Evaluation of CTLA-4 Blockage with Metronomic Chemotherapy for the Treatment of Preclinical Breast Cancer
The targeting of the CTLA-4 protein with the antibody ipilimumab has been a success in terms of producing an increase in the survival of patients with unresectable melanoma, and clinical trials are ongoing to evaluate this strategy in other tumor types. Our aim in this study was to evaluate the combination of CTLA-4 blocking with metronomic chemotherapy regimens. To that end, we subcutaneously implanted murine EMT-6 breast tumor cells into syngeneic Balb/c mice (n=6-8/group) and evaluated therapies on the established tumors. Murine CTLA-4 blocking was achieved using anti-mouse CD152 (CTLA-4), clone 9H10, injected on day 1 (100ug/mouse) and on day 6 (35ug/mouse) of therapy. Anti-CTLA-4 therapy was administered on its own or combined with metronomic regimens. These included; a) Bolus (150mg/kg, i.p.) cyclophosphamide (CTX) followed by metronomic CTX (20mg/kg/day, p.o.), b) metronomic CTX, and c) sequential gemcitabine therapy (160mg/kg every 3 days, i.p.) given to the tumors relapsing after the anti-CTLA-4 therapy. We observed that control (saline) treated tumors, or tumors treated with Bolus CTX plus metronomic CTX, grew rapidly and had to be sacrificed 4 weeks after tumor implantation. Anti-CTLA-4 monotherapy produced an initial tumor regression followed by tumor relapses, 2-3 weeks later, in 5/6 mice. Surprisingly, the Bolus CTX plus metronomic CTX hindered the effective CTLA-4 therapy, failed to produce tumor regression, and resulted in rapidly growing tumors. The combination of anti-CTLA-4 plus metronomic CTX also produced tumor regression and resulted in a longer delay in the appearance of relapsing tumors (p < 0.05 compared to anti-CTLA-4 alone), which also eventually appeared in 5/6 mice. A Kaplan Meier plot showed that the anti-CTLA-4 plus metronomic CTX regimen significantly improved survival compared to the anti-CTLA-4 monotherapy (p < 0.05). The regimen involving first line anti-CTLA4 therapy followed by a second line gemcitabine therapy, produced a sustained tumor regression that continued for over 100 days. In this group, 5/7 mice did not show a tumor regrowth; 1 mouse showed a tumor regrowth under continuous gemcitabine therapy with concomitant development of lung metastasis. Tumor cells lines were derived from the relapsing tumor and from the lung metastasis. Collectively our data shows that Bolus plus metronomic CTX may compromise anti-CTLA-4 therapy. Furthermore, anti-CTLA-4 therapy may be effectively combined with metronomic CTX, or with a sequential gemcitabine therapy, in a preclinical model of breast cancer.