Active immunotherapy using dendritic cells in the treatment of glioblastoma multiforme

Cancer Treatment Reviews xxx (2013) xxx–xxx

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Cancer Treatment Reviews journal homepage: www.elsevierhealth.com/journals/ctrv

Anti-Tumour Treatment

Active immunotherapy using dendritic cells in the treatment of glioblastoma multiforme Amade Bregy a, Theresa M. Wong a, Ashish H. Shah a, John M. Goldberg b, Ricardo J. Komotar a,⇑ a b

University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, FL, USA University of Miami Miller School of Medicine, Division of Pediatric Hematology Oncology, Department of Pediatrics, Miami, FL, USA

a r t i c l e

i n f o

Article history: Received 19 October 2012 Received in revised form 20 May 2013 Accepted 26 May 2013 Available online xxxx Keywords: Glioblastoma multiforme Immunotherapy Outcomes Systematic analysis

a b s t r a c t Objective: Glioblastoma multiforme, the most common malignant brain tumor still has a dismal prognosis with conventional treatment. Therefore, it is necessary to explore new and/or adjuvant treatment options to improve patient outcomes. Active immunotherapy is a new area of research that may be a successful treatment option. The focus is on vaccines that consist of antigen presenting cells (APCs) loaded with tumor antigen. We have conducted a systematic review of prospective studies, case reports and clinical trials. The goal of this study was to examine the efficacy and safety in terms of complications, median overall survival (OS), progression free survival (PFS) and quality of life. Methods: A PubMed search was performed to include all relevant studies that reported the characteristics, outcomes and complications of patients with GBM treated with active immunotherapy using dendritic cells. Reported parameters were immune response, radiological findings, median PFS and median OS. Complications were categorized based on association with the craniotomy or with the vaccine itself. Results: A total of 21 studies with 403 patients were included in our review. Vaccination with dendritic cells (DCs) loaded with autologous tumor cells resulted in increased median OS in patients with recurrent GBM (71.6–138.0 wks) as well as those newly diagnosed (65.0-230.4 wks) compared to average survival of 58.4 wks. Conclusions: Active immunotherapy, specifically with autologous DCs loaded with autologous tumor cells, seems to have the potential of increasing median OS and prolonged tumor PFS with minimal complications. Larger clinical trials are needed to show the potential benefits of active immunotherapy. Ó 2013 Elsevier Ltd. All rights reserved.

Introduction In the year 2012, The National Cancer Institute (NCI) reported that 22,910 adults would be diagnosed with brain or other central nervous system (CNS) tumors; 15% of these tumors are diagnosed as glioblastoma multiforme (GBM). With a yearly incidence of 2.5 in 100,000,1 GBM is the most common and lethal type of brain tumor with a median overall survival (OS) of three months without standard treatment.2 Currently the accepted conventional treatment for GBM is maximal surgical resection of the tumor followed by radiation with 60 Gy of fractionated radiation therapy and chemotherapy with temozolomide.3 This offers a median OS of 14.6 month,4 a prognosis that still remains dismal. Current research points to immunotherapy as a non-surgical adjuvant treatment option with minimal risk of side effects.

⇑ Corresponding author. Address: University of Miami, Department of Neurological Surgery, 1095 NW 14th Terrace, 2nd Floor, Miami, FL, USA. Tel.: +1 (305) 243 2427. E-mail address: [email protected] (R.J. Komotar).

The principle of immunotherapy for cancer is based on stimulating the body’s own immune system in order to amplify both a humoral and cytotoxic immune response to target tumor cells.5 Immunotherapy works either by boosting the immune system entirely or by training the immune system to attack the tumor based on specific antigenicity.6 In the initial stages of this research, immunotherapy was not considered to be an effective treatment option due to the blood brain barrier (BBB) as well as the absence of the conventional lymphatic drainage system.7 The BBB serves as a boundary that separates the peripheral circulation and the CNS, which inherently prevents immune reactions other than those from microglia from occurring in the brain.8 Additionally with the absence of the conventional lymphatic vessels and low levels of circulating T-cells in the brain, it is difficult to understand how activated peripheral immune cells would be able to cross the BBB and target a tumor in the brain.7 Previous literature has established the theory of two-way communication between the CNS and peripheral circulation by either a humoral immune response or nervous transmission.9 The latter relies on afferent or efferent nerve fibers of the CNS to create an autoimmune link across the BBB. This link is exemplified by the

0305-7372/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ctrv.2013.05.007

Please cite this article in press as: Bregy A et al. Active immunotherapy using dendritic cells in the treatment of glioblastoma multiforme. Cancer Treat Rev (2013), http://dx.doi.org/10.1016/j.ctrv.2013.05.007

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A. Bregy et al. / Cancer Treatment Reviews xxx (2013) xxx–xxx

vagus nerve, which has been found to direct communication between the brain and the immune system.10,11 Signals that originate in the brain are transmitted through the vagus nerve as an action potential. This ultimately leads to the release of cytokines, which then mounts an inflammatory immune response. On the other hand, humoral immunity relies on immunoglobulin as the main mediator across the BBB to increase response to foreign antigens (tumors). An example of this type of transmission is the vaccine induced experimental model of autoimmune encephalomyelitis (EAE).9 In these studies, activated CD4+ T-cells have been observed circulating in the periphery and then infiltrating the CNS to induce EAE.12 Therefore, in analogy immunotherapy may be a plausible treatment option where activated immune cells after exposure to a peripheral antigens from the vaccine are transported through the bloodstream and can cross the BBB. However, the exact mechanism by which this occurs is not fully understood.7,13,14 The primary focus of this paper is to describe mechanisms and findings of active immunotherapy using dendritic cells (DCs) as the antigen presenting cells (APCs). This type of treatment is based on training the body’s immune system to create an antitumoral response.15 In this type of therapy, APCs are sensitized with a tumor specific antigen and administered as a vaccine either by intradermal or subcutaneous injection. This results in the generation of appropriate T-cells that mount an antitumor response. Active

immunotherapy is not only applicable in treating the initial tumor, but it may also induce a memory immune response, that offers protection to the body from future tumor recurrences. In order to assess the safety and efficacy of active immunotherapy using DCs as APCs, we have conducted a systematic review of the literature to help establish a general consensus on the safety of active immunotherapy as well as to define a paradigm for treatment protocols (increased median OS, progression free survival (PFS) and the quality of life of the patients).

Materials and methods Study selection Using the MeSH database system of PubMed, a literature search was performed between the years 1992 and 2013 for all articles containing the terms glioblastoma and immunotherapy ((‘‘Glioblastoma’’[Mesh]) AND ‘‘Immunotherapy’’[Mesh]). The articles were limited to English with humans as the only subjects of this study. Additionally, the article types were limited to case reports, clinical trials and randomized controlled trials while reviews, editorials and commentaries were excluded. The initial inclusion criteria focused mainly on immunotherapy as an adjuvant treatment for

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and MetaAnalyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097

Fig. 1. The PRISMA figure illustrates the systematic process that was conducted to locate case reports, clinical trials and prospective studies that we analyzed in this review.

Please cite this article in press as: Bregy A et al. Active immunotherapy using dendritic cells in the treatment of glioblastoma multiforme. Cancer Treat Rev (2013), http://dx.doi.org/10.1016/j.ctrv.2013.05.007

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A. Bregy et al. / Cancer Treatment Reviews xxx (2013) xxx–xxx Table 1 Articles reviewed on active immunotherapy using dendritic cells in the treatment of glioblastoma multiforme. Author and year

Diagnosis Type No. Avg of age + range of study pts. (yrs.)

Treatment history

Type of vaccination

Autologous DC pulsed w/ Allogeneic MHC-1 matched tumor peptides FC of DC + autologous glioma cells

Liau et al. (2000)29 CRp

1

49

R-GBM

SR + RT + chemo (Accutane + Tamoxifen)

Kikuchi et al. (2001)28

CT

8

38 (4–63)

GBM (5), AA(2), AOD(1)\

SR + chemo + RT

Yu et al. 200135

CT

9

49 (28–77) N-GBM (7), N-AA (2)

SR + EBRT

Yamanaka et al. (2003)33

CT

10

46.1 (27– 69)

SR + EBRT

Kikuchi et al. (2004)27

CT

15

45 (29–64) R-GBM (6), R-AA(7), RAOA (2)

SR + RT + chemo (12), SR + RT (2), SR (1)

Rutkowski et al. (2004)24

CT

12

39.7 (11– 78)

PR(2), STR(3), CR (7) + RT &/or chemo

Yu et al.(2004)34

CT

14

Liau et al. (2005)30 CT

12

Yamanaka et al. (2005)26

CT

24

48.9 (20– 73)

Khan et al. (2006)22

CRp

1

57

De Vleeschouwer et al. (2008)19 Wheeler et al. (2008)25

Pros. 56 CT

32

R- GBM (7), R- AOA (1), R-AMG (2)

R-GBM (7), R-AA (4), RODG IV (1) 44.7 (28– R-GBM (9), 61) R-AA (3), NGBM(1), NAA(1) 40 (20–65) R-GBM(5) N-GBM (7)

Med: 45 (7–77) + 54 ± 3 _

49 ± 4

SR + SRS (2), chemo

SR + EBRT SR + RT/chemo

R-GBM (18), SR + EBRT + chemo R-AA (2), RGl (1), RAGM (1), RAOD (1) R-GBM PR + chemo

R-GBM

SR(29)/TR(27) + EBRT + chemo (6)

R-GBM (9), TR (25) + chemo (21) N-GBM (6) R-GBM (12), N-GBM (3) N-GBM STR (6)/TR (2)

Ardon et al. (2010)16

CT

8

Med: 50 (31–62)

Chang et al. (2011)18

CT

17

44.7 (18– 69)

Cho et al. (2011)1 CT

18

52.1 (14– 70)

Fadul et al. (2011)20

CT

10

60 (48–78) N-GBM

STR (7)/PR (2)/TR (1) + EBRT + chemo

Okada et al. (2011)31

CT

22

48 (28–71) R-GBM(13), R-AA(5), RAOD(3), RAOA(1)

SR + RT + chemo (9), SR + RT + chemo + mol(4), SR + SB + RT + chemo (1), SR + GKRS + RT + chemo (2), SB + RT + chemo (4), SB + RT + chemo + mol(1), SB + chemo(1)

R-GBM (6), R-AA(1), RMO(1) N-GBM (8), N-MO(1) N-GBM

SR SR + RT

TR (14)/STR (4) + RT (15) + GKRS (11) + chemo (16)

Notes

DC vaccination for GBMs is feasible, tolerable and promising for inducing a immune response Vaccination with FC safely induces an immune response but further clinical trials with a larger sample size are needed to determine a statistically significant treatment-associated response rate DC vaccination is safe, tolerable and not Autologous DC pulsed with tumor specific MHC- associated with autoimmunity Pts. treated with DC vaccine experiences 1 peptide prolonged survival vs. control group Autologous DC pulsed DC therapy is safe and not associated with ATL with autoimmunity. Further investigations needed to determine optimum dosage, best source of tumor antigen and method of antigen loading FC of DC + glioma cells Vaccination with FC safely induces clinical combined with rhIL-12 antitumor effects in some patients with malignant gliomas. A dose escalation study is the needed for further study Autologous mature DC Tumor vaccination is feasible and has pulsed with ATH potential to benefit patients with minimal residual tumor burden ATL pulsed DC This method is safe, feasible and demonstrates bioactivity of ATL-pulsed DC for pts. with malignant gliomas Autologous DC pulsed w/ A dose escalation study; Method is safe acid-eluted ATCP and feasible. Increased levels of TIL and decreased TGF-b2 correlated with prolonged survival ATL pulsed Autologous Vaccination with ATL-pulsed DC is safe mature and immature DC and increases the OSof GBM pts

Autologous mature DC pulsed w/ whole cell lysate antigenic mixture Autologous mature DC pulsed w/ ATL Autologous mature DC pulsed w/ ATL

DC Therapy has shown to be a safe and efficacious method. It holds promise for larger clinical trials Adjuvant DC immunotherapy is safe and can induce long-term survival Vaccine responders have a longer TTS and TTP when compared with nonresponders

Autologous mature DC pulsed w/ ATCP

ATCP loaded DC vaccine therapy when fully integrated into standard primary post-op. treatment for pts with N-GBM is feasible and well tolerated Vaccination cause tumor shrinkage and increase in TIL CD8 + along with an increase in median survival and quality of life (KPS)

Autologous mature DC pulsed with ATC immunogenically enhanced with IFN – c and heat shock treatment Autologous mature DC Compared to the control group, loaded with ATC treatment of N-GBM pts with DC vaccine results in longer survival and increased quality of life (KPS) Mature DCs loaded with DC vaccination along with RT + chemo is ATL safe an feasible and has resulted in tumor-specific immune responses that are associated with prolonged survival This study is the first clinical evaluation a-type 1 polarized DC of a DC1-based vaccines loaded with loaded with synthetic peptides for GAA epitopes novel GAA-derived epitopes in combination with poly-ICLC. This method is safe and demonstrates the immunogenicity as well the efficacy of the approach

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Please cite this article in press as: Bregy A et al. Active immunotherapy using dendritic cells in the treatment of glioblastoma multiforme. Cancer Treat Rev (2013), http://dx.doi.org/10.1016/j.ctrv.2013.05.007

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A. Bregy et al. / Cancer Treatment Reviews xxx (2013) xxx–xxx

Table 1 (continued) Author and year

Diagnosis Type No. Avg of age + range of study pts. (yrs.)

Treatment history

Type of vaccination

Prins et al. (2011)23

CT

23

51 (26–74) R-GBM (8) N-GBM(15)

SR + RT + chemo SR + EBRT + chemo

DCs pulsed with tumor lysate followed by booster vaccines imiquimod/polyICLC

Ardon et al. (2012)17

CT

77

57 (26–70) N-GBM

TR (51)/STR (26) + RT + chemo

Jie et al. (2012)21

CT

13

40.2 ± 11.2 N-GBM

TR (10)/STR (3) + RT + chemo

Phuphanich et al. (2013)32

CT

21

52 (26–79) R-GBM(3) SR + RT + chemo N-GBM(17), N-BsG

Notes

DC vaccinations are safe as an adjuvant therapy and are not associated with any dose-limiting toxicity. Mesenchymal gene expression profile may be an immunogenic subgroup of GBM that may be more responsive to immune-based therapies Mature DCs loaded with A fully integrated radio-chemo-DC whole tumor lysate immunotherapy post-op proved to be both feasible, safe ad possibly beneficial for N-GBM pts In comparison to the control group, DC Autologous mature DC loaded with heat shocked vaccine therapy increases immune fxn., improves quality of life, prolongs ATC recurrence and increases survival GAA-pulsed DC vaccine for GBM patients Autologous DC pulsed is both feasible and safe. with six ATCP: AIM-2, Expression of four of the ICT-107 targeted MAGE-1, TRP-2, gp100, antigens in pre-vaccine tumors HER2/neu & IL-13R a2. (ICT-107) correlated w/ OS & PFS in N-GBM pts

Acronyms: AA = anaplastic astrocytoma, AMG = anaplastic mixed glioma, AOA = anaplastic oligoastrocytoma, AOD = anaplastic oligodendroglioma, ATC = autologous tumor cell, ATCP = autologous tumor cell peptide, ATH = autologous tumor homogenate, ATL = autologous tumor lysate, BsG = brain stem glioma, chemo = chemotherapy, CR = complete response, CRp = case report, CT = clinical trial, DC = dendritic cell, EBRT = external beam radiation therapy, FC = fusion cells, fxn = function, GAA = glioma associated antigen, GBM = gliobastoma multiforme, GKRS = gamma knife radiosurgery, GM-CSF = granulocyte–macrophage colony-stimulating factor, KPS = Karnofsy Performance Score, MO = malignant oligodendroglioma, mol = molecularly targeted therapy, N- = newly diagnosed, ODG = oligodendroglioma, PR = partial resection, Pros.=prospective study, Pts.=patients, R- = recurrent, rhIL = recombinant human interleukin, RT = radiotherapy, SB = stereotactic biopsy, SR = surgical resection, STR = subtotal resection, TIL = tumor infiltration lymphocyte, TR = total resection, TTS = time to survival, TTP = Time till tumor progression. + Patients that responded to the vaccination. Patients that did not respond to the vaccination. \ Study did not specify whether recurrent or newly diagnosed gliomas.

GBM. 47 articles were found from this initial screen. None of these studies were found to be duplicates. The search was then restricted to include only active immunotherapy strategies specifically those used DCs based therapy. This eliminated active immunotherapy studies that administered other types of APCs as well as studies on adoptive immunotherapy, gene therapy and other drug therapies. Fourteen articles were obtained from this secondary screening. No duplicates were found. A brief search was also conducted on other Internet databases, using the same criteria. Studies were also found through reviewing the papers from the initial search results. An additional seven papers were obtained. None of which included any duplicates. The results of our literature screening are summarized in Fig. 1. The last search was performed on February 7th, 2013.

such, a comparative analysis is limited due to the nature of the data. Data for all patients was reported when available in the literature.

The initial PubMed search returned 47 research studies. After screening for the selected parameters of our study, 21 articles and 403 patients were included in our study (Fig. 1). Eighteen clinical trials, two case reports and one prospective study were found and included in this review. Patient and treatment characteristics of these studies are reported in Table 1.

Data extraction

Antigen and antigen presenting cells

The included studies were carefully analyzed based on patient population, diagnosis, treatment received prior to immunotherapy, protocol, patient outcomes and complications associated with the adjuvant treatment. The studies were separated into groups based on the antigen and APCs used, patient outcomes of patients newly diagnosed with GBM (N-GBM) and of patients with recurrent GBM (R-GBM) as well as vaccine induced-complications. Assessment of the efficacy of each study was based on the immune response and tumor response elicited, PFS and the OS of patients after vaccination therapy. Complications of each protocol were also examined to assess the safety of this treatment. Severe and mild adverse reactions were categorized based on whether or not they were vaccine-induced, or as a result of concomitant treatments such as surgery. It is important to note that not all studies assessed efficacy of the treatment protocol equally nor did they all clearly distinguish the etiology of complications experienced. As

All 21 studies administered autologous DCs as APCs (APCs). Half of the studies specifically administered autologous mature DCs (AMDC).1,16–25 One study in particular by Yamanaka et al. administered both AMDC and autologous immature DCs (AIDC) (4.8%).26 The remaining nine studies (42.9%) did not specify between AMDC and AIDCs.27–35 All but one study cultured APCs with autologous antigens. Autologous tumor cell lysates were the most commonly used antigen (38.1%)17,19,20,23,25,26,33,34 followed by autologous tumor cells (23.8%)1,18,21,27,28 and autologous tumor cell peptides (19.0%).16,30,32,35 Individual studies also used autologous tumor homogenate (ATH) (4.8%),24 whole cell lysate antigen mixture (WCLAM) (4.8%)22 and glioma associated antigens (GAA) (4.8%). Liau et al. was the only study that used allogenic MHC-1 GBM peptides as the antigen in their vaccination trial.29 The vaccine protocols are detailed in Table 2.

Results Study selection

Please cite this article in press as: Bregy A et al. Active immunotherapy using dendritic cells in the treatment of glioblastoma multiforme. Cancer Treat Rev (2013), http://dx.doi.org/10.1016/j.ctrv.2013.05.007

Author & year

Type of No. of Time until immun. study pts. treatment

APC Type

Vol.

Antigen Type

Vol.

Liau et al. (2000)29 Kikuchi et al. (2001)28 Yu et al. (2001)35 Yamanaka et al. (2003)33 Kikuchi et al. (2004)27 Rutkowski et al. (2004)24 Yu et al. (2004)34 Liau et al. (2005)30 Yamanaka et al. (2005)26 Khan et al. (2006)22 De Vleeschouwer et al. (2008)19

CRp.

1

1 month

Auto. DC

5  106

Allo. MHC-1 GBM pept

160 lg

CT

38

–

CT CT

9 10

CT

15

After RT Immediately upon tumor recurrence –

Auto DC 2.4–8.7  106 ATC – DC:ATC fused in a 3:1 to 10:1 ratio. 6 Auto. DC 10 Auto. tumor spec.MHC-1 pept 50 lg/ml Auto DC 10–32  106 ATL 725 lg

CT

12

CT CT

14 12

CT

24

CRp

1

Auto. DC – ATC – DC:ATC fused in a 3:1 to 10:1 ratio. Avg. of 13.7  106 FC After SR of tumor AMDC 2–4  106 ATH 30–200 lg/mil DC 7 8 Immediately after SR Auto. DC 10 -10 ATL 50 lg/ml * 4–28 wks (med. Auto. DC 1, 5 or Acid-eluted ATCP 100 lg/vacc. 18 wks) after SR 10  106 Immediately upon AMDC /AIDC 1–32  106 ATL 50 lg/ml tumor recurrence. – AMDC – WCLAM –

CT

56

–

AMDC

Wheeler et al. (2008)25 Ardon et al. (2010)16

CT

32

15 wks

AMDC

CT

8

9 wks

AMDC

Chang et al. (2011)18

CT

17

Immediately after post-op recovery/RT

Cho et al. (2011)1 CT

18

Fadul et al. (2011)20 Okada et al. (2011)31

CT

10

CT

22

–

Prins et al. (2011)23

CT

23

Ardon et al. (2012)17

CT

Site of administration

Dosage

i.d. in Lt. axilla

2/wks (x3)

i.d. close to cervical lymph nodes s.c. in deltoid region i.d. or i.c.

1/3 wks (1–7 vacc.)

i.d. close to cervical lymph nodes i.d.

1/2 wks for 6 wks

1/2 wks up to 3 vacc. 1/3 wks (1–10 vacc.)

Wk. #1 & #3 + 1/4 wks

i.d. 2/wk for 3 wks i.d. alternating between left and 1/2 wks for 3 wks right axillae i.d or i.d.+i.c. 1/3 wks up to 10 vacc. i.v

1/2 wks up to 5 vacc. CoA: wk#1 + #3 + 1/4 wks CoB: 5/2 wks + 1/4 wks CoC: 1/wk for 4 wks + ATL boster 1/2 wks for 5 wks + 1 at wk#6

0.7– ATL 25.7  106 6 Med: 6  10 10–40  106 ATL

200 lg

i.d. in upper arms

900 lg

s.c in deltoid region

ATCP

1500 lg

i.d. in upper arms (lymph node EBRT + chemo(TMZ) (6 wks) fb. DC loaded ATCP 1/wk region) for 4 wks fb. Chemo (TMZ) + booster ATCP

AMDC

1–12  106 Med: 4.1  106 1–6  107

ATC

s.c. in either axilla

1/wk (x4) + 1/2 wks (x2) + 1/mth (x4)

1–2 months

AMDC

2–5  107

ATC

s.c. bilaterally in subaxillary region.

1/wk (x4) + 1/2 wks (x2)+1/mth(x4)

6–7 wks post-RT

Auto. DC

1  107

108 cells cultured w/ AMDC 5  106/ml (1:1 ratio DC:ATC) –

i.d. in bilateral cervical lymph nodes i.n. in left and right inguinal and auxillary lymph nodes

1/2 wks (3 vacc.)

ATL 7

dl-1: 1  10 dl-2: 3  107

GAA: EphA2, IL-13 receptor a2, YKL-40, gp100

10 lg/mL

 7–30 wks after SR

a-type I polariz-ed DC Auto. DC

–

ATL

100 lg/vacc.

i.d. below axilla

77

9 wks post-SR

Auto. Dc

Med.1500 lg (400–1500 lg)

i.d. in upper third arm

Jie et al. (2012)21 CT

13

1 wk

AMDC

Med.5.2  106 ATL (0.24– 55  106) 6  106 Heat-shocked ATC

1/2 wks (3 vacc.) Booster vacc. administered if pts had no toxic effects to the first 3 DC vacc. as well as SD 1/wk (4 vacc.) + 1/3 wks of booster ATL (3 vacc.)

s.c. in groinal lymph nodes.

1/wk (x2) + 1/2 wks (x2)

Phuphanich et al. CT (2013)32

21

–

Auto. DC

–

i.d. in axilla

1/2 wks (3 vacc.)

6–8 g tumor spec. ATCP: MAGE1, AIM-2, TRP-2, 10 lg/mL gp-100, HER2, IL13Ra2

1/2 wks (4 vacc.) Additional poly-ICLC (20 lg/kg) i.m. 2/wk for 8 wks

A. Bregy et al. / Cancer Treatment Reviews xxx (2013) xxx–xxx

Acronyms: AIDC = autologous immature dendritic cell, AMDC = autologous mature dendritic cells, ATC = autologous tumor cell, ATCP = autologous tumor cell peptide, ATH = autologous tumor homogenate, ATL = autologous tumor lysate, Auto = autologous, chemo = chemotherapy, Co = cohort, CRp = case report, CT = clinical trial, DC = dendritic cell, dl = dose-level, EBRT = external beam radiation therapy, GAA = glioma associated antigen, GM-CSF = granulocyte–macrophage colony-stimulating factor, i.c. =intracranially via ommaya reservoir, i.d. =intradermally, i.n.=intranodal, i.m. =intramuscular, i.v. =intravenously, P1/2 = protocol 1/2, RT = radiotherapy, s.c. =subcutaneously, SD = stable disease, SR = surgical resection, vacc. =vaccination, WCLAM = whole cell lysate antigenic mixture. * Patient population subdivided for dose escalation study.

5

Please cite this article in press as: Bregy A et al. Active immunotherapy using dendritic cells in the treatment of glioblastoma multiforme. Cancer Treat Rev (2013), http://dx.doi.org/10.1016/j.ctrv.2013.05.007

Table 2 Details of the vaccine protocols applied in each study.

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A. Bregy et al. / Cancer Treatment Reviews xxx (2013) xxx–xxx

response if the tumor reduced 25–50% in size; (d) no change if there is an increased or decreased in less than 25% in tumor size; (e) progressive disease if increase in tumor size of more than 25% was observed. Above mentioned radiological findings were reported in 6 out of the 13 studies that included patients with R-GBM specifically (Fig. 3). The majority of patients experienced progressive disease (48.1%) or no change (23.1%). The remaining patients experienced stable disease (9.6%), mixed response (9.6%), partial response (5.8%) and continued complete remission (1.9%). One patient (1.9%) had a radiological response that had not been determined. Progression free survival (PFS)

Fig. 2. The pie graph illustrates the various injection sites of the vaccine.

Treatment start Out of the 15 articles that reported a time until treatment was started, 5 studies reported immediate vaccination therapy after surgical resection and/or radiation therapy.18,21,24,34,35 The remaining studies reported time intervals from one month up to about four months after surgical resection until the vaccine administration1,16,17,20,23,25,29 Two studies from Yamanaka et al. in 2005 and 2003 described administration of the vaccine once the tumor had recurred.26,33 This information is detailed in Table 2.

PFS is defined as the time interval from surgical resection until the first signs of tumor recurrence or disease progression. Six out of the 13 studies that included patients with R-GBM reported data on PFS. All 6 studies documented an increase in PFS in comparison to the control data of 11 wks4 (Fig. 4). The most notable increases in PFS were recorded by Prins et al. in 2011 (63.6 wks)23, Liau et al. in 2005 (62.0 wks)30 and the vaccine responders in the study by Wheeler et al. in 2008 (37.1 wks).25 Liau et al. (2005)30 and Wheeler et al. (2008)25 provided historical control groups. The observed PFS surpassed that of the historical controls for both cases, the exception being the non-responders in Wheeler et al.’s study in which there was a decrease in PFS (20.8 vs. 23.9 wks). Ten studies that included patients with N-GBM reported PFS, all of which showed an increase from the control PFS of 22 wks36 (Fig. 5). Ardon et al.17 reported the longest PFS time of 81.6 wks in 2012 in patients that had completed the vaccine protocol. Similar long PFS times were reported by Ardon et al. (2010) (70 wks),16 Phuphanich et al. (2013) (67.7 wks)32 Prins et al. (2011) (63.6 wks)23 and Liau et al. (2005) (62 wks).30

Site of administration Survival Different injection sites were used to administer the vaccine (Fig. 2). The two most common sites were intradermal (63.6%) and subcutaneous (22.7%), followed by intranodal (4.5%), intracranial via an ommaya reservoir (4.5%) and intravenous (4.5%). None of the studies compared injection sites and their efficacy. Immune response Thirteen studies included patients with R-GBM. Ten out of these 13 articles recorded an immune response post-vaccination that was measured by T-cell infiltration of tumor tissue or increase in lymphocytes. These studies also reported an increase in CD3+,29,30 CD4+23,33 and CD-56.23,33 Ardon et al. (2010) and Wheeler et al. (2008) reported augmentation of IFN-c produced by T-cells after vaccination.16,25 Up-regulation of IFN-a, CXCL10, IL-15, MCP-1, MIP-1b and serum TNF-a and IL-6 were recorded by Okada et al.31 and Prins et al.23 respectively. Table 3 details the elicited immune response of patients with R-GBM. Twelve studies included patients with N-GBM. All but two of these studies reported an immune response post-vaccination. Results included an increase in CD8+,16,18,20,21 CD4+20,21,23 CD3+,21,23,30 CD16+,28 CD25+,16,23 CD56+,28 IFN-c16,25,28 and NK cells (CD3 CD56+).21 A decrease in CD13332 and TGFb230 were also observed. These immune responses are recorded in Table 4. Radiological findings Tumor response was assessed based on radiological findings. Responses were classified as follows26: (a) complete response if the tumor has completely disappeared for at least 4 wks; (b) partial response if tumor size reduced 50% for at least 4 wks; (c) minor

The overall survival is defined as the time period either from the time of diagnosis,1,19,20,23,26,33,34 entry into the study17,31 or from the time of follow-up post vaccination21 to the time of death or end of the study. The median OS was compared to the control group of patients that underwent standard therapy consisting of surgery, chemotherapy and radiation but no vaccine therapy. Twelve studies reported a median OS for patients with R-GBM. Eight out of the 12 studies observed an increased OS in comparison to the control median OS of 58.4 wks (Fig. 6). The maximum median OS observed was 138.0 wks in a 2011 study by Chang et al.18 Yu et al. (2004) as well as Yamanaka et al. in 2003 also reported similarly high median OS of 133.0 wks34 and 111.2 wks33 respectively, all of which are more than twice that of the control median OS. Yu et al. (2004),34 Liau et al. (2005),30 Yamanaka et al. (2005)26 and Chang et al. (2011)18 included their own control groups. All 4 studies demonstrated an increase in median OS of vaccine treated patients. Twelve studies reported median OS times for patients with NGBM (Fig. 7). Eleven out of these 12 studies reported an increase in median OS in comparison to the control of 58.4 wks.4 Three studies in particular reported an increase in median OS of more than twice the OS of this baseline control. The maximum time was reported at 143.6 wks by Prins et al. (2011).23 Similar times were also reported by Cho et al. (2011) (127.6 wks)1 and Fadul et al. (2011) (112.0 wks).20 In addition to this baseline control, comparisons were also made between the control group and the experimental group in studies conducted by Yu et al. (2001),35 Liau et al. (2005),30 Chang et al. (2011),18 Cho et al. (2011)1 and Jie et al. (2012).21 The median OS of these control groups were all less than 58.4 wks with the exception of the median OS of the control group

Please cite this article in press as: Bregy A et al. Active immunotherapy using dendritic cells in the treatment of glioblastoma multiforme. Cancer Treat Rev (2013), http://dx.doi.org/10.1016/j.ctrv.2013.05.007

Author & year

Pre-T Type No. Avg of Age + range KPS of Range study pts. (yrs.)

Med. OS

PD Increased CD3 + T-cell inflammatory tumor infiltrates MR (2) 10 46.1 (27– 30–80 CD-56 increase; CD4+ and NC (2) 69) Med: CD8 + tumor infiltration (2 PD (3) pts) 50 15 45 (29–64) 70–100 Increased tumor infiltration of PD(5) NC(1) Med: CD8 + T lymphocytes; increased cytolytic activity 90 against ATC. 12 39.7 (11– – – CCR (1) 78) NC (3) PD (3)

–

84.0 wks

–

–

– – – –

204.0 wks 66.5 wks 63.0 wks –

*

*

60–100 CD8 + antigen specific T-cell Med: expansion + infiltration 100 12 40 (20–65) 60–100 Increased TIL CD3+; Med:90 decreased expression of TGFb2 24 48.9 (20– 30–100 Minor CD8 + T-cell increase 73) Med: 65

–

–

133.0 wks

–

*

*

– –

MR (3) PR (1) NC (6) PD (8) – –

– – – – – 12.0 wks

202.0 wks Post DC vaccination pts experienced increased CD56 in peripheral – NC 98.0 wks blood. CD4+ and CD8 + tumor infiltration also observed in 2 pts. – (2) PD (1) – – Treatment with DC vaccinations safely induces antitumor PR(4) – immune responses. Four out of 15 pts experienced a deterioration MR(1) of symptoms, the remaining pts had no clinical symptoms preNC(1) treatment and it did not worsen during treament. PD(3) * * MR 12.0 wks 42.0 wks Pts with minimal residual tumor burden more likely to benefit (2) from vaccine treatments NC (1) PD (2) – – – Tumor lysate vaccinated R-GBM pts. (n = 8) experienced increased median OS when compared to the control group (n = 26) (133.0 vs. 30.0 wks) * – – – GBM pts. treated with DC vaccination (n = 12) experienced and increased med. OS (93.6 vs. 33.2 wks) and TTP (62.0 vs. 32.8 wks) over the control group (n = 99) – 51.1 wks GBM patients treated with autologous tumor lysate-pulsed DC NC – 76.3 wks experienced increased OSin comparison to the control group (68.6 (4) vs. 57.1 wks) PD (2) – –

– –

– –

>1.5-fold IFN-c <1.5 or no IFN-c

– –

37.1 ± 12.1 wks 85.6 ± 10.7 wks – 20.8 ± 3.3 wks 57.3 ± 7.6 wks

–

–

–

–

Yamanaka et al. (2003)33

CT

CT

Yu et al. (2004)34

CT

Liau et al. (2005)30

CT

Yamanaka et al. (2005)26

CT

Khan et al. (2006)22 CRp De Vleeschouwer et al. CT (2008)19 Wheeler et al. (2008)25 CT

Notes

Radio. Med. PFS

49

Radio.

Lower Grade Gliomas Med. OS

CRp. 1

Rutkowski et al. (2004)24

GBM pts. Med. PFS

Liau et al. (2000)29

Kikuchi et al. (2004)27 CT

Immun.

-

14 44.7 (28– 61)

1 57 – 56 Med: 45 (7– 50–100 77) Med: 80 32 + 54 ± 3 81 ± 2 49 ± 4 84 ± 3

Chang et al. (2011)18

CT

17 44.7 (18– 69)

70–90 Increased TIL CD8+ Med: 90

Okada et al. (2011)31

CT

22 48 (28–71)

P60

Prins et al. (2011)23

CT

23 51 (26–74) 60–100 Increase in CD3 + CD4+ Med.90 Foxp3+, CD3 + CD4+ CD25 + Foxp3 + lymphocytes, serum TNF-a and IL-6

Up regulation of IFN-a, CXCL10, IL-15, MCP-1, MIP1b.

12.0 wks

62.0 wks

– Tumor regression (n = 1) PR(2) SD(5) PD(5) ND(1) –

42.0 wks

93.6 wks

91.6 wks 105.0 wks 78.1 wks 49.9 wks 32.0 wks 38.4 wks

138.0 wks

16.0 wks

48.0 wks

*

71.6 wks

63.6 wks

–

DC vaccination with allo. GBM peptides induce a strong T-cell proliferation. This method if feasible, tolerable and safe

Patient experienced increased survival after vaccination therapy Age < 35 years is a predictor for better OS PFS is improved with a faster vaccination schedule.

53% of pts. exhibited P 1.5-fold vaccine enhanced cytokine responses * When compared to nonresponders,vaccine responders have a significantly longer TTS (91.7 vs. 61.4 wks) and TTP (44 vs. 23.9 wks) – – 113.5 wks Vaccination caused tumor shrinkage and increased in TIL CD8+ Med. OS for R-GBM pts. (n = 8) vs. control pts. (n = 63) treated with DC immunotherapy was reported as 138.0 vs. 54.3 wks KPS scores increased for 3/17 pts. but decreased in 7/17 pts. SD(6) >48 wks 92.0 wks Vaccination with aDC1-based vaccines with poly-ICLC boosters PD(1) demonstrates safety and immunogenicity ND(2)

–

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This method of vaccination is safe as an adjuvant treatment for RGBM and N-GBM pts. The OS observed was significantly longer for N-GBM pts compared to R-GBM pts.

Acronyms: AT = as-treated, CCR = continued comlete remission, CR = comlete response, CRp = case report, Ct.=control, CT = clinical trial, Ct.=control, DC = dendritic cell, ITT = intent-to-treat, KPS = Karnofsky Perfromance Score, Med.=median, MR = mixed response, N = newly diagnosed, NC = no change, ND = not determined, nyr = not yet reached, OS = overall survival, PD = progressive disease, PFS = progression free survival, PP = per protocol, PR = partial response, R = recurrent, SD = stable disease. + Patients that responded to the vaccination. Patients that did not respond to the vaccination. * Represents the total group of pts. 7

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Table 3 Outcomes measured by quality of life (KPS), immune response, radiological findings, progression free survival (PFS) and over all survival (OS) for R-GBM patients.

Pre-T Type No. Avg of Age + range KPS of range study pts. (yrs.)

Author & year

\

Kikuchi et al. (2001) 28

Yu et al. (2001)35 Liau et al. (2005)

30

Wheeler et al. (2008)25

Immun.

GBM Pts. Radio.

30–100 Increase in CD16+, CD56 + and NC(4) IFN-c Med: MR(1) 70

CT

8

38 (4–63)

CT

9

49 (28–77) >60

Enhanced cytotoxic T-cell – activity (4) 60–100 Increased TIL CD3+; decreased – Med:90 expression of TGFb2

Lower grade gliomas Med. OS

Radio. Med. OS

–

–

NC(1) – PD(1)

30.9 wks (4/7 pts.) * 62.0 wks

65.0 wks

–

(see notes) (see notes) 96.0 wks

CT

12

40 (20–65)

CT

32

+

54 ± 3

81 ± 2

>1.5-fold IFN-c

–

(see notes)

-

49 ± 4

84 ± 3

<1.5 or no IFN-c

–

(see notes)

Ardon et al. (2010)16

CT

8

Med: 50 (31–62)

>70

Increase in CD8+, CD25 + T cells – and IFN-c prod. T cells.

Chang et al. (2011)18

CT

17

44.7 (18– 69)

70–90 Med: 90

Increased TIL CD8+

Cho et al. (2011)1 CT

18

52.1 (14– 70)

70–100 – Med: 85

Fadul et al. (2011)20

CT

10

Prins et al. (2011)23

CT

23

Ardon et al. (2012)17

CT

Jie et al. (2012)21

Phuphanich et al. (2013)32

70.0 wks

*

93.6 wks –

–

–

– Tumor regression (n = 2)

109.0 wks –

–

34.0 wks

127.6 wks –

38.0 wks

112.0 wks –

*

143.6 wks –

77

– 60 (48–78) 70–90 Increase in CD8 + T memory Med:80 cells, naïve B cells and circulating CD4+ TREG cells 51 (26–74) 60–100 Increase in CD3 + CD4+ Foxp3+, – Med.90 CD3 + CD4+ CD25 + Foxp3 + lymphocytes, serum TNF-a and IL-6 57 (26–70) – – –

CT

13

40.2 ± 11.2

CT

21

52 (26–79) 70–100 Decrease in CD133 Med:90

60–80 Increase in CD3+, CD3 + CD4+, Med: - CD4+/CD8+, NK,.

CR (3) PR (6) NC (1) PD (3) –

63.6 wks

67.6 wks

Mean number of vaccinations: of 4.5 (1–9) DC vaccination safely induces immune response. Symptom relief was experienced within two wks of the first immunization. Tumor size did not change but the shift of the midline structure and high intensity area on T2 images decreased. 84.4 wks N-GBM pts. (n = 7) that underwent this treatment experiences prolonged survival when compared to control group (n = 42) (455 vs. 257dys.) * – GBM pts. treated with DC vaccination (n = 12) experienced and increased med. OS (93.6 vs. 33.2 wks) and TTP (62 vs. 32.8 wks) over the control group (n = 99) – 53% of pts. exhibited P 1.5-fold vaccine enhanced cytokine responses. * When compared to nonresponders, vaccine responders have a significantly longer TTS (91.7 vs. 61.4 wks) and TTP (44 vs. 23.9 wks). TTS and TTP were not explicitly reported for N-GBM pts. – Vaccine therapy showed increased in CD8+, CD25 + and IFN-c producing T cells. Post-vacc KPS: 70–100; Med: 85 >281.0 wks Vaccination caused tumor shrinkage and increased in TIL CD8+ Med. OS for N-GBM pts. (n = 8) vs. control pts. (n = 63) treated with DC immunotherapy was reported as 54.4 vs. 54.3 wks. KPS scores increased for 3/17 pts. but decreased in 7/17 pts. – Treatment of N-GBM pts with DC vaccine results in longer survival and increased quality of life (KPS). OS: 31.9 vs. 15.0 months (Ct); duration of study 50% of pts treated remained alive vs. 6.3% (Ct) Post-KPS: med. 70 vs. med. 50 (Ct) – Vaccination along with RT and chmo with TMZ was feasible and pts that were able to mount an anti-tumor response had n improved survival in comparison to the control group. – This method of vaccination is safe as an adjuvant treatment for R-GBM and N-GBM pts. The OS observed was significantly longer for N-GBM pts compared to R-GBM pts.

–

–

Immunological profiles did not predict information on either PFS or OS. However the expression of MGMT promoter is correlated with increased PFS and OS.

–

–

DC vaccine therapy increases immune fxn, improved quality of life, prolonged recurrence (11.92 ± 5.31 vs. 7.75 ± 4.16 months (Ct.)), increased survival (17.0 vs. 10.5 months (Ct.)).

230.4 wks –

–

The expression of AIM-2 and MAGE1 in pts treated with vaccine therapy was correlated with longer PFS and OS.

ITT: 73.2 wks AT: 77.6 wks PP: nyr 47.68 ± 21.24 wks 68 wks

ITT:41.6 wks AT:44.0 wks PP:81.6 wks

Notes

Acronyms: AT = as-treated, CCR = continued comlete remission, CR = comlete response, CRp = case report, Ct.=control, CT = clinical trial, Ct.=control, DC = dendritic cell, ITT = intent-to-treat, KPS = Karnofsky Perfromance Score, Med.=median, MR = mixed response, N = newly diagnosed, NC = no change, ND = not determined, nyr = not yet reached, OS = overall survival, PD = progressive disease, PFS = progression free survival, PP = per protocol, PR = partial response, R = recurrent, SD = stable disease. + Patients that responded to the vaccination. Patients that did not respond to the vaccination. * Data refers to both N-GBM and R-GBM pts. \ Study did not specify N-GBM or R-GBM pts. (see discussion).

A. Bregy et al. / Cancer Treatment Reviews xxx (2013) xxx–xxx

Med. PFS

8

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Table 4 Outcomes measured by quality of life (KPS), immune response, radiological findings, progression free survival (PFS) and overall survival (OS) for N-GBM patients.

A. Bregy et al. / Cancer Treatment Reviews xxx (2013) xxx–xxx

9

in the study by Cho et al. (2011),1 which was reported at 60 wks.1 With the exception of the study by Chang et al. 18 these studies reported an increase in median OS when compared to the both the baseline control of 58.4 wks as well as the median OS of the control group in each individual study. Quality of life One measure of quality of life is the Karnofsky Performance Score (KPS) which was assessed in some of the patients both pre and post vaccination therapy. Seventeen out of the 21 studies reviewed provided details on the pre-treatment KPS scores of patients treated (Tables 3 and 4). The majority of patients were enrolled at a KPS of >60 with Kikuchi et al. (2001),28 Yamanaka et al. (2003)33 and 200526 including patients with a score of 30. Only 3 out of the 21 studies reported a post-vaccination KPS. The study by Cho et al. (2011) showed a decrease in median KPS from 85 to 50 after a median follow-up time of 33 months.1 A second study by Chang et al. (2011) reported a decreased KPS for 7 out of 17 patients and an increased in KPS score in 3 out of 17 patients after immunotherapy.18 It was not possible to determine an increase or decrease in median KPS for the third study by Ardon et al. (2010) since no specific information was available.17 Safety and complications Complications in the treated patients and safety of the vaccine were assessed in all studies (Table 5). No study indicated any sign of autoimmune reaction. The complications are categorized based on whether they are caused by the surgical procedure, such as craniotomy, or a direct effect of the administered vaccination. The side effects observed solely from the vaccination were categorized from all studies (Fig. 8). The majority of side effects analyzed fall under injection site reactions (21.9%). Such manifestations include pain, itching and swelling. De Vleeschouwer et al. (2008)19 reported that all 56 patients experienced redness without itching. Skin reactions (9.9%) that included red papules and delayed-type hypersensitivity (DTH) at the site of vaccine injection were common physical reactions along with induration (4.1%). Wheeler et al. (2008)25 reported that one patient experienced a cutaneous glioblastoma at the site of irradiated tumor cell inoculation for DTH testing. Although not in the site of the vaccine, this could be catalogued as an adverse event associated to the clinical trial. Other common side effects were categorized as lab abnormalities. These included, lymphopenia (13.2%) leukopenia (7.9%), transient abnormal liver function such as elevated transient serum AST/ALT levels (4.1%) and hematoxicity (0.8%). General symptoms were also reported. These included fatigue (19.5%), constipation/diarrhea (1.6%) myalgia/ malaise (1.6%), shivering (1.4%) and vomiting (0.5%). Other symptoms (5.2%) which were categorized based on a frequency of 3 or less in the sample included infection, ischemic bowel perforation, deep vein thrombosis, otitis media serosa, eosophagitits, depression, upper lip blister, sweating, meningeal irritation, hyponatremia, abdominal pain, pain in shoulder, humerus fracture, osteoporotic fracture, allergic rhinitis and general allergic reactions. Cranial manifestations included headaches, meningeal irritations and intra-tumoral hemorrhage. Mild fevers were also reported as side effects. Discussion For the past several centuries, it has been debated as to whether or not the body’s innate immune system could work to recognize and attack a malignant tumor. The 1890’s began a hopeful era for cancer immunotherapy as Dr. William Coley, a New York surgeon,

Fig. 3. Six out of 13 studies that included patients with R-GBM assessed tumor response radiologically based on guidelines outlined by Yamanaka et al. (2005). The pie graph illustrates the tumor response of patients with R-GBM from these 6 studies. (PD = progressive disease, MR = mixed response, NC = no change, CCR = continued complete remission, PR = partial response, SD = stable disease, ND = not determined). Only 2 studies with patients with N-GBM assessed tumor response radiologically, therefore no pie chart was created.

observed tumor reduction in patients suffering from sarcomas and other types of cancer after an acute infection of the bacteria Streptococcus pyogenes.6,37 He reported that some of his cancer patients achieved complete remission following infection from this bacterium. However, in the following years until 1985, Coley’s observations could not be replicated6,37,38 and research failed to explain how immunotherapy could induce an antitumor response.37 In 1995–2002 studies confirmed that an antitumor response could be mounted against tumor-associated antigens (TAA).39–45 Even more convincing was the ability of dendritic cells to present TAA to the body’s adaptive immune system.46–52 Today, cancer immunotherapy remains an available treatment option for certain types of cancer including prostate adenocarcinoma.53 However, the role of immunotherapy for the treatment of high-grade gliomas (HGG) still needs to be evaluated further. In our review, the most common vaccination protocol used in active immunotherapy treatments included autologous mature DCs and some form of the autologous tumor cells (ATCs). However, Yamanaka et al. administered both mature and immature DCs in order to potentiate the continual development of mature DCs in the patients’ immune system after vaccination.26,53 A unique approach was taken by Kikuchi et al. in 2001 and 2004 where the DCs were fused with the ATCs before administration of the vaccine.27,28 This method was proven to be safe and feasible and warranted a dose-escalation study but did not report any PFS or OS. As such we were unable to determine its success in a survival analysis. The use of autologous ATCs appeared to be the approach most commonly used, but the case study by Liau et al. used an allogenic tumor sample to simply assess the safety and feasibility of administering allogenic vaccine.29 The patient died 21 months after initial diagnosis but there was no control group to compare this median OS with. As such, we were not able to conclude whether or not this had an effect on patient outcome Autologous tumor cell peptides (ATCP) were novel antigens used by Liau et al. (2005)30 and Phuphanich et al. (2013).32 The latter two specified the use of acid-eluted ATCPs and ATCPs matched to AIM-2, MAGE-1, TRP2, gp100, HER2/neu & IL-13Ra2 respectively. Both Liau et al. and Phuphanich et al. reported an increase in OS, which is discussed further. Ardon et al. (2010) used DC loaded with autologous tumor

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A. Bregy et al. / Cancer Treatment Reviews xxx (2013) xxx–xxx

Fig. 4. Six of the 13 studies that included patients with R-GBM reported a median PFS that is represented in the column chart. The PFS of the control group used in each study is shown if applicable; horizontal line represents the PFS of 11 wks are reported by Reithmeier et al. (2010). The (*) indicates that the PFS represents both patients with NGBM and R-GBM as these studies did not differentiate (see Table 3).

cell lysates (ATL) for their study.16 This group and De Vleeschouwer et al. (2008) describe ‘‘in situ’’ maturation in which immature DC are administered through imiquimod treated skin.16,19 The results suggest safety and preliminary evidence of benefit for this approach, but like other methods we reviewed, need to be explored further to determine the ultimate role of this treatment in the care of high grade glioma patients.16,19 Site administration may also be an important factor to consider in patients receiving active immunotherapy. The majority of the vaccines were administered via intradermal and subcutaneous injection in lymph nodes, specifically axillary and inguinal lymph nodes. Vaccination treatment should start as early as immediately after tumor recurrence or immediately after surgical resection.18,26,33,34 The majority of vaccines were administered within 1 wk to 3 months of surgical resection.1,16,17,20,21,23,25,29,30,35 One study by Prins et al. (2011) however recorded the time until treatment up to 30 wks (7.5 months).23 However, the time until initiation of the vaccine treatment was not a factor heavily reported for the majority of the studies, thus making it difficult to observe a correlation with patient outcome. After reviewing these 21 studies, it appears that most vaccine protocols defined that autologous mature DC loaded with ATCs, ATCs lysates ATCP or ATCs homogenates were to be administered in the axilla and/or inguinal region of the patient. Future studies may be needed to assess the importance of timing in immunotherapy. Current evidence of immunotherapy in glioblastoma suggest a minimal risk of toxicity or side effects from treatment; however the added benefit of this therapy has not been well characterized.1 Our study assessed the benefits of active immunotherapy in terms of immune response, tumor response, PFS median OS and quality of life.

A significant proportion of the studies reported not only an increase in peripheral T-cells but also T-cell tumor infiltration. Among the immune cells that underwent expansion and tumor infiltration were CD3+, CD4+, CD8+, NK cells (CD3-CD56+).and Langerhans cells. Yu et al. (2001) accredited patients’ prolonged survival with the increase of CD8+ intratumoral infiltration.35 Phuphanich et al. (2013) correlated the longer PFS and OS to the expression of AIM-2 and MAGE1 in which the ATCP had been specifically matched to.32 Another observation by Wheeler et al. was the increase in IFN-c (greater than 1.5-fold) in vaccine responders which correlated with increased survival and increased time until tumor progression (TTP).25 Radiological evidence of change in tumor size such as regression or progression was reported in 9 out of the 21 studies. These 9 studies included both patients with R-GBM and N-GBM. In this sample, about half of the patients experienced progressive disease (PD) (48.1%) while a large proportion experienced no change (NC) (23.1%). Other radiological observations include stable disease (SD) (9.6%), mixed response (MR) (9.6%) partial response (PR) (5.8%) and complete continuous remission (1.9%). Rutkowski et al. reported that one patient with GBM in a 2004 study exhibited complete continued remission for three years.24 This study suggested that patients are more likely to achieve this status after vaccine therapy if they experienced minimal postoperative residual tumor. Liau et al. (2005) also had one patient with a near complete regression but it could have been due to a delayed response to radiotherapy.30 It was however noted in the rest of the patients that the absence of tumor progression at the beginning of treatment was correlated with a longer OS and PFS. This further supports the relationship between the pre-vaccination status of the tumor OS and PFS.

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Fig. 5. Ten of the 12 studies that included patients with R-GBM reported a median PFS that is represented in the column chart. The PFS of the control group used in each study is shown if applicable; horizontal line represents the PFS of 22 wks as recorded by Ohka et al. (2012). The (*) indicates that the PFS represents both patients with N-GBM and R-GBM as these studies did not differentiate (see Table 3).

Fig. 6. The column graph illustrates the median overall survival of Patients with R-GBM in 12 studies that received immunotherapy treatments with DC vaccinations. Four studies included a control group of patients which is shown as applicable. The standard median OS of 58.4 wks is represented by the horizontal control line which indicated the median OS of patients who undergo conventional treatment only. The (*) indicates that the PFS represents both patients with N-GBM and R-GBM as these studies did not differentiate (see Table 3).

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A. Bregy et al. / Cancer Treatment Reviews xxx (2013) xxx–xxx

Fig. 7. The column graph illustrates the median overall survival of patients with N-GBM in 11 studies that received immunotherapy treatments with DC vaccinations. Four studies included a control group of patients which is shown as applicable. The standard median OS of 58.4 wks is represented by the horizontal control line which indicated the median OS of patients who undergo conventional treatment only. The (*) indicates that the PFS represents both patients with N-GBM and R-GBM as these studies did not differentiate (see Table 3).

The studies included in our review measured PFS in two ways: for patients newly diagnosed with GBM, this time interval referred to the time between initial surgical resection of the tumor until it recurred for the first time1,16,21; for patients with recurrent GBM, PFS refers to the time from second surgical resection (which harvested ATCs for vaccine) until the tumor showed signs of recurrence.35 Unfortunately, not all of the studies included PFS as a measure of outcome. The 13 studies that reported a PFS score were analyzed under two categories, patients with R-GBM (Fig. 4) and patients with N-GBM (Fig. 5). Note however that some studies did not distinguish the PFS scores individually and it was therefore not possible to deduce a PFS score for each sample. As such the PFS reported by Liau et al. (2005)30 and Prins et al. (2011)23 included both patients with R-GBM and N-GBM. The PFS for patients with R-GBM that have been treated with only surgery, chemotherapy and radiotherapy is 11.0 wks.4 It is evident that all four studies that consisted of only patients with R-GBM surpassed the control PFS. Rutowski et al.24 2004 and De Vleeschouwer et al. (2008)19 reported only a small increase in PFS (12.0 vs. 11.0 wks). Okada et al. (2011)31 and both the responders and non-responders in Wheeler et al.’s study in 200825 showed more significant increases from 11.0 wks (control) to 16.0 wks, 37.1 wks and 20.8 wks respectively. In the latter two cases, while it appears to be a 3-fold and 2-fold increase compared to the control of 11.0 wks, the results are not as significant when compared to the historical control groups used in the study. The vaccine non-responders actually show a decrease in PFS from 23.9 to 20.8 wks. The vaccine responders represent the highest PFS (37.1 wks) for a sample of patients with R-GBM only. This however is still only a 1.5 increase in PFS compared to the control of 23.9 wks.

The PFS for patients with N-GBM that have been treated with only surgery, chemotherapy and radiotherapy is 22 wks.54 Nine studies analyzed samples that consisted of only patients with NGBM. All 9 reported an increase in PFS in comparison to the control included in Jie et al.’s study in 2012 (21.2 wks)21 as well as the control of 22 wks. The PFS of the vaccine non-responders of Wheeler’s et al.’s study in 2008 fall around the same range presented by the control groups (23.9 wks).25 This allows us to analyze this group as a control in their study rather than the experimental group. The maximum PFS of a sample of only patients with N-GBM was reported at 81.6 wks by Ardon et al. (2012),17 a 3.7-fold increase. In 2010 they also reported a PFS of 70 wks.16 The first study showed positive results with the vaccination of DC pulsed with ATCP. They further altered the vaccine to DC pulsed with ATL and integrated vaccinations into a radio-chemotherapy regime. With 77 patients this 2012 study is the largest study reviewed and with such positive results in regards to PFS is proving to be a highly beneficial treatment for patients with N-GBM. A similarly high PFS of 67.6 wks was also reported by Phuphanich et al. in 2013.32 Increased PFS was associated with the expression of AIM2 and MAGE-1. This positive results points to the potential of specifically match ATCPs in the DC vaccine. The median PFS reported by Liau et al. (2005)30 and Prins et al. (2011)23 includes both patients with R-GBM and N-GBM. Liau et al. reported a PFS of 62 wks and included 5 patients with R-GBM patients and 7 with N-GBM, a fairly balanced sample which can be considered a good representation of the benefits in treating both patients with R-GBM and N-GBM.30 Prins et al. reported a PFS of 63.9 wks which is almost a 6-fold increase in the control PFS.23 This study included about twice as many patients with N-GBM than with R-GBM and the sample could potentially be biased towards

Please cite this article in press as: Bregy A et al. Active immunotherapy using dendritic cells in the treatment of glioblastoma multiforme. Cancer Treat Rev (2013), http://dx.doi.org/10.1016/j.ctrv.2013.05.007

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A. Bregy et al. / Cancer Treatment Reviews xxx (2013) xxx–xxx Table 5 Complications and side effects experienced as a result of surgery or vaccination. Author and year

Type of study

No. of pts.

Craniotomy side effects

Vaccination side effects

Notes

Liau et al. (2000)29

CRp.

1

Increased ataxia and diplopia (1)

–

Kikuchi et al. (2001)28

CT

8

Uncontrollable headache (1)

Erythema (1)

Yu et al. (2001)35

CT

9

–

Yamanaka et al. (2003)33

CT

10

–

Mild fever (1), nausea + vomiting (1), palpable supraclavicular, axillary + inguinal lymph nodes (1) Mild erythema (2), mild headache (1)

DC vaccination for GBMs is feasible, tolerable and promising for inducing a immune response Vaccination with FC is not associated with any serious adverse effects, clinical signs of autoimmune reactions or substantial changes in the results of routine blood tests DC vaccination is safe, tolerable and not associated with autoimmunity

Kikuchi et al. (2004)27

CT

15

General convulsions (1)

Rutkowski et al. (2004)24

CT

12

–

Yu et al. (2004)34

CT

14

–

Headache (3), fatigue (1), erythema (1), seizures (2)

Liau et al. (2005)30

CT

12

Headache (2), nausea/vomiting (3), myalgia (1), seizure (1)

Yamanaka et al. (2005)26

CT

24

Mild headache (1)

Constipation/diarrhea (3), low grade fever (2), fatigue (5), pain/itching at injection site (1), lymph node swelling (2), allergic rhinitis (1), erythema (1), hyponatremia (1) DTH: mild erythema (6)

Khan et al. (2006)22 De Vleeschouwer et al. (2008)19

CRp

1

–

Low grade fever (1)

Prosp

56

Edema (1), temporary redness w/ & w/o itching, Hem. toxicity (2), fatigue (7), myalgia (3)

Wheeler et al. (2008)25

CT

32

post-op subdural hygroma (2), Grade II trans. , hemiparesis (2), dysphasia (4), headache (9), vomiting (2), flu-like (3), increase in epileptic seizures (4), intratumoral hemorrhage (2) –

Ardon et al. (2010)16

CT

8

hemiplagia and aphasia (1), epileptic insult (1), dysphasia (3)

Lymphopenia (1), focal transient fatigue (4), general malaise and myalgia (1)

Chang et al. (2011)18

CT

17

Grade II seizures (3), hydrocephalus, mild anemia, weight gain, myalgia, skull wound (1)

Transient serum AST/ALT elevations (8), Lymphopenia (9)

Cho et al. (2011)1

CT

18

Hemiplegia (1)

Transient abnormal liver fxn. (1), mild lymphopenia (1)

Fadul et al. (2011)20

CT

10

–

Unilateral neck pain at injection site (1)

Okada et al. (2011)31

CT

22

Myalgia (7), headache (7)

Fatigue (16), grade1/2 injection site rxn. (18), fever (5), chills/rigor (4), lymphopenia (1)

Prins et al. (2011)23

CT

23

Nausea/vomiting (4), myalgia (1), headache (1)

Fatigue (4), diarrhea (2), arthralgia (2), low grade fever (2), lymphodenopathy (2), injection site rxn. (4), shingles (1),

Transient grade I fever (1), liver dysfunction (6), leukocytopenia (7), erythema, induration Peritumoral oedema (1), grade II hematoxicity (2), nocturnal sweating (1), meningeal irritation (1)

DTH Testing: cutaneous glioblastoma with single lymph node involvement (1)

DC vaccination is proven to be safe and not associated with autoimmunity. Further investigations needed to determine optimum dosage, best source of tumor antigen and method of antigen loading Treatment with FC vaccinations safely induces antitumor immune responses with no serious adverse effects Tumor vaccination is feasible. Severe adverse effect was observed in 1 pt and 4/ 12 pts experienced mild toxicities due to the vaccination No serious adverse effects were associated with DC vaccination. This method is safe and feasible and there has been no evidence of an autoimmune response DC vaccinations were well tolerated by the treated patients. There were no major adverse events as well as no treatmentrelated hematologic, hepatic, renal or neurological toxicities Autologous tumor lysate-pulsed DC therapy is safe. There were no serious severe adverse effects and no evidence of an autoimmune reaction DC Therapy has shown to be a safe and efficacious method. Adjuvant DC immunotherapy is safe and can induce long-term survival A faster vaccination schedule improves PFS Age of < 35 is a predictor for better OS All adverse effects were attributed to tumor progression and not with the administration of DC vaccine ATCP loaded DC vaccine therapy when fully integrated into standard primary post-op. treatment for pts with GBM-N is feasible and well tolerated There were no severe injection site reactions Minimally elevated AST/ALT elevations were associated with the initiation of the vaccine. This resolved by the 6th-8th injection without impairment of liver fxn Adverse effects of DC treatment are few. This is a safe treatment option to improve short-term survival DC vaccination in addition to radiation and chemotherapy is feasible, safe and has the potential to induce tumorspecific immune responses Treatment with a-type 1 polarized DC loaded with synthetic peptides for GAA epitopes is safe and not associate with any major adverse events DC vaccinations were well tolerated by patients and no adverse events were observed. There were no signs of (continued on next page)

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A. Bregy et al. / Cancer Treatment Reviews xxx (2013) xxx–xxx

Table 5 (continued) Author and year

Type of study

No. of pts.

Craniotomy side effects

Vaccination side effects

Notes

autoimmune reactions in any patient

Ardon et al. (2012)17

CT

77

Myalgia (1), memory impairment (5), epileptic seizures grade-II (13), epileptic seizures grade-III (5), confusion (3), bleeding from ectopic cerebral lesion (1), dysphasia (1), cerebral abscess (1), hydrocephalus (1), dementia (1), focal status epilepticus (2), ischemic stroke (1)

Jie et al. (2012)21

CT

13

–

allergic rhinitis (1), pruritus (2), constipation (1), dermatitis (1), rash (2), anorexia (1), abdominal pain (1), upper lip blister (1) Fatigue (34), gen. rash/itching (4), shoulder pain (2), anorexia (2), humerus fracture (3), Lethargy (2), depression (1), esophagitis (1), otitis media serosa (1), allergic rxn. On TMZ (1) deep vein thrombosis (1), ischemic bowel perforation (1), lung + peripheral edema (1), osteoporotic fracture (1), overwhelming infection (1), lymphopenia grade-I (17), leukopenia grade-I (16), lymphopenia grade-II (7), leucopenia grade-II (5), lymphopenia grade-III (12), thrombopenia grade-III (2), leucopenia grade-III (1), thrombopenia grade-IV (3), lymphopenia grade-IV (1) Mild fever (2), red papules (1)

Phuphanich et al. (2013)32

CT

21

–

–

DC based tumor vaccines were associated with 38 serious adverse events (NCI CTC grade III, IV and V) in 39% of patients. Modifications to the vaccine have the potential for better outcomes

No adverse events were associated with vaccination of any pts GAA-pulsed DC vaccination is both feasible and safe. The patients had been monitored for serious adverse events but none were reported

Acronyms: AST/ALT = aspartate aminotransferase/alanine aminotransferase, chemo = chemotherapy, CRp = case report, Ct.=control, CT = clinical trial, Ct.=control, DC = dendritic cell, DTH = delayed type hypersensitivity reaction, OS = overall survival, PFS = progression free survival, pt = patient, TP = tumor progression.

Fig. 8. The bar diagram illustrates the different complications and side effects observed that were directly associated with vaccine administration and vaccine.

patients with N-GBM. This shows vaccinations with DC APCs loaded with ATL in addition to booster vaccinations could potentially be more beneficial in treating patients with N-GBM. All studies reviewed with the exception of Kikuchi et al. (2001) and (2004) reported median OS for patients undergoing treatment. Ten studies that included only patients with R-GBM reported median OS of at least 38.4 to 138.0 wks. Only 6 of these showed an increase in median OS when compared to the control of 58.4 wks. The most significant increases were reported by Chang et al.

(2011) (138.0 wks),18 Yu et al. (2004) (133.0 wks)34 and Yamanaka et al. (2003) (111.2 wks).33 A common feature among all three studies is the time at which vaccinations were administered. The protocol of all three required that patients be vaccinated immediately after surgery18,34 or upon tumor recurrence.33 Chang et al. and Yu et al. reported at least a 2-fold increase in the median OS of 58.4 wks. They included 17 patients18 and 14 patients34 respectively. When compared to the other studies, it is interesting that the pre-KPS scores were 90 and 100. This suggests that the

Please cite this article in press as: Bregy A et al. Active immunotherapy using dendritic cells in the treatment of glioblastoma multiforme. Cancer Treat Rev (2013), http://dx.doi.org/10.1016/j.ctrv.2013.05.007

Sponsor

Type of study

Estimated enrollment

Clinicaltrials.gov Identifier

Study start date

Estimated study completion date

Vaccine protocol Antigen

APC

Site of admin

Phase II

11

NCT00323115

May 2006

April 2013

Auto. glioma lysate

Auto.DC

i.n

Trimed Biotech BmbH

Ongoing, but not recruiting Recruiting

Phase II

56

NCT01213407

March 2010

December 2012

Auto. tumor lysate

i.n

Cedars-Sinai Medical Center

Unknown

Phase I

39

NCT00576641

May 2007

May 2008

Auto. brain tumor peptide

Oslo University Hospital

Enrolling by invitation only Recruiting

Phase I/II

20

NCT00846456

October 2015

BTSC mRNA

Phase II

37

NCT01006044

June 2014

Auto. tumor tissue

Recruiting

Phase III

300

NCT00045968

June 2013

Auto. tumor lysate antigen

Huashan Hospital

Recruiting

Phase II

100

NCT01567202

January 2009 October 2009 December 2006 March 2012

July 2014

Autogen. Glioma stem-like cells

Cedars-Sinai Medical Center

Completed

Phase II

50

NCT00576537

March 2001

January 2012

Tumor lysate

University Hospital, Antwerp

Enrolling by invitation only Recruiting

Phase I/II

10

NCT01291420

February 2013

Wilms’ tumor gene (WT1) mRNA

Phase I

50

NCT00890032

September 2015

Auto. CD133 + BTSC mRNA

Ongoing, but not recruiting Recruiting

Phase I

16

NCT00639639

June 2012

CMV-mRNA

Phase II

200

NCT01280552

October 2012

Masonic Cancer Center, University of Minnesota University of California, Los Angeles

Suspended

Phase I

9

NCT01171469

October 2013

Immunogenic peptides from auto. tumor antigen Allogeneic tumor antigen from BTSC

Recruiting

Phase II

–

NCT01204684

–

Auto. tumor lysate

Duke University

Ongoing, but not recruiting Ongoing, but not recruiting Ongoing, but not recruiting Recruiting

Phase I/II

6

NCT00626483

February 2011 September 2009 January 2006 January 2011 September 2010 September 2010 March 2007

March 2013

Tumor mRNA

Phase I

8

NCT00612001

May 2006

June 2009

Phase I

18

NCT00068510

June 2003

December 2012

Synthetic glioma-associated antigen peptide Auto. tumor lysate

Phase I

30

NCT01522820

March 2012

September 2012

Auto, tumor proteins

Ongoing, but not recruiting Ongoing

Phase II

12

NCT00693095

December 2016

CMV-mRNA

Phase IIb

146

EudraCT 2009– 018228-14

September 2008 April 2011

–

–

Auto. DC Auto. DC Auto. DC Auto. DC Auto. DC Auto. DC Auto. DC Auto. DC Auto. DC Auto. DC Auto. DC Auto. DC Auto. DC Auto. DC Auto. DC Auto. DC Auto. DC Auto. DC Auto. DC

Dartmouth-Hitchcock Medical Center

Clinica Universidad de Navarra, Universidad de Navarra Northwest Biotherapeutics

Duke University Duke University ImmunoCellular Therapeutics, Ltd.

Jonsson Comprehensive Cancer Center University of California, Los Angeles Roswell Park Cancer Institute Duke University University Hospital Leuven

Status of study

i.d. i.d. s.c. i.d. i.d. s.c. i.d. i.d. i.d. i.d. i.d. i.d. – – i.d. i.n

A. Bregy et al. / Cancer Treatment Reviews xxx (2013) xxx–xxx

i.d. i.d.

Acronyms: Auto.=autologous; autogen.=autogeneic; BTSC = brain tumor stem cell; CMV = cytomegalovirus; DC = dendritic cell; i.d.=intradermal; i.n.=intranodal; s.c.=subcutaneous.

15

Please cite this article in press as: Bregy A et al. Active immunotherapy using dendritic cells in the treatment of glioblastoma multiforme. Cancer Treat Rev (2013), http://dx.doi.org/10.1016/j.ctrv.2013.05.007

Table 6 Ongoing clinical trials for DC vaccine therapy for GBMs.

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A. Bregy et al. / Cancer Treatment Reviews xxx (2013) xxx–xxx

majority of the patients entered the study at an independent status, which likely accounts for the positive outcomes. Additionally the slightly lower median OS reported by Yamanaka et al., could potentially correspond with the lower pre-treatment KPS scores of the patients with R-GBM (med.=50, range = 30–80).33 The patients of the 9 studies that only included patients with NGBM experienced similar success. All 9 studies with the exception of one conducted by Chang et al. (2011) reported an increase in median OS from 60.0 to 127.6 wks.1,16,17,20,21,25,35 Chang et al. reported a median 54.4 wks which is not only below the control of 58.4 wks but is only marginally greater than the control group included in the study (54.3 wks).18 Interestingly, this same vaccine protocol brought about the greatest increase in median OS for patients with R-GBM. In comparison to the other treatments, the protocol included a heat shock treatment. There is however not enough information to determine what exactly is responsible for the more positive response of patients with R-GBM in comparison to N-GBM. What is clear is that this treatment seems to be more beneficial for treating patients with N-GBM. Cho et al. reported the highest median OS for a sample of patients with N-GBM only.1 This study was a clinical trial with 18 patients that reported a median OS of 31.9 months.1 None of the patients received previous treatment. As such, immunotherapy was implemented immediately after conventional treatment, before any signs of tumor recurrence. It is likely that immunotherapy should not just be considered a treatment option for recurrent tumors but also as a part of the conventional treatment plan for newly diagnosed tumors. The study also reported a control median OS that was similar to the literature OS (60.0 vs. 58.4 wks). Based on these results, it may be possible that these studies employed selection bias in the patients enrolled as control patients. However, no information provided in these articles was able to confirm this speculation. Prins et al. reported an even greater median OS of 143.6 wks.23 As mentioned previously this includes both patients with R-GBM (n = 8) and with N-GBM (n = 15). The weight of the sample is towards patients with N-GBM, which could potentially be indicative of the increased benefits of patients with N-GBM from DC vaccinations. This however is only speculative and would need further research to be confirmed. What is common with other studies successful is that the median pre-treatment KPS is 90 (60–100), indicating the highly independent status of patients. These studies point to the fact that subjects have to be fit enough to undergo DC vaccination treatment. It is possible that onlythe fittest patients are referred to the clinical trial centers for consideration of enrollment, leaving less fit patients already at the centers to be considered for the control groups. Several investigators have demonstrated the pre-vaccination performance status and clinical characteristics are predictive of superior survival benefits associated with vaccination. While outside the scope of this review, the significant PFS and median OS reported this implies that moving vaccination earlier in therapy for glioma patients is beneficial. Earlier on in their diagnosis patients would have better performance statuses and likely better immune function which would predict better outcomes in terms of PFS and median OS.17 For our review, the KPS served as a measure of the quality of life of patients. Generally, a KPS >70 classifies a patient as independent, requiring no assistance to be mobile. Unfortunately, while most of the studies enrolled patients with a KPS above 50, only 3 studies recorded a post-treatment KPS.1,16,18 Chang et al. and Cho et al. demonstrated a decrease in KPS while Ardon et al. (2010) was unable to confirm a decrease or increase in KPS in the third study. With the results of only three studies, our analysis was limited. The data was insufficient to assess whether or not the quality of life

of patients improved significantly after vaccine treatment was administered. Contrary to the results obtained thus far from this study, immunotherapy was previously considered as a last resort treatment option for cancers. Although the outcomes were disappointing it has been recognized that these failed studies demonstrated the general safety of immunotherapy. None of the patients passed away as a result of the administered immunotherapy. Additionally, autoimmunity was not induced in any of the studies analyzed. In fact, three studies, one by Cho et al. (2011) and two by Ardon et al. in 2010 and 2012 found that immunotherapy was safe and feasible when incorporated into standard therapy for newly diagnosed high grade glioma patients.1,16,17 The majority of the earlier studies reviewed for this review revealed similar conclusions. DC vaccination therapy is feasible, safe and no signs of autoimmunity were observed. However, one study by Wheeler et al. (2008) described a local complication at the site of the vaccine administration. Histological examination of the skin tissue demonstrated a cutaneous glioblastoma. None of the other studies have mentioned negative side effects at the administration site other than minor skin manifestations of redness, pain and itching. These are other minor side effects are illustrated in.Fig. 8 Based on the information gathered on the reviewed patients, there is also a small risk of cranial manifestations and elevated temperatures. In assessing the side effects, we concluded that these complications are not different from what would be experienced after administering any other type of vaccination. The symptoms are not considered to be severe adverse reactions, but instead, minor side effects that resolved with time. It is important to note that all of the above side effects are considered to be normal or expected side effects of the vaccine or craniotomy, rather than severe adverse effects. Research into active immunotherapy for treatment of GBM is still in phase I and phase II clinical trials. Table 6 presents current clinical trials of DC vaccination therapy available for treating patients with GBM. Most of these clinical trials are ongoing and results have not been published yet. Because of the nature of the current literature available, this study was limited to case reports, clinical trials and prospective studies. The articles reviewed are subject to publication bias and selection bias, which has the potential to lessen or amplify the true potential of active immunotherapy. With these limitations taken into consideration, the intention of this paper is not to create a formal guideline but rather to provide a summary of the current literature surrounding the safety and efficacy of active immunotherapy as a treatment option for GBM.

Conclusion In reviewing the published literature, we attempted to summarize the success and safety of active immunotherapy in the treatment of GBM. Studies suggest that vaccination with autologous DCs loaded with ATCs administered as an adjuvant therapy increases the PFS and median OS for patients with R-GBM and NGBM. However, large randomized clinical trials are required to confirm this trend. Patients with R-GBM experience a PFS of anywhere from 12.0 to 62.0 wks and an increase in median OS from 71.6 to 138.0 wks. Patients with N-GBM were observed to have an increase in PFS from 23.9 to 81.6 wks and increase in median OS from 23.9 to 81.6 wks. It can also be confirmed that with DC vaccination therapy, an increase of tumor infiltrating immune cells were found. It is this immune response that may be responsible for the effect on tumor regression as well as creation of immunologic memory. As such, DC vaccination therapy may also increase the PFS. Unfortunately, our review does not provide sufficient data to assess the effect on quality of life. In assessing the safety of this

Please cite this article in press as: Bregy A et al. Active immunotherapy using dendritic cells in the treatment of glioblastoma multiforme. Cancer Treat Rev (2013), http://dx.doi.org/10.1016/j.ctrv.2013.05.007

A. Bregy et al. / Cancer Treatment Reviews xxx (2013) xxx–xxx

treatment, numerous studies confirm that this treatment is both safe and feasible. No cases of autoimmunity due to vaccine administration were reported in any of the studies. The reviewed articles suggest that this type of active immunotherapy holds significant potential to be a successful treatment. In order to fully explore its potential, larger clinical trials are warranted and some of them are currently ongoing. Larger patients samples would be advantageous to assess median OS, median PFS, and an improvement in quality of life. Conflict of interest None. References 1. D.Y. Cho, et al., Adjuvant Immunotherapy with Whole-Cell Lysate Dendritic Cells Vaccine for glioblastoma multiforme: A Phase II Clinical Trial. World neurosurgery, 2011. 2. Iacob G, Dinca EB. Current data and strategy in glioblastoma multiforme. J Med Life 2009;2(4):386–93. 3. Stupp R et al. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 2005;352(10):987–96. 4. Reithmeier T, Graf E, Piroth T, Trippel M, Pinsker M, Nikkah G. BCNU for recurrent glioblastoma multiforme: efficacy, toxicity and prognostic factors. BMC Cancer 2010;10(30). 5. Schuster M, Nechansky A, Kircheis R. Cancer immunotherapy. Biotechnol J 2006;1(2):138–47. 6. Coley WB. The treatment of malignant tumors by repeated inoculations of erysipelas. With a report of ten original cases. 1893. Clin Orthop Relat Res 1991;262:3–11. 7. McMahon EJ, Bailey SL, Miller SD. CNS dendritic cells: Critical participants in CNS inflammation? Neurochem Int 2006;49:195–203. 8. E. Vauleon, et al., Overview of cellular immunotherapy for patients with glioblastoma. Clin Dev Immunol, 2010. 2010. 9. Banks WA, Erickson MA. The blood-brain barrier and immune function and dysfunction. Neurobiol Dis 2010;37(1):26–32. 10. Tracey KJ. Reflex control of immunity. Nat Rev Immunol 2009;9(6):418–28. 11. Rosas-Ballina M, Tracey KJ. The neurology of the immune system: neural reflexes regulate immunity. Neuron 2009;64(1):28–32. 12. Engelhardt B. The blood-central nervous system barriers actively control immune cell entry into the central nervous system. Curr Pharm Des 2008;14(16):1555–65. 13. Cserr HF, Knopf PM. Cervical lymphatics, the blood-brain barrier and the immunoreactivity of the brain: a new view. Immunol Today 1992;13(12):507–12. 14. Dunn GP, Dunn IF, Curry WT. Focus on TILs: prognostic significance of tumor infiltrating lymphocytes in human glioma. Cancer Immun 2007;7:12. 15. Cooperation D, Active Cellular Immunotherapy: Transforming the Body’s Ability to Fight Cancer, D. Cooperation, Editor 2010. 16. Ardon H et al. Integration of autologous dendritic cell-based immunotherapy in the primary treatment for patients with newly diagnosed glioblastoma multiforme: a pilot study. J Neurooncol 2010;99:261–72. 17. Ardon H et al. Integration of autologous dendritic cell-based immunotherapy in the standard of care treatment for patients with newly diagnosed glioblastoma: results of the HGG-2006 phase I/II trial. Cancer Immunol Immunother 2012;61:2033–44. 18. Chang CN et al. A phase I/II clinical trial investigating the adverse and therapeutic effects of a postoperative autologous dendritic cell tumor vaccine in patients with malignant glioma. J Clin Neurosci 2011;18:1048–54. 19. De Vleeschouwer S et al. Postoperative adjuvant dendritic cell-based immunotherapy in patients with relapsed glioblastoma multiforme. Clin Cancer Res 2008;14:3098–104. 20. Fadul CE et al. Immune response in patients with newly diagnosed glioblastoma multiforme treated with intranodal radiation chemotherapy. J Immunother 2011;34:382–9. 21. Jie X et al. Clinical application of a dendritic cell vaccine raised against heatshocked glioblastoma. Cell Biochem Biophys 2012;62:91–9. 22. Khan JA, Yaqin S. Dendritic cell therapy with improved outcome in glioma multiforme–a case report. J Zhejiang Univ Sci B 2006;7:114–7. 23. Prins RM et al. Gene expression profile correlates with T-cell infiltration and relative survival in glioblastoma patients vaccinated with dendritic cell immunotherapy. Clin Cancer Res 2011;17:1603–15.

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24. Rutkowski S et al. Surgery and adjuvant dendritic cell-based tumour vaccination for patients with relapsed malignant glioma, a feasibility study. Br J Cancer 2004;91:1656–62. 25. Wheeler CJ et al. Vaccination elicits correlated immune and clinical responses in glioblastoma multiforme patients. Cancer Res 2008;68:5955–64. 26. Yamanaka R et al. Clinical evaluation of dendritic cell vaccination for patients with recurrent glioma: results of a clinical phase I/II trial. Clin Cancer Res 2005;11:4160–7. 27. Kikuchi T et al. Vaccination of glioma patients with fusions of dendritic and glioma cells and recombinant human interleukin. J Immunother 2004;27: 452–9. 28. Kikuchi T et al. Results of a phase I clinical trial of vaccination of glioma patients with fusions of dendritic and glioma cells. Cancer Immunol Immunother 2001;50:337–44. 29. Liau LM et al. Treatment of a patient by vaccination with autologous dendritic cells pulsed with allogeneic major histocompatibility complex class I-matched tumor peptides.Case report. Neurosurg Focus 2000;9:e8. 30. Liau LM et al. Dendritic cell vaccination in glioblastoma patients induces systemic and intracranial T-cell responses modulated by the local central nervous system tumor microenvironment. Clin Cancer Res 2005;11:5515–25. 31. Okada H et al. Induction of CD8+ T-cell responses against novel gliomaassociated antigen peptides and clinical activity by vaccinations with {alpha}type 1 polarized dendritic cells and polyinosinic-polycytidylic acid stabilized by lysine and carboxymethylcellulose in patients with recurrent malignant glioma. J Clinical Oncol 2011;29:330–6. 32. Phuphanich S et al. Phase I trial of a multi-epitope-pulsed dendritic cell vaccine for patients with newly diagnosed glioblastoma. Cancer Immunol Immunother 2013;62:125–35. 33. Yamanaka R et al. Vaccination of recurrent glioma patients with tumour lysatepulsed dendritic cells elicits immune responses: results of a clinical phase I/II trial. Br J Cancer 2003;89:1172–9. 34. Yu JS et al. Vaccination with tumor lysate-pulsed dendritic cells elicits antigenspecific, cytotoxic T-cells in patients with malignant glioma. Cancer Res 2004;64:4973–9. 35. Yu JS et al. Vaccination of malignant glioma patients with peptide-pulsed dendritic cells elicits systemic cytotoxicity and intracranial T-cell infiltration. Cancer Res 2001;61:842–7. 36. Ohka F, Natsume A, Wakabayashi T. Current trends in targeted therapies for glioblastoma multiforme. Neurol Res Int 2012;2012:878425. 37. Parish CR. Cancer immunotherapy: the past, the present and the future. Immunol Cell Biol 2003;81(2):106–13. 38. Wiemann B, Starnes CO. Coley’s toxins, tumor necrosis factor and cancer research: a historical perspective. Pharmacol Ther 1994;64(3):529–64. 39. Fenton RG, Longo DL. Genetic instability and tumor cell variation: implications for immunotherapy. J Natl Cancer Inst 1995;87(4):241–3. 40. Stoler DL et al. The onset and extent of genomic instability in sporadic colorectal tumor progression. Proc Natl Acad Sci U S A 1999;96(26):15121–6. 41. Urban JL, Schreiber H. Tumor antigens. Annu Rev Immunol 1992;10:617–44. 42. Boon T et al. Tumor antigens recognized by T lymphocytes. Annu Rev Immunol 1994;12:337–65. 43. Boon T, van der Bruggen P. Human tumor antigens recognized by T lymphocytes. J Exp Med 1996;183(3):725–9. 44. Rosenberg SA. A new era for cancer immunotherapy based on the genes that encode cancer antigens. Immunity 1999;10(3):281–7. 45. Melief CJ et al. Strategies for immunotherapy of cancer. Adv Immunol 2000;75:235–82. 46. Flamand V et al. Murine dendritic cells pulsed in vitro with tumor antigen induce tumor resistance in vivo. Eur J Immunol 1994;24(3):605–10. 47. Mayordomo JI et al. Bone marrow-derived dendritic cells pulsed with synthetic tumour peptides elicit protective and therapeutic antitumour immunity. Nat Med 1995;1(12):1297–302. 48. Celluzzi CM et al. Peptide-pulsed dendritic cells induce antigen-specific CTLmediated protective tumor immunity. J Exp Med 1996;183(1):283–7. 49. Brossart P et al. Dendritic cells in cancer vaccines. Exp Hematol 2001;29(11):1247–55. 50. Steinman RM, Dhodapkar M. Active immunization against cancer with dendritic cells: the near future. Int J Cancer 2001;94(4):459–73. 51. Parmiani G et al. Cancer immunotherapy with peptide-based vaccines: what have we achieved? Where are we going? J Natl Cancer Inst 2002;94(11):805–18. 52. Byrne SN, Halliday GM. Dendritic cells: making progress with tumour regression? Immunol Cell Biol 2002;80(6):520–30. 53. Ge L et al. Immunotherapy of brain cancers: the past, the present, and future directions. Clin Dev Immunol 2010;2010:296453. 54. Ohka F et al. The global DNA methylation surrogate LINE-1 methylation is correlated with MGMT promoter methylation and is a better prognostic factor for glioma. PLoS One 2011;6(8):e23332.

Please cite this article in press as: Bregy A et al. Active immunotherapy using dendritic cells in the treatment of glioblastoma multiforme. Cancer Treat Rev (2013), http://dx.doi.org/10.1016/j.ctrv.2013.05.007