Programmed cell death 1 (PD-1) inhibitors have limited effect in pancreatic ductal adenocarcinoma (PDAC), underscoring the need to co-target alternative pathways. CXC chemokine receptor 4 (CXCR4) blockade promotes T cell tumor infiltration and is synergistic with anti-PD-1 therapy in PDAC mouse models. We conducted a phase IIa, open-label, two-cohort study to assess the safety, efficacy and immunobiological effects of the CXCR4 antagonist BL-8040 (motixafortide) with pembrolizumab and chemotherapy in metastatic PDAC (NCT02826486). The primary outcome was objective response rate (ORR). Secondary outcomes were overall survival (OS), disease control rate (DCR) and safety. In cohort 1, 37 patients with chemotherapy-resistant disease received BL-8040 and pembrolizumab. The DCR was 34.5% in the evaluable population (modified intention to treat, mITT; N = 29), including nine patients (31%) with stable disease and one patient (3.4%) with partial response. Median OS (mOS) was 3.3 months in the ITT population. Notably, in patients receiving study drugs as second-line therapy, the mOS was 7.5 months. BL-8040 increased CD8+ effector T cell tumor infiltration, decreased myeloid-derived suppressor cells (MDSCs) and further decreased circulating regulatory T cells. In cohort 2, 22 patients received BL-8040 and pembrolizumab with chemotherapy, with an ORR, DCR and median duration of response of 32%, 77% and 7.8 months, respectively. These data suggest that combined CXCR4 and PD-1 blockade may expand the benefit of chemotherapy in PDAC and warrants confirmation in subsequent randomized trials.
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No data with mandatory deposition into a public repository are presented. All other datasets generated for the current study and experimental protocols are available from the corresponding author upon reasonable request and with permission of the sponsor and institutional review board. Source data for Fig. 2 and Extended Data Figs. 3–5 are presented with the paper.
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We thank the patients and their families for their participation in this study. This work was supported by BioLineRx and Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. (Kenilworth, NJ, USA). Flow cytometry acquisition was performed at Sheba Medical Center (Tel HaShomer, Ramat Gan, Israel). MultiOmyx tests and analysis were performed at Neogenomics Laboratories (Aliso Viejo, CA, USA). The sponsor BioLineRx participated in the conception of this study. Data were analyzed and interpreted by BioLineRx in collaboration with the academic authors. The sponsor staff, M.H. and B.B., had access to all of the data. All authors vouch for the accuracy and completeness of the data and analyses reported and for the fidelity of the study to the protocol.
B.B.: research funding: NanoView Bioscience; travel expenses: Erytech Pharma. T.M.: research funding: Celgene, Beigene and AstraZeneca; consulting: Celgene, BioLineRx, Eisai, Servier, Incyte, AstraZeneca and Amgen; travel expenses: Servier, Merck, Celgene and BioLineRx. B.M.W.: research funding: Celgene and Eli Lilly; consulting: Celgene, G1 Therapeutics, BioLineRx and GRAIL. T.G.: research funding: AstraZeneca and Merck MSD; consultant or advisory role: AstraZeneca, Abbvie, Teva, Bayer and Merck MSD; speakers bureau: Abbvie and BioLineRx. R.G.: consulting or advisory role: Bayer, MSD, Novartis and BOL Pharma; honoraria: BMS, Eli Lilly, Medison, Roche, Novartis, Janssen, Takeda, MSD, Merck and Pfizer; travel expenses: GAD medical, Merck, Roche, BMS and Bayer; educational grant to the research unit: Novartis. J.O.P.: research funding: Celgene; honoraria: Celgene, Sanofi and Servier; consulting or advisory role: Celgene, Sanofi, Servier and Merck Sereno. R.A.R.: research funding: Merck and Aadi Bioscience; consulting or advisory role: Advanced Accelerator Applications, Curium and Novartis; speakers bureau: Merck, Guardant, AstraZeneca, Genentech, Ipsen and Advanced Accelerator Applications. J.F.: research funding: Merck; consulting or advisory role: Amgen, Ipsen, Eisai, Merck, Roche and Novartis; travel expenses: Servier. A.M.: research funding: Sanofi and Leo Pharma; advisory boards: Celgene, AstraZeneca, Roche, Servier, Sanofi, Pfizer, BMS, Leo Pharma, Daiichi Sankyo, Bayer and Halozyme; speakers bureau: Rovi, Eli Lilly and MSD; travel expenses: Celgene, Roche, Merck Serono, Amgen and Sanofi. M.P.-S.: honoraria: Roche and Servier; consulting or advisory role: AstraZeneca; travel expenses: Roche, BMS and Incyte. M.C. is an employee and shareholder of Merck and Co., Inc. T.M.L., O.B.-K., S.M. Shaw, E.S. and A.V.H. are employees of BioLineRx. D.D.V.H.: research funding: Celgene, Merck, FivePrime Therapeutics, Eli Lilly and BioLineRx; consulting or advisory role: FivePrime Therapeutics, Tolero Pharmaceuticals, CanBas, BioLineRx, CytomX, Fujifilm, Geistlich Pharmaceuticals and Ipsen. M.H.: stock and ownership interests: Champions Oncology, Pharmacyte Biotech, BioOncotech, Nelum and Eng T Cell; honoraria: Pfizer, Novartis, MSD Oncology, Celgene, BioLineRx, Champions Oncology, Roche, SOBI, Agenus, Erytech Pharma and Pharmacyte Biotech; consulting or advisory role: Oncomatryx Biopharma S.L., Novartis, Pfizer, Celgene, Merck, Champions Oncology, Pharmacyte Biotech, SOBI, Roche, BioLineRx, Erytech Pharma, Agenus, Bayer, BMS, Nelum and Eng T Cells; research funding: Berg, Oncomatryx Biopharma S.L., Pfizer, Celgene, Bicycle Therapeutics, BioLineRx and Asana Biosciences; patents, royalties and other intellectual property: Myriad Genetics. The remaining authors declare no conflict of interest.
Peer review information Javier Carmona was the primary editor on this article and managed its editorial process and peer review in collaboration with the rest of the editorial team.
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CONSORT diagram of cohort 1 of the COMBAT trial. ITT, intention to treat. mITT, modified intention to treat. ECOG, Eastern Cooperative Oncology Group performance status.
Spider plot analysis of ITT population (N = 37) receiving the BL-8040 and pembrolizumab combination showing the sum of longest diameters (mm) of target lesions by best response according to RECISTv1.1. Missing baseline (monotherapy Day 5) values were imputed as screening values.
Extended Data Fig. 3 BL-8040 evoked rapid and sustained mobilization of white blood cells to the peripheral blood.
a, Upper panel, Absolute WBC count. Peripheral blood was drawn at the indicated pre- and post-treatment timepoints and WBC count determined by CBC. Lower panel, Fold-change in WBCs from Day 1 pre-treatment. Dotted line indicates levels at pre-treatment. b, As in a, except for upper panel representing Absolute Lymphocyte Count, while lower panel represents Fold-change in Lymphocyte Count from Day 1 pre-treatment. For a-b, Data is presented as geomeans ± 95% CI. Statistical analysis was performed on the log scale using a linear mixed model for repeated measures, incorporating planned a priori comparisons using unadjusted two-sided Least Significant Difference (LSD) tests (*p < 0.0001). All patients were sampled during monotherapy, but the number of patients reduced steadily thereafter as patients came off study. Data was available for: Screening n = 37, Mono n = 37, C1 n = 32, C2 n = 28, C3 n = 14, C4 n = 10, C5 n = 7, C6 n = 5, C7 n = 4, C8 n = 3, C9 n = 2, C10 n = 1, EOT n = 24, FU n = 5. Mono or M, monotherapy; C, cycle; D, day; EOT, end of treatment; FU, follow up.
Extended Data Fig. 4 Effects of BL-8040 and Pembrolizumab on the relative frequency of circulating PD-1 expressing T cells.
a, Fold-change in frequency of PD-1 expressing CD4 + and CD8 + T-cells. Peripheral blood was drawn from subjects at the indicated pre- and post-treatment timepoints and lymphocyte frequency determined by flow cytometry, plotted as fold-change from Day 1 pre-treatment. Dotted line indicates levels at pre-treatment. Data is presented as geomean ± 95% CI. Statistical analysis was performed on fold-change data on the log scale using a linear mixed model for repeated measures, post-hoc analysis, using unadjusted two-sided Least Significant Difference (LSD) tests (*p = 0.04, **p = 0.002, ***p < 0.0001). b, Change in frequency of PD-1 expressing CD4 + cells from subjects at the indicated pre- and post-treatment timepoints in accordance to clinical outcomes. Disease control represents stable disease and partial response. Lymphocyte subtype frequency determined by flow cytometry, plotted as percentage change of PD-1+ cells from the total of CD4 + T cell. Statistical analysis was performed on average percentage change on the log scale using a linear mixed model for repeated measures, post-hoc analysis (**p < 0.01). For a-b, data was available for: Day 1 pre- and post-BL-8040 n = 24, Day 5 pre- and post-BL-8040 n = 22, cycle 2 Day 21 n = 15.
Extended Data Fig. 5 Effects of BL-8040 on the relative frequency of major lymphocyte subsets in the peripheral blood.
Peripheral blood was drawn from subjects at the indicated pre- and post-treatment timepoints and lymphocyte frequency determined by flow cytometry, plotted as fold-change from Day 1 pre-treatment. a, NKT cells. b, NK cells. c, CD3-CD56- cells. Dotted line indicates levels at pre-treatment. Data is presented as geomean ± 95% CI. Statistical analysis was performed on fold-change data on the log scale using a linear mixed model for repeated measures, post-hoc analysis, using unadjusted two-sided Least Significant Difference tests. Data was available for: Day 1 pre- and post-BL-8040 n = 24, Day 5 pre- and post-BL-8040 n = 22, cycle 2 Day 21 n = 15.
Heatmaps show the immunophenotypic profiling on paired pre-screening and on-treatment biopsies of four patients using a multiplexed immunofluorescence platform (MultiOmyx) which simultaneously quantitated expression of tumor infiltrating lymphocyte (TILs) immune markers in (a) or myeloid-derived suppressor cells (MDSCs) markers in (b).
Extended Data Fig. 7 Effect of BL-8040 plus pembrolizumab combination on the composition of immune cells in the tumor microenvironment.
a, Treatment promoted an increase in the density of CD3 + and CD8 + cells in the TME of pancreatic cancer patients. Tumor biopsies were harvested from subjects at pre- and on-treatment timepoints and cell density of CD3 + T cells and CD8 + T cells were calculated. Cell enumerations were done following IHC by manual counting and Image Analysis on paired biopsies of 10 subjects for CD3 + (BL-8040 Monotherapy Day 5, N = 5, red circles; BL-8040 plus pembrolizumab End of Cycle 2, N = 5, black circles) and 9 subjects for CD8 + (BL-8040 Monotherapy Day 5, N = 5, blue circles; BL-8040 plus pembrolizumab End of Cycle 2, N = 4, black circles). b, Treatment promoted an increase in the density of CXCR4 + T cells, CD4 + and activated CD8 + T cells (CD3 + CD8 + Granzyme B + ) and a decrease in the density of G-MDSCs (CD11B + CD33 + HLADR-CD15 + ) in the TME of pancreatic cancer patients. Density of different cell subtypes was assessed on screening and on-treatment biopsies; data presented as cell density compared to screening. Tumor infiltrating lymphocyte and MDSC markers were analyzed by Multi-Omyx on four evaluable paired biopsies (BL-8040 Monotherapy Day 5, N = 3, colored circles; BL-8040 plus pembrolizumab End of Cycle 2, N = 1, black circles).
Extended Data Fig. 8 Clinical Benefit of BL-8040 and Pembrolizumab Combined with Chemotherapy in a Patient with Metastatic Pancreatic Cancer.
Upper panels showing computed tomography scans of a patient with pancreatic cancer (microsatellite stable) who received BL-8040, pembrolizumab and chemotherapy (NAPOLI-1 regimen) as second-line and developed partial response. Pancreatic cancer metastases to liver is marked. Partial response was achieved after 5 cycles of treatment with decrease of tumor burden of 35% from baseline per RECISTv1.1. This patient achieved a nadir at cycle 11 with 40% of decrease in tumor burden from baseline. Response is ongoing as of the last restaging scans.
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Bockorny, B., Semenisty, V., Macarulla, T. et al. BL-8040, a CXCR4 antagonist, in combination with pembrolizumab and chemotherapy for pancreatic cancer: the COMBAT trial. Nat Med 26, 878–885 (2020). https://doi.org/10.1038/s41591-020-0880-x
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