Targeting PD-1 Or PD-L1 in Metastatic Kidney Cancer: Combination Therapy in the First-Line Setting David H

Published OnlineFirst January 16, 2020; DOI: 10.1158/1078-0432.CCR-19-3323

CLINICAL CANCER RESEARCH | REVIEW

Targeting PD-1 or PD-L1 in Metastatic Kidney Cancer: Combination Therapy in the First-Line Setting David H. Aggen1, Charles G. Drake2, and Brian I. Rini3

ABSTRACT ◥ Recent FDA approvals of regimens targeting programmed and regulation of these targets. Here, we review current clinical death 1 (PD-1) in combination with anti-CTLA-4 or with VEGF data on combination immune checkpoint inhibitor therapy in tyrosine kinase inhibitors are reshaping front-line therapy for metastatic kidney cancer and discuss the relevant biology of PD-1 metastatic kidney cancer. In parallel, therapeutics speciﬁcfor and PD-L1. The design of future rational combination therapy programmed death ligand 1 (PD-L1), one of the two major trials in metastatic renal cell carcinoma will rely upon an ligands for PD-1, are under continued investigation. Surprisingly, understanding of this biology, along with an evolving under- not all PD-1 and PD-L1 agents lead to similar clinical outcomes, standing of immune cell populations and their functional states potentially due to biological differences in the cellular expression in the tumor microenvironment.

Introduction Observations in other tumor types support the concept of non- equivalence between PD-1 and PD-L1 targeted therapeutics. In blad- The discovery of programmed death 1 (PD-1) and programmed der cancer, the anti-PD-1 agent pembrolizumab showed an OS benefit death ligand 1 (PD-L1) as a mechanism of peripheral T-cell tolerance compared with second-line treatment in Keynote-045 (7), whereas the spurred the development of multiple therapeutics blocking their anti-PD-L1 antibody atezolizumab did not show an OS benefit when critical interaction (1). In the context of kidney cancer, the PD-1– compared with second-line chemotherapy in a similar patient popu- specific therapies nivolumab (2, 3) and pembrolizumab (4), as well as lation in the IMVigor211 trial (8). In NSCLC, the anti-PD-1 antibody the PD-L1 antibody avelumab (5) are FDA-approved in combination pembrolizumab improved OS relative to second-line chemotherapy in with other therapies for metastatic renal cell carcinoma (RCC). In the Keynote-010 (9), whereas the anti-PD-L1 antibody avelumab failed to past 14 months, four phase III trials have tested the hypothesis that improve OS in a similar cohort of patients (10). Notwithstanding the immunotherapy (I/O)-based combinations are efficacious as first-line limitations of cross-trial comparisons, the discrepancies in clinical therapy in metastatic RCC (Table 1). Combination therapies based on outcome between PD-1 and PD-L1 antibodies beg a lingering question: anti-PD-1 antibodies, pembrolizumab plus axitinib and nivolumab are these therapeutics equivalent? plus ipilimumab, have improved overall (OS) relative to sunitinib (3, 4). Fundamental differences in the biologic mechanisms of anti-PD-1 In contrast, combination therapies with anti-PD-L1 antibodies includ- and anti-PD-L1 may underlay these potentially disparate clinical ing avelumab plus axitinib (Javelin-101; ref. 5) or atezolizumab plus outcomes; thus, understanding these nuances is critical to the design bevacizumab (ImMotion 151; ref. 6) have not yet demonstrated an of next-generation combinatorial strategies. Herein, we describe some overall survival benefit. Overall survival data in these anti-PD-L1 key distinctions in PD-1 and PD-L1 biology in terms of cell type– combination trials are still immature, and ultimately a survival benefit specific expression, differential regulation, and the physiologic effects might be observed with further follow-up. Despite this finding, it is of blockade. The relative contribution of antibody directed cell cyto- notable that occasional complete responses were reported with both toxicity (ADCC) for PD-L1 therapeutics is also discussed. Finally, we anti-PD-1 and anti-PD-L1 combination regimens. Caution should be summarize ongoing clinical activity using these therapeutics in com- exercised in cross-trial comparison due to potential differences in bination regimens. baseline patient characteristics. However, the OS benefits documented in anti-PD-1 combination therapy trials, but not in anti-PD-L1 immunotherapy studies, highlights potential advantages to targeting The PD-1/PD-L1 Interaction Attenuates PD-1 as compared with PD-L1 in specific clinical contexts. a T-Cell Response T-cell activation is initiated by the engagement of a T-cell receptor (TCR) with its cognate peptide-MHC complex—along with an appropriate costimulatory signal (Signal 2). In this setting, the primary 1 2 Memorial Sloan Kettering Cancer Center, New York, New York. Herbert Irving biologic function of PD-1 is to maintain a desirable range of T-cell Cancer Center, New York-Presbyterian/Columbia University Medical Center, New York, New York. 3Division of Hematology/Oncology, Vanderbilt University activation so as to prevent rampant autoimmunity (11). Upon T-cell Medical Center, Nashville, Tennessee. activation, PD-1 is upregulated within 12 to 36 hours and its interaction with PD-L1 and/or PD-L2 downmodulates T-cell proliferation Note: Supplementary data for this article are available at Clinical Cancer Research Online (http://clincancerres.aacrjournals.org/). and effector function (Fig. 1; ref. 12). Biochemically, PD-1 binding to either PD-L1 or PD-L2 (13) activates the tyrosine phosphatase SHP-2 Corresponding Author: David H. Aggen, Memorial Sloan Kettering Cancer – Center, New York, NY 10065. Phone: 646-422-4679; Fax: 646-227-2417; E-mail: in the PD-1 expressing cell; this directly dampens T-cell activation by [email protected] dephosphorylating the TCR and costimulatory molecules like CD28 (14). In the setting of chronic antigen stimulation, PD-1 Clin Cancer Res 2020;26:1–9 preserves T-cell clones that might otherwise undergo activation- doi: 10.1158/1078-0432.CCR-19-3323 induced cell death. As a consequence of its biology, PD-1 expression 2020 American Association for Cancer Research. is both a marker of initial T-cell activation as well as a marker of several

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Table 1. Summary of completed phase III trials in metastatic RCC evaluating combination immune therapies.

Nivolumab þ Ipilimumab Pembrolizumab þ Axitinib Avelumab þ Axitinib Atezolizumab þ Bevacizumab

Trial CheckMate 214 Keynote 426 Javelin 101 ImMotion 151 N 1,096 861 1,096 915 PD-L1þ (%)a 23.0% 59.3% 61.0% 40.0% PD-L1 assay/cutoff Dako 28-8 (1% TC) Dako 22C-3 (CPS 1%) Ventana SP263 (1% IC) Ventana SP-142 (>1% IC) Risk category Favorable 23.0% 31.9% 21.3% 20.0% Intermediate 61.0% 55.1% 61.3% 69.0% Poor 17.0% 13.0% 16.3% 12.0% Liver metastases (%) 24.5% 15.0% NR 17.0% Median follow-up (months) 32.4 12.8 12.0 24.0 ORRb 41.0% 59.3% 51.4% 37.0% CRb 11.0% 5.8% 3.4% 5.0% PFS (months) Combination arm 9.7 15.1 13.8 11.2 Sunitinib arm 9.7 11.1 8.4 8.4 HR (CI) 0.85 (95.0% CI, 0.73–0.98) 0.69 (95% CI, 0.57–0.84) 0.69 (95.0% CI, 0.56–0.84) 0.83 (95.0% CI, 0.70–0.97) OS (months) Combination arm NR NR NR 33.6 Sunitinib arm 37.9 NR NR 34.9 HR (CI) 0.71 (95.0% CI, 0.59–0.86) 0.53 (95% CI, 0.38–0.74) 0.78 (95% CI, 0.55–1.08) 0.93 (95% CI, 0.76–1.14)

Note: HR with statistically signiﬁcant conﬁdence intervals are in bold. Abbreviations: CPS, combined positive score calculated as the number of (total PD-L1 þ TC and IC)/divided by total number of TC x 100; IC, immune Cells; NR, not reported; TC, tumor cells. aPercent PD-L1 positive in combination I/O arm. PD-L1 cutoff and compartment evaluated differs in each trial. bORR and CR rate in combination I/O arm.

states of functional exhaustion. Those states are defined in part by the PD-1 and PD-L1 Are Dynamically coexpression of additional immune checkpoint molecules like LAG-3 Regulated by Cell Extrinsic and Intrinsic and TIM-3 (15). Consequently, not all PD-1–expressing T cells behave as functionally exhausted T cells, and additional cell surface markers Factors and epigenetic signatures are required to more completely define As described above, PD-1 expression is initiated by T-cell immune cell subsets with diminished effector capacity (recently activation. Expression is further modulated by a number of signals reviewed in detail; ref. 16). in the TME including TGFb (25), and IFNa,whichpromote upregulation of PD-1 on both T cells and macrophages (26). PD-1 biology is somewhat complex, with at least 10 transcriptional PD-1 and PD-L1 Protein Expression: factor complexes that function in modulating PD-1 activity depen- Shared but Distinct Cellular dent on the state of T-cell activation (reviewed in detail elsewhere; ref. 27). In acute infection, antigen clearance leads to eventual Compartments downregulation of PD-1, whereas in the context of cancer and In general, PD-1 is expressed on activated/exhausted CD8 and CD4 chronic viral infection persistent antigen exposure drives continued T cells, although expression has been reported on a number of other PD-1 expression on antigen-specific T cells (28). populations including B cells and macrophages (17). PD-L1 may be PD-L1 expression on immune and tumor cell subsets is largely expressed on both tumor cells or other cells in the TME, including induced by TH1cytokineslikeIFNg.FollowingIFNg exposure, dendritic cells, macrophages, and other myeloid populations (18). tumor and immune cells upregulate PD-L1 through a transcrip- Controversy exists regarding the most important PD-L1 expressing tional program involving the JAK1/STAT signaling pathway (29). population—with some studies suggesting that tumor expression is Clinically, this is important, because mutations in the JAK/STAT most critical (19, 20) and other studies highlighting expression on pathway and antigen presentation machinery have been implicated myeloid populations (21, 22). The second major PD-1 ligand, PD-L2, in primary and acquired resistance to PD-1 therapy in melano- has a more restricted expression pattern with predominant expression ma (30). At the genomic level, copy-number alterations (CNA) in on endothelial cells, monocytes, and dendritic cells. In a study eval- the PD-L1 gene in tumor cells may also lead to increased levels of uating PD-L2 expression in seven distinct tumor types, RCC had PD-L1 expression. CNA in PD-L1 at chromosome 9p24 are asso- among the lowest level of tumor PD-L2 expression with relatively high ciated with increased tumor mutation burden (31) and are enriched stromal and endothelial cell expression of this ligand (23). The in a rare but unique RCC subset with sarcomatoid pathologic expression of PD-L2 in the TME is in general under-appreciated, features (32). The latter is of keen interest as gene signatures especially as PD-1 has a higher binding affinity for PD-L2 than for PD- associated with sarcomatoid RCC pathology were enriched in L1 (24). Indeed, the potential of PD-L2 to promote T-cell tolerance patients responding to atezolizumab and bevacizumab in IMMotion provides one potential explanation for the lack of OS benefit with PD- 151 (33). Subgroup analysis of patients with sarcomatoid pathologic L1 combination therapies in kidney cancer. features from Checkmate 214 (nivolumab þ ipilimumab; ref. 34)

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CD8 T cell

Anti-PD-1 PD-1 TAM PD-L2 Pembrolizumab DC Nivolumab Spartalizumab TCR PD-1

VEGF PepMHC PD-L1 B7.1/2 B7.1/2 Pep Anti-PD-L1 MHC Avelumab CD28 CTLA4 Atezolizumab TCR Durvalumab

Anti-CTLA4 Tumor lpilimumab CD4 cell VEGF Tremelimumab VEGF TKIs Axitinib Cabozantinib Sunitinib Bevacizumab Pazopanib Tivozanib Sitravatinib Lenvatinib

Figure 1. PD-1/PD-L1 targeted therapeutics in renal cell carcinoma. Overview of current immunotherapy targets in renal cell carcinoma. The PD-1 antibodies pembrolizumab, nivolumab, and spartalizumab prevent interaction with PD-L1 and PD-L2. In contrast, the PD-L1 antibodies avelumab, atezolizumab, and durvalumab prevent PD1 ligation, but leave PD-1 and PD-L2 ligation unopposed.

and Keynote 426 (pembrolizumab þ axitinib; ref. 35) also demon- with concomitant attenuation of glycolysis (40). This metabolic switch strated improved ORR and OS relative to sunitinib. assists in determination of T cell effector versus memory cell fates and Additional tumor intrinsic factors may also drive PD-L1 expression promotes the maintenance of functional CD8 exhaustion. Similarly, to promote immune tolerance and tumor immune evasion. In clear cell attenuation of glycolysis in CD4 T cells, which may or may not be RCC, HIF2a activation secondary to Von Hippel Landau (VHL) independent of PD-1 signaling, promotes regulatory T cell commit- deficiency promotes PD-L1 expression in vitro (36, 37). However, ment (41). Thus PD-1 and additional costimulatory molecules, such as clinical data supporting this association are not yet available. VHL 4-1BB, are implicated in driving immune cell metabolic programs that inactivation is estimated to occur in >90% of patients with RCC either lead to T cell dysfunction. through direct mutation or promoter hyper-methylation, and one Ongoing PD-1 engagement with its cognate ligands also results in would anticipate the number of PD-L1 expressing tumor samples in epigenetic reprogramming of T cells, which may prevent effective RCC would be dramatically higher if this association were abso- rescue by immune checkpoint blockade. These observations were lute (38). For example, in Checkmate 214, only 20% to 30% of patients initially based on murine studies utilizing the LCMV virus that mimics with RCC had PD-L1 positive tumor cells (3). Similarly, in the chronic antigen stimulation as is observed in cancerous states (42). In COMPARZ trial evaluating pazopanib versus sunitinib, 36% of LCMV murine models, functionally exhausted T-cell remained in a patients had PD-L1–positive specimens (39). As a consequence, the PD-1HI exhausted state even after clearance of antigen, demonstrating association between PD-L1 expression and VHL deficiency certainly that epigenetic mechanisms likely underlie long-lived functional requires additional investigation. exhaustion and PD-1 expression (43). More recent data suggest that distinct epigenetic profiles define Metabolic and Epigenetic Programs states of functional T-cell exhaustion (16). Elegant work identified the nuclear transcription factor TOX as a central regulator of Modulated by the PD-1/PD-L1 Axis epigenetic and transcriptional programs driving T-cell exhaus- PD-1 ligation with PD-L1 or PD-L2 induces T cell functional tion (44, 45). TOX expression increases following chronic antigen exhaustion by causing distinct metabolic changes within the T cell. stimulation, leading to a decrease in markers of self-renewal in T PD-1 binding switches the T cell energy source to fatty acid oxidation cells—including the key transcription factor TCF1 (46). Conversely,

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deletion of TOX restored CD8 T-cell function and differentiation to targeting tumor and immune cells. With adoption of immunother- effector and memory phenotypes. Taken together, these studies apy into the neoadjuvant setting in clinical trials of kidney cancer show that that TOX is a critical driver of early T-cell exhaustion. including PROSPER-RCC (53), we will gain further insights into Advancements in single-cell analysis (47) and epigenetic profiling the mechanistic and kinetic differences in PD-1 and PD-L1 occu- will be critical in further defining the functional and phenotypic pancy and immune blockade. Similarly, adjuvant trials for high-risk heterogeneity within these exhausted states, and clinical interven- RCC evaluating atezolizumab (NCT03024996) and pembrolizumab tions aimed at altering the epigenetic phenotype of T cells remains (NCT03142334) have completed accrual, and peripheral blood an area of active interest (48–50). studies from these trials will enhance our understanding of the relative benefit of perioperative PD-L1 and PD-1 blockade. Functional Consequences of PD-L1–targeted therapies, in contrast, can induce immune tumor rejection through multiple mechanisms (summarized PD-1/PD-L1 Blockade in the Clinic in Fig. 2B–D). First, anti-PD-L1 therapies prevent ligation with Anti-PD-1 agents can restore the functionality of exhausted T PD-1 on immune cells like anti-PD-1 therapeutics. PD-L1 blockade cells through direct ligation of PD-1 on CD4 and CD8 T lympho- also prevents ligation with the costimulatory molecule B7.1 (CD80) cytes, and based on that principle may rescue an immune response either in cis or in trans, which may provide a secondary mechanism relatively independent of tumor PD-L1 expression (Fig. 2A). Direct for T-cell reinvigoration (54). Second, anti-PD-L1 therapeutics may T-cell binding by an anti-PD-1 therapeutic may afford significant also drive direct tumor cell killing through antibody-dependent advantages relative to an anti-PD-L1 treatment, potentially via cellular cytotoxicity (ADCC), in this case via PD-L1 expressed on more rapid T-cell expansion. In patients with melanoma treated tumor cells (Fig. 2C). In murine models, anti-PD-L1 that bind Fc with anti-PD-1, peripheral blood profiling showed that expansion receptors that mediate ADCC led to tumor regression, whereas a of a PD-1þ effector T-cell pool after immune checkpoint blockade similar effect was not observed with anti-PD-1 therapies in those correlated with clinical response (51). Relevant neoadjuvant studies models (55). illustrate peripheral occupancy of PD-1, with peripheral blood Despite these theoretical advantages, there are now two randomized responses detected within 3 weeks on therapy (52). Peripheral phase III trials in metastatic RCC using anti-PD-L1 therapeutics that blood profiling also shows that anti-PD-1 therapeutics rapidly have not yet shown an OS benefit(Table 2). OS data in these trials is stimulate T cells in the periphery, enabling tumor cell lysis, still immature and longer follow-up is awaited. Although the mechan- relatively independent of tumor volume/burden. The kinetics of isms underlying this difference may be challenging to dissect, one T-cell expansion mediated by direct engagement of PD-1 on possibility is that interaction between PD-1 and PD-L2 is unaffected by effector T cells may not be achievable with anti-PD-L1 agents PD-L1 blockade, such that interactions between PD-L2 in the TME

A Prevents PD-L1 interaction B Prevents PD-1 interaction C ADCC on tumor cell D ADCC on immune cell PD-1 Blockade PD-L1 blockade

Direct T-cell engagement Direct tumor engagement Direct tumor engagement Direct T-cell engagement

T cell = Anti-PD-1 T cell = Anti-PD-L1 = Anti-PD-L1 = Anti-PD-L1

TAM TAM PD-1 B7.1 Fc (CD80) PD-1 PD-1 receptor Fc TCR PD-1 PD-L2 PD-L2 TCR receptor pep pep pep MHC TCR PD-L1 DC MHC PD-L1 DC Lytic enzymes MHC Peforin Lytic enzymes PD-L1 Granzymes Peforin TNF Granzymes T cell TNF Tumor Tumor Tumor cell cell cell

• Allows metabolic and • Blocks interaction with PD-1 on • Anti-PD-L1 binds to tumor • Anti-PD-L1 binds to immune epigenetic reprogramming immunocytes and B7.1 (CD80) cells expressing PD-L1 cells expressing PD-L1 of T cells • Does not interact directly with T • Tumor cell killing via Fc-receptor • Potential for immune cell • Blocks interaction between cells mediated antibody-dependent killing and depletion of either PD-1 and PD-L1/PD-L2 cellular cytotoxicity immunosuppressive cells (M2- like TAMs, MDSCs)

Figure 2. Mechanisms of PD-1 and PD-L1 targeting immunotherapy. A, PD-1 blockade exerts direct effects on immune cells upon ligation by driving distinct metabolic and epigenetic programs that reverse T-cell dysfunction. B, PD-L1 blockade on immune cells masks PD-1 ligation. PD-1 can bind PD-L2. C, ADCC from PD-L1 ligation on tumor cells permits tumor cell killing. D, PD-L1 expression on T cells permits ADCC of immune cells overexpressing PD-L1.

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Table 2. Prospects and limitations of anti-PD-1 and anti-PD-L1 immunotherapies for combination therapy in RCC.

Advantages Disadvantages

Anti-PD-1 * Targets T cells directly * No direct tumor effects from antibody * Distinct metabolic and epigenetic changes upon PD-1 * In vitro VEGF TKIs increase PD-1 expression on immune cells providing a binding reverse T-cell exhaustion potential resistance mechanism * Does not require tumor PD-L1 expression for activity * PD-1 occupancy on T cells observed within 3 weeks on treatment

Anti-PD-L1 * Targets tumor cells directly * Does not block PD-1 binding to PD-L2 * May permit ADCC of tumor cells * PD-L1 exists on exosomes and in soluble forms which may act as a “decoy” * May also target immunosuppressive TAMs that express PD- receptor for antibody therapy L1 in the TME * VEGF TKI treatment permits PD-L1 upregulation on tumor cells providing a potential resistance mechanism * Limited engagement of anti-PD-L1 with PD-L1þ tumor T cells allows for continued T cell dysfunction * Potential for ADCC and elimination of PD-L1þ positive immune cells subsets (NK cells, DCs, antitumor TAM) * Kinetics of PD-L1 occupancy are not yet deﬁned and complete saturation to block PD-1 ligation may not be possible

and PD-1 on T cells provides some level of ongoing suppression. A immunotherapy combination approaches may leverage the ability to second theoretical concern involves binding to nontumor cell expres- selectively deplete immunosuppressive cell subsets and potentiate sing isoforms of PD-L1, sequestering antibody that might be important antitumor responses. in blocking the PD-1/PD-L1 interaction. Accordingly, relevant data suggest that PD-L1 expression on exosomes (56) and secreted variants PD-1 Versus PD-L1 in Combination with of PD-L1 (57) may suppress anti-PD-L1 responses. A final potential mechanism of interest is that expression of PD-L1 on immune cells VEGF TKIs might deplete immune effector cells through ADCC in certain cir- In RCC, the addition of a VEGF TKI to an anti-PD-1 or PD-L1 cumstances (Fig. 2D, reviewed below). antibody exploits a number of potentially synergistic mechanisms. VEGF in the tumor ecosystem promotes immunosuppression Antibody Isotype Effects on Clinical by decreasing T-cell trafficking to tumors, increasing immunosuppressive cytokines and initially increasing regulatory T cells. Treat- Activity ment with anti-angiogenic therapies mitigates a number of the An underappreciated aspect of immune checkpoint blockade is immunosuppressive effects of VEGF in preclinical models (61, 62). the relative contribution of T-cell–mediated tumor killing versus For example, the use of sunitinib in a preclinical RCC model the potential for ADCC or complement-dependent cytotoxicity. In decreases immunosuppressive myeloid-derived suppressor cells ADCC, FC gamma receptors (primarily FcgRIII) on the surface of (MDSC), a potential mechanism of adaptive immune resistance to macrophages and NK cells bind to the Fc portion of antibodies PD-1 immunotherapy (63). More recent preclinical data with resulting in depletion of tumor or subsets of immune cells (Fig. 2C axitinib showed antitumor efficacy not only through vascular and D). SpecificIgGsubtypesaremorelikelytopromoteADCC, remodeling but also through depletion of tumor-promoting mast with IgG1 and IgG3 antibody subtypes with a higher binding cells and tumor-associated macrophages (64). In human RCC affinity for Fc receptors (Supplementary Table S1; ref. 58). Thus, specimens, treatment with antiangiogenic therapy increased infil- anti-PD-L1 antibodies of the IgG1 isotype may lead to depletion of tration of CD4 and CD8 effector T cells, supporting the hypothesis both tumor and immune cells. Indeed, avelumab, an IgG1 isotype that VEGF inhibition might potentiate the response to immune antibody, can mediate ADCC and lead to effective direct tumor cell checkpoint blockade by promoting T-cell infiltration (65). Clearly, killing. In theory, ADCC can also occur on PD-L1–positive CD8 the immune effects of VEGF TKIs support nonredundant mechan- effector cells leading to elimination of immune effectors. However, isms of immune activation distinct from the PD1/PD-L1 axis, no definitive evidence of the latter phenomena has been appreciated with TKI immune remodeling affecting the myeloid and T-cell clinically. Importantly, recently presented subgroup analysis from compartment. the Javelin-101 showed no difference in activity of combination Although the MDSC-specific effects of TKIs provide a good ratio- avelumab plus axitinib treatment in patients with FcgRIII poly- nale for combining anti-PD-L1 with VEGF therapy, there are morphisms, demonstrating that ADCC may be only a minor some data suggesting that VEGF TKIs may dampen a T-cell response mechanism in anti-PD-L1 immunotherapy (59). to cancer. Chronic inhibition of VEGF with TKIs can induce a hypoxic Ongoing efforts are focused on improving the efficiency of anti- state within the TME with a concomitant accumulation of HIF1a (66). body-induced cellular cytotoxicity with immune checkpoint blockade Multiple studies show that HIF1a accumulation induces a compen- antibodies. Through modification of glycosylation and fucosylation satory immunosuppressive state through recruitment of MDSCs (67), sites, antibodies can be engineered to have differential effects on ADCC tumor-associated macrophages (68, 69), and Tregs (70). In addition, and cellular depletion (60). To promote ADCC, an Fc-modified (non- accumulation of HIF1a alters PD-L1 expression on immune fucosylated version) of anti-CTLA-4 is in early-phase clinical trials cell subsets (71). That observation is supported by data from human with the goal of regulatory T-cell depletion (NCT#03110107). Future RCC samples showing that TKIs may decrease PD-L1 expression,

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rendering anti-PD-L1 blockade more challenging. Of note, on- Consensus First-Line Therapy treatment biopsies from patients treated with pazopanib or sunitinib Approaches in Metastatic RCC showed transient decreases in PD-L1 expression by IHC (72). In some model systems, VEGF TKIs also decrease immune cell PD- Both nivolumab plus ipilimumab and pembrolizumab plus axitinib 1 expression (73). The decrease in PD-1 expression, however, is not are now consensus first-line treatments for metastatic RCC. At present, absolute, and blockade of remaining PD-1 on T cells with anti-PD-1 the choice of first-line therapy for a given patient is not driven by a therapeutics may explain the improved OS noted with combination randomized, comparative trial, but rather by treatment side-effect anti-PD-1 with VEGF TKIs. Taken together, these collected observa- profile, prognostic risk group, perceived benefits of complete and tions lend support to a hypothesis that limited or intermittent VEGF overall response rate and MD/patient preference. Avelumab plus TKI therapy in combination regimens might allow an even greater axitinib is also FDA approved for first-line RCC, but so far, an OS immune response, but at present all TKI combinations in the phase III benefit relative to sunitinib has not been documented. Finally, the FDA setting have been taken continuously. Further, HIF1 inhibition may be application for drug approval of atezolizumab plus bevacizumab was a therapeutic approach to enhance the clinical benefit of VEGF TKI- withdrawn by the manufacturer, although there may in fact be based combinations. subgroups of patients with specific gene signatures that benefit from

Table 3. On-going immunotherapy trials in RCC.

Estimated Therapy Number Phase Trial ID completion date

First-line metastatic RCC trials Pembrolizumab þ Lenvatinib or Everolimus þ Lenvatinib vs. Sunitinib (CLEAR) 1,050 III NCT02811861 February 2021 Nivolumab þ Ipilimumab Followed by Nivolumab Cabozantinib (PDIGREE) 1,046 III NCT03793166 September 2021 Nivolumab þ Ipilimumab Cabozantinib (COSMIC-313) 676 III NCT03937219 November 2021 Nivolumab þ Cabozantinib vs. Sunitinib 638 III NCT03141177 May 2024 Nivolumab þ bempegaldesleukin (CD122 agonist) vs. Cabozantinib or Sunitinib 600 III NCT03729245 June 2024 Nivolumab þ Ipilimumab vs. Nivo/IDO vs. Nivo/Anti-Lag3 (Relatlimab) vs. 200 Ib/II NCT02996110 January 2022 Nivolumab þ CCR2/CCR5 dual agonist (BMS936558) FRACTION-RCC Nivolumab þ Cabozantinib Ipilimumab 152 I NCT02496208 Early 2020 Nivolumab þ Ipilimumab or Pazopanib or Sunitinib (BIONIKK Biomarker Guided Trial) 150 II NCT02960906 May 2020 Nivolumab with Salvage Nivolumab þ Ipilimumab 120 II NCT03117309 February 2021 Nivolumab þ Bempegaldesleukin (CD122 agonist) Ipilimumab 90 Ib/II NCT02983045 June 2021 Pembrolizumab þ Cabozantinib 55 Ib/II NCT03149822 June 2020 Advanced (second-line or later) metastatic RCC trials Arginase Inhibitor (INCB001158) þ Pembrolizumab 424 Ib/II NCT02903914 January 2020 TLR 7/8 agonist (NKTR 262) þ bempegaldesleukin Nivolumab 393 Ib/II NCT03435640 December 2023 Anti-CD73 (CPI-006) A2AR Antagonist or Pembrolizumab 378 Ib/II NCT03454451 December 2023 Glutaminase Inhibitor (CB-839) þ Nivolumab 299 Ib/II NCT02771626 Early 2020 Anti-TIM3 (MBG453) Spartalizumab (Anti-PD1) 250 Ib/II NCT02608268 Early 2020 Durvalumab Tremelimumab or Savolitinib 195 II NCT02819596 Early 2020 ApoE Agonist (RGX104) þ Nivolumab 150 Ib/II NCT02922764 Early 2020 Anti-CSF1R (Cabiralizumab) þ Anti-CD40 (APX005M) Nivolumab 120 Ib/II NCT03502330 October 2024 HIF-2a Inhibitor (PT2977) þ Cabozantinib 118 II NCT03634540 September 2022 Axitinib þ Nivolumab 98 Ib/II NCT03172754 April 2024 Sitravatinib þ Nivolumab 60 Ib/II NCT03015740 April 2023 Angiopoietin-2 inhibitor (Trebananib) þ Pembrolizumab 60 Ib/II NCT03239145 August 2024 Anti-IL1b (Gevokizumab) þ Cabozantinib 60 Ib NCT03798626 December 2023 Guadecitabine þ Durvalumab 58 Ib/II NCT03308396 December 2020 177Lu-J591 Anti-PSMA Radiolabeled Antibody 50 I NCT00967577 December 2019 Anti-CD25 pyrrolobenzodiazepine toxin conjugate (Camidanlumab Tesirine) 50 I NCT03621982 July 2021 IL-2 (Aldesleukin) þ Pembrolizumab 27 I NCT03260504 March 2021 Perioperative (neoadjuvant RCC trials) Nivolumab – PROSPER RCC 805 III NCT03055013 November 2023 MSKCC 29 Pilot NCT02595918 August 2020 Royal Marsden 19 Pilot NCT02446860 Late 2019 Avelumab þ Axitinib 40 Pilot NCT03341845 August 2025 Durvalumab Tremelimumab 45 Ib NCT02762006 January 2020 Nivolumab þ Sitravatinib 25 II NCT03680521 December 2019 Anti-IL1b (Canakinumab) þ Spartalizumab (anti-PD1) 14 Pilot NCT04028245 2021 Adjuvant RCC immunotherapy trials Durvalumab vs. Durvalumab/Tremelimumab vs. Observation 1,750 III NCT03288532 December 2037 Pembrolizumab vs. Observation 950 III NCT03142334 December 2025 Nivolumab þ Ipilimumab vs. Observation 800 III NCT03138512 July 2023 Atezolizumab vs. Observation 778 III NCT03024996 April 2024

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this combination (74). Taken together, these data support the use of a patients with metastatic RCC, nearly 50% of patients will not receive a PD-1–based immunotherapy combination, either with pembrolizu- second line treatment due to either disease progression or declining mab plus axitinib or nivolumab plus ipilimumab for first-line therapy performance status (80). In real-world data sets, it is estimated that of metastatic RCC. >80% of patients do not receive any second-line treatment (80, 81). As a consequence, maximizing the efficacy of first-line therapy is of Future Combination Therapy utmost importance. Approaches for Metastatic RCC The impressive response rates and OS for patients treated with Conclusions combination anti-PD-1 plus anti-CTLA-4 or anti-PD-1 plus VEGF There are now three FDA-approved combination immunothera- TKI therapy with a favorable side-effect profile and tolerability begs the pies for the treatment of first-line kidney cancer, but only anti-PD- question of utilizing a triplet therapy in the first-line setting (75). 1-based combinations to date have illustrated an OS benefit. Combination nivolumab, ipilimumab, and cabozantinib has been Blockade of PD-1 permits direct reprogramming of T cells, whereas administered safely across GU malignancies, and the activity of this anti-PD-L1 exerts those effect in an indirect fashion and permits triplet will be tested in a phase II expansion cohort and a randomized, binding between PD-1 and PD-L2.Althoughincontemporary phase III trial (76). Triplet therapy, however, likely over treats some models, the activity of anti-PD-1 þ VEGF TKI appears to be patients, such that biomarker-based strategies to select patients for the additive, the remarkable gains in ORR, PFS, and OS will likely appropriate mechanism and intensity of therapy is an unmet need. necessitate that anti-PD-1 therapeutics remain the backbone of One additional combination for first-line treatment, pembrolizumab first-line treatment for renal cell carcinoma. For the foreseeable þ lenvatinib, is currently being tested in large phase III trials. Table 3 future, the selection of first-line treatment will be guided by side- provides a complete listing of trials currently accruing for RCC. effect profile, risk group, and patient preference, whereas the next A potential approach to mitigate the toxicities of I/O–I/O combina- generation of first-line therapies may require clinically validated tions is to incorporate other anti-inflammatory medications into the biomarkers to select the appropriate treatment regimen. first-line treatment regimens. To this end, clinical trials are on-going exploring cytokine targets including anti-IL1b (NCT04028245), anti- Disclosure of Potential Conflicts of Interest IL6, and anti-IL8 (NCT03400332; ref. 77) to augment the immune D.H. Aggen is a paid consultant for Boehringer Ingelheim. C.G. Drake is a paid response and potentially improve regimen tolerability. Another poten- consultant for AstraZeneca, Bristol-Myers Squibb, Roche/Genentech, Merck, Novar- fi tial approach might be to block TNFa in the combination therapy tis, and P zer, and reports receiving speakers bureau honoraria from Bristol-Myers Squibb. B.I. Rini is a paid consultant for Pfizer, Merck, and Bristol-Myers Squibb, and setting. A recent publication in animal models highlighted this reports receiving commercial research grants from Pfizer, Merck, Roche, Bristol- approach, demonstrating increased activity of combination immuno- Myers Squibb, and AstraZeneca. No other potential conflicts of interest were therapy when TNFa blockade was added to anti-PD-1 plus anti- disclosed. CTLA-4 (78). The wealth of treatment options available for RCC also raises the questions of optimal therapeutic sequencing which will be Received October 9, 2019; revised December 6, 2019; accepted January 13, 2020; addressed in an upcoming trial (79). In contemporary cohorts of published first January 16, 2020.

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AACRJournals.org Clin Cancer Res; 26(9) May 1, 2020 OF9

Targeting PD-1 or PD-L1 in Metastatic Kidney Cancer: Combination Therapy in the First-Line Setting

David H. Aggen, Charles G. Drake and Brian I. Rini

Clin Cancer Res Published OnlineFirst January 16, 2020.

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