ABSTRACT
Recurrent high-grade gliomas (HGGs) of childhood have an exceedingly poor prognosis with current therapies. Accordingly, new treatment approaches are needed. We initiated a pilot trial of vaccinations with peptide epitopes derived from glioma-associated antigens (GAAs) overexpressed in these tumors in HLA-A2+ children with recurrent HGG that had progressed after prior treatments. Peptide epitopes for three GAAs (EphA2, IL13Rα2, survivin), emulsified in Montanide-ISA-51, were administered subcutaneously adjacent to intramuscular injections of poly-ICLC every 3 weeks for 8 courses, followed by booster vaccines every 6 weeks. Primary endpoints were safety and T-cell responses against the GAA epitopes, assessed by enzyme-linked immunosorbent spot (ELISPOT) analysis. Treatment response was evaluated clinically and by magnetic resonance imaging. Twelve children were enrolled, 6 with glioblastoma, 5 with anaplastic astrocytoma, and one with malignant gliomatosis cerebri. No dose-limiting non-CNS toxicity was encountered. ELISPOT analysis, in ten children, showed GAA responses in 9: to IL13Rα2 in 4, EphA2 in 9, and survivin in 3. One child had presumed symptomatic pseudoprogression, discontinued vaccine therapy, and responded to subsequent treatment. One other child had a partial response that persisted throughout 2 years of vaccine therapy, and continues at >39 months. Median progression-free survival (PFS) from the start of vaccination was 4.1 months and median overall survival (OS) was 12.9 months. 6-month PFS and OS were 33 and 73 %, respectively. GAA peptide vaccination in children with recurrent malignant gliomas is generally well tolerated, and has preliminary evidence of immunological and modest clinical activity.
Subject(s)
Antigens, Neoplasm/immunology , Brain Neoplasms/immunology , Brain Neoplasms/therapy , Glioma/therapy , Immunotherapy, Active/methods , Adolescent , Antigens, Neoplasm/chemistry , Carboxymethylcellulose Sodium/analogs & derivatives , Child , Child, Preschool , Female , Glioma/immunology , Glioma/metabolism , Humans , Infant , Inhibitor of Apoptosis Proteins/chemistry , Inhibitor of Apoptosis Proteins/immunology , Interleukin-13 Receptor alpha1 Subunit , Male , Peptides/immunology , Pilot Projects , Poly I-C/immunology , Polylysine/analogs & derivatives , Polylysine/immunology , Receptor, EphA2/chemistry , Receptor, EphA2/immunology , Receptors, Interleukin-13/chemistry , Receptors, Interleukin-13/immunology , Survivin , Treatment Outcome , Young AdultABSTRACT
BACKGROUND: Low-grade gliomas (LGGs) are the most common brain tumors of childhood. Although surgical resection is curative for well-circumscribed superficial lesions, tumors that are infiltrative or arise from deep structures are therapeutically challenging, and new treatment approaches are needed. Having identified a panel of glioma-associated antigens (GAAs) overexpressed in these tumors, we initiated a pilot trial of vaccinations with peptides for GAA epitopes in human leukocyte antigen-A2+ children with recurrent LGG that had progressed after at least 2 prior regimens. METHODS: Peptide epitopes for 3 GAAs (EphA2, IL-13Rα2, and survivin) were emulsified in Montanide-ISA-51 and administered subcutaneously adjacent to intramuscular injections of polyinosinic-polycytidylic acid stabilized by lysine and carboxymethylcellulose every 3 weeks for 8 courses, followed by booster vaccines every 6 weeks. Primary endpoints were safety and T-lymphocyte responses against GAA epitopes. Treatment response was evaluated clinically and by MRI. RESULTS: Fourteen children were enrolled. Other than grade 3 urticaria in one child, no regimen-limiting toxicity was encountered. Vaccination induced immunoreactivity to at least one vaccine-targeted GAA in all 12 evaluable patients: to IL-13Rα2 in 3, EphA2 in 11, and survivin in 3. One child with a metastatic LGG had asymptomatic pseudoprogression noted 6 weeks after starting vaccination, followed by dramatic disease regression with >75% shrinkage of primary tumor and regression of metastatic disease, persisting >57 months. Three other children had sustained partial responses, lasting >10, >31, and >45 months, and one had a transient response. CONCLUSIONS: GAA peptide vaccination in children with recurrent LGGs is generally well tolerated, with preliminary evidence of immunological and clinical activity.
Subject(s)
Antigens, Neoplasm/therapeutic use , Brain Neoplasms/drug therapy , Brain Neoplasms/immunology , Carboxymethylcellulose Sodium/analogs & derivatives , Glioma/drug therapy , Glioma/immunology , Interferon Inducers/therapeutic use , Poly I-C/therapeutic use , Polylysine/analogs & derivatives , Vaccination/methods , Adolescent , Antigens, Neoplasm/administration & dosage , Antigens, Neoplasm/adverse effects , Antigens, Neoplasm/immunology , Carboxymethylcellulose Sodium/administration & dosage , Carboxymethylcellulose Sodium/adverse effects , Carboxymethylcellulose Sodium/therapeutic use , Child , Child, Preschool , Disease-Free Survival , Epitopes , Female , Humans , Infant , Inhibitor of Apoptosis Proteins/immunology , Interferon Inducers/administration & dosage , Interferon Inducers/adverse effects , Interferon Inducers/immunology , Interleukin-13 Receptor alpha2 Subunit/immunology , Male , Neoplasm Grading , Pilot Projects , Poly I-C/administration & dosage , Poly I-C/adverse effects , Poly I-C/immunology , Polylysine/administration & dosage , Polylysine/adverse effects , Polylysine/immunology , Polylysine/therapeutic use , Receptor, EphA2/immunology , Survivin , Treatment OutcomeABSTRACT
PURPOSE: Diffuse brainstem gliomas (BSGs) and other high-grade gliomas (HGGs) of childhood carry a dismal prognosis despite current treatments, and new therapies are needed. Having identified a series of glioma-associated antigens (GAAs) commonly overexpressed in pediatric gliomas, we initiated a pilot study of subcutaneous vaccinations with GAA epitope peptides in HLA-A2-positive children with newly diagnosed BSG and HGG. PATIENTS AND METHODS: GAAs were EphA2, interleukin-13 receptor alpha 2 (IL-13Rα2), and survivin, and their peptide epitopes were emulsified in Montanide-ISA-51 and given every 3 weeks with intramuscular polyinosinic-polycytidylic acid stabilized by lysine and carboxymethylcellulose for eight courses, followed by booster vaccinations every 6 weeks. Primary end points were safety and T-cell responses against vaccine-targeted GAA epitopes. Treatment response was evaluated clinically and by magnetic resonance imaging. RESULTS: Twenty-six children were enrolled, 14 with newly diagnosed BSG treated with irradiation and 12 with newly diagnosed BSG or HGG treated with irradiation and concurrent chemotherapy. No dose-limiting non-CNS toxicity was encountered. Five children had symptomatic pseudoprogression, which responded to dexamethasone and was associated with prolonged survival. Only two patients had progressive disease during the first two vaccine courses; 19 had stable disease, two had partial responses, one had a minor response, and two had prolonged disease-free status after surgery. Enzyme-linked immunosorbent spot analysis in 21 children showed positive anti-GAA immune responses in 13: to IL-13Rα2 in 10, EphA2 in 11, and survivin in three. CONCLUSION: GAA peptide vaccination in children with gliomas is generally well tolerated and has preliminary evidence of immunologic and clinical responses. Careful monitoring and management of pseudoprogression is essential.