Anlotinib Combined with Toripalimab as Second-Line Therapy for Advanced, Relapsed Gastric or Gastroesophageal Junction Carcinoma

Abstract

Our study aimed to explore the efficacy and safety of anlotinib-toripalimab combination therapy as a second-line treatment for advanced relapsed gastric or gastroesophageal junction carcinoma (GC/GEJC). In this single arm, single-center extension clinical trial, patients with advanced relapsed GC/GEJC received toripalimab (240 mg, intravenously over 60 minutes, once every 2 weeks) plus anlotinib (12 mg/day, orally, 2 weeks on and 1 week off, every 3 weeks) as second-line therapy. There were 29 patients who achieved partial response, and the ORR was 32.3% (95% CI, 26.6%-38.5%). Grade 3 treatment-related adverse events (TRAEs) were recorded in 7 participants (11.3%), all of which were manageable. The PFS and OS were 4.0 and 11.1 months, respectively. Patients with programmed death-ligand 1 (PD-L1) positive expression showed numerically longer OS than the negative ones although the difference was not significantly. The tumor mutational burden-high (TMB-H) group showed a significantly better OS (P = .05) than the TMB-Low (TMB-L) group. Next-generation sequencing (NGS) revealed that fibroblast growth factor receptor 2 (FGFR2) mutations positively correlated with target lesion reduction (odds ratio [OR] = 0.14; P = .02). The new regimen increased tumor-infiltration of CD8+ T and CD3+ T cells. Furthermore, a patient-derived organoid (PDO) study indicated that anlotinib could promote an immune-supportive tumor microenvironment. As conclusion, the anlotinib-toripalimab combination showed promising efficacy and favorable safety as a second-line treatment for advanced, relapsed GC/GEJC. The PD-L1 expression, TMB, and FGFR2 mutation are potential biomarkers for predicting the efficacy of this regimen (ClinicalTrials.gov registration number: NCT04713059).

Keywords: anlotinib; gastric or gastroesophageal junction carcinoma; second-line therapy; toripalimab; tumor microenviroment.

© The Author(s) 2022. Published by Oxford University Press.

Figures

Figure 1.

Efficacy analysis. (1) Waterfall plot of best percentage change from baseline in size of target tumor lesion; (2) Percentage change in lesion diameters over time; (3) Kaplan-Meier estimates of progression-free survival (PFS); (4) Kaplan-Meier estimates of overall survival (OS).

Figure 2.

(1) ORR (A), PFS (B) and OS (C) of PD-L1 negative or positive patients; (2) ORR (A), PFS (B) and OS (C) of TMB-H, TMB-L and TMB-H (excluding MSI-H); (3) Gene mutation analysis of all the enrolled patients; (4) The ORR of FGFR2-mutated patients, and the FGFR2 mutation ratio in PD-L1 positive or TMB-H groups (A), PFS (B) and OS (C) of FGFR2-mutated patients.

Figure 2.

(1) ORR (A), PFS (B) and OS (C) of PD-L1 negative or positive patients; (2) ORR (A), PFS (B) and OS (C) of TMB-H, TMB-L and TMB-H (excluding MSI-H); (3) Gene mutation analysis of all the enrolled patients; (4) The ORR of FGFR2-mutated patients, and the FGFR2 mutation ratio in PD-L1 positive or TMB-H groups (A), PFS (B) and OS (C) of FGFR2-mutated patients.

Figure 3.

Tumor microenvironment analysis of patient GC-20 who was underwent surgery after 8 courses of combination treatment: (1) The immune microenvironment of the tumor before combination treatment: 1) the immune microenvironment panorama, 2) expression of CD3 and CD8, 3) expression of PD-1, 4) expression of PD-L1, 5) expression of CD8, 6) expression of CD3; (2) The immune microenvironment of the tumor after combination treatment: 1) the immune microenvironment panorama, 2) expression of CD3 and CD8, 3) expression of PD-1, 4) expression of PD-L1, 5) expression of CD8, 6) expression of CD3 (CD8: red; CD3: cyan; PD-L1: yellow; PD-1: green; panCK: purple; DAPI: blue); (3) PET-CT scan of patient GC-20 before and after the combination therapy: 1) the PET-CT showed an uneven thickening of uneven thickening of the gastric body wall with (SUVmax:3.2) before treatment. After treatment, the lateral wall of the greater curvature of the stomach was thickened (SUVmax 3.6), and the lesion was red uced; 2) the PET-CT showed multiple enlarged lymph nodes around left of the gastric artery, great curvature of the gastric body, right lower part of the gastric antrum, upper part of the pancreas, and around the abdominal aorta (SUVmax: 5.1) before the treatment. After the treatment, there was no abnormal metabolism or decreased metabolism in the retroperitoneum; 3) the PET-CT showed multiple lymph nodes could be observed in left subphrenic fat, the anterior omentum of the transverse colon and the left pelvic descending colon (SUVmax: 3.8). After treatment, multiple pelvic lymph nodes in the left anterior omentum of transverse colon could not been observed.

Figure 3.

Tumor microenvironment analysis of patient GC-20 who was underwent surgery after 8 courses of combination treatment: (1) The immune microenvironment of the tumor before combination treatment: 1) the immune microenvironment panorama, 2) expression of CD3 and CD8, 3) expression of PD-1, 4) expression of PD-L1, 5) expression of CD8, 6) expression of CD3; (2) The immune microenvironment of the tumor after combination treatment: 1) the immune microenvironment panorama, 2) expression of CD3 and CD8, 3) expression of PD-1, 4) expression of PD-L1, 5) expression of CD8, 6) expression of CD3 (CD8: red; CD3: cyan; PD-L1: yellow; PD-1: green; panCK: purple; DAPI: blue); (3) PET-CT scan of patient GC-20 before and after the combination therapy: 1) the PET-CT showed an uneven thickening of uneven thickening of the gastric body wall with (SUVmax:3.2) before treatment. After treatment, the lateral wall of the greater curvature of the stomach was thickened (SUVmax 3.6), and the lesion was red uced; 2) the PET-CT showed multiple enlarged lymph nodes around left of the gastric artery, great curvature of the gastric body, right lower part of the gastric antrum, upper part of the pancreas, and around the abdominal aorta (SUVmax: 5.1) before the treatment. After the treatment, there was no abnormal metabolism or decreased metabolism in the retroperitoneum; 3) the PET-CT showed multiple lymph nodes could be observed in left subphrenic fat, the anterior omentum of the transverse colon and the left pelvic descending colon (SUVmax: 3.8). After treatment, multiple pelvic lymph nodes in the left anterior omentum of transverse colon could not been observed.

Figure 4.

PDO studies. (1) HE staining of the patients tumor tissue; (2) HE staining of the patient-derived gastric cancer organoid (PDO); (3) the direct efficacy of anlotinib on the PDOs; (4) viability assay of the different treatment tumor cells from the PDOs cultivated for 7 days; (5) STRING analysis to study the potential mechanism; (6) western-blot analysis of the expression of STAT1 and STAT3 after anlotinib treatment.

Figure 4.

PDO studies. (1) HE staining of the patients tumor tissue; (2) HE staining of the patient-derived gastric cancer organoid (PDO); (3) the direct efficacy of anlotinib on the PDOs; (4) viability assay of the different treatment tumor cells from the PDOs cultivated for 7 days; (5) STRING analysis to study the potential mechanism; (6) western-blot analysis of the expression of STAT1 and STAT3 after anlotinib treatment.