this study was to explore the efficacy and toxicities of a combined regimen of bevacizumab plus immunotherapy and chemotherapy (BIC) and th...
728KB Sizes 0 Downloads 4 Views