First-in-class immune-modulating small molecule Icaritin in advanced hepatocellular carcinoma: preliminary results of safety, durable survival and immune biomarkers

Ying Fan, Shu Li, Xiaoyan Ding, Jian Yue, Jun Jiang, Hong Zhao, Rui Hao, Weiliang Qiu, Kezhen Liu, Ying Li, Shengdian Wang, Limin Zheng, Bin Ye, Kun Meng, Binghe Xu, Ying Fan, Shu Li, Xiaoyan Ding, Jian Yue, Jun Jiang, Hong Zhao, Rui Hao, Weiliang Qiu, Kezhen Liu, Ying Li, Shengdian Wang, Limin Zheng, Bin Ye, Kun Meng, Binghe Xu

Abstract

Background: With poor prognosis and limited treatment options for advanced hepatocellular carcinoma (HCC), development of novel therapeutic agents is urgently needed. This single-arm phase I study sought to assess the safety and preliminary efficacy of icaritin in human as a potential oral immunotherapy in addition to the immune-checkpoint inhibitors.

Methods: Eligible advanced HCC patients with Child-Pugh Class A or B were administered with a fixed oral dose of icaritin at either 600 or 800 mg b.i.d. The primary endpoint was safety, and the secondary endpoints included time-to-progression (TTP), overall survival (OS) and the clinical benefit rate (CBR). Icaritin treatment induced immune biomarkers and immune-modulating activities in myeloid cells were also explored.

Results: No drug-related adverse events ≥ Grade 3 were observed in all 20 enrolled HCC patients. Among the 15 evaluable patients, 7 (46.7%) achieved clinical benefit, representing one partial response (PR, 6.7%) and 6 stable disease (SD, 40%). The median TTP was 141 days (range: 20-343 days), and the median OS was 192 days (range: 33-1036 days). Durable survival was observed in PR/SD patients with a median OS of 488 days (range: 72-773). TTP was significantly associated with the dynamic changes of peripheral neutrophils (p = 0.0067) and lymphocytes (p = 0.0337). Icaritin treatment induced changes in immune biomarkers-and immune-suppressive myeloid cells were observed.

Conclusions: Icaritin demonstrated safety profiles and preliminary durable survival benefits in advanced HCC patients, which were correlated with its immune-modulation activities and immune biomarkers. These results suggested the potential of icaritin as a novel oral immunotherapy for advanced HCC in addition to antibody-based PD-1/PD-L1 blockade therapies.

Trial registration: Clinicaltrial.gov identifier. NCT02496949 (retrospectively registered, July 14, 2015).

Keywords: Phase I trial in advanced hepatocellular carcinoma; Small molecule immune modulation.

Conflict of interest statement

Ethics approval and consent to participate

All patients provided written informed consent before enrolment. The study was performed in accordance with good clinical practices and Declaration of Helsinki guidelines. Approval from the appropriate ethics committees and institutional review boards was obtained and documented before the study. (Name of Ethics committee: Cancer Hospital, Chinese Academy of Medical Sciences, National GCP Center for Anticancer Drugs; Ethic approval letter ID: 11–95/530, Clinical Protocol ID: TG11141CR; Approval date: Nov. 24, 2011. This trial was registered with Consent for publication

In addition to the consent form for the enrolment purpose, the signed consent forms also cover the agreement that the enrolled patients allow his/her data generated from this study to be published with blinded ID and privacy protection, regardless any format of presentation.

Competing interests

Y F, B X, Funding from Chinese Academy of Medical Science (CAMS) Initiative for Innovative Medicine; S L and R H: Ex-employees of Beijing Shenogen Biomedical Ltd.; X D, J Y, J J, H Z, R H, W Q, K L, Y I, S W, L Z, Nothing to disclose; B Y, K M: Employee of Beijing Shenogen Biomedical Ltd.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Icaritin induces anti-cancer activities in advanced HCC patients. a. Plot view of overall survival (OS) of all enrolled 20 (15 were evaluable) hepatocellular carcinoma (HCC) patients. Patients with star (*) indicate the second line treatment and with baseline refractory progression status after sorafenib or chemo-treatment. b. Icaritin treatment outcome was associated with the dynamic changes of circulating immune cells in advanced HCC patients. Icaritin treatment induced changes of neutrophil percentage were normalized with baseline as 100% (B1, green lines show stable disease (SD) patients with transient decreases in neutrophils). Icaritin treatment induced changes of neutrophil from baseline to D8 were significantly associated with time-to-progression (TTP) (p = 0.0067, B2). Dynamic changes of lymphocyte percentage were normalized to baseline as 100% (B3, green lines show SD patients with transient increases in lymphocytes after icaritin treatment). Icaritin treatment induced lymphocyte changes from baseline to D8 were significantly associated with TTP (p = 0.0337, B4). c. Baseline levels of inflammation and immune cell indices including neutrophil-to-lymphocyte ratio (NLR, C1), inflammation-immune index (SII, C2), and platelet-to-lymphocyte ratio (PLR, C3) and AFP (C4), were associated with OS in HCC. Median values were used as cut-off for survival estimation per the Kaplan-Meier analysis
Fig. 2
Fig. 2
Icaritin induces durable partial response and immune biomarkers. a. Time course images (MRI and RECIST1.1) of a PR patient demonstrate tumour shrinkage after 8, 16 and 32 weeks of icaritin treatment compared to the baseline image. The CT images show that the retroperitoneal multiple lymph node metastases (not liver tumour lesion; multiple lesion sites are indicated by the arrows in red) were significantly reduced during the time course of icaritin treatment. The red arrows indicate lesions with diameter > 1.5 cm at baseline and week 8 of treatment. After 16 weeks of treatment, target lesions were evaluated as complete response (CR) (with maximum measurable diameter < 0.5 cm) according to RECIST1.1. b. Dynamic changes of AFP biomarkers and cytokine panel (IL-6, IL-8 IL-10, ΤΝF-α, and IFN-γ) in the time course of icaritin treatment. (Note: The time course tumour CT 3D-tomography images may not from identical sections, but they are valid for comparison of the dynamic changes and drug efficacy. a) By selecting the section with the maximum diameter of lesion using the RECIST1.1 global standard, the section location reference was according to the great vessels of the retroperitoneum, especially the large vessels of the retroperitoneum. b) Tumour shrinkage asymmetrically. c) CT section of images of organs may vary from time to time due to breath and other uncontrolled factors of patient)
Fig. 3
Fig. 3
Icaritin blocks the immune-suppression in myeloid cells in vitro. a. Icaritin treatment induced gene expression patterns of M1-type and M2-type macrophages in vitro. The relative copy numbers of M1-type genes (INOS, TNF-α and CXCL10) and M2-type genes (Arg1, Ym1 and Fizz1) were induced by icaritin (2 and 10 μM) and normalized to β-actin. b. Icaritin treatment down-regulates immune MDSCs (M-CSFR expression, a key marker of activated MDSCs). Flow cytometric analysis of M-CSFR in cytokine-induced CB-MDSCs with or without icaritin (2.5 μM, 72 h) treatment with CD14+ and CD15+ sorting. Summary of cell population ratio of CD14+M-CSFR+ and CD15+M-CSFR+ cells in cytokine-induced CB-MDSCs with or without icaritin treatment (*p < 0.05, see additional file for method details)
Fig. 4
Fig. 4
Schematic mechanism of Icaritin treatment induced anti-cancer and immune-modulation activities via IL-6/JAK2/Stat3-associated protein networking in hepatocellular carcinoma (HCC). a. Icaritin induced anti-tumour cell proliferation, anti-inflammation and immune modulation activities. b. Simplified sketch for the potential cytokine-mediated network interactions between tumour cells and immune cells in the tumour microenvironment (modified from Dr. Fisher DT et al. Semin Immunol. 2014; 26(1): 38–47. doi:10.1016/j.smim.2014.01.008)

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