Patients with metastatic cancer refractory to standard systemic therapies have a poor prognosis and few therapeutic options. Radiotherapy can shape the tumor microenvironment (TME) by inducing immunogenic cell death and promoting tumor recognition by natural killer cells and T lymphocytes. Granulocyte macrophage-colony stimulating factor (GM-CSF) was known to promote dendric cell maturation and function, and might also induce the macrophage polarization with anti-tumor capabilities. A phase II trial (ChiCTR1900026175) was conducted to assess the clinical efficacy and safety of radiotherapy, PD-1 inhibitor and GM-CSF (PRaG regimen). This trial was registered at http://www.chictr.org.cn/index.aspx. A PRaG cycle consisted of 3 fractions of 5 or 8 Gy delivered for one metastatic lesion from day 1, followed by 200 μg subcutaneous injection of GM-CSF once daily for 2 weeks, and intravenous infusion of PD-1 inhibitor once within one week after completion of radiotherapy. The PRaG regimen was repeated every 21 days for at least two cycles. Once the PRaG therapy was completed, the patient continued PD-1 inhibitor monotherapy until confirmed disease progression or unacceptable toxicity. The primary endpoint was objective response rate (ORR). A total of 54 patients were enrolled with a median follow-up time of 16.4 months. The ORR was 16.7%, and the disease control rate was 46.3% in intent-to-treat patients. Median progression-free survival was 4.0 months (95% confidence interval [CI], 3.3 to 4.8), and median overall survival was 10.5 months (95% CI, 8.7 to 12.2). Grade 3 treatment-related adverse events occurred in five patients (10.0%) and grade 4 in one patient (2.0%). Therefore, the PRaG regimen was well tolerated with acceptable toxicity and may represent a promising salvage treatment for patients with chemotherapy-refractory solid tumors. It is likely that PRaG acts via heating upthe TME with radiotherapy and GM-CSF, which was further boosted by PD-1 inhibitors.

Patients with metastatic gastric cancer had limited treatments and often had a somber prognosis, especially when patients were unable to tolerate high-intensity cytotoxic treatment due to poor physical condition or organ dysfunction after the failure of standard therapy. Here, we reported a metastatic and proficient mismatch repair (pMMR) gastric adenocarcinoma patient with the Eastern Cooperative Oncology Group (ECOG) performance status score of 2 associated with hypoproteinemia and fatigue, and poor appetite that was unable to tolerate high-intensity therapy after several chemotherapy regimens and anti-angiogenic therapy. After receiving novel triple-combination therapy, which consists of PD-1 inhibitor, Radiotherapy and Granulocyte-macrophage colony-stimulating factor (GM-CSF) therapy (PRaG for short), the patient achieved a complete response (CR) with a progression-free survival time of 14 months, and ECOG performance status score improved from 2 to 0. A significant systemic effect was observed in this case and the PRaG triple-combination therapy might provide a novel treatment strategy for metastatic pMMR gastric cancer patients.

e14614 Background: Cancer immunotherapy has emerged as one of the most promising approaches in many kinds of advanced tumors. The PRaG therapy is an innovative cancer immunotherapy, when combined with radiotherapy, PD-1/L1 inhibitor and GM-CSF to generate the desired in situ vaccine effect to activate the immune response and modulate the tumor microenvironment. Previous studies have showed encouraging efficacy of the PRaG regimen in the treatment of advanced refractory tumors. RC48-ADC, an anti-HER2 antibody-drug conjugate with MMAE as cytotoxic payload has been recently demonstrated that ADCs are also able to induce immunogenic cell death and widespread release of cancer cell antigens, synergize with immunotherapy by promoting effector T-cell activation. The aim of this study is to explore efficacy and safety of PRaG3.0 regimen for therapy of HER2-expressing advanced solid tumors. Methods: Participants with advanced, confirmed HER2-expressing (IHC3+, 2+ or 1+) solid tumors that had progressed after standard of care, or intolerance were enrolled. In the cycle, those received RC48-ADC (2.0 mg/kg d1, every 3 weeks), then HFRT (2-3 doses of 5-8Gy) was delivered for one metastatic lesion every other day, followed by GM-CSF (200 μg d3-7), sequential IL-2 (2million IU d8-12), and PD-1/L1 inhibitor was dosing within one week after completion of HFRT. After RC48-ADC combined with PD-1/L1 inhibitor sequential cytokines for at least 6 cycles, then maintenance with PD-1/PD-L1 inhibitor was administered until disease progression or unacceptable toxicity. The primary endpoint was objective response rate (ORR). Results: As of Jan 2023, a total of 32 patients (n=6 for gynecological cancer, n=5 for pancreatic cancer, n=21 for other cancers) were enrolled, 26 of them completed at least 1 tumor assessment. The ORR was 38.5%, and the disease control rate was 69.2%. The ORR was 66.7% in gynecological cancer, 25.0% in pancreatic cancer, and 31.3% in other cancers. Notably, patients who were HER2 IHC1+ responded similarly to those who were IHC2+~3+, with ORR of 43.8% and 30.0%, respectively. Median progression-free survival was 7.2 months (95%CI: 4.9, 9.5). The most common treatment-related adverse events (TRAEs) included fatigue (28.1%), fever (28.1%), alopecia (28.1%) and anorexia (18.8%). Grade ≥3 TRAEs occurred in two patients (6.3%). In addition, activated plasmacytoid dendritic cell was significantly higher at baseline in responders (CR+PR) vs. nonresponders (SD+PD). Conclusions: The schedule of RC48-ADC was changed from once every 2 weeks to once every 3 weeks, and was still effective with significantly reduced side effects. These preliminary results suggest that PRaG3.0 regimen has a manageable safety profile and enhancing potential sensitivity in pretreated patients with HER2-expressing cancers. Clinical trial information: NCT05115500 .