Increased expression of adenosine 2A receptors in metastatic renal cell carcinoma is associated with poorer response to anti-vascular endothelial growth factor agents and anti-PD-1/Anti-CTLA4 antibodies and shorter survival

Abstract

Background: Adenosine and its adenosine 2A receptors (A2AR) mediate the immunosuppressive mechanism by which tumors escape immunosurveillance and impede anti-tumor immunity within the tumor microenvironment. However, we do not know whether the adenosine pathway (CD39/CD73/A2AR) plays a role in renal cell carcinoma (RCC). Therefore, we studied the role of immunosuppression in RCC by assessing the adenosine pathway in patients with RCC treated with anti-vascular endothelial growth factor (anti-VEGF) agents or immune checkpoints inhibitors (ICIs) or both.

Methods: In 60 patients with metastatic RCC, we examined the expression of CD39, CD73, A2AR, and programmed cell death 1 ligand 1 (PD-L1) immunohistochemically in surgically resected tumor tissues and studied the clinicopathological characteristics of these patients. Patients were treated by cytoreductive nephrectomy with systemic therapy with anti-VEGF agent or a combination of the ICIs anti-cytotoxic T-lymphocyte-associated antigen 4 (CTLA4) antibody and programmed cell death 1 (PD-1) antibody.

Results: Increased expression of A2AR in the primary tumors was associated with metastatic profiles. Patients treated with anti-PD-1 antibody in monotherapy, a combination of anti-PD-1 and anti-CTLA4 antibodies, or anti-VEGF agents showed better response and longer overall survival if the primary tumor had higher PD-L1 expression and lower A2AR expression. In Cox multivariate regression analysis, higher expression of A2AR was associated with shorter overall survival.

Conclusions: Our findings suggest that the expression of A2AR and PD-L1 in the primary tumors in RCC might predict the outcomes of treatment with anti-VEGF agents and ICIs and that the A2AR pathway might be a molecular target for immunotherapy.

Keywords: Adenosine 2A receptor (A2AR); CD39; CD73; PD-L1; Renal cell carcinoma.

Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1

Immunohistochemistry of a case of better response to anti-VEGF therapies and longer survival. 73 y.o. male of left clear cell renal cell carcinoma with Fuhrman grade 2, pT2bN0M1 (PUL, LYM). CD8; high expression, PD-L1; low expression, CD39: high expression, CD73; low expression, A2AR; low expression. After cytoreductive nephrectomy, this patient had received sunitinib as first-line anti-VEGF therapy for 17 months with best response of partial response. After refractory to sunitinib, he has received axitinib as second-line anti-VEGF therapy with alive with disease for 29 months

Fig. 2

Immunohistochemistry of a case of worse response to first-line anti-VEGF therapy and second-line nivolumab and shorter survival. 64 year old male of right clear cell renal cell carcinoma with Fuhrman grade 3, pT2aN0M1 (PUL, HEP). CD8; high expression, PD-L1; high expression, CD39: high expression, CD73; high expression, A2AR; high expression. After cytoreductive nephrectomy, this patient had received pazopanib as first-line anti-VEGF therapy for 3 months, while the metastatic disease progressed. Then the patient received nivolumab as second-line therapy for 3 months. The best response was partial response for pulmonary and liver lesions, however, the lesions progressed rapidly and the patient dead

Fig. 3

Immunohistochemistry of a case of worse response to first-line combination of ipilimumab and nivolumab and shorter survival. 57 year old male of right collecting duct renal cell carcinoma with Fuhrman grade 3, pT2aN0M1 (PUL, HEP). CD8; low expression, PD-L1; low expression, CD39: high expression, CD73; high expression, A2AR; high expression. After cytoreductive nephrectomy, the patient had received combination of ipilimumab and nivolumab as first-line therapy. He showed no response to the therapy and dead after 4 months

Fig. 4

Immunohistochemistry of clear cell RCC with muscle and pulmonary metastases. 71 y.o. male of left clear cell renal cell carcinoma with Fuhrman grade 3, pT1aN0M1 (PUL, OTH). Primary renal tumor showed high expression for A2AR and negative staining for PD-L1. Metastatic tumor in psoas major muscle showed high reaction for A2AR and negative reaction for PD-L1. After cytoreductive nephrectomy and resection of metastatic tumor in psoas major muscle, this patient had received sunitinib as first-line anti-VEGF therapy for 5 months, but pulmonary disease progressed slowly. Then the patient has received nivolumab as second-line therapy. He showed no response to the therapy and dead after 21 months

Fig. 5

Overall survival curve. This overall survival curve is based on the expression status of PD-L1 (a), CD39 (b), CD73 (c), A2AR (d), combination of PD-L1 and A2AR in all patients (e) and in the patients treated with immune checkpoints inhibitors (ICIs) (f). In Figure E, in comparison to the patients in type I (PD-L1 low and A2AR high), the relative risk (RR) of the patients in type IV (PD-L1 high and A2AR low) was 0.107 (95% confidential intervals (CI); 0.030–0.380, P = 0.0005), RR in type III (PD-L1 low and A2AR low) was 0.134 (95%CI; 0.035–0.515, P = 0.0034), and RR in type II (PD-L1 high and A2AR high) was 0.468 (95%CI; 0.153–1.427, P = 0.1820). In Figure F, compared to the patients in low–high type-I, the relative risk (RR) of the patients in high-low type-IV was 0.060 (95% confidential intervals (CI); 0.006–0.628, P = 0.0108), RR in low-low type-III was 0.143 (95%CI; 0.014–1.512, P = 0.1060), and RR in high-high type-II was 0.595 (95%CI; 0.151–2.351, p = 0.4589)