Precise Therapeutic Benefits And Underlying Mechanisms Of Anti-angiogenesis Agents Combined With Checkpoint Immunotherapy In Advanced Non-small-cell Lung Cancer

Background:As one of the most dangerous malignant tumors in the world,lung cancer has become the malignant tumor with the highest mortality and morbidity in the world.Non-small lung cancer accounts for about 85%.Most patients have advanced lung cancer before diagnosis,and most patients have tumor progression or distant metastasis within four to six months after regular first-line therapy.In addition to first-line treatment,51.8% of the patients also needed second-line chemotherapy and other adjuvant treatments,but the long-term survival benefit of the patients was very low.With the current research and exploration of some frontier biomedical knowledge direction and continuous deepening of exploration,tumor biology can further rapid development,anti-angiogenesis therapy gradually come into people’s vision.Angiogenesis plays a key role in the growth,development and metastasis of malignant tumors,and blocking angiogenesis can inhibit tumor growth and metastasis.Antirotinib is a novel small-molecule multi-target tyrosine kinase inhibitor independently developed,produced and successfully applied in clinical treatment in China in recent years,which acts on the receptor genes of the three main pathways of angiogenesis.By inhibiting the activation of PDGFRβ,FGFR1 and VEGFR2 targets and blocking the signaling of downstream extracellular regulatory protein kinase,antirotinib can significantly reduce tumor microvascular growth density and inhibit angiogenesis in the short term,and ultimately effectively inhibit tumor growth.Both androtinib and immunocheckpoint inhibitors have been widely used in the third-line treatment of advanced metastatic non-small cell lung cancer(NSCLC).It has significant antitumor angiogenesis and inhibition of tumor growth.But even among these patients with the driver mutation,most will eventually develop resistance as the disease progresses and treatment progresses.Therefore,there is an urgent need to develop new therapeutics for NSCLC.In recent years,the development of immunocheckpoint inhibitor therapy in the world has benefited patients with NSCLC and greatly changed the standard of treatment for patients with advanced NSCLC.Even so,immune checkpoint inhibitors often become resistant as treatment progresses and patients’ disease progresses.One of the mechanisms of immunotherapy resistance may be the abnormal microvascular system in the immunosuppressed tumor microenvironment,which can inhibit the maturation of dendritic cells and prevent T cells from invading the tumor.Previous studies have shown that targeted anti-angiogenesis therapy modulates the immunosuppressive tumor microenvironment and may reverse immune checkpoint resistance,suggesting the potential clinical value of combining the two standard therapies of anti-angiogenesis and checkpoint blocking.Currently,increasing evidence suggests that tumor vascular system abnormalities may be one of the mechanisms of immunotherapy resistance,and immunotherapy can improve clinical outcomes in previously treated NSCLC patients with EGFR-variant.Immunotherapy can improve clinical outcomes in some previously treated NSCLC patients with EGFR variants.However,there have been no studies on the combination of these two standard therapies in the first-line post-treatment of patients with advanced NSCLC and their mechanisms of action.But its limited clinical benefit rate still puzzles researchers.If this intractable problem is to be solved,the abnormal tumor vascular system may be one of the mechanisms of anti-tumor immune resistance.Tumor microvascular disorders have been found to have immunosuppressive effects,and antiangiogenic therapy can modulate the tumor immunosuppressive microenvironment and may help reverse immunotherapy resistance.This special study intends to further explore the efficacy improvement and potential mechanism of anti-angiogenesis targeted therapy combined with anti-PD-1 immunotherapy in patients with advanced NSCLC,and further build a prognosis and efficacy prediction model.Research objectives:(1)To explore the clinical benefit rate of anti-PD-1 immunotherapy in patients with advanced NSCLC in combination with anrotinib;(2)To determine the effect of antirotinib on tumor immune microenvironment;(3)The prediction model of immunotherapy efficacy in NSCLC patients was successfully constructed;(4)Objective To explore the mechanism by which anrotinib acts on lung cancer cell lines and promotes the clinical benefit rate of anti-PD-1 immunotherapy in advanced patients.Methods:1.Clinical treatment data collection and efficacy evaluation of patients with advanced NSCLCAccording to the relevant inclusion criteria and exclusion criteria established in this study,patients were enrolled and clinically diagnosed.The randomized control group was divided into allotinib group,immunotherapy group and combination therapy group.Prior to treatment,patient-related baseline tests were performed to evaluate the tumor status of patients,and the baseline content of patients was evaluated again after 1,2,and 3 cycles of treatment.2.The prognostic model of NSCLC patients and the prediction of immunotherapy efficacy were constructed based on anrotinib response MarkerBy downloading and preprocessing data from online database,differential gene screening analysis,univariate and multivariate Cox regression analysis,machine learning LASSO regression screening factor,construction of NSCLC patients’ prognosis risk scoring model,and by evaluating the efficacy and robustness of the risk score,finally establish a risk scoring model that can predict the prognosis by stratification.3.Potential mechanism of anrotinib’s effect on the immune microenvironment of NSCLC patientsGO and KEGG enrichment analysis was conducted on Anrotinib response marker to focus on the mechanism of Anrotinib’s possible regulation of NSCLC immune microenvironment.Results:1.Allotinib combined with immunotherapy promotes therapeutic benefits and toxic side effects in patients with advanced NSCLC.In the framework of the plan to complete the clinical study series of this study,we used a retrospective research-based approach to track clinical study results.To analyze and explore the efficacy and safety of anrotinib combined with PD-1 m Ab in the treatment of advanced NSCLC.From July 2018 to October 2021,a total of 142 patients with advanced NSCLC were included,among whom 106(74.6%)were males and only 36(25.4%)were diagnosed as female patients,aged between 37 and81(median age 59).The median PFS and OS were 6.8 months and 17.3 months respectively in 22 patients with NSCLC treated with the combination of antirotinib and PD-1 monoclonal antibody.The disease control rate(DCR)and objective response rate(ORR)were 90.9% and 36.4%,including 1 complete response(4.6%)and 7 partial response(31.8%).The median duration of response was 3.9 months and the median duration of response was 6.8 months.Common grade 1-2 adverse events were fatigue 10/22(45.5%),decreased appetite 9/22(40.9%)and hypertension10/22(45.5%).Common Grade 3 and 4 adverse events were hypertension in2/22(9.1%)and oral ulcers in 2/22(9.1%).2.Multi-factor COX model constructionAccording to the 21 genes obtained by lasso regression,R-package glmnet was used for multi-factor COX regression analysis,and 13 genes were screened for model construction.Combined with the clinical information of the TCGA samples,the effectiveness of the model is evaluated effectively.Risk is divided into two groups based on the median risk score: low risk and high risk.The effective survival time of the high-risk group was significantly lower than that of the low-risk group The AUC values for 1-year,3-year,and 5-year survival were all around 0.7(Figure 7).3.Anrotinib sensitivity gene enrichment analysis1273 differentially expressed genes were enriched and expressed by GO and KEGG using R Cluster Profiler.It is mainly concentrated in biological processes such as cell structure tissue(GO: 0043062)and cell matrix tissue(GO:0030198),collagen-containing extracellular matrix(GO:0062023),basement membrane(GO:0005604),extracellular matrix structural constituent(GO:0005201),glycosaminoglycan binding(GO:0005539)and other molecular functions,Cell adhesion molecules(hsa04514),Phagosome(hsa04145)and other pathways,and the results are shown in Figure 13.Conclusion:Antirotinib combined with PD-1 mab has better efficacy in the treatment of non-small cell lung cancer at the third-line or more distant line,and has a highly predictive clinical benefit with tolerable adverse reactions.Moreover,we found that androtinib regulates the tumor immunosuppressive microenvironment by inhibiting tumor microangiogenesis,and may reverse immunotherapy resistance by doing so.To demonstrate the clinical benefit of combined therapy against angiogenesis and immune checkpoint blockade.LASSO regression and dimensionality reduction of key markers were carried out by machine learning to screen prognostic related factors and construct prognostic models,and the performance of this prognostic model in immunotherapy efficacy of NSCLC was further evaluated,so as to provide new ideas for clinical application.The potential mechanism of antirotinib regulating the effect of immunotherapy may be related to cytokine receptor interactions,Phagosomes,cell adhesion molecules,and leukocyte migration signaling pathways,as well as extracellular matrix structure and glycosaminoglycan binding.