Abstract
The human cytomegalovirus (CMV) antigen pp65 is expressed in high-grade glioma (HGG) and medulloblastoma but not in the adjacent brain. This single-arm phase 1 trial (NCT03299309) assessed the safety and immunogenicity of a peptide vaccine (PEP-CMV) targeting pp65 in individuals (3–35 years old) with recurrent HGG or medulloblastoma. Thirty-six individuals with HGG received PEP-CMV. The mean age was 22.75 ± 9.34 years. The primary outcome, percentage of unacceptable toxicity, was met. The maximum-grade adverse events (AE) related to PEP-CMV were 17 grade 1 AEs, 15 grade 2 AEs, 1 grade 3 AE (pyramidal tract syndrome) and 1 grade 4 AE (cerebral edema). As a secondary outcome, in 21 individuals with evaluable data, T cell reactivity, measured as change in baseline interferon-γ pp65 enzyme-linked immunospot assay reactivity, had an estimated increase of 46 spots (95% confidence interval (95% CI): 8, 194) after treatment with PEP-CMV. As exploratory endpoints, the median progression-free survival was 2.5 months (95% CI: 2.2, 3.2), and median overall survival was 6.5 months (95% CI: 4.6, 8.4). PEP-CMV is well tolerated and elicits an antigen-specific immune response in individuals with multiply recurrent HGG. Only two individuals with medulloblastoma were enrolled, showing one grade 3 encephalopathy possibly related to PEP-CMV, while neither had postvaccine immune assessments due to progression-free survival and overall survival less than 2 months.
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Data availability
The study protocol is available in the Supplementary Information. The data that support the findings of this study are available within the article and Supplementary Information. All requests for data will be considered on a case-by-case basis under a data use agreement. Access is controlled to maintain participant confidentiality. Deidentified data will not be shared. Data that may be shared include additional patient demographic details. Access requests can be made to D.L. at daniel.landi@duke.edu. Responses to requests are estimated to occur within 10 days. Source data are provided with this paper.
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Acknowledgements
This study was funded in part by the Pediatric Brain Tumor Foundation. The Pediatric Brain Tumor Foundation had no role in the conceptualization, design, data collection, analysis, decision to publish or preparation of the manuscript. We wish to thank all the patients and patients’ families who participated in this trial, physicians who referred the patients, B. Perry (Duke University) for administrative support and M. Janampalli (Duke University) and K. Patel (Duke University) for specimen processing assistance.
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Contributions
Concept and design: E.M.T., G.A., G.V., E.R., J.E.H., D.A.M. and J.H.S. Provision of study materials or patients: E.M.T., D.L., G.A., K.S., A.D., M.O.J., K.P., D.R., M.K., H.F., D.A.M., D.M.A. and J.H.S. Collection and assembly of data: E.M.T., D.L., K.A., P.N., A.W., B.A., C.F., D.J., L.G., L.A.S., K.C., K.H. and S.L.C. Data analysis and interpretation: E.M.T., D.L., G.A., K.A., P.N., J.E.H., E.D.B., D.M.A., A.D., M.K., L.A.S., K.C., K.H., S.L.C. and E.M. Manuscript writing: E.M.T. Manuscript revision: all authors. Final approval of manuscript: all authors.
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Competing interests
D.A.M. and J.H.S. hold the patent to PEP-CMV (Compositions, methods and kits for eliciting an immune response, US 11,376,322). A.W. is currently employed by Day One Biopharmaceuticals, G.V. is currently employed by GSK, E.R. is currently employed by Q2 Solutions, L.A.S. is currently employed by Tune Therapeutics, and K.C. is currently employed by Tune Therapeutics. M.K. reports grants or contracts from BMS, AbbVie, BioNTech, CNS Pharmaceuticals, Daiichi Sankyo, Immorna Therapeutics, Immvira Therapeutics, JAX lab for genomic research and Personalis; received consulting fees from AnHeart Therapeutics, Berg Pharma, George Clinical, Manarini Stemline and Servier; received honoraria from GSK and is on a data safety monitoring board for BPG Bio. The other authors declare no competing interests.
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Extended data
Extended Data Fig. 1
CONSORT diagram of the trial.
Extended Data Fig. 2
Kaplan Meier plot of PFS and OS since the time of original diagnosis.
Extended Data Fig. 3 Kaplan Meier plots of all patients by tumor grade, sex, and bevacizumab use.
Kaplan Meier plots of PFS (left column) and OS (right column) by WHO Grade (a, b), sex (c, d), and on-study bevacizumab use (e, f). A two-sided log-rank test was used to generate the p values. P values were not adjusted for mutliple comparisons.
Extended Data Fig. 4 Kaplan Meier plots of HLA-A2 positive patients by CMV serological status.
Kaplan Meier plots of PFS (a) and OS (b) of HLA-A2 positive patients by CMV serological status. A two-sided log-rank test was used to generate the p values. P values were not adjusted for multiple comparisons.
Extended Data Fig. 5 Line graphs of lymphocytes before and after temozolomide and regulatory T cells (Tregs) over time.
Line graphs of % lymphoctes (a) and absolute lymphoctes (b) before and after temozolomide as well as % Tregs (c) and absolute number of Tregs (d) over time by patient. From baseline to Day 20, there was a −0.55% (95% CI −3.5%, 2.35%) estimated change % lymphocytes (A, P = 0.72) and 0.1 (95% CI −0.05, 0.25) estimated change of absolute lymphocytes (B, P = 0.72). From baseline to Vaccine 4, there was a −0.49 (95% CI −3.49, 2.44) estimated changed of % Tregs (C, P = 0.8) and a 0.31 (−0.001, 0.62) change of absolute Tregs (D, P = 0.52). A 2-sided Wilcoxon Signed-rank Test was used for these analyses.
Extended Data Fig. 6 Forest plots of pretreatment immune cell subtypes and their association with survival.
Forest plots of pretreatment immune cell subtypes and their association with PFS (top panel) and OS (bottom panel). Increased pretreatment Treg percent was predictive of worse PFS (HR 1·79 [95%CI 1·03, 3·11]). Lines indicate 95% confidence interval of the hazard ratio (HR). Cox models using the Benjamini-Hochberg correction method to account for multiple tests was used.
Extended Data Fig. 7 Dot plots of CD8 counts over time and OS.
Dot plots at baseline at at vaccine #4 for all patients (a, n = 21), only CMV positive patients (b, n = 11), and only CMV negative patients (c, n = 10) does not demonstrate significant correlation by Pearson’s R between CD8 + T cells and OS. P values are two-sided.
Extended Data Fig. 8 T cell responses to PEP-CMV treatment.
a) Patients with levels of absolute naïve CD8 T cells, as determined by flow cytometry, at the time of their last vaccine above the median had longer PFS than those below the median. b) There was no difference in OS between the two groups. There is no clear association between absolute naïve (c) or percent naïve (d) CD8 + T cells and number of vaccines received as determined by flow cytometry. A two-sided log-rank test was used to generate the p values in A and B. P values were not adjusted for multiple comparisons.
Extended Data Fig. 9 Polyfunctional T cell results of select patients.
Pie graphs of demonstrating T cell polyfunctionality based on INF-γ, TNF-a, and IL-2 phenotype. Increasing number of vaccines corresponded with increasing polyfunctionality. Td Pre = baseline, V = vaccine number.
Supplementary information
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Supplementary Table 1 (download XLSX )
Supplementary Tables 1–9.
Supplementary Data 1 (download PDF )
CONSORT checklist.
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Source Data Figs. 1–4 and Extended Data Figs. 2–5, 7 and 8 (download XLSX )
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Thompson, E.M., Ashley, D.M., Ayasoufi, K. et al. A peptide vaccine targeting the CMV antigen pp65 in children and young adults with recurrent high-grade glioma and medulloblastoma: a phase 1 trial. Nat Cancer 6, 1559–1569 (2025). https://doi.org/10.1038/s43018-025-00998-z
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DOI: https://doi.org/10.1038/s43018-025-00998-z
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