Nivolumab in Metastatic Adrenocortical Carcinoma: Results of a Phase 2 Trial
Benedito A. Carneiro,1* Bhavana Konda,2* Rubens B. Costa,1 Ricardo L. B. Costa,1 Vinay Sagar,1,3 Demirkan B. Gursel,4 Lawrence S. Kirschner,2 Young Kwang Chae,1 Sarki A. Abdulkadir,1,3,4 Alfred Rademaker,5 Devalingam Mahalingam,1 Manisha H. Shah,2 and Francis J. Giles1
1Developmental Therapeutics Program, Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois 60611; 2Ohio State University Comprehensive Cancer Center, Columbus, Ohio 43210; 3Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611; 4Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611; and 5Department of Preventive Medicine, Northwestern University, Chicago, Illinois 60611
ORCID numbers: 0000-0002-5468-1126 (B. A. Carneiro).
Context: Systemic treatment of metastatic adrenocortical carcinoma (ACC) remains limited to chemotherapy and mitotane. Preliminary evidence suggesting that antitumor immune responses can be elicited in ACC has fostered interest in checkpoint inhibitors such as anti-PD-1 nivolumab.
Objective: The primary endpoint was objective response rate according to the response evaluation criteria in solid tumors. Secondary endpoints were progression-free survival (PFS), overall survival, and safety.
Design: Single-arm, multicenter, phase 2 clinical trial with two-stage design.
Setting: Comprehensive cancer center.
Patients: Ten adult patients with metastatic ACC previously treated with platinum-based chemotherapy and/or mitotane as well as patients who declined front-line chemotherapy.
Intervention: Nivolumab (240 mg) IV every 2 weeks.
Results: Ten patients with metastatic ACC were enrolled between March and December 2016. The median number of doses of nivolumab administered was two. Three patients only received one treatment [one died of disease progression, one discontinued due to adverse events (AEs), one withdrew after beginning treatment]. The median PFS was 1.8 months. The median follow-up was 4.5 months (range, 0.1 to 25.6 months). Two patients had stable disease for a duration of 48 and 11 weeks, respectively. One patient had an unconfirmed partial response but discontinued the study due to an AE. Most AEs were grade 1/2. The most common grade 3/4 treatment-related AEs were aspartate aminotransferase and alanine aminotransferase elevations, mucositis, and odynophagia.
Conclusion: Nivolumab demonstrated modest antitumor activity in patients with advanced ACC. The nivolumab safety profile was consistent with previous clinical experience without any un- expected AEs in this population. (J Clin Endocrinol Metab 104: 6193-6200, 2019)
First Published Online 5 July 2019
*B.A.C. and B.K. contributed equally to this study.
Abbreviations: ACC, adrenocortical carcinoma; AE, adverse event; ALT, alanine ami- notransferase; AST, aspartate aminotransferase; CTCAE, Common Terminology Criteria for Adverse Events; EDPM, etoposide, doxorubicin, platinum, and mitotane; ER, epitope retrieval; IGF-1R, IGF-1 receptor; IHC, immunohistochemistry; LFT, liver function test; mTOR, mammalian target of rapamycin; NGS, next-generation sequencing; PFS, progression-free survival; PR, partial response; OS, overall survival; RECIST, Response Evaluation Criteria on Solid Tumors; TRAE, treatment-related adverse event; ULN, upper limit of normal.
A drenocortical carcinoma (ACC) is a rare malignancy with an approximate incidence of one case per million per year (1-3). Patients can be diagnosed with indolent disease during evaluation of endocrinopathies (i.e., hypercortisolism) or on abdominal imaging. However, metastatic disease carries a dismal prognosis with 5-year survival rates of <15% (4). This aggressive clinical course is attributed to a complex landscape of genomic alter- ations. Comprehensive genomic analysis of 91 ACC tu- mors identified driver genes, pathways, and refined disease subtypes (5). Relevant mutations, copy-number alter- ations, and epigenetic silencing involved TP53, ZNRF3, CDKN2A, CTNNB1, TERT, and PRKAR1A. Wnt/B- catenin and p53/Rb1 cell-cycle pathways were altered in 41% to 45% of tumors, and epigenetic regulators (i.e., MLL, MLL2, MLL4, ATRX, and DAXX) were disrupted in 22% of cases. Moreover, whole-genome doubling was identified as an important and frequent molecular feature of ACC driving tumor progression (5).
Despite the expanding knowledge of the molecular pathogenesis of ACC, chemotherapy and mitotane remain the only available therapeutic options for advanced disease (3). The only phase 3 randomized clinical trial completed in advanced ACC compared mitotane (adrenolytic agent), etoposide, doxorubicin, and cisplatin [etoposide, doxorubi- cin, platinum, and mitotane (EDPM)] to mitotane plus streptozocin (6). Response rates (23% vs 9%) and median progression-free survival (PFS; 5 vs 2 months) favored EDPM, but there was no significant overall survival (OS) improvement (14 vs 12 months, P = 0.07). Furthermore, serious adverse events (AEs) occurred in up to 58% of pa- tients treated with EDPM (6). Although preclinical data support targeting vascular endothelial growth factor and IGF-1 receptor (IGF-1R)/mammalian target of rapamycin (mTOR) signaling pathways, clinical studies using vascular endothelial growth factor pathway inhibitors (i.e., bev- acizumab, sorafenib, and sunitinib), IGF-1R inhibitors (lin- sitinib, cixutumumab), and mTOR inhibitor (everolimus) led to disappointing results (7-13). The lack of meaningful clinical benefit with targeted therapies coupled with pre- liminary evidence suggesting that antitumor immune re- sponses can be elicited in ACC using vaccine approaches fostered the interest to explore the clinical activity of checkpoint inhibitors including anti-PD-1 and anti-PD-L1 in advanced ACC (14-16). The present trial was designed to investigate the safety and efficacy of anti-PD-1 checkpoint inhibitor nivolumab in patients with advanced ACC.
Methods
Study design
This was a multicenter, single-arm, open-label, phase 2 study evaluating the safety and efficacy of nivolumab in patients with
metastatic or locally advanced ACC. The primary endpoint was overall response rate using Response Evaluation Criteria on Solid Tumors (RECIST; version 1.1) criteria. Response was assessed every two cycles, and a cycle consisted of 4 weeks of therapy. Secondary endpoints included PFS, OS, and quanti- tative and qualitative characterization of AEs graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE; version 4.0.3) before every treatment.
The study was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. The study protocol was reviewed and approved by the Institutional Re- view Boards before study initiation. All patients provided written informed consent. The Robert H. Lurie Comprehensive Cancer Center of Northwestern University was the coordinating site, and patients were enrolled there and at the Ohio State University Comprehensive Cancer Center.
Study participants
Eligible patients were at least 18 years old and had histo- logically confirmed metastatic or locally advanced ACC with disease progression after or refusal of first-line systemic therapy.
Inclusion criteria included measurable disease according to the RECIST version 1.1 by CT scans or MRI completed within 28 days prior to registration; Eastern Cooperative Group performance status of 0 to 3; and adequate bone marrow (absolute neutrophil count ≥1500/mm3, Hb ≥9 g/dL, platelets ≥100,000/mm3), hepatic [total bilirubin ≤1.5 upper limit of normal (ULN), aspartate aminotransferase (AST) or alanine aminotransferase (ALT) ≤2.5 ULN], and renal (serum creati- nine <3 x ULN or creatinine clearance >30 mL/min using the Cockcroft-Gault formula) functions. Patients with history of central nervous system metastases that were radiographically and neurologically stable for at least 6 weeks prior to study registrations and did not require corticosteroids for symp- tomatic management were eligible.
Exclusion criteria included chemotherapy or radiotherapy within 4 weeks prior to study entry; use of other investigational agents and/or anti-PD-1 or anti-PD-L1 inhibitors; active or prior history of autoimmune disease, or any condition requiring treatment with corticosteroids (>10 mg daily prednisone equiv- alents) or other immunosuppressive medications within 14 days prior to the first dose of the study drug; and uncontrolled in- tercurrent illness (e.g., hypertension, active infection requiring systemic treatment, symptomatic congestive heart failure, unstable angina, cardiac arrhythmia, psychiatric illness/social situations limiting compliance).
Treatment schedule
Nivolumab (240 mg) was administered as an IV infusion for 30 minutes every 2 weeks until disease progression, with- drawal of consent, unacceptable toxicity, or death. Chest, abdomen, and pelvis MRI or CT scans (per investigator choice) were performed within 28 days of registration and cycle 1 day 1. The same imaging modality used at baseline was used throughout study duration. Tumor assessment was performed every 8 weeks for the first 13 months, then every 12 weeks until disease progression or treatment discontinuation (whichever occurred first). Brain MRI was required during screening in eligible subjects with a history of central nervous system in- volvement. Tumor assessment was based on RECIST (version
1.1) and clinical criteria. Treatment with study drug after disease progression was permitted for patients who had clinical benefit without substantial adverse effects, as determined by the investigator. Safety was assessed every 2 weeks while on therapy and at the end of treatment visit and graded according to CTCAE. After treatment discontinuation, patients were followed every 3 months to document survival and disease progression for up to 2 years.
Analysis of PD-L1, PD-1, CD8+, and CD4+ tumor- infiltrating lymphocytes
Immunohistochemical studies were performed on formalin- fixed, paraffin-embedded patient tissue sections for PD-L1, PD- 1, CD4+, and CD8+. Specimens included archival tissue from primary tumors or metastatic sites. Sections were placed in a 58 to 60℃ oven for 60 minutes to increase the tissue adherence to glass surface. All dewax and antigen retrieval methods were performed with the Leica Bond-Max autostainer. Dewaxing was completed by using Leica Bond dewax solution (AR9222), followed by antigen retrieval with epitope retrieval (ER)1 (AR9961; pH 6) for 20 minutes. By using the protocol for Leica Bond Polymer Refine detection kit (DS9800), the following incubation times applied for different steps: peroxide block for 5 minutes, primary antibody for 15 minutes, post-primary antibody for 8 minutes, polymer horseradish peroxidase (sec- ondary antibody) for 8 minutes, and substrate chromogen (diaminobenzidine) for 10 minutes followed by hematoxylin. All slides were rehydrated through alcohol and xylene, mounted, and coverslipped. Appropriate known control tissue was used for positive control, and primary antibodies were omitted in negative controls. Dilution and Leica protocol used were as follows: PD-1 (catalog no. 137132, Abcam), 1:250 ER1 (20 minutes; pH 6), Leica Bond-Max protocol F; PD-L1 (cat- alog no. 13684, Cell Signaling Technology), dilution 1:200 ER2 (20 minutes; pH 9), Leica Bond-Max protocol F; CD4 (catalog no. PA0368, Leica), dilution ready-to-use ER2 (10 minutes; pH 9), Leica Bond-Max protocol F; CD8 (catalog no. PA0183, Leica), dilution ready-to-use ER2 (20 minutes; pH 9), Leica Bond-Max protocol F. Expression of PD-L1 and PD-1 by immunohistochemistry (IHC) staining was assessed on tumor cells and tumor-infiltrating lymphocytes. IHC staining was considered positive for PD-L1 when >5% of cancer cells expressed it on their surface. Characterization of tumor- infiltrating lymphocytes was also performed with IHC staining for CD4 and CD8 T cells and estimation of percentage of positive cells.
Peripheral blood lymphocyte phenotypes
Lymphocyte subsets (CD3, CD4, CD8, CD19, and CD56) were analyzed at baseline and after two doses according to absolute cell numbers per microliter of whole blood, percent representation among all lymphocytes, and coexpression of the activation markers CD25, HLA-DR, and CD45RO using au- tomated flow cytometric techniques at the Flow Cytometry Core Laboratory, Robert H. Lurie Cancer Center of North- western University.
Statistical analysis
A Simon two-stage optimum phase 2 design was used. We planned to enroll 33 patients into the trial. In the first stage, up to 12 patients would be enrolled to achieve 10 evaluable
patients. If no patient showed a confirmed tumor response, the trial would be terminated due to lack of significant antitumor activity. If ≥1 of 10 showed a response, then up to 22 additional patients would be enrolled to achieve 19 evaluable patients. If ≤3 of 29 showed a response, then the trial would conclude that the response rate could be as low as 5%. If four or more responded, then the trial would conclude that the response rate was >5%. This design had a 20% chance of falsely concluding that the response rate was 5% (false-negative type II error rate of 20%, or power of 80%), and a 5% chance of falsely con- cluding that the response rate was 20% (false-positive type I error rate of 5%). There was a 60% probability of early ter- mination of the trial when the true response rate was 5%. Owing to unevaluable patients and dropout, target accrual was up to 33 patients. Because no confirmed response was seen after the first stage of 10 patients, the study was terminated, and we report the results of the 10 first-stage patients.
PFS and OS were analyzed using Kaplan-Meier curves. CIs for median survival were calculated using the method of Brookmeyer and Crowley (17). For survival at specific times, equal precision CIs were calculated using the method of Nair (18). AEs were summarized descriptively using frequencies and percentages. Statistics were given on type, severity, frequency, and attribution of AEs. Sample size considerations were as aforementioned described. For PFS and OS, all registered pa- tients were included in the analysis. The intention-to-treat analysis was performed in patients evaluable for toxicity. This trial is registered with ClinicalTrials.gov (no. NCT02720484).
Results
Patient population
Ten patients with advanced/metastatic ACC were enrolled between March and December 2016. The me- dian participant age was 57. Seven patients were female. Four patients had hormone-producing tumors (two pa- tients had tumors producing cortisol, one patient with a primarily aldosterone-producing tumor, two patients had elevated testosterone and androstenedione) and six had nonfunctional tumors. Two patients had not re- ceived systemic treatment prior to trial enrollment. Six patients had received etoposide, doxorubicin, cisplatin chemotherapy, and mitotane during their treatment course for metastatic disease. One patient had received mitotane alone. Two patients had been treated with other chemotherapy drugs (i.e., 5-fluorouracil and streptozo- cin). Baseline and clinical characteristics are shown in Tables 1 and 2.
Safety
Grade 3/4 treatment-related adverse events (TRAEs) were documented in three patients (Table 3). One patient developed grade 3 hypokalemia and tremor possibly related to nivolumab. Another patient developed grade 3 stomatitis, odynophagia, and AST/ALT elevation in the setting of immune-related hepatitis that developed 45 days after a single dose of nivolumab; the same patient
| Baseline Characteristics | Total (N = 10) |
|---|---|
| Age, y, median (range) | 57 (31-67) |
| Sex | |
| Male | 3 |
| Female | 7 |
| Race | |
| White | 10 |
| Black | — |
| Asian | — |
| ECOG performance status | |
| 0 | 5 |
| 1 | 3 |
| 2-3 | 2 |
| Hormone-producing tumors | |
| Yes | 4 |
| No | 6 |
| Location of metastasesª | |
| Lymph nodes | 3 |
| Lung | 6 |
| Bone | 1 |
| Liver | 7 |
| Peritoneum | 2 |
| Number of prior systemic therapies | |
| 0 | 2 |
| 1 | 5 |
| 2 | 1 |
| ≥3 | 2 |
| Type of prior treatment of advanced disease | |
| EDP + mitotane | 6 |
| Single agent mitotane | 1 |
| Streptozocin | 2 |
| Axitinib | 1 |
| Other cytotoxic drugs | 1 |
| Liver-directed therapy® | 2 |
Abbreviations: ECOG, Eastern Cooperative Group; EDP, etoposide, doxorubicin, platinum.
ªCan be more than one metastasis location.
by-90 radioembolization.
developed grade 4 ALT elevation (the only grade 4 TRAE), and was discontinued from the study. One other patient was removed from study treatment due to grade 3
immune-related pneumonitis that occurred 15 days after cycle 5 day 15 of nivolumab. One patient received only one treatment and died 2 days later from progressive disease. The overall incidence of treatment-related AEs is summarized in Table 3.
There were no treatment-related deaths. One pa- tient discontinued study treatment after a single dose of nivolumab due to liver function abnormalities while using mitotane concurrently. This patient developed oral and anal mucositis and maculopapular skin rash ~1 week after the first and only dose of nivolumab. On day 22, she was noted to have elevated liver function tests (LFTs) as follows: alkaline phosphatase 127 (range, 32 to 126 U/L); ALT 92 (range, 9 to 48 U/L); AST 110 (range, 14 to 14 U/L). Bilirubin and albumin levels were normal. Skin rash worsened by day 26, and she was initiated on high-dose prednisone (1.5 mg/kg/d) with a slow taper. However, transaminases peaked on day 45 with ALT of 1242, AST of 663, alkaline phosphatase of 444, with total bilirubin of 1.7 ng/ml (normal <1.5). The patient was initiated on IV methylprednisolone (2 mg/kg/d), mitotane was discontinued, and she was taken off study treatment. Inpatient work-up revealed an elevated cytomegalovirus IgG and positive Epstein-Barr virus viral capsid antigen IgG; however, cytomegalovirus IgM, Epstein-Barr virus viral capsid antigen IgM, and hepatitis B and C panels were negative. She had no history of alcohol or acetaminophen intake, and liver ultrasound was unremarkable. LFTs improved on ste- roids, and she was discharged home on high-dose prednisone (2 mg/kg/d) 8 days later. High-dose ste- roids were continued until near complete resolution of transaminitis, after which a taper was begun. Her course on high-dose steroids was complicated by influenza A unrelated to study drug. Her liver function tests com- pletely normalized 4 months after she was initiated on
| Subject No. | Age | Sex | No. of Prior Systemic Therapies (n) | Prior EDP With/Without Mitotane (Y/N) | Cycles of Nivolumab Received (Total) | Best Response | Hormone-Producing Tumors (Y/N) |
|---|---|---|---|---|---|---|---|
| 1 | 52 | F | 1 | Y | 4 | PD | N |
| 2 | 67 | M | 0 | N | 1 | NE | N |
| 3 | 62 | F | 2 | Y | 4 | PD | Y |
| 4 | 57 | F | 1 | Y | 3 | PD | Y |
| 5 | 31 | F | 3 | Y | 6 | PD | N |
| 6 | 57 | M | 4 | Y | 10 | SD | N |
| 7 | 50 | M | 0 | N | 29 | SD | N |
| 8 | 64 | F | 1 | Ya | 1 | PRb | N |
| 9 | 62 | F | 1 | Y | 4 | PD | Y |
| 10 | 39 | F | 1 | Y | 2 | PD | Y |
Abbreviations: EDP, etoposide, doxorubicin, platinum; F, female; M, male; NE, not evaluable; PD, progressive disease; PR, partial response; SD, stable disease. ªReceived only mitotane. bUnconfirmed.
| AEsª | Treatment Population (N = 10) | ||
|---|---|---|---|
| Grade 1-2 (N) | Grade 3 (N) | Grade 4 (N) | |
| Rash | 3 | 0 | 0 |
| Nausea | 1 | 0 | 0 |
| Cough | 2 | 0 | 0 |
| Fatigue | 3 | 0 | 0 |
| ALT increase | 1 | 0 | 1 |
| AST increase | 2 | 1 | 0 |
| Bilirubin elevation | 2 | 0 | 0 |
| Hypokalemia | 0 | 1 | 0 |
| Dehydration | 0 | 1 | 0 |
| Mucositis | 3 | 0 | 0 |
| Tremor | 0 | 1 | 0 |
| Edema | 2 | 0 | 0 |
| Immune pneumonitis | 0 | 1 | 0 |
| Immune hepatitis | 0 | 1 | 0 |
ªAEs considered related to nivolumab according to CTCAE (version 4.0) assessed by the investigator. Patients with multiple events in the same category are counted only once in that category. Patients with events in more than one category are counted in each of those categories. Ad- ditional grade 1-2 AEs with one patient each included anemia, fever, infusion-related reaction, lymphopenia, and weight loss.
high-dose steroids. This patient remains with adrenal insufficiency requiring steroid replacement (~18 months since initial AE at the time of submission of this man- uscript), suggesting permanent functional impairment of adrenal glands mediated by the robust inflammatory response observed in this patient and likely a contrib- uting factor to antitumor response.
Efficacy
All 10 patients enrolled in the study received at least one dose of nivolumab. A total of nine patients had radiographic evaluation of their disease after receiving one dose of nivolumab. Although all criteria for evalu- ability were technically not met (one patient received one dose of nivolumab and died a few days later due to clinical progression, and disease could not be reeval- uated), the data are presented based on those who had measurable disease at baseline and who received at least one dose of nivolumab (Table 4). Eight patients had disease evaluation after two cycles. One patient had an
| N (%) (Total N = 10) | |
|---|---|
| Stable disease | 2 (20) |
| Partial response | 1 (10)ª |
| Complete response | 0 |
| Progressive disease | 7 (70) |
ªUnconfirmed.
unconfirmed partial response (PR) at first imaging as- sessment at 8 weeks. This patient only received a single dose of nivolumab and was subsequently taken off study treatment due to grade 3 immune-related hepatitis. Stable disease was documented in two patients for a duration of 48 and 11 weeks, respectively. Six patients had pro- gressive disease (PD) after one to five cycles of treatment (five patients with PD after cycle 2 and one after cycle 5) (Table 2). After a median follow-up of 4.5 months, the median PFS was 1.8 months (95% CI, 0.1 to 4.3). The 3- and 6-month PFS rates were 30% (95% CI, 2% to 70%) and 20% (95% CI, 0% to 62%), respectively. The 3- and 6-month OS rates were 79% (95% CI, 14% to 90%) and 56% (95% CI, 8% to 88%), respectively (Fig. 1). The median number of doses of nivolumab administered was two. Reasons for discontinuation of study drug included PD (n = 8), AEs (n = 1), and withdrawal of consent after one cycle unrelated to AEs (n = 1).
IHC analysis
Expression of PD-L1, PD1, CD8, and CD4 was evaluated prior to treatment in eight patients enrolled in
(a) 100-
Progression-Free Survival (%)
75-
50-
25-
0
0
3
6
9
12
15
18
21
24
27
(b)
Months
100-
Overall Survival (%)
75-
50-
25
0
0
3
6
9 12 15 18 21 24 27
Months
this trial. IHC staining was positive for PD-L1 in six patients. PD-1 expression was also positive in six cases (1% to 5% in four cases, >5% in 1 case, and >50% in one case). Tumors demonstrated a wide variation of prevalence of CD8+ (1% to 50%) and CD4+ (5% to 80%) T cells in the stroma, indicative of heterogeneity of tumor-infiltrating lymphocytes that could impact the antitumor immune response.
Molecular analysis of tumor samples and flow cytometry of immune cells
Genomic profiling of tumor specimens by next- generation sequencing (NGS) available for five pa- tients identified genomic alterations that affected cell cycle pathway (CDKN2A/B loss, CDK4 amplification), tumor suppressor genes (NF1, TP53), DNA repair complexes (MSH2, BRCA1, ATM), the metabolome (IDH2 A416V), telomerase function (TERT, ATRX), epithelial-to-mesenchymal transition (CTNNb1 splice site 14-191_97del275, CTNNB1 W25*), epigenetic regulation (ASXL1, DNMT3A), interferon production modulation (IRF2 loss), and cell survival and pro- liferation (RICTOR, NOTCH3). Out of five patients, TP53 mutation was identified in two patients. Variants of unknown significance in the following genes were also identified: BRAC2, ATM, CD79B, GATA2, TGFBR3, and PPP2R1A. All five patients with NGS results had microsatellite stable tumors, including two patients who had stable disease as the best response and the patient with an unconfirmed PR.
Peripheral blood flow cytometry immunopheno- typic analysis was performed at baseline and after 6 weeks of treatment. The decrease in the percentage of CD3+CD56- cells (NKT cells) was statistically sig- nificant in all patients after 6 weeks when analyzed by the Wilcoxon signed rank test (P = 0.031). No other variation in the percentage of immune cells when evaluated by flow cytometry and analyzed by the rank test was statistically significant.
Discussion
Metastatic ACC remains a major therapeutic challenge with available treatments showing limited clinical benefit and significant toxicities. Results from several thera- peutic trials targeting the mTOR, IGF-1R, and angio- genesis pathways have been largely disappointing (7-13). The current standard of care for patients with advanced ACC is combination chemotherapy with etoposide, doxorubicin, platinum, and mitotane, which has <25% response rates (6).
The current study is the first phase 2 clinical trial evaluating the role of nivolumab in patients with
advanced ACC. The trial used a Simon two-stage op- timum phase 2 design and planned to enroll 33 patients. Given the lack of confirmed PR in the first 10 patients, the trial was terminated. Although no confirmed PRs were documented, stable disease and unconfirmed PR were observed in three patients. The patient who had an unconfirmed PR also had a PD-1 expression of 50% (tumor-infiltrating immunocyte score). This patient only received one dose of nivolumab and was taken off study treatment due to immune-related hepatitis and grade 3/4 transaminase elevation requiring a prolonged course of steroids. The limited number of cases with comprehensive genomic analysis (only five patients had tumors available for NGS profiling) limited the ability to explore biomarkers of response, including the associ- ation between molecular alterations and epigenetic changes in mismatch repair proteins and response to checkpoint inhibitors.
The treatment of advanced ACC with nivolumab was generally well tolerated. The rate of TRAEs such as liver function abnormalities, fatigue, fever, nausea, immune- related hepatitis, and pneumonitis are consistent with previous reports from trials with single-agent nivolumab (19-21). Immune-mediated hepatitis requiring cortico- steroid use was seen in one patient in the current study and it has been described in <5% of patients in prior clinical trials using anti-PD-1 therapy (22). Although treatment with nivolumab possibly contributed to the increased transaminases in our patient, concurrent use of mitotane may have exacerbated the hepatotoxicity in agreement with observation of increased LFTs in a similar patient population receiving avelumab (23, 24). LFTs improved off mitotane and with the administration of a high-dose steroids course during 4 months prior to normalization of LFTs.
This study has several limitations inherent to clinical trials designed for patients with rare but aggressive cancers, including small number of patients accrued, single-arm design, and short interval to disease pro- gression. Four patients had hormone-producing tumors, raising the question of whether hormone production could impact treatment response, especially considering tumors with glucocorticoid excess that might compro- mise antitumor immune response. Of note, three out of five patients with disease progression after two cycles had hormone-producing tumors.
Results from a phase 1b study evaluating the anti-PD- L1 antibody avelumab among 50 patients with meta- static ACC who progressed after platinum-based therapy provide meaningful comparison with the results of the current study. Previous treatment with mitotane was allowed and the drug was given until progression, tox- icity, or withdrawal. Eight (16%) patients developed
grade 3 treatment-related adverse effects (six patients were receiving concomitant mitotane and two were not) that included ALT/AST increase, hypothyroidism, ad- renal insufficiency, y-glutamyl transferase increase, and pneumonitis. Grade 3 elevation of liver enzymes occurred only among patients receiving concomitant mitotane. The overall response rate was 6% and stable disease was observed in 21 patients (42%), resulting in a disease control rate of 48%. Median PFS was 2.6 months, and PFS rate at 12 months was 8.7% (24). Preliminary results from a phase 2 study investigating pembrolizumab among 11 patients with metastatic ACC showed PRs in 2 patients, stable disease in 1 patient, and a 6-month PFS of 27%. Disease progression was observed more frequently among patients with hormone-producing tumors (25).
In the current study, nivolumab showed modest clinical activity in patients with advanced ACC, and better therapies are urgently needed. Comprehensive genomic characterization of ACC has led to the iden- tification of several driver genes, including PRKAR1A, RPL22, TERF2, CCNE1, and NF1. Whole-genome doubling has been shown to be associated with an aggressive clinical course and possibly a hallmark of disease progression. Integrated subtype analysis has now identified three ACC subtypes with distinct clinical outcome and molecular alterations, proposing a strategy for stratification based on molecular markers (3). These results illustrate how the integration of molecular and clinicopathological data may be applied to inform thera- peutic decisions potentially leading to improved patient outcomes. Additionally, the European Network for the Study of Adrenal Tumors provides a digitally inter- connected infrastructure for clinicians specializing in adrenal tumors, facilitating collaboration with medical research communities (26). The National Cancer Institute is also collecting data, tissue, and blood samples from patients with ACC (NCT02015026). Un- derstanding how to integrate complex information with clinical and pathological data will be essential in developing novel therapies in patients with advanced ACC (3, 27).
In sum, nivolumab as a single agent only showed modest antitumor activity among patients with advanced ACC. Nivolumab had a favorable safety profile without any unexpected AEs. The study was closed after stage 1 due to failure to achieve its primary endpoint.
Acknowledgments
We thank all participating patients and their families. We also thank Suchitra Swaminathan at the Robert H. Lurie Com- prehensive Cancer Center of Northwestern University, Flow Cytometry Core Facility.
Financial Support: This work was supported by Bristol- Myers Squibb Rare Population Malignancy Program and by the Women’s Board of Northwestern Memorial Hospital.
Clinical Trial Information: ClinicalTrials.gov no. NCT02720484 (registered 28 March 2016).
Additional information
Current Affiliation: B.A. Carneiro’s current affiliation is the Division of Hematology/Oncology, Lifespan Cancer In- stitute, Warren Alpert Medical School, Brown University, Providence, Rhode Island 02903. R.L.B. Costa’s current af- filiation is the Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida 33612. F.J. Giles’ current affiliation is the Developmental Thera- peutics Consortium, Chicago, Illinois 60654.
Correspondence and Reprint Requests: Benedito A. Carneiro, MD, Lifespan Cancer Institute, Division of Hematology/ Oncology, Warren Alpert Medical School, Brown University, 164 Summit Street, Fain Building 2nd Floor, Providence, Rhode Island 02906. E-mail: benedito_carneiro@brown.edu.
Disclosure Summary: B.A.C. has served on advisory boards for Bristol-Myers Squibb and Bayer and has received institutional research support from Abbvie, AstraZeneca, MedImmune, Bristol-Myers Squibb, Bayer, and Merck. B.K. has received institutional research support from Bristol-Myers Squibb. Y.K.C. has received research grants from Abbvie, Bristol-Myers Squibb, Biodesix, Lexent Bio, and Freenome and has received honoraria/served on Advisory Boards for Roche/Genentech, AstraZeneca, Foundation Medicine, Coun- syl, Neogenomics, Guardant Health, Boehringer Ingelheim, Biodesix, Immuneoncia, Lilly Oncology, Merck, and Takeda. M.H.S. has received research support from LOXO and Merck. The remaining authors have nothing to disclose.
Data Availability: The datasets generated during and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.
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