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Cancer Therapy: Clinical
A Live-Attenuated Listeria Vaccine (ANZ-100) and
aLive-Attenuated Listeria Vaccine Expressing Mesothelin(CRS-207)
for Advanced Cancers: Phase I Studies of Safetyand Immune
Induction
Dung T. Le1, Dirk G. Brockstedt4, Ran Nir-Paz5, Johannes Hampl6,
Shruti Mathur6, John Nemunaitis7,Daniel H. Sterman8, Raffit
Hassan9, Eric Lutz1, Bentley Moyer6, Martin Giedlin6, Jana-Lynn
Louis1,Elizabeth A. Sugar1,2, Alice Pons1, Andrea L. Cox1,3,
Jordana Levine3, Aimee Luck Murphy4, Peter Illei1,Thomas W.
Dubensky Jr6, Joseph E. Eiden6, Elizabeth M. Jaffee1, and Daniel A.
Laheru1
AbstractPurpose: Listeriamonocytogenes (Lm)-based vaccines
stimulate both innate and adaptive immunity. ANZ-
100 is a live-attenuated Lm strain (Lm DactA/DinlB). Uptake by
phagocytes in the liver results in localinflammatory responses and
activation and recruitment of natural killer (NK) andT cells, in
associationwith
increased survival of mice bearing hepatic metastases. The Lm
DactA/DinlB strain, engineered to expresshuman mesothelin
(CRS-207), a tumor-associated antigen expressed by a variety of
tumors, induces
mesothelin-specific T-cell responses against
mesothelin-expressing murine tumors. These two phase I
studies test ANZ-100 and CRS-207 in subjects with liver
metastases and mesothelin-expressing cancers,
respectively.
Experimental Design: A single intravenous injection of ANZ-100
was evaluated in a dose escalation
study in subjects with liver metastases. Nine subjects received
1� 106, 3� 107, or 3 � 108 colony-formingunits (cfu). CRS-207 was
evaluated in a dose-escalation study in subjects with mesothelioma,
lung,
pancreatic, or ovarian cancers. Seventeen subjects received up
to 4 doses of 1 � 108, 3 � 108, 1 � 109,or 1 � 1010 cfu.Results: A
single infusion of ANZ-100 was well tolerated to the maximum
planned dose. Adverse events
included transient laboratory abnormalities and symptoms
associated with cytokine release. Multiple
infusions of CRS-207 were well tolerated up to 1 � 109 cfu, the
determined maximum tolerated dose.Immune activation was observed
for both ANZ-100 and CRS-207 as measured by serum cytokine/
chemokine levels and NK cell activation. In the CRS-207 study,
listeriolysin O and mesothelin-specific
T-cell responses were detected and 37% of subjects lived �15
months.Conclusions: ANZ-100 and CRS-207 administration was safe and
resulted in immune activation.
Clin Cancer Res; 18(3); 858–68. �2011 AACR.
Introduction
Cancer vaccines aim to induce immunity specific toprotein
antigens that are differentially expressed by cancercells relative
to thenormal cells fromwhich they are derived.Through its network
of specialized antigen-presenting andeffector cells, the immune
system has the ability to becomeactivated to recognize and lyse
cancer cells. Current vaccinestrategies aim to provide a series of
signals that activate andmature dendritic cells (DC) for efficient
antigen processingand presentation which in turn activate effector
cells of theadaptive immune response. Listeria monocytogenes
(Lm)-based vaccine vectors directly target and activate DCs invivo,
but in addition, take advantage of the capability ofimmunogenic
infectious vectors to stimulate both adaptive
Authors' Affiliations: 1The Sidney Kimmel Cancer Center, the
Skip ViraghClinical Pancreatic Cancer Center, and the
SolGoldmanPancreaticCancerCenter at Johns Hopkins; 2Bloomberg
School of Public Health at JohnsHopkins; 3Johns Hopkins Department
of Medicine, Baltimore, Maryland;4Aduro BioTech, Berkeley,
California; 5Hadassah Hebrew-University Med-ical Center, Jerusalem,
Israel; 6Cerus Corporation, Concord, California;7Mary Crowley
Cancer Center, Dallas, Texas; 8Abramson Cancer Center atthe
University of Pennsylvania, Philadelphia, Pennsylvania; and
9NationalCancer Institute, Bethesda, Maryland
Note: Supplementary data for this article are available at
Clinical CancerResearch Online
(http://clincancerres.aacrjournals.org/).
Corresponding Author: Dung T. Le, Sidney Kimmel Cancer Center
atJohns Hopkins University School of Medicine, 1650 Orleans Street,
Room407, Baltimore, MD 21231. Phone: 443-287-0002; Fax:
410-614-8216;E-mail: [email protected]
doi: 10.1158/1078-0432.CCR-11-2121
�2011 American Association for Cancer Research.
ClinicalCancer
Research
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and innate immune responses. Lm is an intracellular bac-terium
that has access to both class I and II antigen-proces-sing
pathways. Lm provides a potent stimulation of innateimmunity and
also stimulates an adaptive immuneresponse through recruitment and
activation of CD4þ andCD8þ T cells specific for encoded
heterologous antigens(1–4). The ability of Lm to stimulate adaptive
immunity ismainly based on its intracellular lifecycle and the
ability totarget DCs in vivo (4). ANZ-100 is a live-attenuated
double-deleted Lm strain (LADD; Lm DactA/DinlB). This strain
hasdeletions of 2 virulence genes, actA and internalin B
(InlB).These virulence determinants facilitate cell-to-cell
spreadand invasion of nonphagocytic cells, and their
combineddeletion results in 1,000-fold attenuation when
comparedwith wild-type Lm (5). However, uptake of ANZ-100
byphagocytic cells in the liver and spleen is retained and
resultsin a local proinflammatory cytokine response resulting
inactivation and recruitment of both innate and adaptiveeffector
cells. This immune response results in delay intumor growth and
increased survival ofmice bearing hepat-ic metastases (6, 7).
Importantly, multiple doses of Lmfurther extend survival.The LADD
strain has also been engineered to express
humanmesothelin and the resulting strain has been termedCRS-207
(Lm-mesothelin). CRS-207 has been shown toefficiently deliver
mesothelin antigen into both class I andII antigen-processing
pathways. Mesothelin is a tumor-associated antigen present on
normal mesothelial cells andhighly expressed by many human tumor
types, includingmesotheliomas, pancreatic adenocarcinomas (PDA),
non–small cell lung cancers (NSCLC), and ovarian cancers (8–16).
This expression profile, combined with limited expres-sion on the
surface of normal tissues, makes mesothelin anattractive target for
active tumor-specific immunotherapy.Support formesothelin as a
T-cell target comes from studies
showing a correlation between positive clinical outcomesand the
induction of mesothelin-specific cellular immunityin subjects with
PDA following vaccination with an irradi-ated allogeneic whole-cell
vaccine encoding granulocytemacrophage colony-stimulating factor
(GM-CSF). In aphase I study, a dose-dependent systemic
antitumorresponse was reported to be associated with
anti-mesothe-lin CD8þ T-cell responses (17, 18). In subsequent
studies,the induction of mesothelin-specific T cells as well as
theincreased post-vaccination diversity and avidity of the
T-cellrepertoire were shown to be associated with
improveddisease-free (DFS) and overall survival (OS; refs. 19,
20).Furthermore, CRS-207 mediates the induction of
mesothe-lin-specific T-cell responses that correlatewith tumor
regres-sions of mesothelin-expressing murine tumors (unpub-lished
data).
A single intravenous dose of ANZ-100 underwent eval-uation in a
phase I dose escalation study of safety andtolerability in adults
with carcinoma and liver metastases(NCT00327652). A total of 9
subjects received single-doseinfusions at 3 dose levels [1� 106, 3�
107, 3� 108 colony-forming units (cfu)]. Subsequently, CRS-207
underwentevaluation in a phase I, open-label, multiple dose,
dose-escalation study in subjects with mesothelioma, NSCLC,PDA, or
ovarian cancer (NCT00585845). Seventeen sub-jects were enrolled
into 4 cohorts (1� 108, 3� 108, 1� 109,and 1� 1010 cfu). Here, we
report the safety, shedding andclearance data, clinical activity,
and the induction of immu-nologic responses to both ANZ-100 and
CRS-207.
Subjects and Methods
Construction of ANZ-100 and CRS-207ANZ-100 (LADD; Lm
DactA/DinlB), Lm strain CERS
382.20, was constructed by deletion of the actA and inlBgenes
from the Streptomycin-resistant wild-type strain DP-L4056. Using
standard techniques, deletions of actA andinlB were made by
homologous recombination of themutant alleles into the wild-type
chromosome (21). Dele-tion mutations were confirmed by PCR.
CRS-207, Lm strain hMeso38, was constructed by theaddition of a
mesothelin expression cassette into the CERS382.20 strain. The same
homologous recombinationapproach used to delete inlBwas used to
insert themesothe-lin antigen. Mesothelin is expressed as an ActA
fusionprotein under the transcriptional control of the actA
pro-moter. The actA promoter is strongly induced in host
cells,resulting in efficient production of the heterologous
anti-gen. All genomicmodifications were confirmed by PCR andDNA
sequencing, and the attenuated phenotype of bothstrains were showed
in vivo by LD50 (tested inCD-1, C57BL/6, and BALB/cmice: LD50 of
8.0� 107, 1.2� 108, and 8.4�107 cfu, respectively, compared with
3.0 � 104 cfu of thewild-type Lm strain) and clearance in liver and
spleen ofmice and in vitro by infectivity and intracellular
growthkinetics. Clinical grade material of ANZ-100 and CRS-207 was
manufactured at the Waisman Clinical BioManu-facturing
Facility.
Translational Relevance
Listeria monocytogenes (Lm)-based vaccine vectors canstimulate
both innate and adaptive immune responses.In preclinical studies,
administration of Lm vaccinesresults in enhanced tumor-specific
immune responses,delayed tumor growth, and improved survival.
Further-more,Lm canbemodified to encodeheterologous tumorantigens
resulting in recruitment and activationof tumorantigen–specific T
cells. In these two first-in-humanphase I clinical studies in
patients with advanced cancer,ANZ-100 [a live-attenuated Lm strain
(Lm DactA/DinlB)]and CRS-207 (the Lm DactA/DinlB strain engineered
toexpress human mesothelin), were well tolerated withencouraging
dose-dependent evidence of immune acti-vation. These results
provide valuable insight into thesafety and dosing of this new
vaccine approach that willadvance the further development of Lm
vaccines asanticancer agents for multiple tumor types.
Live-Attenuated Listeria Vaccines for Advanced Cancer
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Study designNine subjects were enrolled into the ANZ-100 study
at
Johns Hopkins University (JHU), Baltimore, MD, andMaryCrowley
Cancer Center, Dallas, TX, between October 9,2006, and January 7,
2008. The primary objective of theANZ-100 study was to determine
the maximum tolerateddose (MTD) of a single dose of ANZ-100 in
subjects withcarcinoma and liver metastases. Using a standard 3 þ
3design, eligible subjects received a single 2-hour intrave-nous
infusion of ANZ-100 (22).
Seventeen subjects were enrolled into the CRS-207 studyat JHU;
the National Cancer Institute (NCI), Bethesda, MD;the University of
Pennsylvania, Philadelphia, PA; Hadas-sah-Hebrew University Medical
Center, Jerusalem, Israel;and at Mary Crowley Cancer Center between
December 13,2007, and January 5, 2009. The primary objective of
theCRS-207 studywas to determine theMTDofmultiple dosesof CRS-207
in subjects with malignancies known to expressmesothelin. Secondary
objectives included assessing safety,biodistribution and clearance
of Lm, immunologic end-points, and antitumor activity. Using a 3 þ
3 design,sequential cohorts of 3 to 6 subjects received up to 4
dosesof CRS-207 administered 3 weeks apart.
These multi-institutional, first-in-human, phase I,
dose-escalation studies were reviewed and approved by
localInstitutional Review Boards, Institutional Biosafety
Com-mittees, the U.S. Food and Drug Administration, and theNIH
Recombinant DNA Advisory Committee. All partici-pating subjects
signed informed consent.
Subject selectionIn the ANZ-100 study, eligible subjects had
treatment-
refractory carcinoma and hepatic metastases. In the CRS-207
study, eligible subjects had treatment-refractory meso-thelioma,
PDA, NSCLC or ovarian cancer. For both studies,main eligibility
criteria included: no cancer therapy for 4weeks, age�18 years old,
a life expectancy of�12weeks,
anEasternCooperativeOncologyGroupperformance status of0 to 1 or
Karnofsky performance status of 80% to 100%,adequate organ
function, no ongoing infections, history ofbrain metastases, or
history of autoimmunity. Concurrentantineoplastic therapies,
history of listeriosis or vaccinationwith a Lm-based vaccine, known
allergy to both penicillinand sulfa, and artificial implants
(except biliary stents) werenot permitted. Subjects who were HIV,
HTLV-1, HCV, orHBV positive were excluded.
Procedures and treatmentTests were conducted for baseline
toxicity (complete
blood counts and chemistry profile) and tumor
assessment(computerized tomography scan). The intervention anddata
collection schedules are shown in Supplementary Figs.S1 (ANZ-100)
and S2 (CRS-207).
Nine subjects [6 with colorectal cancer (CRC), 2 withPDA, 1 with
melanoma] with treatment-refractory carci-noma and liver metastases
received a single-dose 2-hourinfusion at 1 of 3 dose levels (1�
106, 3� 107, 3� 108 cfu)of ANZ-100 (Table 1). Subjects were
observed in an
in-patient facility for 5 days and evaluated for toxicity ondays
6, 9, 16, and 28.
Seven subjects with PDA, 5 with mesothelioma, 3 withNSCLC, and 2
with ovarian cancer received up to 4 intra-venous infusions of
CRS-207 in 21-day intervals and wereobserved for toxicities in an
in-patient facility for 24 to 48hours (Table 1). Subjects were
evaluated for toxicity on days4 and 7 in the clinic and by phone on
day 14. Following thefinal administration, subjects were evaluated
by phone 21days after dosing and returned for a final clinic visit
on the28th day after the final dose (day 91).
A 10-day course of oral amoxicillin or
trimethoprim/sulfamethoxazole in penicillin-allergic subjects was
initiat-ed 6 to 7days following the subject’s last dose.
Subjectswererestaged radiographically [Response Evaluation Criteria
inSolid Tumors (RECIST) 1.0] at days 28 and 91 (CRS-207study only).
Subjects with progressive disease at day 28 onthe CRS-207 study
were allowed to continue on study ifclinically stable.
AssessmentsToxicities. Adverse events were graded using the
NCI
Common Terminology Criteria for Adverse Events(CTCAE) v3.0.
Initially, a dose-limiting toxicity (DLT)was defined as the
occurrence of any NCI CTCAE (Version3.0) �grade III that were
determined to be possibly orprobably related to the agent, during
the 28 days after thefirst dose. For individuals who had alanine
aminotrans-ferase (ALT), aspartate aminotransferase (AST), or
alka-line phosphatase elevations � grade I severity at studyentry,
a DLT was defined as enzyme elevations >5� upperlimit of normal
(ULN) that were determined to be relatedand persisted for more than
7 days. For individuals whohad ALT, AST, or alkaline phosphatase
levels that wereabove 2.5 � ULN to 3.5 � ULN at study entry, a DLT
wasdefined as enzyme elevations above 10 � ULN that weredetermined
to be related and persisted for more than 7days. Early initiation
of antibiotics coincident with iso-lation of Lm from a sterile body
site, other than blood(e.g., CSF, joint fluid) was considered a
DLT. DLT criteriawere modified several times during the CRS-207
study. Inaddition to the liver enzyme criteria mentioned, a DLTwas
defined as a treatment-related � grade III laboratoryabnormality
lasting for more than 48 hours, fever above40�C lasting greater
than 24 hours, hypotension unre-sponsive to intravenous fluids, and
grade IV lymphocytedecreases that persisted for more than 4 days.
The MTDwas the highest dose at which no more than 1 of 6subjects
experienced a DLT.
Shedding and clearance. Specimens were obtained forculture to
assess the Lm distribution and clearance. Witheach administration
of ANZ-100, blood, urine, stool, andsputum specimens were cultured
at baseline, 6 hours, days1–5, days 8, 16, and 28. An additional
blood culture wastaken at 2 hours. With each administration of
CRS-207,urine and stool cultures were obtained at baseline, 4
hours,days 1, 4, and 7. Blood cultures were obtained at baseline,
4hours, days 1 and 4.
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Immunohistochemistry. Mesothelin expression on thetumor was not
required for CRS-207 study entry, butimmunohistochemistry (IHC) was
conducted on availablearchived tissue. IHC was conducted using a
monoclonalantibody (2C6) on a Leica BondMax autostainer. The
stain-ing intensity and extent were scored. The percentage oftumor
cells showingmembranous staining (predominantlyluminal) were
evaluated for intensity (0, none; 1þ, weakthin; 2þ, moderate; and
3þ, strong and thick membranousstaining).
Immunologic assessmentsMultiplexed serum chemokine assay.
Chemokines were
detected using a custom Cytokine Bead Array (BD) usingfrozen
serum samples collected before, 4 hours, and 24hours postinfusion
with ANZ-100 and at baseline and at 24hours after CRS-207. The
array was specific for interleukin(IL)-6, IL-8, IL-9, IL-10,
IFN-g–induced protein 10 (IP-10),lymphotoxin-a (LT-a), monocyte
chemotactic protein-1(MCP-1), macrophage inflammatory protein-1a
(MIP-1a),
andMIP-1b. Upon collection of all samples within a
patientcohort, samples were tested by a blinded operator. Dataare
presented as change in fold concentration becausepredose chemokine
concentration in sera varied consider-ably between subjects.
Multiplexed serum cytokine assay. Cytokines weredetected using
the Meso Scale Discovery (MSD) platformusing frozen serum samples
collected before, 4 hours, and24 hours postinfusionwith ANZ-100 or
CRS-207. ANZ-100samples were tested using a 9-plex proinflammatory
kit(GM-CSF, IFN-g , IL-1b, IL-2, IL-6, IL-8, IL-10, IL-12p70,TNF-a)
and CRS-207 samples were tested using a 7-plex kit(IFN-g , IL-1b,
IL-6, IL-8, IL-10, IL-12p70, TNF-a). Uponcollection of all samples
within a patient cohort, sampleswere tested by a blinded operator.
Results are expressed asmean � SD.
Lymphocyte counts. For the ANZ-100 study, a BDFACSCalibur was
used to determine absolute numbersof lymphocyte subpopulations
after applying BD Mul-titest CD3/CD16, CD56/CD45/CD19 with
Trucount,
Table 1. Patient characteristics
ID Age (sex) Cancer type Dose level, cfu ECOG PS Prior therapies
Mesothelin IHCa No. of doses
ANZ-10001-002 57 (F) Pancreatic 106 0 2 NA 102-003 53 (M)
Colorectal 106 0 2 NA 102-006 69 (M) Colorectal 106 1 5 NA 101-005
62 (M) Pancreatic 3 � 107 0 2 NA 102-054 66 (M) Melanoma 3 � 107 0
4 NA 102-058 71 (M) Colorectal 3 � 107 0 4 NA 101-008 49 (F)
Colorectal 3 � 108 0 4 NA 102-062 57 (M) Colorectal 3 � 108 0 5 NA
102-064 60 (M) Colorectal 3 � 108 0 5 NA 1
CRS-207001-001 65 (M) Pancreatic 108 0 5 50%, 2–3þ 4001-002 61
(F) Pancreatic 108 0 4 NE 4003-001 65 (F) Mesothelioma 108 0 2 25%,
1–2þ 4002-001 64 (F) Ovarian 108 1 8 NE 2002-002 60 (M)
Mesothelioma 108 1 1 NE 2004-001 55 (M) Mesothelioma 108 0 4 NE
3005-002 56 (F) NSCLC 3 � 108 0 4 70%, 2–3þ 1001-004 68 (F)
Pancreatic 3 � 108 0 1 NE 3001-005 60 (M) Pancreatic 3 � 108 1 1
75%, 2–3þ 2005-003 79 (F) Pancreatic 3 � 108 0 0 80%, 2–3þ 2004-002
59 (M) Pancreatic 109 1 4 NE 4005-001 56 (F) NSCLC 109 0 5 50%, 2þ
4001-003 61 (M) Pancreatic 109 0 2 NE 4002-003 72 (F) NSCLC 109 1 5
100%, 3þ 4002-004 75 (M) Mesothelioma 109 1 4 NE 2003-002 52 (F)
Ovarian 109 1 10 NE 4003-003 40 (M) Mesothelioma 1010 1 2 NE 1
Abbreviations: ECOG, Eastern Cooperative Oncology Group; NA, not
applicable; NE, not evaluable; PS, performance status.aMesothelin
IHC: the percentage of tumor cells showing membranous staining were
evaluated for intensity (0, no staining; 1þ, weakstaining; 2þ,
moderate staining; 3þ, strong staining).
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and BD Multitest CD3/CD8/CD45/CD4 with Trucountreagent
cocktails.
Determination of cellular activation. For the ANZ-100study, a BD
FACSCalibur was used to determine the expres-sion level of CD38 on
natural killer (NK) cells in bloodusing CD3-FITC, CD38-PE,
CD4-PerCp, CD16-APC, CD56APC, and IgG Isotype-PE. CD38 expression
levels wereanalyzed by a blinded operator and reported as a ratio
ofpeak CD38 MESF value between 48 and 96 hours postdos-ing and
predose value. A histogram is also presented forsubjects
001–005.
Detection of antigen-specific T cells. Peripheral
bloodmononuclear cells (PBMC) were prepared within 4 to 6hours
after collection and cryopreserved at each clinical site.
Detection of listeriolysin O–specific T cells by IFN-gELISPOT.
PBMCs were analyzed using a 2-step IFN-gELISPOT assay inwhich first
autologousDCswere obtainedthrough in vitro culture (23). Monocytes
were isolated fromPBMCs using a 1-hour adherence step. Nonadherent
cellswere collected and cryopreserved. Adherent cells were
cul-tured for 2 days in DC induction medium (RPMI with 1%autologous
plasma and GM-CSF and IL-4) and then acocktail containing IL-1b,
IL-6, and prostaglandin E2-a(24). After 2 days of culture, mature
DCs were harvested,counted, and added at a 1:10 ratio to 2 � 105
nonadherentthawed PBMCs. Antigen was added as pools of
15-merpeptides whose sequences overlap by 11 amino acids andcover
the entire sequence of the listeriolysin O (LLO), a 130amino acid
protein (25, 26). The CEF pool was used as apositive control. The
CEF is a pool of 32 peptides of definedCD8þ epitopes against
cytomegalovirus (CMV), Epstein-Barr virus (EBV), and influenza
(27). Cells were cultured for24 hours in RPMI containing 10% human
AB serum beforethey were washed and spots visualized using BD
Bios-ciences’ Human IFN-g ELISPOT and AEC substrate kits.Spots were
enumerated in an ELISPOT reader (CellularTechnology, Ltd.) and
analyzed using a software package(Immunospot software v. 3.6).
T-cell responses to LLOwereconsidered positive when specific T-cell
frequencies were�1 in 105 PBMCs and increased by at least 2-fold
comparedwith baseline.
Detection of mesothelin-specific T cells by IFN-gELISPOT. The
methodology for the synthesis of peptides,ELISA assay for
identifying reactive mesothelin peptides,and ELISPOT assays have
previously been described (18–20). Samples were tested from
subjects with HLA-A1, A2,A3, and A24 alleles if pre- and
posttreatment samples wereavailable. T-cell responses to mesothelin
were consideredpositivewhen the frequencyof specific
responseswere�1 in105 CD8þ peripheral blood lymphocytes (PBL) above
thecontrol sample and increased by at least 2-fold comparedwith
baseline. Themaximal response to a single best peptideis
reported.
Statistical considerationsThe main objectives of these studies
were to determine
the MTD of ANZ-100 or CRS-207 in subjects with cancer. Astandard
3þ3designwasused for dose-escalation (22). The
incidence of toxicities is summarized by cohort.
Exploratoryanalyses included evaluation of RECIST response, OS,
cyto-kine/chemokine responses, immune cell phenotyping, andT-cell
responses. The NK cell and lymphocyte values beforeand after
treatment are plotted for each individual. Log-linear models are
used to compare fold-upregulation andinduction between dose levels.
For analysis incorporatingmultiple time points, linear
mixed-effects models are usedto account for the within-individual
repeated measure-ments. The numbers of individuals with
LLO-specific andmesothelin-specific T-cell responses were
tabulated. Thesurvival is documented for each individual and
individualswith survival �15 months are considered "long-term"
sur-vivors. The relationship between disease and
immunologiccharacteristics are explored by tabulating the number
oflong-term survivors in different subcategories.
Results
Subject characteristicsSubject characteristics for both studies
are shown in Table
1. For ANZ-100, 6 subjects with CRC, 2 with PDA, and
1withmelanoma received a single dose of either 106, 3� 107,or 3 �
108 cfu of Lm. Their median age was 60 (range, 49–71). The median
number of prior therapies was 4. For CRS-207, 5 subjects with
mesothelioma, 7 with PDA, 3 withNSCLC, and 2 with ovarian cancer
received at least oneinfusion of CRS-207 (6 subjects at 1� 108, 4
subjects at 3�108, 6 subjects at 1 � 109, and 1 subject at 1 � 1010
cfu).Their median age was 61 (range, 40–79). The mediannumber of
prior therapies was 4.
Treatment-related toxicities and DLT eventsA detailed
description of treatment related grade �II
toxicities for both studies is provided in SupplementaryTable
S1. ANZ-100 was well tolerated at all dose levels. Themost frequent
adverse events of any grade were transientgrade �III lymphopenia (9
patients, 100%), grade �IIIhyperglycemia (8 patients, 89%),
hypophosphatemia (5patients, 56%), and fever (7 patients, 78%). No
DLTs wereobserved and ANZ-100 was well tolerated up to the max-imum
planned dose.
CRS-207 was also well tolerated. The most frequentadverse events
of any grade were transient lymphopenia(17 patients, 100%),
hypophosphatemia (6 patients, 35%),transaminitis (7 patients, 41%),
fever (9 patients, 53%),chills/rigors (9 patients, 53%), nausea (9
patients, 53%),fatigue (6 patients, 35%), and hypotension (6
patients,35%). All of these adverse events were grade �II except
fortransient �grade III lymphopenia and hypophosphatemia,one grade
III transaminitis, and one grade III fever. The firstdose cohort
received 1 � 108 cfu of CRS-207 at 3-weekintervals for 4 doses. Two
adverse events occurred in sub-jects dosed in cohort 1 (1 � 108
cfu) which met the initialprotocol-defined criteria of DLTs. One
subject experiencedtransient grade III hypophosphatemia 4 hours
followingthe second infusion of CRS-207. A second subject
experi-enced a grade III temperature approximately 22 hours
after
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receiving the first infusion. The subject was treated
withacetaminophen and temperature returned to baseline with-in 24
hours. DLT criteria were amended to allow for tran-sient grade III
hypophosphatemia and fever. After transientgrade IV lymphopenia was
identified in the 1� 109 cohort,grade IV lymphopenia was considered
as a DLT only if itpersisted for more than 4 days. Following dosing
of 3subjects in cohort 2 (1 � 109 cfu) without reaching a DLT,one
subject was dosed in cohort 3 at 1� 1010 cfu dose. Thissubject
experienced a grade II cytokine release syndromerequiring
aggressive fluid resuscitation. Because of thenature of the event,
this was considered a DLT and thedose level was considered too
toxic for further recruitment.The MTD was determined to be 1 � 109
cfu. To bettercharacterize toxicities, additional subjects were
enrolledinto cohort 2 (1 � 109 cfu, n ¼ 3 þ 3 ¼ 6).
Manageablehypotension and modest elevations in liver function
tests(LFT) were observed. An intermediate dose of 3 � 108 cfuwas
also added. Four subjects were enrolled into this cohortbefore the
study was terminated. Manageable hypotensionand transient LFT
elevations (3 of 4 subjects) was alsoobserved at the new dose
level. One subject had elevationsup to 11 � ULN after a second dose
in the absence of anychanges in bilirubin. The LFTs improved
without interven-tion. The subject was not redosed.In general,
subjects treated at all dose levels experienced
symptoms that might be expected from a cytokine release–like
syndrome from a bacteremia. While not all subjectsexperienced the
same events, a constellation of symptomswas common. Lmwas
administered intravenously over a 2-hour period. Subjects typically
had a temperature peak at 2to 4 hours, sometimes associated with
rigors, nausea, head-aches, dehydration, and dry mouth. Mild
hypotension wasself-correcting or corrected with intravenous
fluids. Themost consistent laboratory abnormalities were
transient,self-correcting electrolyte abnormalities, and
lymphopeniaswith nadirs at 4 hours postinfusion. The degree of
lympho-penia was dose-dependent and the most significant
hypo-tension occurred at the highest dose level. The
transient,self-correcting nature suggests that these abnormalities
arethe result of electrolytes and lymphocytes transiently shift-ing
out of the blood compartment. Overall review of thesafety data from
the trial did not identify any significanttoxicity with Lm or
Lm-mesothelin that was not reversible orunexpected from either
previous studies in cynomologusmonkeys or based on mechanism of
action.
Shedding and clearanceANZ-100 was not detected in the blood,
stool, urine, or
sputumspecimens collected at any timepoint. Lm suspectedto be
CRS-207 was detected in blood cultures of 4 subjects.In 2 of the
subjects, the cultures were negative by 24 hours.An ovarian cancer
subject who received a dose of 1� 108 cfuhad positive cultures at 4
and 24 hours after the firstintravenous infusion. Subsequent blood
cultures 4 daysafter dosing were negative. Blood cultures taken
after hersecond infusion were negative. Lm suspected to be
CRS-207was detected in blood cultures of a mesothelioma subject
receiving 1 � 109 cfu at day 4 after the second
intravenousinfusion. Subsequent cultures were negative. All
remainingblood, stool, or urine specimens collected throughout
thestudy for all subjects were negative.
ImmunohistochemistryMesothelin membranous staining was detected
in all 7
available archived samples for subjects enrolled into theCRS-207
study. The extent of staining is listed in Table 1.
PBMC phenotype analysis after ANZ-100administration
Peripheral blood was analyzed prior to treatment withANZ-100,
daily for 5 days following treatment, and thenweekly for 1month.
Immune activation was determined byphenotypic analysis of NK cells
(CD3�CD16/56þ). Inter-estingly, there was a transient reduction in
peripheral lym-phocyte andNK cell numbers (Fig. 1A and B) that
reached anadir at day 2 following treatment, suggesting the
possibil-ity that ANZ-100–induced activation results in
lymphocyteandNK cellmargination from the peripheral blood to
othercompartments. A significant upregulation of the
activationmarker CD38 was noted on NK cells for all dose levels(P¼
0.0008; Fig. 1C). There appears to be a dose-dependenttrend but it
was not statistically significant (P ¼ 0.1238).This level increased
at the 96-hour time point as shown forone patient (Fig. 1D).
Cytokine/chemokine induction after ANZ-100 andCRS-207
administration
Serum samples were collected prior to and at 2 hours, 6hours,
and daily for 5 days following ANZ-100 adminis-tration and analyzed
for the presence of MCP-1, MIP-1a,MIP-1b, LT-a, IP-10, IL-1b, IL-2,
IL-3, IL-4, IL-5, IL-6, IL-7,IL-8, IL-10, IL-12p70, IFN-g , and
TNF-a. At the highest doselevel of 3� 108 cfu, a significant
induction of cytokines andchemokines such as MCP-1 and MIP-1b was
observed(P ¼ 0.0006 and 0.0002, respectively; Fig. 2A and B).
Theresponse peaked at 2 hours after the completion of the2-hour
intravenous ANZ-100 infusion and returned tobaseline within 48 to
72 hours. Subjects at the highest doselevel also had a consistent
induction of the TH1 cytokinesIFN-g and IL-12p70 (Fig. 2C and D).
The upregulation ofthe CD38 activation marker suggests biologic
activity ofANZ-100 at doses as low as 1 � 106 cfu. However, a
moreconsistent induction of proinflammatory cytokines andchemokines
was observed in subjects receiving the higherdose level of 3 � 108
cfu.
In the CRS-207 study, chemokine induction was notedfor all dose
levels including the starting dose level of 1� 108cfu. For MCP-1,
MIP-1b, and IP-10, the pattern was con-sistently elevated for all
dose levels (P¼ 0.0050, P < 0.0001,and P < 0.0001,
respectively) and did not vary significantlyacross time points
(Fig. 3A–C). The degree of upregulationis less than that observed
in the ANZ-100 study, whichmaybedue to the fact that the levelswere
taken at 24hours ratherthan at the expected 2-hour postinfusion
peak (Fig. 3A–C).The induction of IL-10 (P ¼ 0.049), IL-12p70 (P ¼
0.100),
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IL-6 (P ¼ 0.059), and TNF-a (P ¼ 0.092) are higher in the1 � 109
cfu dose level than in the 3 � 108 dose level (Fig.3D). There was
no significant difference in the inductionlevels for IFN-g (P¼
0.375) or IL-8 (P¼ 0.171). The data forthe single subject with a
dose of 1� 1010 cfu are included inthe plot for reference.
Detection of LLO-specific and mesothelin-specificT-cell
responses after CRS-207 administration
LLO-specific T-cell responses were analyzed in 8 subjectswith
viable samples pretreatment and after the second andfourth infusion
of CRS-207 (Fig. 4A). Final T-cell responsesare reported. Six of
the subjects were positive for vaccine-induced Lm-specific
responses. The CEF-specific responsesare provided in Supplementary
Fig. S3. In the CRS-207study, mesothelin-specific CD8þ T-cell
responses wereinduced in 6 of the 10 evaluable subjects (Fig.
4B).
Efficacy and survivalWhile the CRS-207 study enrolled subjects
with multiple
disease types andwas not powered to assess survival, 37%ofthis
phase I patient population survived for �15 months,with 3 subjects
alive as ofOctober 14, 2010 (Table 2).Of the6 long-term survivors,
3 had PDA, 2 had NSCLC, and 1 hadmesothelioma. These 6 subjects had
prior immunotherapyor subsequent local radiation. Five of 6
subjects received all4 doses of CRS-207 and all 5 evaluable
subjects showedvaccine-induced Lm-specific responses. One subject
hadbeen discontinued from study after 1 dose because of aprotocol
violation and samples were not collected forimmunologic evaluation.
In addition, 4 of the 5 evaluablesubjects among the long-term
survivors had stable diseaseby RECIST at day 91 (end of study).
Eight of 8 evaluablesubjects in the group that survived
-
�15 months developed LLO responses. One additionalsubject lived
�15 months but was not tested because aposttreatment sample was not
collected. Thus, the induc-tion of LLO-specific T-cell responses
may serve as a bio-marker of immunocompetency in future studies. In
thissmall subset of 10 subjects withmultiple histologic types
ofcancer, the induction of mesothelin-specific responses didnot
correlate with survival. The induction of mesothelin-specific
T-cell responses as amarker of response to CRS-207requires further
investigation in a larger study of morehomogenous subjects. These
data provide the rationale forfurther evaluation of this
Lm-mesothelin vaccine in a phaseII study.
Discussion
These data from the phase I studies of ANZ-100 and CRS-207 Lm
vaccines support the following conclusions. First,both vaccines are
safe and tolerable in subjects withadvanced, treatment-refractory
cancers at immune activat-ing doses. Second, there is a
dose-dependent augmentationof systemic cytokine and chemokine
responses that mayserve as biomarkers of Lm vaccine bioactivity.
Finally, a
tumor antigen–modified Lm can induce tumor antigen–specific
T-cell responses in subjectswith advanced cancer. Assuch, Lm
vaccine responses require further evaluation as acandidate
biomarker of improved clinical outcomes.
These studies support that an attenuated bacteria can begiven
safely to subjects with advanced cancer with transientside effects.
This is inmarked contrast tomany conventionaloptions in which the
toxicities can be cumulative andimpairment in quality of life have
to be weighed againstpotential benefit. Defining the tolerability
of these con-structs as single agents lays important groundwork
forfuture studies in which these vaccines will be used
incombinations. There are a number of unpublished preclin-ical
studies testing Lm vaccines in combination with eitherother vaccine
constructs or immune-modifying agentswhich show enhanced efficacy
of the combination. A clin-ical trial has recently opened to
enrollment testing CRS-207in combination with an allogeneic
GM-CSF–secreting PDAvaccine in subjects with advanced PDA. The
study concept isbased on mouse models which show that the
combinationof the GM-CSF and Lm-based vaccines in a
heterologousprime/boost regimen results in the induction of
antigen-specific T-cell responses of greater magnitude than
either
MCP-1
1 × 106 3 × 107 3 × 1080
50
100
150 60
40
20
0
Cohort1 × 106 3 × 107 3 × 108
Cohort
Fo
ld-u
pre
gu
lati
on
IL-12p70
–8 –41
10
100
1,000
–2 –1 0 1 2 3 4 5 6 7 8 101520
01-00802-06202-064
Days post ANZ-100 infusion
IFN
-γ (
pg
/mL
)
–8 –41
10
100
–2 –1 0 1 2 3 4 5 6 7 8 101520
01-00802-06202-064
Days post ANZ-100 infusion
IL-1
2p70
(p
g/m
L)
IFN-γ
A
DC
BMIP-1β
Fo
ld-u
pre
gu
lati
on
Figure 2. ANZ-100 induction of chemokines/cytokines is dose
dependent and favors the induction of Th1 cytokines. A, MCP-1
chemokine expressionpresented by cohort dose level. Ratio
calculated from peak chemokine value 2 hours postdose compared with
mean chemokine value of 2 predosemeasurements. At the highest dose
level of 3 � 108 cfu, a significant induction of MCP-1 was observed
(P ¼ 0.0006). B, MIP-1b chemokine expressionpresented by cohort
dose level. Ratio calculated from peak chemokine value 2 hours
postdose compared with mean chemokine value of 2
predosemeasurements. At the highest dose level of 3� 108 cfu, a
significant induction of MIP-1bwas observed (P¼ 0.0002). C, IFN-g
cytokine expression after ANZ-100 administration in subjects at the
3� 108 dose level. D, IL-12p70 cytokine expression after ANZ-100
administration in subjects at the 3� 108 dose level.
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agent alone and correlates with superior antitumorresponses.
Interestingly, all 3 PDA subjects on the CRS-207 study who lived
�15 months had received prior GM-CSF vaccine therapy.
With both biologic and targeted agents, dose selectioncan be
complex as the usual drug development philosophyof using the MTDmay
not be relevant. The maximum dosemay not be the most biologically
effective dose. There does
MIP-1β
0
2
4
6
8
Cohort
Fo
ld-u
pre
gu
lati
on
MCP-1
0
2
4
6
8
10
Cohort
Fo
ld-u
pre
gu
lati
on
IP-10
1 ×
108
1 ×
109
1 ×
1010
1 ×
108
1 ×
109
1 ×
1010
1 ×
108
1 ×
109
1 ×
1010
1 ×
108
1 ×
109
1 ×
1010
1 ×
108
1 ×
109
1 ×
1010
1 ×
108
1 ×
109
1 ×
1010
0
5
10
15
20
Cohort
Fo
ld-u
pre
gu
lati
on
Dose 1 Dose 2 Dose 2Dose 1
Dose 1 Dose 2
A B
DC
IFN
IL-1
0
IL-1
2p70 IL
-6IL
-8TN
F
1
10
100
1,000
10,000 3 × 108
1 × 109
1 × 1010
Cytokine
pg
/mL
Figure 3. CRS-207 induction ofchemokines/cytokines is presentat
all dose levels tested. A, MCP-1chemokine expression presentedby
cohort dose level after dose 1and 2. B, MIP-1>b
chemokineexpression presented by cohortdose level after dose 1 and
2. C,IPhemokine expression presentedby cohort dose level after dose
1and 2. D, cytokine expression 24hours after first dose of
CRS-resented by cohort dose level. Thedata for the single subject
with adose of 1� 1010 cfu are included inthe plot for
reference.<
005-004-003-002-001-003-004-001-001 001 001 002 003 002 002
001
1 × 108 cfu 1 × 108 cfu 3 × 108 cfu 1 × 109 cfu1 × 109 cfu
*
**
*
* *
3/4 3/4
Patient #
Dose
001-003-005-004-005-001-001-003-004-001-001 001 001 004 005 003
002 001 002 003
1/3 2/3 3/4
*
*
*
**
Patient #
Dose
Mesothelin-specific T-cell responsesLLO-specific T-cell
responsesA B
Pre
Po
stP
reP
ost
Pre
Po
stP
reP
ost
Pre
Po
stP
reP
ost
Pre
Po
stP
reP
ost
Pre
Po
stP
reP
ost
0
50
100
150
200
250300600900
IFN
-γ s
po
ts/1
× 1
06 C
D8+
T c
ells
IFN
-γ s
po
ts/1
× 1
06 T
cel
ls
Pre
Po
st
Pre
Po
st
Pre
Po
st
Pre
Po
st
Pre
Po
st
Pre
Po
st
Pre
Po
st
Pre
Po
st
0
50
100
150
200400600800
*
Figure 4. CRS-207 induces both LLO-specific and
mesothelin-specific T-cell responses. A, LLO-specific T-cell
responses were analyzed using IFN-gELISPOT. B, mesothelin-specific
T-cell responses were analyzed using IFN-g ELISPOT. �, T-cell
responses were considered positive when the frequency ofspecific
responses were �1 in 105 PBMCs (LLO ELISPOT) or CD8þ PBL
(mesothelin ELISPOT) and increased by at least 2-fold compared with
baseline.Final T-cell responses are reported. The maximal response
to a single best peptide is reported. The boxed patient
identification numbers representsubjects who survived �15
months.
Le et al.
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appear to be a dose-dependent augmentation of cytokineand
chemokine responses. However, it remains unknownwhether there is a
dose-dependent induction of T-cellresponses. Importantly, these
studies show not only safetybut also immune activity in the range
of doses selected fortesting. Of note, a phase I study of a
different Lm-basedvaccine has been reported (28). This study
evaluatedLm-LLO-E7, a live-attenuated Lm that secretes the HPV-E16
E7 antigen fused to LLO, in subjects with previouslytreated
cervical carcinoma and reported a similar adverseevent profile and
similar dose range for the MTD.The transient transaminitis cases
were expected on the
basis of mechanism of action and preclinical studies.Another
example of transaminitis in the context of immu-notherapy is the
flares in chronic hepatitis B patientsinduced by Peg-IFN-a-2b (29).
Interestingly, host-induced flares which were followed by HBV
DNAdecreases were highly associated with response. Theseflares are
thought to be due to the stimulatory effect ofIFN, which is capable
of increasing T-cell cytolytic activityand NK cell function.
Likewise, with Lm-based therapies,the transaminitis is likely to be
inflammatory in natureand not necessarily a negative finding. This
will be mon-itored in future studies.With the recent approval of
Provenge for the treatment of
metastatic castrate-resistant prostate cancer, there is
mixedenthusiasm and continued skepticism about vaccination asa
treatment for cancer. Provenge has been shown to prolong
survival without evidence of appreciable RECIST responseor
prolongation of time to progression (30). In addition,another
recently approved immunotherapy, ipilimumab,an antagonist antibody
to cytotoxic T-lymphocyte–associ-ated-4 (CTLA-4), has also shown a
survival benefit inmelanoma despite 5.7% to 10.9% response rates
(31). Inthese studies, some subjects show increases in tumor
vol-ume before a delayed response and therefore response rateis
likely to underestimate the activity of these agents. There-fore,
OS is currently the best endpoint to evaluate immu-notherapeutic
agents in advanced cancer.While the survivaldata presented here are
only hypothesis generating, it isprovocative.
Conclusions
In summary, Lm-based vaccines, ANZ-100 and CRS-207,arewell
tolerated in subjects with advanced cancers. There isencouraging
evidence of immune activation and potentialclinical benefit, thus
warranting further clinical studies.
Disclosure of Potential Conflicts of Interest
Under licensing agreements betweenAduroBioTech, Inc. (Aduro) and
theJHU, E.M. Jaffee and JHU have the potential to receive royalties
received onsales of products/technology described in this article.
The terms of thisarrangement are being managed by JHU in accordance
with its conflict ofinterest policies. D.G. Brockstedt, A.L.
Murphy, and T.W. Dubensky haveownership interests in Aduro. T.W.
Dubensky is a member of the scientificadvisory board of Aduro. J.E.
Eiden has ownership interests in Cerus
Table 2. CRS-207 clinical and immune response summary
ID Cancer Dose level LLO response Mesothelin response RECIST
Survival, mo Prior immunotherapy
�15 mo OS001-001 PDA 108 Yes No PD 15 GVAX001-002 PDA 108 Yes NE
SD 30þ GVAX003-001 Mesothelioma 108 Yes Yes SD 29þ IFN-b gene
transfera005-002 NSCLC 3 � 108 NE NE NE 23 No004-002 PDA 109 Yes No
SD 17 GVAX005-001 NSCLC 109 Yes Yes SD 26þ No
-
Corporation. P. Illei is a consultant for Leica Microsytem. No
potentialconflicts of interests were disclosed by other
authors.
Grant Support
D.T. Le has received American Society of Clinical Oncology
CareerDevelopment Award and NIH/GI SPORE (2P50 CA062924). E. Lutz
hasreceived AACR-FNAB Fellows Grant for Translational Pancreatic
CancerResearch and Anti-Cancer Drug Development Fellowship (NIH/NCI
T32CA009243). E.M. Jaffee has obtained grant from NIH/GI SPORE
(2P50
CA062924). D.A. Laheru has obtained support from NIH/GI SPORE
(2P50CA062924), NCI K23 CA093566-01A1, and The Viragh Family
Foundation.
The costs of publication of this article were defrayed in part
by thepayment of page charges. This article must therefore be
hereby markedadvertisement in accordance with 18 U.S.C. Section
1734 solely to indicatethis fact.
Received August 22, 2011; revised November 11, 2011;
acceptedNovember 26, 2011; published OnlineFirst December 6,
2011.
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