Pilot study of Tremelimumab with and without cryoablation in patients with metastatic renal cell carcinoma

Abstract

Cryoablation in combination with immune checkpoint therapy was previously reported to improve anti-tumor immune responses in pre-clinical studies. Here we report a pilot study of anti-CTLA-4 (tremelimumab) with (n = 15) or without (n = 14) cryoablation in patients with metastatic renal cell carcinoma (NCT02626130), 18 patients with clear cell and 11 patients with non-clear cell histologies. The primary endpoint is safety, secondary endpoints include objective response rate, progression-free survival, and immune monitoring studies. Safety data indicate ≥ grade 3 treatment-related adverse events in 16 of 29 patients (55%) including 6 diarrhea/colitis, 3 hepatitis, 1 pneumonitis, and 1 glomerulonephritis. Toxicity leading to treatment discontinuation occurs in 5 patients in each arm. 3 patients with clear cell histology experience durable responses. One patient in the tremelimumab arm experiences an objective response, the median progression-free survival for all patients is 3.3 months (95% CI: 2.0, 5.3 months). Exploratory immune monitoring analysis of baseline and post-treatment tumor tissue samples shows that treatment increases immune cell infiltration and tertiary lymphoid structures in clear cell but not in non-clear cell. In clear cell, cryoablation plus tremelimumab leads to a significant increase in immune cell infiltration. These data highlight that treatment with tremelimumab plus cryotherapy is feasible and modulates the immune microenvironment in patients with metastatic clear cell histology.

Conflict of interest statement

M.T.C. reports consulting/advisory roles for AstraZeneca, Astellas, Eisai, EMD Serono, Exelixis, Genentech, Pfizer, Seattle Genetics, Consulting: AXDev, Exelixis, Pfizer, Research grants: ApricityHealth, EMD Serono, Exelixis, Janssen, Pfizer, Non-CME education: Bristol Myers-Squibb, Merck, Roche, Pfizer. S.F.M. reports consulting/advisory roles for Johnson and Johnson and Research Funding from QED; Education—Ology education. A.L.T. reports consulting/advisory roles for Boston Scientific, Cello Therapeutics, Endocare, AstraZeneca; and Research Funding from Boston Scientific, Johnson & Johnson. R.A.S. reports consulting/advisory roles for Varian, Boston Scientific. J.A.K. reports consulting/advisory roles for Pfizer, Merck, Roche/Genentech, and Research Funding from Roche/Genentech, Mirati, Merck, Elypta; Stock Ownership: Allogene, MedTek, ROM Technologies. N.M.T. reports consulting/advisory roles for Bristol Myers-Squibb; Pfizer; Nektar Therapeutics; Exelisis, Inc, Eisai Medical Research; Eli Lilly; Oncorena; Calithera Bioscience; Surface Oncology; Novartis, Ipsen; Merck Sharp & Dohme and Research Funding from Bristol Myers-Squibb; Nektar Therapeutics; Calithera Bioscience; Arrowhead Pharmaceuticals, Inc. E.J. reports consulting/advisory roles for Eisai, Exelixis, Novartis, Merck, Pfizer, Roche. And Research support from Exelixis, Merck, Pfizer. J.G. reports consulting/advisory roles for Seattle Genetics, Jounce Therapeutics, Pfizer, Janssen, Symphogen, AstraZeneca, ARMO biosciences, CRISPR Therapeutics AG. A.J.Z. reports consulting/advisory roles for AstraZeneca and Bayer and Research funding to his institution from Infinity Pharma, Honoraria from Pfizer, and Janssen. A.Y.S. reports consulting/advisory roles for Ad boards, Pfizer, Exelixis, and Research Grant funding from Bristol Myers-Squibb, Eisai, EMD Serono. J.P.A. reports consulting, advisory roles, and/or stocks/ownership for Achelois, Apricity Health, BioAtla, Codiak BioSciences, Dragonfly Therapeutics, Forty-Seven Inc., Hummingbird, ImaginAb, Jounce Therapeutics, Lava Therapeutics, Lytix Biopharma, Marker Therapeutics, Polaris, BioNTech, and Adaptive Biotechnologies; and owns a patent licensed to Jounce (61/247,438; “Combination Immunotherapy for the Treatment of Cancer”). P.S. reports consulting, advisory roles, and/or stocks/ownership for Achelois, Apricity Health, BioAlta, Codiak BioSciences, Constellation, Dragonfly Therapeutics, Forty-Seven Inc., Hummingbird, ImaginAb, Jounce Therapeutics, Lava Therapeutics, Lytix Biopharma, Marker Therapeutics, Oncolytics, Infinity Pharma, BioNTech, Adaptive Biotechnologies, and Polaris; and owns a patent licensed to Jounce Therapeutics (61/247,438; “Combination Immunotherapy for the Treatment of Cancer”). The remaining authors declare no potential competing interest.

© 2021. The Author(s).

Figures

Fig. 1. Study design and outcomes.

a Clinical trial schema. b Consort diagram showing patients accrued in the study. c and d Kaplan–Meier curves showing estimates of c overall survival and d progression-free survival, orange lines denote Treme alone arm and purple line denotes Cryo+Treme arm (e) Swimmer’s Plot with PFS based on treatment arm. Orange lines denote patients in the Treme alone arm, purple lines denote patients in the Cryo+Treme arm and green triangles show patients with an ongoing response. Treme tremelimumab monotherapy, Cryo+Treme Cryoablation+Tremelimumab combination therapy, PD progressive disease, PFS progression-free survival.

Fig. 2. Durable responses in mRCC patients with clear cell histology.

a Patient #19 with clear cell histology with an ongoing radiographic response showing baseline cross-sectional imaging (2.5 mm cuts) showing lung metastasis (31.5 mm × 27.5 mm) and post-treatment response at 18 months (marked with red line). Radiographic analysis related to the image shown was performed once. b Patient #19 with favorable changes in the tumor immune microenvironment. Single stain IHC images showing an increased infiltration with T cells, B cells, and immune cells expressing Granzyme B (GrB) and PD-1 post treatment with two doses of tremelimumab. The analysis shown in the micrographs was performed once. c Swimmer’s plot with PFS based on histology. Kaplan–Meier curve of overall survival in mccRCC versus mnccRCC patients. Blue lines denote mccRCC patients, red lines denote mnccRCC patients, and green arrows in the swimmer’s plot show patients with ongoing responses. IHC immunohistochemistry, PFS progression-free survival, mccRCC metastatic clear cell renal cell carcinoma, mnccRCC metastatic non-clear cell renal cell carcinoma.

Fig. 3. Patients with mccRCC have a favorable tumor immune microenvironment.

a–c Nanostring analysis comparing pre-treatment tissue samples of 20 mRCC patients with clear cell (mccRCC) versus non-clear cell (mnccRCC) histology (mccRCC, n = 11; mnccRCC, n = 9). a Volcano plot illustrating differentially expressed genes (DEGs). Colored points above the cutoff in the plot show DEGs with p < 0.05 and fold change ≥1.5 that are either upregulated (red) or downregulated (blue) in mccRCC compared to mnccRCC samples. Two-sided P values are from Welch’s t test. b Bar plots showing differentially activated pathways in tumor tissue samples from patients with mccRCC versus mnccRCC. Upregulated pathways in mccRCC are indicated by red bars while downregulated pathways are indicated by blue bars. P values (FDR-adjusted <0.2) are from GSEA algorithm and c Boxplot showing infiltration with Th1 cells. The ends of the box are the upper and lower quartiles (75th and 25th percentiles), the median is the horizontal line inside the box, and whisker lines extend to outliers (minimum and maximum). P value was calculated using the two-tailed unpaired Mann–Whitney test. Each patient is identified by a unique symbol as shown in the inset on the right. Red box whiskers show mccRCC and blue box whiskers show mnccRCC cohort of patients. Patients with ongoing responses are shown in green. P < 0.05 denotes significant differences. mccRCC metastatic clear cell renal cell carcinoma, mnccRCC metastatic non-clear cell renal cell carcinoma, NES normalized enrichment score, Th1 T helper cells type 1. Source data are provided as Source Data file.

Fig. 4. Treatment with tremelimumab monotherapy or cryo-tremelimumab combination therapy leads to favorable changes in post-treatment tissue samples of patients with clear cell histology.

a–d Pre and post-treatment tissue samples of patients with clear cell (mccRCC) and non-clear cell (mnccRCC) histology were analyzed by NanoString (a and c, mccRCC: pre (n = 11), post (n = 11); mnccRCC: pre (n = 9), post (n = 5)) and IHC (b, d and e, mccRCC: pre (n = 13), post (n = 11); mnccRCC: pre (n = 11), post (n = 5)). Box plots showing a infiltration of CD8 T cells, B cells, and cytotoxic cells, b percentage of CD3 T cells, CD8 T cells, CD20+ B cells, and immune cells expressing Granzyme B and PD-1, c TLS gene signature score and, d TLS density. For box plots (a–d), the ends of the boxes are the upper and lower quartiles (75th and 25th percentiles), the median is the horizontal line inside the box, and whisker lines extend to outliers (minimum and maximum). Each patient is identified by a unique symbol as shown in the inset on the right. Patients with ongoing responses are shown in green. Red box whiskers show mccRCC and blue box whiskers show mnccRCC cohort of patients. P values were calculated using the two-tailed unpaired Mann–Whitney test. P < 0.05 denotes significant differences. P values were adjusted for multiple comparisons using the Benjamini–Hochberg procedure. e Representative single stain IHC images showing a TLS from a post-treatment tumor tissue sample of patient #2 with clear cell histology who has an ongoing response. The analysis shown in the micrographs was performed once. IHC immunohistochemistry, mccRCC; metastatic clear cell renal cell carcinoma, mnccRCC metastatic non-clear cell renal cell carcinoma, Pre pre-treatment sample, Post post-treatment sample, GrB granzyme B, TLS tertiary lymphoid structures. All source data are provided as a Source Data file.

Fig. 5. Adding cryoablation to tremelimumab leads to immune cell infiltration in the tumor microenvironment of mRCC patients with clear cell histology.

Pre- and post-treatment tissue samples from patients with clear cell histology who had evaluable tumor tissue samples were analyzed for immune cell infiltration by IHC. a Box plots showing infiltration of CD3 and CD8 T cells, CD20 + B cells, and immune cells expressing PD-1 in the tumor microenvironment of pre, (red, n = 12) and post-treatment tumor samples of patients treated with tremelimumab monotherapy (post Treme, orange, n = 4) or cryoablation plus tremelimumab combination therapy (Post Cryo+Treme, purple, n = 5). For the box plots, the ends of the box are the upper and lower quartiles (75th and 25th percentiles), the median is the horizontal line inside the box, whisker lines extend to outliers (minimum and maximum) and b Bar plots showing the preferential distribution of immune cells as in a between the tumor and stromal compartments of the tumor microenvironment. Pre shown in red, post Treme shown in orange, and Post Cryo+Treme shown in purple. Patients with ongoing responses are shown in green. Error bars represent the mean with minimum to maximum value range. P values were calculated using a two-tailed, unpaired Mann–Whitney test. P values were adjusted for multiple comparisons using the Benjamini–Hochberg procedure. P < 0.05 denotes significant differences. Pre pre-treatment sample, Post Treme, post-treatment sample treated with tremelimumab monotherapy, Post Cryo+Treme post-treatment sample treated with cryoablation plus tremelimumab combination therapy. All source data are provided as a Source Data file.