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A Phase IB Trial of Autologous Cytokine‐Induced Killer Cells in Combination with Sintilimab, Monoclonal Antibody Against Programmed Cell Death‐1, plus Chemotherapy in Patients with Advanced Non‐Small‐Cell Lung Cancer

  • Author Footnotes
    # These authors contributed equally to this work.
    Li Zhou
    Footnotes
    # These authors contributed equally to this work.
    Affiliations
    Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Author Footnotes
    # These authors contributed equally to this work.
    Yanjuan Xiong
    Footnotes
    # These authors contributed equally to this work.
    Affiliations
    Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Author Footnotes
    # These authors contributed equally to this work.
    Yang Wang
    Footnotes
    # These authors contributed equally to this work.
    Affiliations
    Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Yuan Meng
    Affiliations
    Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Weihong Zhang
    Affiliations
    Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Meng Shen
    Affiliations
    Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Xinwei Zhang
    Affiliations
    Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Shuzhan Li
    Affiliations
    Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Baozhu Ren
    Affiliations
    Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Runmei Li
    Affiliations
    Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Ying Han
    Affiliations
    Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Jiali Zhang
    Affiliations
    Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Shui Cao
    Affiliations
    Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Weijiao Du
    Affiliations
    Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Qian Sun
    Affiliations
    Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Feng Wei
    Affiliations
    Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Xiumei An
    Affiliations
    Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Lili Yang
    Affiliations
    Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Yuwei Zhang
    Affiliations
    Department of Radiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Wenchao Ma
    Affiliations
    Department of Radiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Wengui Xu
    Affiliations
    Department of Radiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Yi Zhang
    Affiliations
    Biotherapy Center & Cancer Center, the First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, Henan, China
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  • Jingting Jiang
    Affiliations
    Department of Tumor Biological Treatment, Third Affiliated Hospital of Soochow University, Changzhou 213003, Jiangsu, China
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  • Xiang Xu
    Affiliations
    Department of Stem Cell & Regenerative Medicine, State Key Laboratory of Trauma, Burn and Combined Injury, Daping Hospital, Army Medical University, Chongqing 400042, China
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  • Jianchuan Xia
    Affiliations
    State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine; Department of Biotherapy, Sun Yat-Sen University Cancer Center, Guangzhou 510060, Guangdong, China
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  • Liang Liu
    Correspondence
    Address for correspondence: Xiubao Ren, MD, PhD, Liang Liu, MD, Department of Immunology and Biotherapy, Key Laboratory of Cancer Immunology and Biotherapy, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Huanhu Xi Road, Hexi District, Tianjin 300060, China
    Affiliations
    Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
    Search for articles by this author
  • Xiubao Ren
    Correspondence
    Address for correspondence: Xiubao Ren, MD, PhD, Liang Liu, MD, Department of Immunology and Biotherapy, Key Laboratory of Cancer Immunology and Biotherapy, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Huanhu Xi Road, Hexi District, Tianjin 300060, China
    Affiliations
    Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China

    Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China

    Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China

    Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

    Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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  • Author Footnotes
    # These authors contributed equally to this work.
Open AccessPublished:July 20, 2022DOI:https://doi.org/10.1016/j.cllc.2022.07.009

      Abstract

      Introduction

      Can the Cytokine-induced killer (CIK) cells in combination with immune checkpoint inhibitor further improve the efficacy of chemotherapy in non-small cell lung cancer (NSCLC) patients? What are the adverse reactions of this combination therapy? But these problems are not clear. Therefore, we conducted a phase 1b trial to evaluate the safety and efficacy of autologous CIK cells therapy combined with Sintilimab, antibody against programmed cell death-1, plus chemotherapy in untreated, advanced NSCLC patients.

      Patients and Methods

      Patients with stage IIIB/IIIC/IV NSCLC received Sintilimab, platinum-based doublet chemotherapy, and CIK cells every 3 weeks for 4 cycles, then maintenance treatment with Sintilimab in squamous and with Sintilimab plus pemetrexed in non-squamous NSCLC until disease progression or unacceptable toxicity or 2 years. The primary endpoints were safety and objective response rate (ORR).

      Results

      Thirty-four patients received the treatment. 94.1% of patients experienced treatment-related adverse events (TRAEs). Grade 3 or greater TRAEs occurred in 64.7% of patients. One (2.9%) patient died of grade 5 immune-related pneumonia. The ORR and DCR were 82.4% (95% CI, 65.5%-93.2%) and 100.0% (95% CI, 89.7%-100.0%), respectively. Objective responses were evaluated in 14 of 15 non-squamous patients (93.3%; 95% CI, 68.1%-99.8%) and in 14 of 19 squamous patients (73.7%; 95% CI, 48.8%-90.9%). Median PFS was 19.3 months (95% CI, 8.3 months to not available).

      Conclusion

      Autologous CIK cells immunotherapy in combination with Sintilimab plus chemotherapy was well tolerable and showed encouraging efficacy in patients with previously untreated, advanced NSCLC (ClinicalTrials.gov number, NCT03987867).

      Keywords

      Introduction

      Lung cancer is the most common cancer worldwide. In 2018, GLOBOCAN estimated 2.09 million new cases (11.6% of total cancer cases) and 1.76 million deaths (18.4% of total cancer deaths) in lung cancer.
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      Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
      Anti-programmed cell death protein 1 (PD-1) monotherapy has shown the benefit in patients with non-small cell lung cancer (NSCLC).
      • Carbone DP
      • Reck M
      • Paz-Ares L
      • et al.
      First-line nivolumab in stage IV or recurrent non-small-cell lung cancer.
      • Gandhi L
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      • Gadgeel S
      • et al.
      Pembrolizumab plus chemotherapy in metastatic non-small-cell lung cancer.
      • Paz-Ares L
      • Luft A
      • Vicente D
      • et al.
      Pembrolizumab plus chemotherapy for squamous non-small-cell lung cancer.
      • West H
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      • et al.
      Atezolizumab in combination with carboplatin plus nab-paclitaxel chemotherapy compared with chemotherapy alone as first-line treatment for metastatic non-squamous non-small-cell lung cancer (IMpower130): a multicentre, randomised, open-label, phase 3 trial.
      It has prolonged the overall survival (OS) for patients with metastatic NSCLC regardless the programmed cell death protein ligand-1 (PD-L1) expression and tumor mutational burden (TMB). In the KEYNOTE-189 and KEYNOTE-407 trail, Pembrolizumab plus chemotherapy showed significantly better response rate, and longer progression-free survival (PFS) and OS than chemotherapy alone in metastatic NSCLC.
      • Gadgeel S
      • Rodriguez-Abreu D
      • Speranza G
      • et al.
      Updated analysis from KEYNOTE-189: pembrolizumab or placebo plus pemetrexed and platinum for previously untreated metastatic nonsquamous non-small-cell lung cancer.
      ,
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      • Vicente D
      • Tafreshi A
      • et al.
      A randomized, placebo-controlled trial of pembrolizumab plus chemotherapy in patients with metastatic squamous NSCLC: protocol-specified final analysis of KEYNOTE-407.
      Sintilimab, a fully-humanized immunoglobulin G4 anti-programmed cell death protein-1 (PD-1) monoclonal antibody, had already shown clinically meaningful anti-tumor activity with acceptable safety for patients with advanced NSCLC in the phase 3 ORIENT-11 and ORIENT-12 trials.
      • Yang Y
      • Wang Z
      • Fang J
      • et al.
      Efficacy and safety of sintilimab plus pemetrexed and platinum as first-line treatment for locally advanced or metastatic nonsquamous NSCLC: a randomized, double-blind, phase 3 Study (Oncology pRogram by InnovENT anti-PD-1-11).
      ,
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      • et al.
      Sintilimab plus platinum and gemcitabine as first-line treatment for advanced or metastatic squamous NSCLC: results from a randomized, double-blind, phase 3 trial (ORIENT-12).
      Cytokine-induced killer (CIK) cells are heterogeneous, major histocompatibility complex (MHC)-unrestricted T lymphocytes.
      • Liu L
      • Zhang W
      • Qi X
      • et al.
      Randomized study of autologous cytokine-induced killer cell immunotherapy in metastatic renal carcinoma.
      They comprise CD3+/CD56+ cells, CD3/CD56+ natural killer (NK) cells, and CD3+/CD56 cytotoxic T cells expanded by cytokines in vivo. CIK cells have emerged in first- and second-line therapy for NSCLC and become a dynamic field in which new combinations are constantly being evaluated.
      • Liu L
      • Zhang W
      • Qi X
      • et al.
      Randomized study of autologous cytokine-induced killer cell immunotherapy in metastatic renal carcinoma.
      ,
      • Li R
      • Wang C
      • Liu L
      • et al.
      Autologous cytokine-induced killer cell immunotherapy in lung cancer: a phase II clinical study.
      In the preliminary study, CIK cells combination with PD‐1 blockade antibodies can significantly increase CD3+ CD56+ CD16+ T cells in comparison with the pretreatment level, while myeloid‐derived suppressor cells were significantly increased with PD‐1 blocking antibody therapy alone but not with combination therapy.
      • Han Y
      • Mu D
      • Liu T
      • et al.
      Autologous cytokine-induced killer (CIK) cells enhance the clinical response to PD-1 blocking antibodies in patients with advanced non-small cell lung cancer: A preliminary study.
      In our previously retrospective and prospective clinical trials, the results showed that CIK cells immunotherapy could improve the efficacy of chemotherapy in patients with advanced NSCLC.
      • Li R
      • Wang C
      • Liu L
      • et al.
      Autologous cytokine-induced killer cell immunotherapy in lung cancer: a phase II clinical study.
      ,
      • Liu L
      • Gao Q
      • Jiang J
      • et al.
      Randomized, multicenter, open-label trial of autologous cytokine-induced killer cell immunotherapy plus chemotherapy for squamous non-small-cell lung cancer: NCT01631357.
      CIK cells are composed of a large number of immune cells, especially T lymphocytes. PD-1 inhibitors can release the braking mechanism of immune cells and improve their ability to kill tumor cells. Can CIK cells in combination with PD-1 inhibitor play a synergistic role and further improve the efficacy of chemotherapy in NSCLC patients? What are the adverse reactions of this combination therapy? But so far, there is no clinical study in lung cancer and these problems are not clear. So, we designed this single-arm, open-label, phase 1b study to evaluate the clinical safety and efficacy of autologous CIK cells therapy in combination with Sintilimab plus chemotherapy in patients with advanced NSCLC.

      Patients and Methods

      Patients and Study Design

      This study was a single-center, open-label, phase 1b trial (CCICC-002a ClinicalTrials.gov number, NCT03987867), approved by the State Food and Drug Administration of China (2006L01023), by the National Key Technologies R&D Program of China (2018YFC1313400), and by the Ethical Committee of Cancer Hospital of Tianjin Medical University, according to the guidelines of the Declaration of Helsinki. Informed consent was obtained from all subjects. Patients who were eligible for enrollment had to meet the following criteria: age between 18 and 75 years, pathologically confirmed stage IIIB/IIIC/IV squamous or non-squamous NSCLC without EGFR/ALK/ROS1 mutations (according to the eighth edition of the Cancer Staging Manual of the American Joint Committee on Cancer),
      • Rami-Porta R
      • Bolejack V
      • Giroux DJ
      • et al.
      The IASLC lung cancer staging project: the new database to inform the eighth edition of the TNM classification of lung cancer.
      not suitable for concomitant chemoradiotherapy, receiving no previous systemic therapy for advanced disease, an Eastern Cooperative Oncology Group (ECOG) performance status score of 0 or 1,
      • Oken MM
      • Creech RH
      • Tormey DC
      • et al.
      Toxicity and response criteria of the eastern cooperative oncology group.
      at least 1 measurable lesion according to version 1.1 of the Response Evaluation Criteria in Solid Tumors (RECIST),
      • Eisenhauer EA
      • Therasse P
      • Bogaerts J
      • et al.
      New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1).
      and expected survival duration of ≥ 3 months. Patients were excluded if they had symptomatic central nervous system metastases, had immune deficiency or autoimmune diseases, had severe allergic disorder, had a history of noninfectious pneumonitis, had other malignancies, had received more than 30 Gy of radiotherapy to the lung in the previous 6 months, had uncontrollable medical condition, or were receiving systemic immunosuppressive treatment. Full eligibility criteria are listed in the trial protocol.

      Treatment and Endpoints

      As showed in Supplementary Appendix Figure S1, patients received Sintilimab (200 mg, d1), carboplatin (area under the concentration-time curve, 5 mg per milliliter per minute, d1), pemetrexed (for non-squamous patient, 500 mg per square meter, d1) or paclitaxel (for squamous patient, 135 mg per square meter, d1), and autologous CIK cells (total count ≥ 1 × 1010, d13, shown in Supplementary Appendix Table 1), administered intravenously every 3 weeks for 4 cycles. Then, non-squamous patients received Sintilimab (200 mg, d1) plus pemetrexed (500mg per square meter, d1), and squamous patients received Sintilimab (200 mg, d1) every 3 weeks as maintenance therapy until radiographic progression, unacceptable toxic effects, investigator decision, patient withdrawal of consent, or 2 years, whichever occurred first.
      Table 1Demographic and Disease Characteristics of Patients at Baseline
      CharacteristicN = 34
      Age, years
       Median62.5
       Range40-73
      Gender, n (%)
       Male29 (85.3)
       Female5 (14.7)
      ECOG PS, n (%)
       013 (38.3)
       120 (58.8)
       21 (2.9)
      Smoking history, n (%)
       Current/former28 (82.4)
       Never6 (17.6)
      Histology, n (%)
       Squamous19 (55.9)
       Non-squamous15 (44.1)
      Stage at diagnosis, n (%)
       IIIB/IIIC6 (17.6)
       IV28 (82.4)
      Sites of metastasis, n (%)
       Liver6 (17.6)
       Brain3 (8.8)
       Bone3 (8.8)
       Other22 (64.8)
      PD-L1 subgroups, n (%)
       TPS ≥ 1%15 (44.1)
       TPS<1%17 (50.0)
       Unknown2 (5.9)
      CD8+ TIL density, n (%)
       Top 60%19 (55.9)
       Bottom 40%13 (38.2)
       Unknown2 (5.9)
      Abbreviations: ECOG = Eastern Cooperative Oncology Group; PS = performance status score; PD-L1 = programmed death ligand-1; TPS = tumor proportion score, the percentage of tumor cells with membranous programmed cell death protein ligand-1 staining; TIL = tumor infiltrating lymphocyte, used the top 60th percentile of CD8+ TIL percentage as the cutoff point of CD8+ TIL density; Low, CD8+ TIL bottom 40%; High, CD8+ TIL top 60%.
      The primary endpoints were investigator-assessed safety, objective response rate (ORR) according to RECIST version 1.1. The secondary endpoints were disease control rate (DCR), duration of response (DOR), PFS, OS, and status of PD-L1 and other biomarkers. ORR was defined as the proportion of patients with a best overall response of complete response (CR) or partial response (PR); DCR was the proportion of patients with a best overall response of CR, PR, and stable disease (SD); PFS was the time from the initial treatment until the date of disease progression or the date of death from any cause, whichever occurred first; and OS was the time from the initial treatment until the date of death from any cause. Adverse events were assessed according to the National Cancer Institute Common Terminology Criteria for Adverse Events, version 5.0. Patients were assessed by 2 independent experienced radiologists using dynamic computed tomography or magnetic resonance imaging every 6 weeks from baseline for 12 months, and then every 2 months. If patients had clinical symptoms or aggravation symptoms during follow-up, they would receive imaging examination immediately. 18F-FDG PET/CT was used at the baseline and the best effect to detect residual tumor activity. The evaluation of complete metabolic response (CMR) was based on the Positron Emission Tomography Response Criteria in Solid Tumors (PERCIST) 1.0.
      • Wahl RL
      • Jacene H
      • Kasamon Y
      • et al.
      From RECIST to PERCIST: Evolving considerations for PET response criteria in solid tumors.

      CIK Cells Preparation

      CIK cells were prepared as described in our previous studies.
      • Liu L
      • Zhang W
      • Qi X
      • et al.
      Randomized study of autologous cytokine-induced killer cell immunotherapy in metastatic renal carcinoma.
      ,
      • Li R
      • Wang C
      • Liu L
      • et al.
      Autologous cytokine-induced killer cell immunotherapy in lung cancer: a phase II clinical study.
      ,
      • Liu L
      • Gao Q
      • Jiang J
      • et al.
      Randomized, multicenter, open-label trial of autologous cytokine-induced killer cell immunotherapy plus chemotherapy for squamous non-small-cell lung cancer: NCT01631357.
      Brief description of CIK cells preparation was showed in Supplementary Appendix Figure S2.

      PD‐L1 and Other Biomarkers Expression Analysis

      Tumor biopsy samples were obtained from 32 patients and pleural fluid sediment samples were obtained from another 2 patients before treatment initiation. We did not detect the PD-L1 expression, CD8+ tumor infiltrating lymphocyte (TIL), and other tumor biomarkers in pleural fluid sediment specimens. PD-L1 expression was assessed by means of the PD-L1 immunohistochemistry (IHC) 22C3 pharmDx assay (Agilent) in formalin-fixed tumor samples obtained before the treatment. Expression was categorized according to the tumor proportion score (TPS) (ie, the percentage of tumor cells with membranous PD-L1 staining). Multiplex IHC analysis was performed in patients’ tumor issues. The immune markers included CD8+ T cells, CD68+ macrophages (M1), CD68+ CD163+ macrophages (M2) and CD56+ natural killer (NK) cells. In all, antibodies against CD8 (ZA-0508, clone SP16; Zsbio; 1:100 diluted), PD-1 (ZM0381, UMAB199, Zsbio; 1:100 diluted), CD68 (ZM-0060, clone KP1; Zsbio; 1:400 diluted), CD163 (ZM0428, 10D6, Zsbio; 1:200 diluted), and PD-L1 (CST13684, E1L3N, CST, 1:100 diluted) were employed. Other biomarkers expression analysis was showed in Supplementary Appendix.

      Statistical Analysis

      Sample size of this study was determined on the primary endpoint of ORR. Based on phase 3 KEYNOTE-189 and KEYNOTE-407 trials in metastatic NSCLC treatment with Pembrolizumab plus chemotherapy,
      • Gandhi L
      • Rodriguez-Abreu D
      • Gadgeel S
      • et al.
      Pembrolizumab plus chemotherapy in metastatic non-small-cell lung cancer.
      ,
      • Paz-Ares L
      • Luft A
      • Vicente D
      • et al.
      Pembrolizumab plus chemotherapy for squamous non-small-cell lung cancer.
      where a 47.6% ORR was observed in non-squamous NSCLC and a 57.9% ORR in squamous NSCLC, we assumed the efficacy for Sintilimab plus chemotherapy is approximately 55% in advanced NSCLC. We would except the ORR of CIK cells combination with Sintilimab plus chemotherapy to be 80%. At a 2-sided significance level of P = .05, a total of 28 patients could provide 80% power to show the efficacy of CIK cells combination with Sintilimab plus chemotherapy when the targeted ORR of the combination therapy is 80% compared with 55% for Sintilimab plus chemotherapy. Assuming a dropout rate of 10%, an initial 31-patient enrollment was planned. Safety and efficacy analyses included all patients who received 1 or more dose of study medication. The ORR and its 95% confidence intervals (CIs) were determined by the Clopper and Pearson method. PFS and OS were plotted using the Kaplan-Meier method, with medians and corresponding 2-sided 95% CIs reported. In univariate evaluations of the efficacy impact of continuous variable, the optimal cut point was determined using the Receive Operating Characteristic (ROC) Curve method. A P value less than .05 using 2-sided tests indicates statistical significance. All calculations were performed using R software version 3.5.1.

      Results

      Patient Characteristics

      From May 17, 2019, to January 15, 2021, 36 patients were assessed. Among them, 2 were excluded before treatment owing to EGFR mutation. 34 patients received at least 1 dose of treatment (Figure 1). By the cutoff date of August 31, 2021, 14 patients were undergoing treatment and 1 patient finished 2 years treatment, 19 patients discontinued treatment because of disease progression (n = 12), refused further maintenance treatment after achieved objective response (n = 3), intolerable adverse event (n = 1), death from grade 5 immune-related pneumonitis (n = 1), death from non-treatment related intracerebral hemorrhage (n = 1), and loss of follow-up (n = 1). Baseline characteristics were listed in Table 1. 19 (55.9%) of 34 patients had squamous NSCLC, and 15 (44.1%) had non-squamous NSCLC. 28 patients (82.4%) had stage IV disease, among of them, 3 had brain metastasis, 3 had liver metastasis, and 7 had bone metastasis. PD-L1 expression and CD8+ TIL density was assessed in 32 patients. Tumor PD-L1 expression at baseline was 1% or higher in 15 (44.1%) patients.
      Figure 1
      Figure 1NCT03987867 CONSORT Diagram for The Phase IB Trial of Autologous Cytokine-Induced Killer Cell Therapy in Combination With Sintilimab Plus Chemotherapy in Patients With Advanced NSCLC. EGFR = epidermal growth factor receptor; NSCLC = non-small cell lung cancer; PD = progressive disease; 2nd, second; PR = partial response; CMR = complete metabolic response; CR = complete response; SD = stable disease; #, this patient died from non-treatment related intracerebral hemorrhage.

      Treatment‐Related Toxicity

      By August 31, 2021 of the cutoff date, 7.5 months after the last patient was enrolled, patients received 2 to 33 cycles treatments. The treatment-related adverse events (TRAEs) were reported in 32 (94.1%) patients (Table 2). Grade 3 or greater TRAEs occurred in 22 (64.7%) patients. Grade 3 or greater TRAEs of more than 5% included neutropenia (23.5%), fatigue (20.6%), nausea (11.8%), leukopenia (8.8%), thrombocytopenia (5.9%), and pneumonia (5.9%). Immune-related adverse events (irAEs) occurred in 11 (32.4%) patients (Table 2). Grade 3 or greater irAEs occurred in 4 (11.8%) patients. Grade 3 or greater irAEs included pneumonia (5.9%), cardiomyopathy (2.9%), dysphagia (2.9%), rash (2.9%), and cough (2.9%). Discontinuation of all trial drugs because of adverse events occurred in 2 (5.9%) patients. Discontinuation of Sintilimab, CIK cells, and chemotherapy occurred in 4 (11.8%), 2 (5.9%), and 3 (8.8%) patients, respectively. One (2.9%) patient died from grade 5 immune-related pneumonia after 2 cycles of treatment.
      Table 2Adverse Events in The Phase IB Study
      Treatment-Related Adverse EventsAny GradeGrade 3, 4, or 5
      Number of Patients (%)
      Any event32 (94.1)22 (64.7)
      Event leading to discontinuation of all treatment2 (5.9)2 (5.9)
      Discontinuation of Sintilimab4 (11.8)4 (11.8)
      Discontinuation of CIK cells2 (5.9)2 (5.9)
      Discontinuation of Chemotherapy3 (8.8)3 (8.8)
      Event leading to death1 (2.9)1 (2.9)
       Anemia23 (67.6)1(2.9)
       Neutropenia20 (58.8)8 (23.5)
       Leukopenia23 (67.6)3 (8.8)
       Thrombocytopenia10 (29.4)2 (5.9)
       Nausea22 (64.7)4 (11.8)
       Alanine aminotransferase increased8 (23.5)1 (2.9)
       Aspartate aminotransferase increased5 (14.7)1 (2.9)
       Hypoalbuminemia13 (38.2)0 (0)
       Fatigue17 (50.0)7 (20.6)
       Rash4 (11.8)1 (2.9)
       Cough10 (29.4)1 (2.9)
       Pneumonia5 (14.7)2 (5.9)
       Hypothyroidism8 (23.5)0
       Adrenal insufficiency3 (8.8)0
       Cardiomyopathy1 (2.9)1 (2.9)
       Mucostitis oral1 (2.9)1 (2.9)
       Dysphagia1 (2.9)1 (2.9)
      Immune-Related Adverse EventAny GradeGrade 3, 4, or 5
      Number of Patients (%)
      Any event11 (32.4)4 (11.8)
      Event leading to death1 (2.9)1 (2.9)
       Hypothyroidism8 (23.5)0
       Pneumonia5 (14.7)2 (5.9)
       Rash4 (11.8)1 (2.9)
       Adrenal insufficiency3 (8.8)0
       Cough2 (5.9)1 (2.9)
       Cardiomyopathy1 (2.9)1 (2.9)
       Dysphagia1 (2.9)1 (2.9)
      Abbreviations: CIK = cytokine-induced killer.

      Antitumor Activity

      By August 31, 2021, the median follow-up time was 14.4 months. In 34 patients, 2 achieved CR, 5 CMR, and 21 PR (Table 3). The ORR of 34 patients per irRECIST was 82.4% (95% CI, 65.5%-93.2%), and DCR was 100.0% (95% CI, 89.7%-100.0%). The median time of 34 patients to response was 1.5 months (range, 0.7-6.5 months). The median DOR of 34 patients was 17.9 months [(95% CI, 10.5 months to not available (NA)]. Then we performed subgroup analysis in squamous cell carcinoma and non-squamous groups. Objective responses were evaluated in 14 of 15 non-squamous patients (93.3%; 95% CI, 68.1%-99.8%) and in 14 of 19 squamous patients (73.7%; 95% CI, 48.8%-90.9%). In the 3 patients with brain metastasis, 2 achieved CR and 1 for SD. Until the cutoff date, the 3 patients were still ongoing response, and no new patient developed into brain metastasis. 32 (94.1%) of 34 patients got tumor shrinkage including 15 patients (44.1%) with tumor reduction more than 50% (Figure 2). The median PFS was 19.3 months (95% CI, 8.3-NA) in all patients, not reached in non-squamous patients, and 17.0 months (95% CI, 5.0-NA) in squamous patients, respectively. The median OS was not reached in all patients and in non-squamous patients, and 20.3 months (95% CI, 7.2-NA) in squamous patients. (Figure 3).
      Table 3Summary of Response in The Phase IB Study
      VariableITT (N = 34)SQ (N = 19)NSQ (N = 15)
      ORR, n (%)28 (82.4)14 (73.7)14 (93.3)
      95% CI65.5-93.248.8-90.968.1-99.8
      DCR, n (%)34 (100)19 (100)15 (100)
      95% CI89.7-100.082.4-100.078.2-100.0
      CR, n (%)2 (5.9)0 (0)2 (13.3)
      CMR, n (%)5 (14.7)3 (15.8)2 (13.3)
      PR, n (%)21 (61.8)11 (57.9)10 (66.7)
      SD, n (%)6 (17.6)5 (26.3)1 (6.7)
      Median time to response, months (range)1.5 (0.7-6.5)1.5 (0.7-6.51.9 (1.4-3.8)
      Median DOR, months17.917.9NR
      95% CI10.5-NA9.3-NANA
      Abbreviations: ITT = intention to treat analysis; SQ = squamous; NSQ = non-squamous; ORR = objective response rate; CI = confidence interval; DCR = disease control rate; CR = complete response; CMR = complete metabolic response; PR = partial response; SD = stable disease; DOR = duration of response; NR = not reached; NA = not available.
      Figure 2
      Figure 2(A) Maximal change of tumor size from base line assessed by investigator per Response Evaluation Criteria in Solid Tumors (RECIST) version1.1 (N = 34). The length of the bar represents maximal decrease or minimal increase in target lesion(s). (B) Change in individual tumor burden over time from baseline assessed by investigator per RECIST version 1.1 (N = 34). (C) Exposure and duration of response per RECIST version 1.1 (N = 34). SQ = squamous; Non-SQ = non-squamous; ECOG = Eastern Cooperative Oncology Group; PS = performance status; TPS = the tumor proportion score, the percentage of tumor cells with membranous programmed cell death protein ligand-1 staining; TIL = tumor infiltrating lymphocyte, used the top 60th percentile of CD8+ TIL percentage as the cutoff point of CD8+ TIL density; Low, CD8+ TIL bottom 40%; High, CD8+ TIL top 60%; UN = unknown; CR = complete response; CMR = complete metabolic response; PR = partial response; SD = stable disease; PD = progressive disease; EOT = end of treatment.
      Figure 3
      Figure 3(A) Progression-free survival, and (B) overall survival, in all patients, squamous patients, and non-squamous patients by Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1. PFS = progression-free survival; OS = overall survival; All = all patients (N = 34); SQ, squamous patients (N = 19); non-SQ = non-squamous patients (N = 15); CI, confidence interval; NA = not available.

      PD‐L1 Expression and CD8+ TIL in Tumor

      15 PD-L1 positive samples (46.9%) and 17 PD-L1 negative samples (53.1%) were identified in the study. The ORR in PD-L1 positive patients was higher than that in PD-L1 negative patients (ORR, 86.7% vs. 76.5%, respectively), but not statistical difference (P = .659, Supplementary Appendix Figure S3A). PD-L1-positive patients had a statistically significant PFS advantage compared with PD-L1-negative patients per irRECIST [hazard ratio (HR), 0.16; 95% CI, 0.04-0.75; P = .008; Supplementary Appendix Figure S3B)]. In this study, patients were stratified into 2 subgroups using the top 60th percentile of CD8+ TIL percentage as the cutoff point of CD8+ TIL density. There were 19 patients with CD8+ TIL top 60% (55.9%) and 13 with CD8+ TIL bottom 40% (38.2%). The ORR in patients with CD8+ TIL top 60% was significantly higher than that in patients with CD8+ TIL bottom 40% (ORR, 94.7% vs. 61.5%, respectively; P = .029, Supplementary Appendix Figure S3C). Median PFS in patients with CD8+ TIL top 60% was significantly longer than that in in patients with CD8+ TIL bottom 40% (HR, 0.23; 95% CI, 0.07-0.77; P = .009; Supplementary Appendix Figure S3D). The ORR in patients with PD-L1 positive and/or CD8+ TIL top 60% was significantly higher than that in patients with PD-L1 negative and CD8+ TIL bottom 40% (ORR, 91.3% vs. 55.6%, respectively; P = .039, Supplementary Appendix Figure S3E). Median PFS in patients with PD-L1 positive and/or CD8+ TIL top 60% was significantly longer than that in in patients PD-L1 negative and CD8+ TIL bottom 40% (HR, 0.15; 95% CI, 0.05-0.47; P < .001; Supplementary Appendix Figure S3F). The impact of PD-L1 expression and CD8+ TIL on OS were showed in Supplementary Appendix Figure S4.

      Other Biomarkers and Subgroups Analysis

      In our study, we also analyzed CD8+ TOX+ (thymocyte selection-associated high mobility group box protein) T cells in peripheral blood. 28 responders displayed lower proportion of CD8+ TOX+ T cells as compared with 6 non-responders at baseline (P = .044) (Supplementary Appendix Figure S5). Patients were stratified into 2 subgroups using the top 55th percentile of CD8+ TOX+ T cells percentage as the cutoff point. The top 55% subgroup showed worse ORR than the bottom 45% subgroup (P = .024) but did not show a significant difference in PFS between the 2 subgroups (P = .8).
      We also detected 59 immunological factors in plasma (Supplementary Appendix Other Biomarkers Expression Analysis). Plasma concentrations of stromal cell-derived factor-1α (SDF-1α) was associated with ineffective treatment in ORR, PFS, and OS (Supplementary Appendix Figure S6).
      Additional clinical characters analyzed for correlation with clinical efficacy included age, sex, smoking, ECOG PS and tumor metastatic stage (Supplementary Appendix Tables S1 and S2). Among the subgroups, patients with ECOG PS < 1 had a higher ORR, a longer PFS, and a longer OS than the rest of the patients (P = .062, P < .001, and P = .005, respectively) (Supplementary Appendix Figure S7). And PET-CT was used to show the metabolic status of the tumor before and after the therapy (Supplementary Appendix Figure S8).

      Discussion

      In a review of the literature, we found that, to date, this trial has been the first study of CIK cells immunotherapy combination with PD-1 inhibitor plus chemotherapy in lung cancer. In this phase 1b trail of 34 patients with advanced NSCLC, the TRAEs were 94.1%, grade 3 or greater TRAEs were 64.7%, and 1 patient (2.9%) died from grade 5 immune-related pneumonia. The ORR was 82.4%, DCR was 100.0%, median DOR was 17.9 months, median PFS was 19.3 months, and median OS was not reached. These results showed that CIK cells combined with PD-1 inhibitor and chemotherapy had good tolerance and encouraging efficacy in advanced NSCLC.
      The first concern in this trail was safety. Every cycle, more than 1 × 1010 CIK cells were infused into patient. PD-1 inhibitors release the brake of immune cells and activate immune cells. Chemotherapy was combined at the same time. The TRAEs, especially irAEs, maybe increase significantly. In the phase 3 KEYNOTE-189, KEYNOTE-407, ORIENT-11, and ORIENT-12 trial, the TRAEs were 98.2% to 99.8%, grade 3 or greater TRAEs were 61.7% to 86.6%, irAEs were 22.7% to 48.5%, grade 3 or greater irAEs were 5.6% to 15.7%, and TRAEs leading to death were 2.3% to 10.8%.
      • Gandhi L
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      • et al.
      Pembrolizumab plus chemotherapy in metastatic non-small-cell lung cancer.
      ,
      • Paz-Ares L
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      Pembrolizumab plus chemotherapy for squamous non-small-cell lung cancer.
      ,
      • Yang Y
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      • Fang J
      • et al.
      Efficacy and safety of sintilimab plus pemetrexed and platinum as first-line treatment for locally advanced or metastatic nonsquamous NSCLC: a randomized, double-blind, phase 3 Study (Oncology pRogram by InnovENT anti-PD-1-11).
      ,
      • Zhou C
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      • et al.
      Sintilimab plus platinum and gemcitabine as first-line treatment for advanced or metastatic squamous NSCLC: results from a randomized, double-blind, phase 3 trial (ORIENT-12).
      In this trial, the TRAEs, grade 3 or greater TRAEs, irAEs, grade 3 or greater irAEs, and TRAEs leading to death were 94.1%, 64.7%, 32.4%, 11.8%, and 2.9%, respectively. These findings indicated that the addition of CIK cells to PD-1 inhibitor plus chemotherapy did not increase TRAEs, irAEs and mortality.
      In the phase 1/2 KEYNOTE-02118 trail for untreated advanced NSCLC, there were 24 non-squamous patients treatment with pembrolizumab plus chemotherapy in cohort C, the ORR, median PFS, and median OS were 75%, 10.2 months, and 16.7 months, respectively;
      • Gadgeel SM
      • Stevenson JP
      • Langer CJ
      • et al.
      Pembrolizumab and platinum-based chemotherapy as first-line therapy for advanced non-small-cell lung cancer: Phase 1 cohorts from the KEYNOTE-021 study.
      in cohort G of 60 non-squamous patients treatment with pembrolizumab plus chemotherapy, the ORR, median PFS, and median OS were 58%, 24.5 months, and 34.5 months, respectively.
      • Borghaei H
      • Langer CJ
      • Gadgeel S
      • et al.
      24-Month overall survival from KEYNOTE-021 Cohort G: pemetrexed and carboplatin with or without pembrolizumab as first-line therapy for advanced nonsquamous non-small cell lung cancer.
      In phase 1b study of Sintilimab plus chemotherapy for first-line advanced NSCLC,
      • Jiang H
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      • Qian J
      • et al.
      Efficacy and safety of sintilimab in combination with chemotherapy in previously untreated advanced or metastatic nonsquamous or squamous NSCLC: two cohorts of an open-label, phase 1b study.
      there were 21 non-squamous patients in cohort D, the ORR and median PFS were 68.4% and 11.4 months, respectively. In the experimental group of phase 3 KEYNOTE-189 trail, the tumor response was 47.6% with median PFS of 9.0 months and median OS of 22.0 months in the first line treatment for patients with metastatic non-squamous NSCLC.
      • Gandhi L
      • Rodriguez-Abreu D
      • Gadgeel S
      • et al.
      Pembrolizumab plus chemotherapy in metastatic non-small-cell lung cancer.
      In the phase 3 ORIENT-11 trail of first line treatment for patients with advanced non-squamous NSCLC, additional Sintilimab to chemotherapy, patients received the better ORR (51.9%), median PFS (8.9months), and median OS (not reached).
      • Yang Y
      • Wang Z
      • Fang J
      • et al.
      Efficacy and safety of sintilimab plus pemetrexed and platinum as first-line treatment for locally advanced or metastatic nonsquamous NSCLC: a randomized, double-blind, phase 3 Study (Oncology pRogram by InnovENT anti-PD-1-11).
      In this phase 1b trail, there were 15 non-squamous patients. Additional CIK cells to Sintilimab plus chemotherapy, the ORR was 93.3%, the median PFS and OS were not reached after 14.4 months median follow-up. The median PFS will expect to exceed 19.3 months, because of 19.3 months median PFS of all patients. It was noteworthy that the CR plus CMR rate was as high as 26.7%, the DCR was 100.0%, and 9 patients (60%) had tumor shrinkage rate ≥ 50%.
      For squamous NSCLC, in the phase 1/2 KEYNOTE-021 trail, there were 25 advanced patients treatment with pembrolizumab plus chemotherapy in cohort A, the ORR, median PFS, and median OS were 48%, 10.3 months, and 21.4 months, respectively.
      • Gadgeel SM
      • Stevenson JP
      • Langer CJ
      • et al.
      Pembrolizumab and platinum-based chemotherapy as first-line therapy for advanced non-small-cell lung cancer: Phase 1 cohorts from the KEYNOTE-021 study.
      In phase 1b study of Sintilimab plus chemotherapy for first-line advanced NSCLC, there were 20 squamous patients in cohort E, the ORR and median PFS were 64.7% and 6.8 months, respectively.
      • Jiang H
      • Zheng Y
      • Qian J
      • et al.
      Efficacy and safety of sintilimab in combination with chemotherapy in previously untreated advanced or metastatic nonsquamous or squamous NSCLC: two cohorts of an open-label, phase 1b study.
      In the experimental group of phase 3 KEYNOTE-407 trail, the tumor response was 57.9% with median PFS of 8.0 months and median OS of 17.1 months in the first line treatment for metastatic patients.
      • Paz-Ares L
      • Luft A
      • Vicente D
      • et al.
      Pembrolizumab plus chemotherapy for squamous non-small-cell lung cancer.
      In the phase 3 ORIENT-12 trail of first line treatment for patients with advanced squamous NSCLC, additional Sintilimab to chemotherapy, patients received the better ORR (44.7%), median PFS (5.5months), and median OS (not reached).
      • Zhou C
      • Wu L
      • Fan Y
      • et al.
      Sintilimab plus platinum and gemcitabine as first-line treatment for advanced or metastatic squamous NSCLC: results from a randomized, double-blind, phase 3 trial (ORIENT-12).
      In this phase 1b trail, there were 19 squamous patients. Additional CIK cells to Sintilimab plus chemotherapy, the ORR was 73.7%, the median PFS was 17.0 months, and median OS was 20.3 months. 13 of 19 patients discontinued treatment at the cutoff date, including disease progression (n = 9), refused maintenance treatment after objective response (n = 2), death from non-treatment related intracerebral hemorrhage (n = 1), and loss of follow-up (n = 1). Among the 9 disease progression patients, 5 received second line treatment in which 1 patient died, but the other 4 refused to accept second-line or supportive treatment in which all patients died within 3 months (range, 1.1-2.2 months) after progression. The median OS was not reached in the 5 patients and 7.2 months in the 4 patients. Whereas in the 15 non-squamous patients, 3 patients developed into disease progression who all received second line treatment, and they are all alive. This may be the reason for the short time interval between median PFS and OS (17.0 and 20.3 months, respectively), and PFS is not converted into OS in squamous patients.
      To our knowledge, the survival benefit associated with the anti-PD-1 combination therapy was related to PD-L1 expression. Although not relationship between PD-L1 expression and ORR in this study, higher PD-L1 expression was associated with longer PFS. We also found that patients with more CD8+ TILs in the tumor microenvironment, or more CD8+ TOX T cells, or lower SDF1-α expression in peripheral blood circulation had a higher ORR; and patients with more CD8+ TILs, or lower SDF1-α expression had a longer PFS. CD8+ T cells play a critical role in eradicating cancer cells. However, human overexpression data support the conclusion that CD8+ TOX+ drives an exhausted phenotype. When co-culturing human CD8+ T cells which overexpress TOX with tumor cells that present the cognate antigen, it was observed lower interferon-γ (IFN-γ) and tumor necrosis factor (TNF) production compared to control cells.
      • Alfei F
      • Kanev K
      • Hofmann M
      • et al.
      TOX reinforces the phenotype and longevity of exhausted T cells in chronic viral infection.
      Similar results were found in our study. The elevated percent of CD8+ TOX+ T cells was a prognostic and predictive biomarker of bad response. Meanwhile, we examined the CD8+ TOX+ T cells of peripheral blood in 20 patients treated with Sintilimab plus chemotherapy from phase II trial [Randomized controlled phase II clinical study of Sintilimab and chemotherapy combined with or without autologous CIK in the treatment of stage IV non-small cell lung cancer: NCT04836728, not published], 34 patients treatment with CIK cells combination with Sintilimab plus chemotherapy in this study showed lower percent of CD8+ TOX+ T cells, as compared with the 20 patients treatment with Sintilimab plus chemotherapy after 4 cycles treatments (P = .002). We speculate that CIK cells may increase functional T cells, reduce the proportion of exhausted T cells, thus promote the efficacy. SDF-1α with its receptor CXCR4 are always known as immunosuppressive cytokines by sustaining tumor cells proliferation, recruiting immunosuppressive cells (Treg cells, monocyte), inducing osteoclasts activation and bone metastasis, inducing neo angiogenesis, and guiding tumor cells to disseminate to distant organs.
      • Aldinucci D
      • Colombatti A
      The inflammatory chemokine CCL5 and cancer progression.
      ,
      • Sun R
      • Luo H
      • Su J
      • et al.
      Olaparib Suppresses MDSC Recruitment via SDF1alpha/CXCR4 Axis to Improve the Anti-tumor Efficacy of CAR-T Cells on Breast Cancer in Mice.
      In our study, the higher concentration of SDF-1α was correlated with decreasing trend of therapeutic response.
      Conventional chemotherapy can mediate tumor cell sensitivity to adoptive T-cell transfer. Chemotherapy can induce autophagy in tumor cells. Autophagosomes improve the mannose-6-phosphate receptor (MPR) accumulation on the membrane of tumor cells. MPR can bind granzyme B, which is released by activated CTLs, on the membrane of tumor cells.
      • Ramakrishnan R
      • Huang C
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      • et al.
      Autophagy induced by conventional chemotherapy mediates tumor cell sensitivity to immunotherapy.
      ,
      • Cancer Amaravadi RK:
      Autophagy in tumor immunity.
      On the other hand, CIK cells can reverse chemoresistance. Our previous research showed that CIK cells could reverse the cisplatin (DDP) resistance of A549/DDP cell line in a time-dependent manner by reducing glutathione-S-transferase-π expression to increase the accumulation of DDP. The effect of CIK cells on re-sensitizing lung cancer cells to the chemotherapy drug was partially dependent on the secretion of IFN-γ.
      • Yang L
      • Du C
      • Wu L
      • et al.
      Cytokine-induced killer cells modulates resistance to cisplatin in the A549/DDP Cell line.
      Immunotherapies of checkpoint inhibitors have transformed the clinical care of patients with cancer. However, whether the T cell response to checkpoint inhibitor relies on reinvigoration of pre-existing tumor-infiltrating lymphocytes or on recruitment of novel T cells remains unclear. Recently, Yost and colleagues showed that, through paired single-cell RNA and T cell receptor sequencing on 79,046 cells from site-matched tumors from patients with basal or squamous cell carcinoma before and after anti-PD-1 therapy, pre-existing tumor-specific T cells may have limited reinvigoration capacity, and that the T cell response to checkpoint inhibitor derives from a distinct repertoire of T cell clones that may have recently entered the tumor.
      • Yost KE
      • Satpathy AT
      • Wells DK
      • et al.
      Clonal replacement of tumor-specific T cells following PD-1 blockade.
      CIK cells as exotic T cells may have stronger ability to kill tumor cells when compared with pre-existing tumor-infiltrating lymphocytes. CIK cells may be crucial in some way to turn “cold” tumor into “hot” 1. Novel strategies to overcome the absence of pre-existing immunity in cold tumors warrant further exploration in future. These findings suggest that the addition CIK cell immunotherapy to chemotherapy plus PD-1 inhibitors can further improve the efficacy.
      In summary, this phase 1b study provides evidence for the safety and efficacy of the combination of CIK cells immunotherapy with PD-1 antibody Sintilimab plus chemotherapy in patients with previously untreated, advanced NSCLC. A large sample, multi-center randomized, phase 2 trial is being carried out to further validate these findings (CCICC-002b ClinicalTrials.gov number, NCT04836728).

      Clinical Practice Points

      • Anti-programmed cell death protein 1 (PD-1) monotherapy plus chemotherapy showed significantly better response rate, and longer progression-free survival (PFS) and OS than chemotherapy alone in metastatic NSCLC. In our previously retrospective and prospective clinical trials, the results showed that CIK cells immunotherapy could improve the efficacy of chemotherapy in patients with advanced NSCLC. We designed a single-arm, open-label, phase 1b study to evaluate the clinical safety and efficacy of autologous CIK cells therapy in combination with Sintilimab, antibody against programmed cell death-1, plus chemotherapy in patients with advanced NSCLC.
      • Patients with stage IIIB/IIIC/IV NSCLC received Sintilimab, platinum-based doublet chemotherapy, and CIK cells every 3 weeks for 4 cycles, then maintenance treatment with Sintilimab in squamous and with Sintilimab plus pemetrexed in non-squamous NSCLC. In this study, the treatment shows good antitumor effect and safety. And we also analyzed and discussed biomarkers with clinical efficacy.
      • This sudy is important and will be of interest to readers of Clinical Lung Cancer, as it has provided new strategy to many patients with NSCLC.

      Acknowledgment

      We thank the patients who participated in this study and their families, thank the Suzhou Xinda biopharmaceutical Co., LTD for assistance with statistical analysis.
      Supported by the National Key Technologies R&D Program of China grant Awards No. 2018YFC1313400 (to Jianchuan Xia), by the National Natural Science Foundation of China grants Awards No. 81974416, 81872166, 82103001 and U20A20375, the Tianjin Natural Science Foundation No. 19JCYBJC27600.

      Disclosure

      This study has presented in part at the American Society of Clinical Oncology (ASCO) Annual Meeting on Developmental Therapeutics-Immunotherapy, Chicago, IL, June 4-8, 2021. The authors reported no potential conflicts of interest.

      CRediT authorship contribution statement

      Li Zhou: Conceptualization, Investigation, Formal analysis, Data curation, Writing – original draft. Yanjuan Xiong: Conceptualization, Investigation, Formal analysis, Data curation, Writing – original draft. Yang Wang: Conceptualization, Investigation, Formal analysis, Data curation, Writing – original draft. Yuan Meng: . Weihong Zhang: Validation, Investigation, Data curation, Writing – original draft. Meng Shen: Validation, Investigation, Data curation, Writing – original draft. Xinwei Zhang: Validation, Investigation, Data curation, Writing – original draft. Shuzhan Li: Validation, Investigation, Data curation, Writing – original draft. Baozhu Ren: Validation, Investigation, Data curation, Writing – original draft. Runmei Li: Validation, Investigation, Data curation, Writing – original draft. Ying Han: Validation, Investigation, Data curation, Writing – original draft. Jiali Zhang: Validation, Investigation, Data curation, Writing – original draft. Shui Cao: Validation, Investigation, Data curation, Writing – original draft. Weijiao Du: Validation, Investigation, Data curation, Writing – original draft. Qian Sun: Investigation, Resources, Visualization. Feng Wei: Investigation, Resources, Visualization. Xiumei An: Investigation, Resources. Lili Yang: Investigation, Resources, Visualization. Yuwei Zhang: Formal analysis, Data curation. Wenchao Ma: Formal analysis, Data curation. Wengui Xu: Formal analysis, Data curation. Yi Zhang: Conceptualization, Formal analysis. Jingting Jiang: Conceptualization, Formal analysis. Xiang Xu: Conceptualization, Formal analysis. Jianchuan Xia: Conceptualization, Formal analysis. Liang Liu: Conceptualization, Methodology, Writing – review & editing, Supervision, Project administration. Xiubao Ren: Conceptualization, Methodology, Writing – review & editing, Supervision, Project administration.

      Appendix. Supplementary materials

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