Background
Angiogenic factors are important for the growth of malignant tumors, and vascular endothelial growth factor (VEGF)-A/ VEGF receptors (VEGFRs) signaling is the most potent [
1]. Glioblastoma is a highly malignant tumor that exhibits extensive vascularity. The expression of VEGF-A/ VEGFRs is strongly upregulated in glioblastoma, and the expression degree correlates with the grade of malignancy and prognosis in malignant glioma [
2,
3]. It has been reported that both VEGFR1 and VEGFR2 are expressed on not only vascular endothelial cells, but also tumor cells [
4]. VEGFR1 signaling is critical for tumor growth [
5]. VEGFR2 plays an important role in the proliferation of tumor stem cells [
6]. Furthermore, VEGF/VEGFR signaling plays a pivotal role in the development of the immunosuppressive tumor microenvironment in glioblastomas [
7].
Therefore, VEGF-A and VEGFRs targeted anti-angiogenic therapies have been previously used in glioblastomas. Bevacizumab, which targets circulating VEGF-A, and multikinase inhibitor, such as cediranib, sunitinib, and sorafenib, were associated with favorable event-free survival in patients with glioblastomas [
8‐
12]. In addition, combinational therapy with anti-angiogenic therapy and chemotherapy has been an attractive treatment strategy in glioblastomas, because anti-angiogenic therapy induces a functional normalization of the tumor vasculature, increasing tumor cell exposure, and enhancing the activity of co-administered chemoradiotherapies [
13]. The combinational therapy involving sorafenib plus daily temozolomide (TMZ), which is the primary chemotherapy used globally for glioblastoma treatment [
14], was used for the recurrent glioblastomas, indicating that it is feasible, safe, and has some effect on patients [
15].
Cancer immunotherapy has become the fourth preferred modality of cancer treatment after surgery and chemoradiotherapy. Peptide vaccination is an immunotherapy that aims to activate cytotoxic T lymphocytes (CTLs) in patients by inoculating antigen peptides. We have previously conducted exploratory clinical studies investigating VEGFRs peptide vaccination with and without multiple glioma oncoantigens in patients with recurrent high-grade gliomas [
16,
17]. Recently, VEGFRs peptide vaccine was used in patients with progressive neurofibromatosis type 2 (NF2) [
18]. In the study, the number of Foxp3-positive regulatory T cells (Tregs) decreased after the vaccination, suggesting that the CTLs induced by the vaccination can directly kill a wide variety of cells associated with tumor growth, including tumor vessels, tumor cells, and Tregs expressing VEGFR1 and/or VEGFR2. Furthermore, the combinational usage of chemotherapy and immunotherapy is also effective with synergistic activity [
19], because chemotherapy suppressed immunosuppressive T cells and immunotherapy sustains the proliferation of potential effector immune cells [
20,
21].
Based on these backgrounds, in this trial, VEGFR1 and 2 vaccine was used with TMZ-based chemoradiotherapy for the patients with primary glioblastomas [
14]. VEGFRs peptide vaccination might have both the advantages of anti-angiogenic therapy and immunotherapy. In addition, we successfully evaluated the histopathological changes after the VEGFR1 and 2 vaccination using paired pre- and post-vaccination patient-derived specimens, proving the synergic effects when administered with chemotherapy.
Discussion
VEGF /VEGFRs signaling plays a pivotal role in the tumor angiogenesis and the development of the immunosuppressive tumor microenvironment in glioblastomas by inhibiting the maturation of dendritic cells (DCs) and stimulating the proliferation of Tregs, TAMs, and myeloid-derived suppressor cells (MDSCs) with VEGFRs expressions [
7,
29‐
32]. Therefore, anti-angiogenic therapy targeting VEGF and/or VEGFRs, including VEGFRs peptide vaccination, has not only anti-angiogenic effects, but also immune-supportive effects [
19,
26]. In addition, VEGFRs peptide vaccination has the advantages of immunotherapy. CTLs induced by the vaccination may persist in the long-term. In the present study, the synergistic activity of the combinational usage of VEGFRs peptide vaccination and TMZ-based chemotherapy was investigated for the patients with primary glioblastomas.
In this study, the disappearance of a radiographically enhanced lesion in the patient with unmethylated MGMT promoter was suggestive. The histopathological changes after the VEGFRs vaccination using paired pre- and post-vaccination specimens demonstrated that VEGFR1 and 2 peptide vaccination induced the normalization of vascular structure with decreased VEGFR1 and 2 expressions, and the reduction of MVD in the recurrent tumor after vaccination. We have previously reported the histopathological changes after the administration of bevacizumab (anti-VEGF-A monoclonal antibody) using actual human glioblastoma specimens resected in 3 different settings: glioblastomas before any treatment; glioblastomas resected following bevacizumab therapy; and recurrent glioblastomas after long-term bevacizumab therapy [
26,
27,
33]. In these previous studies, the expressions of VEGFR1 and 2 were upregulated in recurrent glioblastomas after long-term bevacizumab therapy [
33]. The present histopathological results might suggest that memory CTL induced by VEGFRs peptide vaccination may overcome the problems of anti-angiogenic molecular targeting agents, which include apparent drug resistance and rebound upregulated VEGF-A/VEGFRs signaling [
34]. However, peptide-based vaccination results in the induction of T cell exhaustion. The transient upregulation of PD-1 during T-cell activation and its maintenance on chronically stimulated exhausted T cells enable PD-1 to negatively regulate T-cell function [
35,
36]. Therefore, Immune checkpoint inhibition may exert synergic effects when administered with this type of CTL-mediated antitumor immunotherapy. In the future, we will reveal the difference in the target of inhibition, VEGF compared with VEGFRs using these valuable human tumor specimens.
Furthermore, the combinational usage of chemotherapy and immunotherapy was reported to be effective with synergistic activity [
19‐
21]. The combination of TMZ and immunotherapy with fusions of dendritic cells (DCs) and glioma cells safely induced anti-tumor effects in patients with glioblastomas [
37]. However, the Tregs population increases rapidly, known as the rebound phenomenon, during long-term TMZ therapy for glioblastomas [
38]. Importantly, the present histopathological finding of cleaved caspase 3 also proved that VEGFR1 and 2 peptide vaccination could target wide variety of cells associated with tumor growth, such as vascular endothelial cells, tumor cells, and Foxp3 + Tregs expressing VEGFR1 and/or VEGFR2, which was considered as one of the rationales behind using VEGFRs peptide vaccination with TMZ. Previous study also demonstrated that VEGFR2-targeting treatment has the possibility of selectively killing Tregs, because Foxp3(+) Tregs express VEGFR2 [
39,
40], which was compatible with the present results.
Although immunotherapy has become an increasingly available and vital cancer treatment option, it has some disadvantages. Immunotherapy’s potential side effects result from an overstimulated or misdirected immune response. However, fewer severe side effects were reported in the clinical setting. The clinical trials with peptide-based vaccine therapy using VEGFR-derived epitopes have been previously conducted for the patients with advanced gastrointestinal cancers and renal cell cancer, wherein the treatment exhibited the safety (Additional file
2: Table S1) [
20,
41‐
47]. Chemotherapy attacks all rapidly-dividing cells within the body, effectively targeting fast-growing tumors. In contrast, immunotherapy takes longer time to work compared with other treatments [
48].
The present study might demonstrate that the preliminary safety and immunogenicity of this approach. VEGFR1 and 2-specific CTLs inductions were detected under treatment with TMZ. In addition, paired pre- and post-vaccination specimens suggested that VEGFR1 and 2 peptide vaccination may possibly enhance the effects of TMZ. The limitation of the present study was the paucity of the number of enrolled patients. Further studies involving more patients are warranted to confirm the findings of this study.
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