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Neoadjuvant nivolumab modifies the tumor immune microenvironment in resectable glioblastoma

Nature Medicine volume 25, pages 470–476 (2019)Cite this article

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Abstract

Glioblastoma is the most common primary central nervous system malignancy and has a poor prognosis. Standard first-line treatment, which includes surgery followed by adjuvant radio-chemotherapy, produces only modest benefits to survival1,2. Here, to explore the feasibility, safety and immunobiological effects of PD-1 blockade in patients undergoing surgery for glioblastoma, we conducted a single-arm phase II clinical trial (NCT02550249) in which we tested a presurgical dose of nivolumab followed by postsurgical nivolumab until disease progression or unacceptable toxicity in 30 patients (27 salvage surgeries for recurrent cases and 3 cases of primary surgery for newly diagnosed patients). Availability of tumor tissue pre- and post-nivolumab dosing and from additional patients who did not receive nivolumab allowed the evaluation of changes in the tumor immune microenvironment using multiple molecular and cellular analyses. Neoadjuvant nivolumab resulted in enhanced expression of chemokine transcripts, higher immune cell infiltration and augmented TCR clonal diversity among tumor-infiltrating T lymphocytes, supporting a local immunomodulatory effect of treatment. Although no obvious clinical benefit was substantiated following salvage surgery, two of the three patients treated with nivolumab before and after primary surgery remain alive 33 and 28 months later.

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Fig. 1: Study design and efficacy results.
Fig. 2: Immune composition of tumors before and after neoadjuvant nivolumab.
Fig. 3: TCR clonality assessments by mRNA-based next-generation-sequencing analysis of tumor samples before and after surgical resection.
Fig. 4: Multiplex immunofluorescence assessment of immune cells in the tumor microenvironment before and after treatment.

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Data availability

The molecular data analyzed in the current study linked to patient anonymized IDs are available from corresponding author on reasonable request. Nanostring raw data are available as Supplementary Table 7.

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Acknowledgements

We thank R. Latek and D. McDonald from Bristol-Myers Squibb and the study coordinators and staff from our Clinical Research Unit, E. Guirado, L. Resano and B. Palencia for project coordination. We also thank Laura Johnson and Josh Haimes from ArcherDx for experimental and technical support. Financial support was through the Immunoncology Network (I-ON) supported by Bristol-Myers Squibb. Additional funds came to K.A.S. from Department of Defense LCRP Career Development Award W81XWH-16-1-0160, NIH Lung SPORE in Lung Cancer P50CA196530, and Stand Up To Cancer Translational Research Grants SU2C-AACR-DT17-15 and SU2C-AACR-DT22-17, and to I.M. from MINECO (SAF2014-52361-R and 2017-83267-C2-1-R), Fundación de la Asociación Española Contra el Cáncer (AECC), Fundación BBVA. M.E.R.-R. received a Rio Hortega contract from ISCIII.

Author information

Author notes

  1. These authors contributed equally: Kurt A. Schalper, Maria E. Rodriguez-Ruiz, Ricardo Diez-Valle.

  2. These authors jointly supervised this work: Jose L. Perez-Gracia, Ignacio Melero.

Authors and Affiliations

  1. Department of Pathology, Yale School of Medicine, New Haven, CT, USA

    Kurt A. Schalper, Angelo Porciuncula, Franz Villarroel-Espindola & Miguel F. Sanmamed

  2. Department of Oncology, Clínica Universidad de Navarra, Pamplona, Spain

    Maria E. Rodriguez-Ruiz, Alfonso Gúrpide, Iosune Goicoechea, Miguel F. Sanmamed & Jose L. Perez-Gracia

  3. Centro de Investigación Biomedica en Red de Oncología (CIBERONC), Madrid, Spain

    Maria E. Rodriguez-Ruiz, Jose L. Perez-Gracia & Ignacio Melero

  4. Instituto de Investigación Sanitaria de Navarra (IDISNA), Pamplona, Spain

    Maria E. Rodriguez-Ruiz, Jose L. Perez-Gracia & Ignacio Melero

  5. Department of Neurosurgery, Clínica Universidad de Navarra, Pamplona, Spain

    Ricardo Diez-Valle, Sonia Tejada & Ignacio Melero

  6. Department of Immunology, Clínica Universidad de Navarra, Pamplona, Spain

    Ricardo Diez-Valle, Susana Inogés, Ascensión López-Diaz de Cerio & Ignacio Melero

  7. Department of Pathology, Clínica Universidad de Navarra, Pamplona, Spain

    Alvaro López-Janeiro, Miguel A. Idoate & Carlos de Andrea

  8. Centro de Investigación Medica Aplicada (CIMA), Universidad de Navarra, Pamplona, Spain

    Pedro Berraondo

  9. Department of Genetics, Yale School of Medicine, New Haven, CT, USA

    Jungmin Choi

  10. Department of Pharmacy, Clínica Universidad de Navarra, Pamplona, Spain

    Miriam Giraldez

  11. Department of Neurology, Clínica Universidad de Navarra, Pamplona, Spain

    Jaime Gallego Perez-Larraya

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Contributions

K.A.S. designed research, analyzed data and wrote the draft of the manuscript and revised the manuscript. M.E.R.-R. wrote the study protocol, treated patients, analyzed data, prepared figures and revised the manuscript. R.D.-V. performed neurosurgery operations, evaluated clinical results and revised the manuscript. A.L.-J. performed experiments, analyzed data, prepared figures and revised the manuscript. A.P. performed experiments, analyzed data and prepared figures. M.A.I. collected and processed histology samples. S.I. performed flow cytometry experiments and prepared figures. C.d.A. collected and processed histology samples and analyzed data. A.L.-D.d.C. performed flow cytometry experiments. S.T. performed neurosurgery operations, evaluated clinical results and revised the manuscript. P.B. analyzed data, prepared figures and revised the manuscript. F.V.-E. performed experiments and revised the manuscript. J.C. performed statistical analyses and revised the manuscript. A.G. treated patients and analyzed data. M.G. was the clinical pharmacist in charge of the clinical trial. I.G. was the study coordinator and staff nurse in the clinical trial. J.G.P.-L. treated patients and analyzed data. M.F.S. analyzed data and revised the manuscript. J.L.P.-G. wrote the study protocol, obtained financial support, treated patients, analyzed data, prepared figures and drafted the manuscript. I.M. designed the study, obtained financial support, supervised patient treatment, evaluated and analyzed data and drafted the manuscript. All authors approved the final version of the manuscript.

Corresponding author

Correspondence to Ignacio Melero.

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Competing interests

K.A.S. is a consultant for Celgene, Moderna Therapeutics and Shattuck Labs and has received research funding from Vasculox, Moderna, Takeda, Surface Oncology, Tesaro, Pierre-Fabre, Merck and Bristol-Myers Squibb. I.M. is a consultant for BMS, Merck-Serono, Roche-Genetech, Tusk, Alligator, Genmab, Molecular Partners, F-Star, Bayer, Seattle Genetics and Alligator and has received research funding from BMS, Roche, Bioncotech and Alligator. J.L.P.-G. is a consultant for and has received research support, travel grants and lecture fees from BMS and Roche as well as research support and travel grants from MSD.

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Extended data

Extended Data Fig. 1 Swimmer plot graph of treated patients.

Progression of patients included in the trial in months, including subsequent anticancer treatments that the patients received. Duration of nivolumab treatment is also included. DT, death from tumor; DO, death from other cause; RT, radiotherapy; TMZ, temozolamide; UK, unknown.

Extended Data Fig. 2 PD-1 receptor occupancy on tumor-infiltrating CD8 T cells.

Cell suspensions, as in Fig. 2f, from three indicated cases that had sufficient CD8 cells with PD-1 surface expression were immunostained with a nivolumab-competing monoclonal antibody and with a non-competing anti-PD-1 monoclonal antibody. Top, mean intensity of fluorescence (MFI) of cells. Bottom, percentage of positive cells.

Extended Data Fig. 3 TCRγδ clonality assessments by mRNA sequencing of tumor samples before and after surgical resection.

a,b, Charts showing the number of TRG (a) and TRD clones (b) detected in pre- and postsurgical samples of patients from the neoadjuvant nivolumab and control groups. Only cases with detectable TRD sequences are shown. P values were obtained using paired two-tailed Wilcoxon rank-sum tests and corrected with Benjamini–Hochberg method and are indicated above each graph. ns, not significant (P < 0.05).

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Supplementary Table 7

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Schalper, K.A., Rodriguez-Ruiz, M.E., Diez-Valle, R. et al. Neoadjuvant nivolumab modifies the tumor immune microenvironment in resectable glioblastoma. Nat Med 25, 470–476 (2019). https://doi.org/10.1038/s41591-018-0339-5

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