Addition of losartan to FOLFORINOX and chemoradiation downregulates pro-invasion and immunosuppression-associated genes in locally advanced pancreatic cancer

• Published in: medRxiv
• Main Authors: Boucher, Yves, Posada, Jessica M, Subudhi, Sonu, Rosario, Spencer R, Gu, Liqun, Kumar, Ashwin S, Kumra, Heena, Mino-Kenudson, Mari, Talele, Nilesh P, Duda, Dan G, Fukumura, Dai, Wo, Jennifer Y, Clark, Jeffrey W, Ryan, David P, Fernandez-Del Castillo, Carlos, Hong, Theodore S, Pittet, Mikael J, Jain, Rakesh K
• Format: Paper
• Language: English
• Published: Cold Spring Harbor Cold Spring Harbor Laboratory Press 13.06.2022
• Subjects: Adenocarcinoma; Antigen presentation; Cancer therapies; CD4 antigen; Cell activation; Chemoradiotherapy; Chemotherapy; Clinical trials; Cytolytic activity; Dendritic cells; Foxp3 protein; Gene expression; Grants; Health care; Immunohistochemistry; Immunoregulation; Immunosuppression; Leukocyte migration; Lymphocytes T; Macrophages; Medical research; Oncology; Osteonectin; p53 Protein; Pancreatic cancer; Patients; Tumor microenvironment; Tumor suppression; Tumors
• DOI: 10.1101/2022.06.09.22275912

Abstract Purpose: Adding losartan to FOLFIRINOX (FFX) chemotherapy followed by chemoradiation (CRT) resulted in 61% R0 surgical resection in our phase II trial in patients with locally advanced pancreatic cancer (LAPC). Here we identify potential mechanisms of benefit by assessing the effects of neoadjuvant losartan+FFX+CRT versus FFX+CRT on the stromal tumor microenvironment. Experimental Design: We performed a gene expression analysis of RNA extracted from pancreatic cancer tissue sections and immunohistochemistry (IHC) for cancer cells and immune cells using archived surgical samples from patients treated with losartan+FFX+CRT (NCT01591733), FFX+CRT (NCT01591733) or surgery upfront, without any neoadjuvant therapy. We then assessed whether certain gene sets could stratify the overall survival (OS) of patients. Results: Neoadjuvant losartan+FFX+CRT and FFX+CRT increased the expression of genes linked to vascular normalization, transendothelial migration of leukocytes, T cell activation and cytolytic activity, and dendritic cell (DC) related genes versus no neoadjuvant treatment. In comparison to FFX+CRT, losartan+FFX+CRT downregulated pro-invasion, immunosuppression, and M2 macrophages related genes, and upregulated genes associated with tumor suppression, including the p53 pathway. Furthermore, immunostaining revealed significantly less residual disease in lesions treated with losartan+FFX+CRT versus FFX+CRT. Losartan+FFX+CRT also reduced CD4+FOXP3+ regulatory T cells in PDAC lesions with a complete/near complete response. OS was associated with DC and antigen presentation genes for patients treated with FFX+CRT, and with immunosuppression and invasion genes or DC- and blood vessel-related genes for those treated with losartan+FFX+CRT. Conclusions: Adding losartan to FFX+CRT reduced pro-invasion and immunosuppression related genes, which were associated with improved treatment outcomes in patients with LAPC. Competing Interest Statement RKJ received Consultant fees from Elpis, Innocoll, SPARC, SynDevRx; owns equity in Accurius, Enlight, SynDevRx; Serves on the Board of Trustees of Tekla Healthcare Investors, Tekla Life Sciences Investors, Tekla Healthcare Opportunities Fund, Tekla World Healthcare Fund and received a Research Grant from Boehringer Ingelheim. DGD received consultant fees from Innocoll and research grants from Bayer, Surface Oncology, Exelixis and BMS. MRM received consultant fees from AstraZeneca, BMS, Sanofi and Janssen Oncology, and loyalties from Elsevier, all of which are unrelated to this study. DPR received consultant fees from MPM Capital, Boeringer Ingelheim, Exact Sciences, Uptodate, McGraw Hill, and Thrive Earlier Detection; Equities in Exact Science and MPM Capital. No reagents or support from these companies was used for this study. No potential conflicts of interest were disclosed by other authors. Funding Statement Financial Support: This work was supported by NIH grant U01-CA224348 (to RKJ). RKJ research is supported by grants from NIH R35-CA197743, R01-CA259253, R01-CA208205, R01-NS118929, U01CA261842, Janes Trust Foundation, Ludwig Cancer Center at Harvard, National Foundation for Cancer Research, and Niles Albright Research Foundation. YB research is supported by NIH grant U01-CA224348, by Department of Defense grant W81XWH-20-1-0016. DGD research is supported by NIH grants R01CA254351, R01CA260857, R01CA247441, and R03CA256764, by Department of Defense grants PRCRP W81XWH-19-1-0284 and PRCRP W81XWH-21-1-0738, and by the Samuel Singer Brown Fund for Pancreatic Ductal Adenocarcinoma Research. TSH research is supported through NIH grant P01CA261669. J.M.P. was supported by NIH Training Grants (grant no. T32HL007627 and T32CA251062). NPT is supported by Cancer Research Institute/Merck Fellowship. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Institutional Review Board of Massachusetts General Hospital gave full ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes Data Availability All data produced in the present study are available upon reasonable request to the authors