Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Letter
  • Published:

Neoadjuvant nivolumab modifies the tumor immune microenvironment in resectable glioblastoma


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.

This is a preview of subscription content, access via your institution

Access options

Buy this article

Prices may be subject to local taxes which are calculated during checkout

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.

Similar content being viewed by others

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.


  1. Stupp, R. et al. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N. Engl. J. Med. 352, 987–996 (2005).

    Article  CAS  Google Scholar 

  2. Stupp, R. et al. Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a randomised phase III study: 5-year analysis of the EORTC-NCIC trial. Lancet Oncol. 10, 459–466 (2009).

    Article  CAS  Google Scholar 

  3. Stummer, W. et al. Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomised controlled multicentre phase III trial. Lancet Oncol. 7, 392–401 (2006).

    Article  CAS  Google Scholar 

  4. Senft, C. et al. Intraoperative MRI guidance and extent of resection in glioma surgery: a randomised, controlled trial. Lancet Oncol. 12, 997–1003 (2011).

    Article  Google Scholar 

  5. Wick, W., Osswald, M., Wick, A. & Winkler, F. Treatment of glioblastoma in adults. Ther. Adv. Neurol. Disord. 11, 1–13 (2018).

    Article  Google Scholar 

  6. Wick, W. et al. Lomustine and bevacizumab in progressive glioblastoma. N. Engl. J. Med. 377, 1954–1963 (2017).

    Article  CAS  Google Scholar 

  7. Chinot, O. L. et al. Bevacizumab plus radiotherapy-temozolomide for newly diagnosed glioblastoma. N. Engl. J. Med. 370, 709–722 (2014).

    Article  CAS  Google Scholar 

  8. Ribas, A. & Wolchok, J. D. Cancer immunotherapy using checkpoint blockade. Science 359, 1350–1355 (2018).

    Article  CAS  Google Scholar 

  9. Weber, J. et al. Adjuvant nivolumab versus ipilimumab in resected stage III or IV melanoma. N. Engl. J. Med. 377, 1824–1835 (2017).

    Article  CAS  Google Scholar 

  10. Eggermont, A. M. M. et al. Adjuvant pembrolizumab versus placebo in resected stage III melanoma. N. Engl. J. Med. 378, 1789–1801 (2018).

    Article  CAS  Google Scholar 

  11. Wainwright, D. A. et al. Durable therapeutic efficacy utilizing combinatorial blockade against IDO, CTLA-4, and PD-L1 in mice with brain tumors. Clin. Cancer Res. 20, 5290–5301 (2014).

    Article  CAS  Google Scholar 

  12. Ashizawa, T. et al. Antitumor effect of programmed death-1 (PD-1) blockade in humanized the NOG-MHC double knockout mouse. Clin. Cancer Res. 23, 149–158 (2017).

    Article  CAS  Google Scholar 

  13. Kim, J. E. et al. Combination therapy with anti-PD-1, anti-TIM-3, and focal radiation results in regression of murine gliomas. Clin. Cancer Res. 23, 124–136 (2017).

    Article  CAS  Google Scholar 

  14. Nduom, E. K. et al. PD-L1 expression and prognostic impact in glioblastoma. Neuro-oncol. 18, 195–205 (2016).

    Article  CAS  Google Scholar 

  15. Lim, M., Xia, Y., Bettegowda, C. & Weller, M. Current state of immunotherapy for glioblastoma. Nat. Rev. Clin. Oncol. 15, 422–442 (2018).

    Article  CAS  Google Scholar 

  16. Reardon, D. A. et al. OS10.3 randomized phase 3 study evaluating the efficacy and safety of nivolumab vs bevacizumab in patients with recurrent glioblastoma: CheckMate 143. Neuro-oncol. 19, iii21 (2017).

    Article  Google Scholar 

  17. Reiss, S. N., Yerram, P., Modelevsky, L. & Grommes, C. Retrospective review of safety and efficacy of programmed cell death-1 inhibitors in refractory high grade gliomas. J. Immunother. Cancer 5, 99 (2017).

    Article  Google Scholar 

  18. Melero, I., Berraondo, P., Rodriguez-Ruiz, M. E. & Perez-Gracia, J. L. Making the most of cancer surgery with neoadjuvant immunotherapy. Cancer Discov. 6, 1312–1314 (2016).

    Article  CAS  Google Scholar 

  19. Forde, P. M. et al. Neoadjuvant PD-1 blockade in resectable lung cancer. N. Engl. J. Med. 378, 1976–1986 (2018).

    Article  CAS  Google Scholar 

  20. Blank, C. U. et al. Neoadjuvant versus adjuvant ipilimumab plus nivolumab in macroscopic stage III melanoma. Nat. Med. 24, 1655–1661 (2018).

    Article  CAS  Google Scholar 

  21. Amaria, R. N. et al. Neoadjuvant immune checkpoint blockade in high-risk resectable melanoma. Nat. Med. 24, 1649–1654 (2018).

  22. Wick, W. et al. MGMT testing—the challenges for biomarker-based glioma treatment. Nat. Rev. Neurol. 10, 372–385 (2014).

    Article  CAS  Google Scholar 

  23. Yan, H. et al. IDH1 and IDH2 mutations in gliomas. N. Engl. J. Med. 360, 765–773 (2009).

    Article  CAS  Google Scholar 

  24. Mueller, S. N. & Mackay, L. K. Tissue-resident memory T cells: local specialists in immune defence. Nat. Rev. Immunol. 16, 79–89 (2016).

    Article  CAS  Google Scholar 

  25. Korn, T. & Kallies, A. T cell responses in the central nervous system. Nat. Rev. Immunol. 17, 179–194 (2017).

    Article  CAS  Google Scholar 

  26. Cloughesy, T. F. et al. Neoadjuvant anti-PD-1 immunotherapy promotes a survival benefit with intratumoral and systemic immune responses in recurrent glioblastoma. Nat. Med. (in the press).

  27. Melero, I. et al. Evolving synergistic combinations of targeted immunotherapies to combat cancer. Nat. Rev. Cancer 15, 457–472 (2015).

    Article  CAS  Google Scholar 

  28. Reardon, D. A. et al. Glioblastoma eradication following immune checkpoint blockade in an orthotopic, immunocompetent model. Cancer Immunol. Res. 4, 124–135 (2016).

    Article  CAS  Google Scholar 

  29. Liau, L. M. et al. First results on survival from a large phase 3 clinical trial of an autologous dendritic cell vaccine in newly diagnosed glioblastoma. J. Transl. Med. 16, 142 (2018).

    Article  Google Scholar 

  30. Antonios, J. P. et al. PD-1 blockade enhances the vaccination-induced immune response in glioma. JCI Insight 1, e87059 (2016).

  31. Brown, C. E. et al. Regression of glioblastoma after chimeric antigen receptor T-cell therapy. N. Engl. J. Med. 375, 2561–2569 (2016).

    Article  CAS  Google Scholar 

  32. O’Rourke, D. M. et al. A single dose of peripherally infused EGFRvIII-directed CAR T cells mediates antigen loss and induces adaptive resistance in patients with recurrent glioblastoma. Sci. Transl. Med. 9, eaaa0984 (2017).

  33. John, L. B. et al. Anti-PD-1 antibody therapy potently enhances the eradication of established tumors by gene-modified T cells. Clin. Cancer Res. 19, 5636–5646 (2013).

    Article  CAS  Google Scholar 

  34. Liu, Y. et al. Targeting myeloid-derived suppressor cells for cancer immunotherapy. Cancer Immunol. Immunother. 67, 1181–1195 (2018).

    Article  CAS  Google Scholar 

  35. Desjardins, A. et al. Recurrent glioblastoma treated with recombinant poliovirus. N. Engl. J. Med. 379, 150–161 (2018).

    Article  CAS  Google Scholar 

  36. Lang, F. F. et al. Phase I study of DNX-2401 (Delta-24-RGD) oncolytic adenovirus: replication and immunotherapeutic effects in recurrent malignant glioma. J. Clin. Oncol. 36, 1419–1427 (2018).

    Article  CAS  Google Scholar 

  37. Johnson, W. E., Li, C. & Rabinovic, A. Adjusting batch effects in microarray expression data using empirical Bayes methods. Biostatistics 8, 118–127 (2007).

    Article  Google Scholar 

  38. Love, M. I., Huber, W. & Anders, S. Moderated estimation of fold change and dispersion for RNA-seq data with DESeq2. Genome. Biol. 15, 550 (2014).

    Article  Google Scholar 

  39. Bolotin, D. A. et al. MiXCR: software for comprehensive adaptive immunity profiling. Nat. Methods 12, 380–381 (2015).

    Article  CAS  Google Scholar 

  40. Shannon, C. E. The mathematical theory of communication. 1963. MD Comput. 14, 306–317 (1997).

    CAS  PubMed  Google Scholar 

Download references


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

Authors and Affiliations



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.

Ethics declarations

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.

Additional information

Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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).

Supplementary information

Supplementary information

Supplementary Tables 1–6.

Reporting Summary

Supplementary Table 7

Supplementary Table 7

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

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).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:

This article is cited by


Quick links

Nature Briefing: Cancer

Sign up for the Nature Briefing: Cancer newsletter — what matters in cancer research, free to your inbox weekly.

Get what matters in cancer research, free to your inbox weekly. Sign up for Nature Briefing: Cancer