A.J.M. van den Eertwegh

Choi response criteria for early prediction of clinical outcome in patients with metastatic renal cell cancer treated with sunitinib

Background:Because sunitinib can induce extensive necrosis in metastatic renal cell cancer (mRCC), we examined whether criteria defined by Choi might be valuable to predict early sunitinib efficacy.Methods:Computed tomography was used for measurement of tumour lesions in mm and lesion attenuation in Hounsfield units (HUs). According to Choi criteria partial response (PR) was defined as ⩾10% decrease in size or ⩾15% decrease in attenuation.Results:A total of 55 mRCC patients treated with sunitinib were included. At first evaluation, according to the Response Evaluation Criteria in Solid Tumours (RECIST) 7 patients had PR, 38 stable disease (SD), and 10 progressive disease (PD), whereas according to Choi criteria 36 patients had PR, 6 SD and 13 PD. Median tumour attenuation decreased from 66 to 47 HUs (P⩽0.001). In patients with PR, Choi criteria had a significantly better predictive value for progression-free survival and overall survival (both Ps<0.001) than RECIST (P=0.685 and 0.191 respectively). The predictive value for RECIST increased (P=0.001 and <0.001 respectively), when best response during treatment was taken into account.Conclusion:Choi criteria could be helpful to define early mRCC patients who benefit from sunitinib, but the use of these criteria will not change the management of these patients.

Predictive factors for severe toxicity of sunitinib in unselected patients with advanced renal cell cancer

Sunitinib has been registered for the treatment of advanced renal cell cancer (RCC). As patient inclusion was highly selective in previous studies, experience with sunitinib in general oncological practice remains to be reported. We determined the efficacy and safety of sunitinib in patients with advanced RCC included in an expanded access programme. ECOG performance status >1, histology other than clear cell and presence of brain metastases were no exclusion criteria. Eighty-two patients were treated: 23% reached a partial response, 50% had stable disease, 20% progressed and six patients were not evaluable. Median progression-free survival (PFS) was 9 months and median overall survival (OS) was 15 months. Importantly, 47 patients (57%) needed a dose reduction, 35 (43%) because of treatment-related adverse events, 10 (12%) because of continuous dosing, and two because of both. Stomatitis, fatigue, hand–foot syndrome and a combination of grade 1–2 adverse events were the most frequent reasons for dose reduction. In 40 patients (49%), there was severe toxicity, defined as dose reduction or permanent discontinuation, which was highly correlated with low body surface area, high age and female gender. On the basis of age and gender, a model was developed that could predict the probability of severe toxicity.

Skin tests predict survival after autologous tumor cell vaccination in metastatic melanoma: Experience in 81 patients

BACKGROUND Currently there is no standard adjuvant treatment following surgical resection of metastatic melanoma. We investigated whether surgery followed by autologous tumor cell-BCG vaccination was beneficial for malignant melanoma patients. In this study we focus on the prognostic value of DTH response following vaccination therapy. PATIENTS AND METHODS Eighty-one patients with AJCC stage III and IV melanoma were selected. Whenever feasible, radical metastasectomy was performed. ASI was initiated by the administration of three weekly intra-cutaneous vaccinations with 10(7) irradiated autologous tumor cells, starting four weeks after surgery. Depending on the size of DTH response to the first three injections, subsequent vaccinations were planned. The first two vaccines also contained 10(7) BCG organisms as an immune stimulatory adjuvant. RESULTS Induration as well as erythema correlated strongly with survival (P < 0.0001 and P = 0.0004). After radical metastasectomy in stage III melanoma patients a five-year survival of 48% was observed. In stage IV disease, a five-year survival of 34% was seen, after radical surgery had been performed. When macroscopic disease was present at start of vaccination treatment, no clinical responses occurred. Apart from transient skin ulceration at the site of BCG-containing vaccinations, no serious side effects were observed. CONCLUSIONS This study shows that large-scale preparation of autologous melanoma cell vaccines is feasible. while vaccination results in DTH responses that correlate significantly with survival. ASI seemed to be beneficial in stage III and stage IV melanoma when given in the adjuvant setting, while causing only very mild side effects.

IFN-gamma-producing human invariant NKT cells promote tumor-associated antigen-specific cytotoxic T cell responses.

CD1d-restricted invariant NKT (iNKT) cells can enhance immunity to cancer or prevent autoimmunity, depending on the cytokine profile secreted. Antitumor effects of the iNKT cell ligand α-galactosylceramide (αGC) and iNKT cell adoptive transfer have been demonstrated in various tumor models. Together with reduced numbers of iNKT cells in cancer patients, which have been linked to poor clinical outcome, these data suggest that cancer patients may benefit from therapy aiming at iNKT cell proliferation and activation. Herein we present results of investigations on the effects of human iNKT cells on Ag-specific CTL responses. iNKT cells were expanded using αGC-pulsed allogeneic DC derived from the acute myeloid leukemia cell line MUTZ-3, transduced with CD1d to enhance iNKT cell stimulation, and with IL-12 to stimulate type 1 cytokine production. Enhanced activation and increased IFN-γ production was observed in iNKT cells, irrespective of CD4 expression, upon stimulation with IL-12-overexpressing dendritic cells. IL-12-stimulated iNKT cells strongly enhanced the MART-1 (melanoma Ag recognized by T cell 1)-specific CD8+ CTL response, which was dependent on iNKT cell-derived IFN-γ. Furthermore, autologous IL-12-overexpressing dendritic cells, loaded with Ag as well as αGC, was superior in stimulating both iNKT cells and Ag-specific CTL. This study shows that IL-12-overexpressing allogeneic dendritic cells expand IFN-γ-producing iNKT cells, which may be more effective against tumors in vivo. Furthermore, the efficacy of autologous Ag-loaded DC vaccines may well be enhanced by IL-12 overexpression and loading with αGC.

Effects of α‐galactosylceramide (KRN7000), interleukin‐12 and interleukin‐7 on phenotype and cytokine profile of human Vα24+ Vβ11+ T cells

The α‐galactosylceramide KRN7000 was reported to be presented by CD1d to natural killer (NK) T cells, cells that are thought to play an important role in the rejection of malignant tumours and in the regulation of several autoimmune diseases. Here we analysed human peripheral blood (PB) NK T cells (Vα24+ Vβ11+ T cells) before and after a short‐term culture in the presence of KRN7000. KRN7000 strongly activated PB Vα24+ Vβ11+ T cells and, when stimulated, the vast majority of these cells expressed interferon‐γ (IFN‐γ). Exposure of these KRN7000‐cultured Vα24+ Vβ11+ T cells to interleukin‐12 (IL‐12), but not to IL‐7, resulted in a relative increase in IFN‐γ‐expressing Vα24+ Vβ11+ T cells, compared with IL‐4‐expressing Vα24+ Vβ11+ T cells, indicating a shift towards a T‐helper type 1 (Th1) phenotype. KRN7000 strongly up‐regulated the expression of the cytotoxic molecule granzyme B (GrB) in Vα24+ Vβ11+ T cells. Although IL‐7 resulted in a decrease in GrB levels in KRN7000‐cultured Vα24+ Vβ11+ T cells, IL‐12 increased GrB levels in both Vα24+ Vβ11+ T cells and in Vα24+ Vβ11+ T‐cell clones and increased cytotoxicity against hCD1d‐transfected HeLa cells. Our data provide further insight into the characteristics of human Vα24+ Vβ11+ T cells and indicate that KRN7000 is a potent activator of Vα24+ Vβ11+ T cells. Combined with the established anti‐tumour effects of KRN7000 in mouse models, these results may support the use of KRN7000 as an anti‐tumour agent in man.

Defective Differentiation of Myeloid and Plasmacytoid Dendritic Cells in Advanced Cancer Patients is not Normalized by Tyrosine Kinase Inhibition of the Vascular Endothelial Growth Factor Receptor

Tumor-derived vascular endothelial growth factor (VEGF) has previously been identified as a causative factor in the disturbed differentiation of myeloid dendritic cells (DC) in advanced cancer patients. Here, we investigated the potential of vascular endothelial growth factor receptor (VEGFR) tyrosine kinase (TK) inhibition to overcome this defective DC differentiation. To this end, peripheral blood DC (PBDC) precursor and subset frequencies were measured in 13 patients with advanced cancer before and after treatment with AZD2171, a TK inhibitor (TKI) of VEGFR, coadministered with gefitinib, and an epidermal growth factor receptor (EGFR) TKI. Of note, not only myeloid DC but also plasmacytoid DC frequencies were significantly reduced in the blood of the cancer patients prior to treatment, as compared to healthy controls. Moreover, besides an accumulated population of immature myeloid cells (ImC), a population of myeloid suppressor cells (MSC) was significantly increased. Upon systemic VEGFR TK inhibition, DC frequencies did not increase, whereas the rate of circulating MSC showed a slight, but not significant, decrease. In conclusion, TK inhibition of VEGFR with AZD2171 does not restore the defective PBDC differentiation observed in advanced cancer patients.

4-1BB-mediated expansion affords superior detection of in vivo primed effector memory CD8+ T cells from melanoma sentinel lymph nodes.

We have been studying the re-activation of tumor-associated antigen (TAA)-specific CD8(+) T cells in sentinel lymph nodes (SLN) of melanoma patients upon intradermal administration of the CpG-B oligodeoxynucleotide PF-3512676. To facilitate functional testing of T cells from small SLN samples, high-efficiency polyclonal T cell expansion is required. In this study, SLN cells were expanded via classic methodologies with plate- or bead-bound anti-CD3/CD28 antibodies and with the K562/CD32/4-1BBL artificial APC system (K32/4-1BBL aAPC) and analyzed for responsiveness to common recall or TAA-derived peptides. K32/4-1BBL-expanded T cell populations contained significantly more effector/memory CD8(+) T cells. Moreover, recall and melanoma antigen-specific CD8(+) T cells were more frequently detected in K32/4-1BBL-expanded samples as compared with anti-CD3/CD28-expanded samples. We conclude that K32/4-1BBL aAPC are superior to anti-CD3/CD28 antibodies for the expansion of in vivo-primed specific CD8(+) T cells and that their use facilitates the sensitive monitoring of functional anti-tumor T cell immunity in SLN.

Neo)adjuvant systemic therapy for melanoma

Surgery still is the cornerstone of treatment for patients with stage II and III melanoma, but despite great efforts to gain or preserve locoregional control with excision of the primary tumour, satellites, intransits, sentinel node biopsy and lymphadenectomy, surgery alone does not seem to improve survival any further. Prognosis for patients with high risk melanoma remains poor with 5-year survival rates of 40 to 80%. Only interferon-2b has been approved as adjuvant therapy since 1995, but clinical integration is low considering the high risk-benefit ratio. In recent years systemic targeted- and immunotherapy have proven to be beneficial in advanced melanoma and could be a promising strategy for (neo)adjuvant treatment of patients with resectable high risk melanomas as well. Randomised, placebo- controlled phase III trials on adjuvant systemic targeted- and immunotherapy are currently being performed using new agents like ipilimumab, pembrolizumab, nivolumab, vemurafenib and dabrafenib plus trametinib. In this article we review the literature on currently known adjuvant therapies and currently ongoing trials of (neo)adjuvant therapies in high risk melanomas.

A randomized phase II/III study of cabazitaxel versus vinflunine in metastatic or locally advanced transitional cell carcinoma of the urothelium (SECAVIN)

Background Despite the advent of immunotherapy in urothelial cancer, there is still a need to find effective cytotoxic agents beyond first and second lines. Vinflunine is the only treatment approved in this setting by the European Medicines Agency and taxanes are also widely used in second line. Cabazitaxel is a taxane with activity in docetaxel-refractory cancers. A randomized study was conducted to compare its efficacy versus vinflunine. Patients and methods This is a multicenter, randomized, open-label, phase II/III study, following a Simons optimal method with stopping rules based on an interim futility analysis and a formal efficacy analysis at the end of the phase II. ECOG Performance Status, anaemia and liver metastases were stratification factors. Primary objectives were overall response rate for the phase II and overall survival for the phase III. Results Seventy patients were included in the phase II across 19 institutions in Europe. Baseline characteristics were well balanced between the two arms. Three patients (13%) obtained a partial response on cabazitaxel (95% CI 2.7-32.4) and six patients (30%) in the vinflunine arm (95% CI 11.9-54.3). Median progression-free survival for cabazitaxel was 1.9 versus 2.9 months for vinflunine (P = 0.039). The study did not proceed to phase III since the futility analysis showed a lack of efficacy of cabazitaxel. A trend for overall survival benefit was found favouring vinflunine (median 7.6 versus 5.5 months). Grade 3- to 4-related adverse events were seen in 41% patients with no difference between the two arms. Conclusion This phase II/III second line bladder study comparing cabazitaxel with vinflunine was closed when the phase II showed a lack of efficacy of the cabazitaxel arm. Vinflunine results were consistent with those known previously. Trial number NCT01830231.

Improved Survival In Patients With Advanced Melanoma In Real-World Clinical Practice: First Results Of The Dutch Melanoma Treatment Registry.

PCN62 ImProved SurvIval WIth IPIlImumab IN PatIeNtS WIth advaNCed melaNoma IN real-World ClINICal PraCtICe: FIrSt reSultS oF the dutCh melaNoma treatmeNt regIStry Leeneman B1, Franken MG2, Jochems A3, Schouwenburg MG4, Wouters MW5, Van den Eertwegh AJ6, Haanen JB5, Van der Hoeven KJ3, Uyl de Groot CA2 1Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands, 2Erasmus University, Rotterdam, The Netherlands, 3Leiden University Medical Center, Leiden, The Netherlands, 4Dutch Institute for Clinical Auditing, Deventer, The Netherlands, 5Netherlands Cancer Institute, Amsterdam, The Netherlands, 6VU University Medical Center, Amsterdam, The Netherlands Objectives: Ipilimumab improved the survival of advanced melanoma patients in phase III trials (MDX010-20 [previously treated patients] and CA184-024 [treatment naïve patients]). Uncertainty exists, however, whether this benefit can be translated to real-world clinical practice. We investigated the use and survival outcomes of ipilimumab in The Netherlands. MethOds: We retrieved data from the populationbased Dutch Melanoma Treatment Registry (DMTR). The DMTR includes all Dutch patients with unresectable stage IIIc/IV melanoma. Detailed data were prospectively collected from start of diagnosis until death or loss to follow-up. Survival outcomes (overall survival [OS] and one-year survival) in patients receiving ipilimumab in clinical practice were assessed using Kaplan-Meier estimates, and were compared with outcomes of pivotal trials and outcomes of real-world patients diagnosed before the introduction of ipilimumab (2003-2011; stage IV only) using data from the Dutch Comprehensive Cancer Centres. Results: From 2012-2015, 545 patients received at least one dose of ipilimumab in real-world practice (65% received four dosages; median follow-up 4.6 months; data cut-off March 9, 2015). Ipilimumab was most frequently prescribed in the second line (60%), followed by the first (31%), third (8%), and fourth line (2%), respectively. Median OS was 7.7 months (IQR:3.6-NR) and one-year survival was 40%. This is somewhat lower than in the pivotal trials, which may be due to differences in baseline characteristics and time of follow-up (MDX010-20: median follow-up 27.8 months, median OS 10.1 months, one-year survival 46%; CA184-024: median follow-up 11.0 months, median OS 11.2 months, one-year survival 48%). However, the survival was higher compared to the survival in the period before the introduction of ipilimumab (2003-2011: median OS 6.8 months [IQR:3.3-18.5], one-year survival 33%). cOnclusiOns: Melanoma survival has improved since the introduction of ipilimumab. Although survival was somewhat lower in real-world compared to pivotal trials, a survival benefit was observed in Dutch real-world clinical practice.