Neoadjuvant cemiplimab for resectable hepatocellular carcinoma: a single-arm, open-label, phase 2 trial

Abstract

Background: Surgical resection of early stage hepatocellular carcinoma is standard clinical practice; however, most tumours recur despite surgery, and no perioperative intervention has shown a survival benefit. Neoadjuvant immunotherapy has induced pathological responses in multiple tumour types and might decrease the risk of postoperative recurrence in hepatocellular carcinoma. We aimed to evaluate the clinical activity of neoadjuvant cemiplimab (an anti-PD-1) in patients with resectable hepatocellular carcinoma.

Methods: For this single-arm, open-label, phase 2 trial, patients with resectable hepatocellular carcinoma (stage Ib, II, and IIIb) were enrolled and received two cycles of neoadjuvant cemiplimab 350 mg intravenously every 3 weeks followed by surgical resection. Eligible patients were aged 18 years or older, had confirmed resectable hepatocellular carcinoma, an Eastern Cooperative Oncology Group performance status of 0 or 1, and adequate liver function. Patients were excluded if they had metastatic disease, if the surgery was not expected to be curative, if they had a known additional malignancy requiring active treatment, or if they required systemic steroid treatment or any other immunosuppressive therapy. After resection, patients received an additional eight cycles of cemiplimab 350 mg intravenously every 3 weeks in the adjuvant setting. The primary endpoint was significant tumour necrosis on pathological examination (defined as >70% necrosis of the resected tumour). Secondary endpoints included delay of surgery, the proportion of patients with an overall response, change in CD8+ T-cell density, and adverse events. Tumour necrosis and response were analysed in all patients who received at least one dose of cemiplimab and completed surgical resection; safety and other endpoints were analysed in the intention-to-treat population. Patients underwent pre-treatment biopsies and blood collection throughout treatment. This trial is registered with ClinicalTrials.gov (NCT03916627, Cohort B) and is ongoing.

Findings: Between Aug 5, 2019, and Nov 25, 2020, 21 patients were enrolled. All patients received neoadjuvant cemiplimab, and 20 patients underwent successful resection. Of the 20 patients with resected tumours, four (20%) had significant tumour necrosis. Three (15%) of 20 patients had a partial response, and all other patients maintained stable disease. 20 (95%) patients had a treatment-emergent adverse event of any grade during the neoadjuvant treatment period. The most common adverse events of any grade were increased aspartate aminotransferase (in four patients), increased blood creatine phosphokinase (in three), constipation (in three), and fatigue (in three). Seven patients had grade 3 adverse events, including increased blood creatine phosphokinase (in two patients) and hypoalbuminaemia (in one). No grade 4 or 5 events were observed. One patient developed pneumonitis, which led to a delay in surgery by 2 weeks.

Interpretation: This report is, to our knowledge, the largest clinical trial of a neoadjuvant anti-PD-1 monotherapy reported to date in hepatocellular carcinoma. The observed pathological responses to cemiplimab in this cohort support the design of larger trials to identify the optimal treatment duration and definitively establish the clinical benefit of preoperative PD-1 blockade in patients with hepatocellular carcinoma.

Funding: Regeneron Pharmaceuticals.

Conflict of interest statement

Declaration of interests TUM has received research funding from Boehringer Ingelheim, Bristol Myers Squibb, Merck, and Regeneron Pharmaceuticals. TUM has served on advisory boards or data safety monitoring boards, or both, for AstraZeneca, Atara, Boehringer Ingelheim, Celldex, Chimeric Therapeutics, Genentech, Regeneron Pharmaceuticals, Riboscience, and the Rockefeller University. MIF reports involvements with the following organisations: President of the New York Pathological Society (2019–21); President of the Hans Popper Hepatopathology Society of the United States and Canadian Academy of Pathology (2016–18); Central Pathologist at Progenity; and Central Pathologist at Alexion Biopharma. SCW received salary support in 2021 from a Pilot Award (grant) from the Neuroendocrine Tumor Research Foundation; SCW will also be receiving salary support from a research grant from Boehringer Ingelheim International GmbH in 2021–23. DD reports consulting for Atheneum Partners, Boston Healthcare Associates, Boerhinger Ingelheim, Dedham Group, Global Data, Guidepoint Global Advisors, Ipsen, and MJH Life Sciences. AOK reports a consulting role with Engine Biosciences and Axon Advisors LLC. MWS reports consulting roles with Eisai and Genentech. NF, NTG, RD, WW, FW, JM, BK, SL, VJ, NJ, SCH, HKC, JSS, EM, GT, and IL are employees and shareholders eof Regeneron Pharmaceuticals. PTh reports stock ownership in Mannkind and is an employee and shareholder of Regeneron Pharmaceuticals. NB reports a consulting role with Regeneron Pharmaceuticals; stocks and other ownership interest in Avidea, Apricity, and PrimeVax; royalty payments from Neostem and Rome Therapeutics; scientific advisory board roles for Avidea, BioNTech, Boehringer Ingelheim Corporation, BreakBio, Carisma, CureVac, Duke University, Genentech, Genotwin, Gilead Sciences, Human Vaccines Project, MD Anderson Cancer Center, Novartis, Rome Therapeutics, Roswell Park, and Tempest Therapeutics; and both, for Merck, and research funding from Regeneron, Harbor Biomed, and the Parker Institute for Cancer Immunotherapy. SG reports consultancy or advisory roles, or both, for Bristol-Myers Squibb, Genentech, Janssen R&D, Merck, OncoMed, Pfizer, and Regeneron Pharmaceuticals; research funding from Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Genentech, Janssen R&D, Pfizer, Regeneron Pharmaceuticals, and Takeda; and is a named co-inventor on an issued patent for multiplex immunohistochemistry to characterise tumours and treatment responses. The technology is filed through the Icahn School of Medicine at Mount Sinai; the Icahn School of Medicine at Mount Sinai has received payments associated with licensing this technology and both the Icahn School of Medicine at Mount Sinai and SG is entitled to future payments. SG is also partially supported by the National Institutes of Health (grant numbers CA224319, DK124165, CA234212, and CA196521). BT reports grants from Bayer Healthcare, Regeneron Pharmaceuticals, Takeda, and Helio Health; and is a consultant for Bayer Healthcare and Helio Health. MM reports consulting roles with Asher Bio, Celsius Therapeutics, Compugen, Dren Bio, Genenta, Innate Pharma, Morphic Therapeutic, Myeloid Therapeutics, and Nirogy Therapeutics; receives research funding from Boehringer Ingelheim, Genentech, Regeneron Pharmaceuticals, and Takeda; honoraria from Amgen and GSK; and reports ownership interest less than 5% in Asher Bio, Celsius Therapeutics, Compugen, Dren Bio, Genenta, Morphic Therapeutic, Myeloid Therapeutics, and Nirogy Therapeutics. All other authors report no competing interests.

Copyright © 2022 Elsevier Ltd. All rights reserved.

Figures

Figure 1:. Response as assessed by standard imaging, and tumour necrosis assessed by pathological examination and imaging

(A) Waterfall plot of responses in patients ordered by increasing response with standard RECIST measurements (green bars; dashed line correlates with 30% decrease in tumour size). Degree of necrosis as assessed pathologically by two expert hepatopathologists (light blue bars; based on absolute change in necrosis) and degree of necrosis on MRI done after treatment, before surgery (dark blue bars; dashed line correlates with 70% necrosis to achieve the primary endpoint of significant tumour necrosis). (B) Comparative analysis of necrosis measurements by MRI and as per pathological analyses. The blue dashed line is the regression line. *Imaging data not available for analysis of necrosis; denotes a patient for whom MRI was contraindicated, so MRI-based analysis of necrosis was not possible; pathological necrosis was 0%. †Patients with confirmed significant tumour necrosis. ‡Patient without MRI to quantify necrosis.

Figure 2:. Tissue analysis by multiplex immunohistochemistry, mass cytometry, and RNA sequencing

(A) Representative image of a multiplex immunohistochemistry panel (comprising CD3, CD8, FOXP3, CD68, and CD20) used to do quantitative image analysis. (B) Mean density of each immune subset at baseline and at resection in patients with 50% or more necrosis according to multiplex immunohistochemistry. Immune subsets are defined as T cells (CD3+, CD8+ T cells), conventional CD4 cells (CD3+, CD8−, FOXP3− cells), regulatory T cells (CD3+, FOXP3+ cells), myeloid cells (CD68+), and B cells (CD20+). Error bars indicate one standard error of the mean. (C) Heat map representation of bulk RNA sequencing of biopsy cores and tumour resection from 11 patients (seven patients with little to no necrosis on resection [all <50% necrosis] and four patients with ≥50% necrosis). Genes used in previously published gene signatures correlating with immune lineage are shown at baseline and after treatment. (D) Comparison of immune lineage populations taken from RNA sequencing analysis with publicly available gene signatures associated with CD8 T cells, regulatory T cells, monocyte-derived macrophages, and B cells, as well as activated or dysfunctional, cytotoxic, and naive programmes. DAPI=4′,6-diamidino-2-phenylindole.

Figure 2:. Tissue analysis by multiplex immunohistochemistry, mass cytometry, and RNA sequencing

(A) Representative image of a multiplex immunohistochemistry panel (comprising CD3, CD8, FOXP3, CD68, and CD20) used to do quantitative image analysis. (B) Mean density of each immune subset at baseline and at resection in patients with 50% or more necrosis according to multiplex immunohistochemistry. Immune subsets are defined as T cells (CD3+, CD8+ T cells), conventional CD4 cells (CD3+, CD8−, FOXP3− cells), regulatory T cells (CD3+, FOXP3+ cells), myeloid cells (CD68+), and B cells (CD20+). Error bars indicate one standard error of the mean. (C) Heat map representation of bulk RNA sequencing of biopsy cores and tumour resection from 11 patients (seven patients with little to no necrosis on resection [all <50% necrosis] and four patients with ≥50% necrosis). Genes used in previously published gene signatures correlating with immune lineage are shown at baseline and after treatment. (D) Comparison of immune lineage populations taken from RNA sequencing analysis with publicly available gene signatures associated with CD8 T cells, regulatory T cells, monocyte-derived macrophages, and B cells, as well as activated or dysfunctional, cytotoxic, and naive programmes. DAPI=4′,6-diamidino-2-phenylindole.