Skip to main content

Thank you for visiting nature.com. 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.

Pembrolizumab in soft-tissue sarcomas with tertiary lymphoid structures: a phase 2 PEMBROSARC trial cohort

Nature Medicine volume 28, pages 1199–1206 (2022)Cite this article

Subjects

Abstract

Immune checkpoint inhibitors (ICIs) show limited clinical activity in patients with advanced soft-tissue sarcomas (STSs). Retrospective analysis suggests that intratumoral tertiary lymphoid structures (TLSs) are associated with improved outcome in these patients. PEMBROSARC is a multicohort phase 2 study of pembrolizumab combined with low-dose cyclophosphamide in patients with advanced STS (NCT02406781). The primary endpoint was the 6-month non-progression rate (NPR). Secondary endpoints included objective response rate (ORR), progression-free survival (PFS), overall survival (OS) and safety. The 6-month NPR and ORRs for cohorts in this trial enrolling all comers were previously reported; here, we report the results of a cohort enrolling patients selected based on the presence of TLSs (n = 30). The 6-month NPR was 40% (95% confidence interval (CI), 22.7–59.4), so the primary endpoint was met. The ORR was 30% (95% CI, 14.7–49.4). In comparison, the 6-month NPR and ORR were 4.9% (95% CI, 0.6–16.5) and 2.4% (95% CI, 0.1–12.9), respectively, in the all-comer cohorts. The most frequent toxicities were grade 1 or 2 fatigue, nausea, dysthyroidism, diarrhea and anemia. Exploratory analyses revealed that the abundance of intratumoral plasma cells (PCs) was significantly associated with improved outcome. These results suggest that TLS presence in advanced STS is a potential predictive biomarker to improve patients’ selection for pembrolizumab treatment.

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

Relevant articles

Open Access articles citing this article.

Access options

Rent or buy this article

Prices vary by article type

from$1.95

to$39.95

Learn more

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

Fig. 1: Flow chart of the study.
Fig. 2: Efficacy of pembrolizumab in patients with TLS-positive advanced sarcomas.
Fig. 3: Characterization of the determinants of response to pembrolizumab in TLS-positive sarcomas.

Data availability

The datasets that support the findings of this study are not publicly available due to information that could compromise research participant consent. According to French/European regulations, any reuse of the data must be approved by the ethics committee ‘CPP du Sud-Ouest et d’ Outre-Mer III’, Bordeaux, France. Individual participant data that underlie the results reported in this article can be shared upon request to the corresponding author (A.I.). Proposals may be submitted up to 36 months following article publication.

References

  1. Coley, W. B. II Contribution to the knowledge of sarcoma. Ann. Surg. 14, 199–220 (1891).

    Article  CAS  Google Scholar 

  2. Tawbi, H. A. et al. Pembrolizumab in advanced soft-tissue sarcoma and bone sarcoma (SARC028): a multicentre, two-cohort, single-arm, open-label, phase 2 trial. Lancet Oncol. 18, 1493–1501 (2017); erratum 18, e711; 19, e8 (2018).

  3. Toulmonde, M. et al. Use of PD-1 targeting, macrophage infiltration, and IDO pathway activation in sarcomas: a phase 2 clinical trial. JAMA Oncol. 4, 93–97 (2018).

    Article  Google Scholar 

  4. Italiano, A., Bellera, C. & D’Angelo, S. PD1/PD-L1 targeting in advanced soft-tissue sarcomas: a pooled analysis of phase II trials. J. Hematol. Oncol. 13, 55 (2020).

    Article  Google Scholar 

  5. Petitprez, F. et al. B cells are associated with survival and immunotherapy response in sarcoma. Nature 577, 556–560 (2020).

    Article  CAS  Google Scholar 

  6. Sautès-Fridman, C., Petitprez, F., Calderaro, J. & Fridman, W. H. Tertiary lymphoid structures in the era of cancer immunotherapy. Nat. Rev. Cancer 19, 307–325 (2019).

    Article  Google Scholar 

  7. Eisenhauer, E. A. et al. New response evaluation criteria in solid tumors: revised RECIST guidelines (version 1.1). Eur. J. Cancer 45, 228–247 (2009).

    Article  CAS  Google Scholar 

  8. Garon, E. B. et al. KEYNOTE-001 Investigators. Pembrolizumab for the treatment of non-small-cell lung cancer. N. Engl. J. Med. 372, 2018–2028 (2015).

    Article  Google Scholar 

  9. Zollinger, D. R., Lingle, S. E., Sorg, K., Beechem, J. M. & Merritt, C. R. GeoMx™ RNA assay: high multiplex, digital, spatial analysis of RNA in FFPE tissue. Methods Mol. Biol. 2148, 331–345 (2020).

    Article  CAS  Google Scholar 

  10. de Chaisemartin, L. et al. Characterization of chemokines and adhesion molecules associated with T cell presence in tertiary lymphoid structures in human lung cancer. Cancer Res. 71, 6391–6399 (2011).

    Article  Google Scholar 

  11. Danaher, P. et al. Advances in mixed cell deconvolution enable quantification of cell types in spatial transcriptomic data. Nat. Commun. 13, 385 (2022).

    Article  CAS  Google Scholar 

  12. D’Angelo, S. P. et al. Prevalence of tumor-infiltrating lymphocytes and PD-L1 expression in the soft tissue sarcoma microenvironment. Hum. Pathol. 46, 357–365 (2014).

    Article  Google Scholar 

  13. Edris, B. et al. Antibody therapy targeting the CD47 protein is effective in a model of aggressive metastatic leiomyosarcoma. Proc. Natl Acad. Sci. USA 109, 6656–6661 (2012).

    Article  CAS  Google Scholar 

  14. Kroeger, D. R., Milne, K. & Nelson, B. H. Tumor-infiltrating plasma cells are associated with tertiary lymphoid structures, cytolytic T cell responses and superior prognosis in ovarian cancer. Clin. Cancer Res. 22, 3005–3015 (2016).

    Article  CAS  Google Scholar 

  15. Seow, D. Y. B. et al. Tertiary lymphoid structures and associated plasma cells play an important role in the biology of triple-negative breast cancers. Breast Cancer Res. Treat. 180, 369–377 (2020).

    Article  CAS  Google Scholar 

  16. Yao, C. et al. Tumor-infiltrating plasma cells are the promising prognosis marker for esophageal squamous cell carcinoma. Esophagus 18, 574–584 (2021).

    Article  Google Scholar 

  17. Weiner, A. B. et al. Plasma cells are enriched in localized prostate cancer in black men and are associated with improved outcomes. Nat. Commun. 12, 935 (2021).

    Article  CAS  Google Scholar 

  18. Germain, C. et al. Presence of B cells in tertiary lymphoid structures is associated with a protective immunity in patients with lung cancer. Am. J. Respir. Crit. Care Med. 189, 832–844 (2014).

    Article  CAS  Google Scholar 

  19. Montfort, A. et al. A strong B-cell response is part of the immune landscape in human high-grade serous ovarian metastases. Clin. Cancer Res. 23, 250–262 (2017).

    Article  CAS  Google Scholar 

  20. Kalergis, A. M. & Ravetch, J. V. Inducing tumor immunity through the selective engagement of activating Fcgamma receptors on dendritic cells. J. Exp. Med. 195, 1653–1659 (2002).

    Article  CAS  Google Scholar 

  21. Meylan, M. et al. Tertiary lymphoid structures generate and propagate anti-tumor antibody-producing plasma cells in renal cell cancer. Immunity 55, 527–541 (2022).

    Article  CAS  Google Scholar 

  22. Domblides, C. et al. Tumor-associated tertiary lymphoid structures: from basic and clinical knowledge to therapeutic manipulation. Front Immunol. 12, 698604 (2021).

    Article  CAS  Google Scholar 

  23. Huang, H. Y. et al. Identification of a new subset of lymph node stromal cells involved in regulating plasma cell homeostasis. Proc. Natl Acad. Sci. USA 115, E6826–E6835 (2018).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Joshi, N. S. et al. Regulatory T cells in tumor-associated tertiary lymphoid structures suppress antitumor T cell responses. Immunity 43, 579–590 (2015).

    Article  CAS  Google Scholar 

  25. Simon, R. Optimal two-stage designs for phase II clinical trials. Control Clin. Trials 10, 1–10 (1989).

    Article  CAS  Google Scholar 

  26. Van Glabbeke, M., Verweij, J., Judson, I. & Nielsen, O. S. EORTC Soft Tissue and Bone Sarcoma Group. Progression-free rate as the principal end-point for phase II trials in soft-tissue sarcomas. Eur. J. Cancer 38, 543–549 (2002).

    Article  Google Scholar 

Download references

Acknowledgements

This study was sponsored by Institut Bergonié (Bordeaux, France). Funding was provided by MSD, the French Ministry, the Association pour la Recherche contre le Cancer, the Ligue contre le Cancer, INSERM, Sorbonne Université, Université de Paris, the French National Cancer Institute and the Agence Nationale de la Recherche (RHU CONDOR).

Author information

Author notes

  1. These authors contributed equally: A. Italiano, A. Bessede, M. Pulido.

Authors and Affiliations

  1. Department of Medical Oncology, Institut Bergonié, Bordeaux, France

    A. Italiano, M. Toulmonde & M. Spalato

  2. DITEP, Gustave Roussy, Villejuif, France

    A. Italiano

  3. University of Bordeaux, Bordeaux, France

    A. Italiano & F. Le Loarer

  4. Explicyte, Bordeaux, France

    A. Bessede, J. P. Guegan & C. Rey

  5. Unité de Recherche et d’Epidémiologie Cliniques, Institut Bergonié, Bordeaux, France

    M. Pulido, C. Bellera & C. Cantarel

  6. INSERM CIC, Bordeaux, France

    M. Pulido, C. Bellera & C. Cantarel

  7. Department of Medical Oncology, Institut de Cancérologie de L’Ouest, Nantes, France

    E. Bompas

  8. Department of Medical Oncology, Institut Curie, Paris, France

    S. Piperno-Neumann

  9. Department of Medical Oncology, Oncopole Toulouse, Toulouse, France

    C. Chevreau

  10. Department of Medical Oncology, Centre Oscar Lambret, Lille, France

    N. Penel

  11. Department of Medical Oncology, Institut Paoli Calmettes, Marseille, France

    F. Bertucci

  12. Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université Paris Cité, Paris, France

    C. Sautès-Fridman, A. Bougoüin & W. H. Fridman

  13. Equipe Labellisée Ligue contre le Cancer, Paris, France

    C. Sautès-Fridman, A. Bougoüin & W. H. Fridman

  14. Department of Imaging, Institut Bergonié, Bordeaux, France

    M. Kind

  15. Department of Pathology, University Hospital Centre of Nice, Nice, France

    B. Dadone-Montaudie

  16. Department of Pathology, Institut Bergonié, Bordeaux, France

    F. Le Loarer

  17. Department of Medical Oncology, Centre Léon Bérard, Lyon, France

    J. Y. Blay

Authors
  1. A. Italiano
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. A. Bessede
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. M. Pulido
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. E. Bompas
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. S. Piperno-Neumann
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. C. Chevreau
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. N. Penel
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. F. Bertucci
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. M. Toulmonde
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. C. Bellera
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. J. P. Guegan
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. C. Rey
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. C. Sautès-Fridman
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. A. Bougoüin
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. C. Cantarel
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. M. Kind
    View author publications

    You can also search for this author in PubMed Google Scholar

  17. M. Spalato
    View author publications

    You can also search for this author in PubMed Google Scholar

  18. B. Dadone-Montaudie
    View author publications

    You can also search for this author in PubMed Google Scholar

  19. F. Le Loarer
    View author publications

    You can also search for this author in PubMed Google Scholar

  20. J. Y. Blay
    View author publications

    You can also search for this author in PubMed Google Scholar

  21. W. H. Fridman
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

A.I., C.S.-F., C.B., M.P. and W.H.F. conceived and designed the study; B.D.-M. and F.L.L. performed histologic analyses; A.Bougoüin, C.S.-F. and W.H.F. performed TLS screening assays; E.B., S.P.N., C.Chevreau, N.P., F.B., M.K., J.P.G., A.Bessede, M.T., J.Y.B. and A.I. provided study material or treated patients; all authors collected and assembled the data; A.I., A.Bessede, C.Cantarel and J.P.G. developed the tables and figures; A.I., A.Bessede, C.S.-F. and W.H.F. conducted the literature search and wrote the manuscript; and all authors were involved in critical review of the manuscript and approved the final version.

Corresponding author

Correspondence to A. Italiano.

Ethics declarations

Competing interests

A.Bessede, J.P.G. and C.R. are employees of Explicyte. A.I. received research grants from AstraZeneca, Bayer, BMS, Chugai, Merck, MSD, Pharmamar, Novartis and Roche and personal fees from Epizyme, Bayer, Deciphera, Lilly, Parthenon, Roche and Springworks. W.H.F. received a research grant from AstraZeneca and personal fees from Anaveon, AstraZeneca, Catalym, Elsalys, Novartis, OSE Immunotherapeutics and Parthenon. J.Y.B. received research grants from Bayer, GSK, Merck, Novartis, Pharmamar and Roche and personal fees from Bayer, GSK, Lilly, Novartis, Pharmamar and Roche. All other authors have no competing interests.

Peer review

Peer review information

Nature Medicine thanks Melissa Burgess and the other, anonymous, reviewer(s) for their contribution to the peer review of this work. Primary Handling editor: Saheli Sadanand, in collaboration with the Nature Medicine team.

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 Representative image field with CD4/CD8/CD56/Foxp3/GzmA/DAPI multiplexed immunohistofluorescence panel on a soft-tissue sarcoma section.

Each panel represent a TLS structure with the corresponding staining.

Extended Data Fig. 2 Representative image field with CD27/Col1A1/Mum1/IgG/CD20/CD3/DAPI multiplexed immunohistofluorescence panel on a soft-tissue sarcoma section.

Each panel represent a TLS structure with the corresponding staining.

Extended Data Fig. 3 Representative example of a sarcoma expressing IgG at the surface of tumor cells.

Representative example of a sarcoma expressing IgG at the surface of tumor cells. A Undifferentiated spindle cell sarcoma of high grade of malignancy (hematoxylin eosin saffron staining) that B showed strong expression of IgG on immunofluorescence. There was a hybrid membranous and cytoplasmic pattern of staining (IgG staining in orange, DAPI counterstaining of nuclei). Twenty total cases were stained.

Extended Data Fig. 4 Antigen presenting cells tumor-infiltration is associated with anti-PD-1 response in TLS-positive sarcoma patients.

(a) Representative image field of a tumor area stained with CD83/CD1c/CD11c/CD68/HLA-DRA/DAPI multiplexed immunohistofluorescence (IHF) panel on a soft-tissue sarcoma section. IHF signals were unmixed for better discrimination. (b) Kaplan–Meier curves of PFS according to CD11c + /HLA-DR + High (n = 6) versus Low (n = 14) status. (c) Kaplan-Meir curves of OS according to CD11c + /HLA-DR + High (n = 6) versus Low (n = 14) status. (d) Kaplan–Meier curves of PFS according to CD68 + /HLA-DR + High (n = 5) versus Low (n = 15) status. (e) Kaplan-Meir curves of OS according to CD68 + /HLA-DR + High (n = 5) versus Low (n = 15) status.

Extended Data Table 1 Characteristics of the patients screened for TLS status (n = 240)
Full size table
Extended Data Table 2 Genes differentially expressed by TLS CD20 negative cells between responders and non-responders
Full size table
Extended Data Table 3 Two-sided Wilcoxon–Mann-Whitney analyses of the difference in TLS cell population estimates between Responders and Non-responders
Full size table
Extended Data Table 4 Two-sided Wilcoxon–Mann-Whitney analyses of the difference in stroma cell population estimates between Responders and Non-responders
Full size table

Supplementary information

Supplementary Information

Supplementary Table 1 and Figures 1–4.

Reporting Summary

Rights and permissions

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Italiano, A., Bessede, A., Pulido, M. et al. Pembrolizumab in soft-tissue sarcomas with tertiary lymphoid structures: a phase 2 PEMBROSARC trial cohort. Nat Med 28, 1199–1206 (2022). https://doi.org/10.1038/s41591-022-01821-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41591-022-01821-3

This article is cited by

Search

Advanced search

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