Background Enhancing anti-tumor immunity is a foundational therapeutic strategy against cancer.1 The Aliya Pulsed Electric Fields (PEF) proprietary system has been shown to promote local and systemic anti-tumor immune activation in pre-clinical murine models through the activation of immunogenic cell death (ICD) and the release of damage associated molecular patterns (DAMPs) and tumor-specific antigens.2 3 Unlike apoptosis, often immunosuppressive, ICD mechanisms generate a potent immune response by releasing DAMPs that are recognized by and attract immune cells.4 ICD mechanisms can suppress cancer cell proliferation and migration.5 6 In this study we evaluated PEF’s capability for modulating anti-tumor immunity in patients with NSCLC.
Methods The treat-and-resect INCITE ES study enrolled patients with suspected or confirmed NSCLC stage IA2-IB and no cancer treatment history within two years. This two-arm study included 34 patients in the treatment group and 8 patients in the control group. Treatment group subjects received AliyaTM PEF (GTI-00018 investigational device; Galvanize Therapeutics) after the diagnostic biopsy, whereas the control group only had the biopsy. Blood, serum, and tissue samples were collected pre- and post-PEF at specific timepoints (figure 1).
Results Ingenuity Pathway Analysis (IPA) of serum cytokines predicts that host innate immunity pathways that drive immune cell trafficking, differentiation and activation are activated in PEF-treated samples, including the Acute Phase Response, IL-6, JAK-STAT and Th17/IL-17 signaling (figure 2A).7–9 scRNA-Seq from this initial cohort of patients additionally shows that PEF-treated tumors have a significant increase in the proportion of plasma B cells, T cells and neutrophils, with neutrophils expressing genes indicative of functional activation (figure 2B).7 In samples from PEF-treated patients, IPA further predicts activation of ICD mechanisms, such as pyroptosis and HMGB1 signaling (figure 3A,B).4 10 After this initial innate immune response, IPA predicts activation of Th2 signaling, responsible for dampening acute inflammation and orchestrating adaptive anti-tumor immunity (figure 4A).11 Flow cytometry analysis further suggests activation of adaptive immunity, as PEF samples have higher levels of circulating B cells and effector memory T cells, and lower Tregs (figure 4B). Within the tumor microenvironment, PEF tumors show increased proportion of cytotoxic CD8+ T cells, plasma B cells and tumor leukocytes overexpressing antigen-presentation genes (figure 4C).
Conclusions Data from this initial cohort show the first clinical evidence that PEF may have the potential to induce inflammatory changes in the tumor microenvironment capable of engaging host innate and adaptive immune responses, which may elicit anti-tumor activity.
Acknowledgements The authors wish to acknowledge Dr Cristina Teodosio and Julio Pozo for their assistance with the flow cytometry analysis.
Trial Registration The study is registered on clinicaltrials.gov (NCT04732520).
Sanmamed MF, Chen L. A Paradigm Shift in Cancer Immunotherapy: From Enhancement to Normalization. Cell. 2018 Oct 4;175(2):313-326.
M Silvestrini, S Tamakloe, C Pastori, T O’Brien, R Neal. Local Treatment with Pulsed Electric Fields Generates a Tumor Specific Response. Journal of Vascular and Interventional Radiology 2022 June;33(6 Supplement):S161-S162.
C Pastori, M Wagh, E Nafie, F Murad, R Neal. Pulsed Electric Field (PEF) Ablation Invokes Different Immune Cytokine Profile and Tumor Response than Radiofrequency Thermal Ablation for Matched Ablation Volumes in the EMT6 Mouse Model. SIR 2023, Phoenix, AZ.
Kroemer G, Galassi C, Zitvogel L, et al. Immunogenic cell stress and death. Nat Immunol 2022;23:487–500.
Zhang Z, et al. Gasdermin E suppresses tumour growth by activating anti-tumour immunity. Nature 2020;579:415–420.
Wang Q, et al. A bioorthogonal system reveals antitumour immune function of pyroptosis. Nature 2020;579:421–426.
Mantovani A, Garlanda C. Humoral Innate Immunity and Acute-Phase Proteins. N Engl J Med. 2023 Feb 2;388(5):439-452.
Tanaka T, Narazaki M, Kishimoto T. IL-6 in inflammation, immunity, and disease. Cold Spring Harb Perspect Biol. 2014 Sep 4;6(10):a016295.
Gaffen SL, Jain R, Garg AV, Cua DJ. The IL-23-IL-17 immune axis: from mechanisms to therapeutic testing. Nat Rev Immunol. 2014 Sep;14(9):585-600.
Wei X, Xie F, Zhou X, et al. Role of pyroptosis in inflammation and cancer. Cell Mol Immunol 2022;19:971–992.
Walker JA, McKenzie ANJ. TH2 cell development and function. Nat Rev Immunol. 2018 Feb;18(2):121-133.
Xie Z, Bailey A, Kuleshov MV, Clarke DJB, Evangelista JE, Jenkins SL, Lachmann A, Wojciechowicz ML, Kropiwnicki E, Jagodnik KM, Jeon M, Ma'ayan A. Gene set knowledge discovery with Enrichr. Current Protocols, 2021;1:e90.
Zhou R, Tardivel A, Thorens B, Choi I, Tschopp J. Thioredoxin-interacting protein links oxidative stress to inflammasome activation. Nat Immunol. 2010 Feb;11(2):136–40.
Ethics Approval This study was approved by C.E.I.M. reference 20/1615 (E.C.P.S.) (Spain); CUHK-NTEC CREC 2021.294-T (Hong Kong); CMO Arnhem-Nijmegen Region NL-number: NL76406.091.21 (Netherlands).
Consent The patient was identified as an appropriate candidate and consented for study, standard of care procedures, and publication of the data for the Ethics Committee-approved INCITE ES trial (NCT04732520)
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