MIDRIXNEO-LUNG Dendritic Cell Vaccine in Patients With Non-small Cell Lung Cancer

Immunotherapy, in the shape of immune checkpoint inhibitors, is now being investigated as an adjuvant therapy in resected NSCLC, with issues unsolved with respect to the optimal duration of treatment, in addition to the unpredictable nature of side-effects with this class of compounds. Also, it is known from advanced disease stages that only a minority of patients respond to checkpoint inhibitors.

An alternative, highly targeted immunotherapeutic approach with an excellent safety track record consists of vaccination. Cancer vaccines aims to prime and/or expand tumor antigen-targeting T-cells and induce immunological memory against later disease relapse. Whereas immune checkpoint blockade boosts inactivated responses of effector T cells, vaccination can potentially activate naive T cells with tumor specificity and in this way broaden the tumor-specific immune responses. However, simple protein-based cancer vaccines have failed in lung cancer so-far, suggesting that the optimal vaccination modality for NSCLC still needs to be established.

Dendritic cells (DCs) are specialized antigen presenting leukocytes that are now recognized as the central controllers of the immune response. The DCs unique capacity to induce robust, highly antigen-specific cytotoxic T-cell responses has led to the use of in vitro-generated autologous DCs as cancer vaccines.

The investigators have developed a novel DC vaccine design that combines robust immunogenicity together with the targeting of patient-tumor specific mutations, also known as neoantigens. The DC vaccine is produced in 2 stages: (1) First, DNA and RNA is isolated from the surgical tumor specimen, sequenced and the sequence is compared to blood cell DNA. In this way, the tumor-specific mutations are identified and the most immunogenic mutated sequences are synthetized. This process takes 3-4 months starting from surgical resection of the tumor. (2) Next, patients undergo a leukapheresis for the harvest of monocytes which are differentiated in vitro into activated DCs. The DCs are finally loaded with the neoantigen-encoding sequences, producing the IMP, MIDRIXNEO.

Inclusion criteria

• Male and female patients older than 18 years with histologically or cytologically proven diagnosis of non-small cell lung cancer, considered functionally operable and surgically resectable (cT1-3 cN0-1 M0 per 8th TNM classification; cT4N0-1 are considered for surgery on a case-by-case basis) and patients considered resectable in an oligometastatic treatment plan
• WHO-ECOG performance status 0 to 2 and absence of any persisting and assessable toxicity > CTC grade 2 due to a previous therapy (surgery and if applicable adjuvant chemotherapy)
• Before patient registration and screening, written informed consent must be given for the interventional study and for the "Prelevation and storage of human tissues and cells" according to ICH/GCP and institutional practice.
• Adequate organ function, including:

• Adequate bone marrow reserve: absolute neutrophil count > 1.5*10E9/L, platelet count > 100*10E9/L, and Hb > 9.0 g/dL
• Sufficient renal function as defined by eGFR > 40 ml/min
• Sufficient hepatic function as defined by total bilirubin ≤1.5× ULN OR direct bilirubin within normal limits for participants with total bilirubin levels >1.5× ULN; AST and ALT ≤ 2.5x ULN
• Having passed all tests defined in the institutional Leukapheresis Donor Fitness Screening, including:

• Adequate peripheral vein access to perform leukapheresis
• Adequate coagulation function defined as international normalized ratio (INR) or prothrombin time (PT) ≤ 1.5 x ULN and activated partial thromboplastin time (aPTT) ≤ 1.5 x ULN unless the participant is receiving anticoagulant therapy
• Negative test results for HBs-antigen, anti-HBc-serology, anti-HCV serology, anti-HIV1-2 serology, anti-CMV IgM, anti-Syphilis (Treponema pallidum) serology
• Negative test results for Epstein-Barr virus (IgG and IgM) and for toxoplasmosis (IgG and IgM)
• For female participants: a negative serum beta-HCG test result less than 1 week before the day of leukapheresis
• For female participants with child-bearing potential, the willingness to follow contraceptive guidance and pregnancy testing during the projected duration of the trial (see Appendix B on Contraceptive Guidance and Pregnancy Testing)
• For male participants having a partner with child-bearing potential: agreement to use contraception during the projected duration of the trial, starting with the screening visit through 90 days after the last dose of trial treatment. Sperm donation must have been performed before anti-cancer treatment as per standard practice

Exclusion criteria

• Presence of oncogenic driver genomic alterations for which a targeted therapy is available
• Concomitant participation in another clinical interventional trial
• Prior treatment with autologous or allogeneic dendritic cell-based vaccines
• Prior malignancy, except for adequately treated basal cell, superficial or in situ cancer of the bladder or the cervix, or other cancer for which the patient has been disease-free for at least five years.
• Dermatological pathology interfering with the in vivo immunomonitoring readout (DTH skin test)
• Disease requiring chronic treatment with systemic glucocorticosteroids with a daily dose > 10 mg oral prednisolone or equivalent, or other immunosuppressive drugs. Inhaled corticosteroids and topical corticosteroids on skin sites other than those used for DTH are allowed.
• Chronic or active concomitant infection requiring active therapy, including including HIV, viral hepatitis (HBV, HCV), CMV or fungal infection
• Autoimmune disease requiring active treatment at the time of the study
• Organ allograft
• Chronic comorbidity (such as asthma, COPD, heart failure, renal failure, arterial hypertension or diabetes mellitus) that is uncontrolled or not stabilized under medication at the time of study enrollment, OR stable yet severe enough to constitute an unwarranted high risk for the investigational cellular therapy.
• For female participants: pregnancy or lactation, or expecting to conceive or father children within the projected duration of the trial, starting with the screening visit through 90 days after the last dose of trial treatment
• Any organic brain syndrome or other significant psychiatric abnormality which would comprise the ability to give informed consent and preclude participation in the full protocol and follow-up.
• Any psychological, familial, sociological or geographical condition potentially hampering compliance with the study protocol and follow-up schedule; those conditions should be discussed with the patient before registration in the trial