Advanced ccRCC Research Articles

Crosstalk between GBP2 and M2 macrophage promotes the ccRCC progression.

Clear cell renal cell carcinoma (ccRCC) represents a highly heterogeneous kidney malignancy associated with the poorest prognosis. The metastatic potential of advanced ccRCC tumors is notably high, posing significant clinical challenges. There is an urgent imperative to develop novel therapeutic approaches to address ccRCC metastasis. Recent investigations indicated a potential association between GBP2 and tumor immunity. However, the precise functional role of GBP2 in the progression of ccRCC remains poorly understood. The present study revealed a strong correlation between GBP2 and M2 macrophages. Specifically, our findings demonstrated that the inhibition of GBP2 significantly impedes the migratory and invasive capabilities of ccRCC cells. We observed that the presence of M2 macrophages can reverse the effects of GBP2 knockdown on tumor cell migration and invasion. Mechanistically, we demonstrated that M2 macrophages promote the expression of the GBP2/p-STAT3 and p-ERK axis in tumor cells through the secretion of interleukin-10 (IL-10) and transforming growth factor-β (TGF-β), thereby substantially enhancing the migratory and invasive capacities of the tumor cells. Simultaneously, we have identified that GBP2 promotes the polarization of macrophages to the M2 phenotype by stimulating the secretion of interleukin-18 (IL-18). In summary, our investigation anticipates that the GBP2/IL-18/M2 macrophages/IL-10 and the TGF-β/GBP2, p-STAT3, p-ERK loop plays a crucial role in ccRCC metastasis. The collective findings from our research underscore the significant role of GBP2 in tumor immunity and emphasize the potential for modulating GBP2 as a promising therapeutic strategy for targeting ccRCC metastasis.

Integrating Bulk and Single-Cell RNA-Seq Data to Identify Prognostic Features Related to Activated Dendritic Cells in Clear-Cell Renal-Cell Carcinoma.

Dendritic cells (DCs) serve as key regulators in tumor immunity, with activated DCs potentiating antitumor responses through the secretion of pro-inflammatory cytokines and the expression of co-stimulatory molecules. Most current studies focus on the relationship between DC subgroups and clear-cell renal-cell carcinoma (ccRCC), but there is limited research on the connection between DCs and ccRCC from the perspective of immune activation. In this study, activated DC genes were identified in both bulk and single-cell RNA-seq data. A prognostic model related to activated DCs was constructed using univariate, multivariate Cox regression and LASSO regression. The prognostic model was validated in three external validation sets: GSE167573, ICGC, and E-MTAB-1980. The prognostic model consists of five genes, PLCB2, XCR1, IFNG, HLA-DQB2, and SMIM24. The expression of these genes was validated in tissue samples using qRT-PCR. Stratified analysis revealed that the prognostic model was able to better predict outcomes in advanced ccRCC patients. The risk scores were associated with tumor progression, tumor mutation burden, immune cell infiltration, and adverse outcomes of immunotherapy. Notably, there was a strong correlation between the expression of the five genes and the sensitivity to JQ1, a BET inhibitor. Molecular docking indicated high-affinity binding of the proteins encoded by these genes with JQ1. In conclusion, our study reveals the crucial role of activated DCs in ccRCC, offering new insights into predicting immune response, targeted therapy effectiveness, and prognosis for ccRCC patients.

MDK promotes M2 macrophage polarization to remodel the tumour microenvironment in clear cell renal cell carcinoma

The efficacy of immunotherapy for clear cell renal cell carcinoma (ccRCC), especially advanced ccRCC, is limited, presenting a clinical challenge. This limitation is closely tied to the immune regulation network. Understanding the heterogeneity of the tumour microenvironment (TME) is crucial for developing advanced ccRCC therapies. Using publicly available ccRCC data (scRNA-seq, bulk RNA-seq, and somatic mutation data), a multiomics study was performed to explore TME heterogeneity. Three distinct ccRCC immune subtypes were identified through combined scRNA-seq and bulk RNA-seq analysis. A prognostic model based on unique cell signalling molecules in immunosuppressive tumour subtype was validated in the TCGA and CheckMate cohorts. MDK emerged as a critical regulatory gene in the immunosuppressive subtype, predicting a poor ccRCC prognosis and a poor immunotherapy response. MDK promotes M2 macrophage polarization via the MDK-LRP1 interaction, and the inhibition of MDK suppressed M2 polarization. This study revealed the heterogeneity of the ccRCC TME and a reliable prognostic model, shedding light on the vital role of MDK in the immunosuppressive TME and paving the way for optimized ccRCC immunotherapy.

7 A Phase 1 study of fianlimab (anti–LAG-3) in combination with cemiplimab (anti–PD-1) in patients with advanced ccRCC

Abstract Background Concurrent blockade of lymphocyte-activation gene 3 (LAG-3) may enhance efficacy of anti–programmed cell death-1 (PD-1) therapies. We present safety and clinical activity data from a Phase 1 study (NCT03005782) in patients with clear cell renal cell carcinoma (ccRCC) treated with anti–LAG-3 (fianlimab) + anti–PD-1 (cemiplimab). Methods Patients with advanced or metastatic ccRCC who had received no more than two previous regimens of anti-angiogenic therapy who were anti–PD-(ligand[L])1-naïve (cohort 3) or anti–PD-(L)1-experienced with most recent dose within 3 months prior to screening (cohort 4) were eligible. All patients were to receive fianlimab 1600 mg + cemiplimab 350 mg intravenously every 3 weeks for up to 24 months. Tumor measurements were performed by Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 every 6 weeks for 24 weeks, then every 9 weeks. The study objectives were to assess safety and antitumor activity of fianlimab + cemiplimab combination therapy in patients with ccRCC. Results Overall, 15 patients (median age: 64 years) each in cohorts 3 and 4 (total N=30) were enrolled and treated with fianlimab + cemiplimab as of November 1, 2022 data cutoff. For cohorts 3 and 4, 80% and 87% of patients were male, and 40% and 87% were White, respectively. All patients had prior cancer-related systemic therapy. In total, 60% and 93% of patients in cohorts 3 and 4 had ≥2 lines of prior therapies, respectively. For cohorts 3 and 4, median treatment duration was 27 weeks and 18 weeks, and median follow-up was 13 months and 24 months, respectively. Grade ≥3 treatment-emergent adverse events (TEAEs) occurred in 53% and 33% of patients in cohorts 3 and 4, respectively. Serious TEAEs occurred in 33% and 13% of patients in cohorts 3 and 4, respectively. Treatment-related AEs (TRAEs) were reported in 80% of patients in cohort 3 and 60% of patients in cohort 4. The most common TRAEs (any Grade) were rash (27%) and infusion related reaction (Grade 1 and 2; 27%) in cohort 3, and fatigue (20%) in cohort 4. Grade ≥3 TRAEs occurred in 27% of patients in cohort 3; there were no Grade ≥3 TRAEs in cohort 4. Treatment was discontinued due to any TEAE in three patients in cohort 3 and one patient in cohort 4. There was one death in cohort 3; a 79-year-old woman with a history of antiphospholipid syndrome died from complications of biopsy-proven ischemic colitis, which was attributed to study treatment. RECIST 1.1-based investigator-assessed objective response rate was 20% (3 partial responses [PRs]) in cohort 3 and 7% (1 PR) in cohort 4. The disease control rate was 60% and 73% in cohorts 3 and 4, respectively. Kaplan–Meier estimation of median progression-free survival was 4 months (95% confidence interval [CI] 1–10) in cohort 3 and 4 months (95% CI 1–7) in cohort 4. Durations of response were 4, 7, and 26 months in three responders in cohort 3, and 6 months in one responder in cohort 4. Conclusions Fianlimab + cemiplimab demonstrated promising signs of clinical activity with durable responses among patients who were anti–PD-(L)1-naïve (cohort 3) and anti–PD-(L)1-experienced (cohort 4), with an acceptable safety profile.

14 Natural killer cells have impaired cytotoxicity in advanced renal cell carcinoma

Abstract Background Natural killer (NK) cells are key mediators of anti-tumor activity in multiple cancers, including clear cell renal cell carcinoma (ccRCC). However, the phenotype and function of NK cells across different disease stages of ccRCC is incompletely characterized. Methods Single-cell RNA (scRNA)-sequencing (10x Genomics) data from tumor and adjacent normal kidney from ccRCC was analyzed at multiple clinical stages (localized – stage I/II/III; and advanced – stage IV). Graph-based clustering and lineage markers were used to identify distinct NK cell populations. Differential gene expression analysis was performed to further investigate NK cell phenotype and to derive a gene expression signature (GES). Gene signatures from NK cell subclusters of interest were used to interrogate bulk transcriptomic datasets and expression with clinical outcomes. Tumor-infiltrating NK cell function (cytokine production and cytotoxicity) was assessed by isolation of live NK cells from ccRCC tissue, co-culture with K562 target cells, and measurement of cytokine (IFNgamma) and cytotoxicity (CD107a) markers by flow cytometry. Results Single-cell transcriptomic data were analyzed from 13 patients with ccRCC (tumor and normal kidney), resulting in 21,139 high-quality NK cells. Patients with advanced/metastatic RCC had a lower proportion of NK cells versus total immune cells in the tumor microenvironment compared to normal kidney (p=0.036) and localized ccRCC (p=0.088). Clustering analysis revealed 6 distinct NK cell subsets. The C0.Bright-like NK cell cluster was significantly enriched in advanced ccRCC compared to localized ccRCC (p=0.048) and normal kidney (p=0.0059), expressed markers of tissue residency (ZNF683, ITGA1, CD9, ITGAE), and had decreased expression of cytotoxicity genes (GZMB, PRF1). A GES signature composed of genes upregulated in the dysfunctional C0.Bright-like NK cell cluster was used to interrogate bulk RNA-sequencing data from The Cancer Genome Atlas clear cell cohort, providing validation in a large, independent cohort, of an increase in this dysfunctional NK subset in advanced ccRCC compared to localized ccRCC (p=0.00039) and normal tissue (p=5.3e-05). To functionally confirm the decreased cytotoxicity of this dysfunctional NK population, CD45+CD56+CD3- NK cells were isolated from advanced ccRCC, and co-cultured with K562 target cells. Consistent with the transcriptomic phenotype, tumor-resident CD49a+CD9+ NK cells had cytokine production (IFNgamma) but decreased markers of cytotoxicity (CD107a) compared to CD49a-CD9- NK cells. By contrast, CD49a+CD9+ NK cells isolated from peripheral blood or normal kidney tissue maintained cytotoxic activity. Conclusions Among patients with ccRCC, a single-cell transcriptomic analysis revealed heterogeneous NK cell populations. A dysfunctional tumor resident NK cell phenotype was enriched among patients with advanced disease in ccRCC, and functionally confirmed to have diminished cytotoxicity. This study therefore provides insight into a new axis of immune dysfunction – decreased NK-mediated cytotoxicity – in advanced ccRCC. An improved understanding of NK cell dysfunction within ccRCC may provide a foundation for therapeutic restoration of NK-mediated anti-tumor activity in ccRCC. DOD CDMRP Funding: yes

Socioeconomic and Demographic Disparities in Immunotherapy Utilization for Advanced Kidney and Bladder Cancer

ObjectivesImmunotherapy (IO) drugs have been increasingly utilized in locally advanced or metastatic clear cell renal cell carcinoma (ccRCC) and urothelial carcinoma of the bladder (UC). Multiple trials have demonstrated clear survival benefit, however, there are often barriers to access for these advanced therapies which has been demonstrated in other non-urologic malignancies. The goal of this study was to assess socioeconomic and demographic factors associated with the receipt of IO for advanced ccRCC and UC. Materials and methodsWe queried the National Cancer Database (NCDB) for patients with stage IV ccRCC and UC. The study period was 2015 to 2020 for ccRCC (FDA approval date of IO) and 2017 to 2020 for UC (FDA approval date of broadened indication for IO, initial limited approval in 2016). The primary outcome of interest was receipt of IO therapy using multivariable logistic regression, adjusting for relevant socioeconomic and demographic variables. ResultsWe identified 15,926 patients with stage IV ccRCC and 10,380 patients with stage IV UC of which 5,419 (34.0%) and 2,231 (21.5%) received IO therapy, respectively. IO utilization increased with each successive year. In both malignancies, treatment at a non-academic facility, education level, income, and insurance were independently associated with IO utilization. For ccRCC, black (OR = 0.77, 95% CI, 0.64–0.93, P = 0.009) and Hispanic race (OR = 0.73, 95% CI, 0.61–0.86, P = 0.006) were each associated with decreased IO utilization but there were no independent associations between race and receipt of IO in patients with UC. ConclusionsIn the era of FDA-approved IO therapy for advanced ccRCC and UC, this national cohort analysis suggests that IO utilization is increasing over time, but significant disparities exist based on income, education, and insurance status in both malignancies. Additionally, patients treated at non-academic facilities were less likely to receive IO therapy for these specific genitourinary malignancies. In ccRCC, additional disparities were seen black and Hispanic races which each were associated with lower odds of IO receipt. Identifying strategies to mitigate these differences and provide equitable access to IO therapy is of imperative need.

Comparison of the Efficacy and Safety of Nivolumab Plus Cabozantinib versus Sunitinib in the Treatment of Elderly Patients with Advanced Clear Cell Renal Cell Carcinoma.

Advanced clear cell renal cell carcinoma (ccRCC) seriously affects the life and health of patients, but effective treatment for this disease is still lacking in clinic. This study investigated the efficacy of nivolumab plus cabozantinib versus sunitinib in the treatment of elderly patients with advanced ccRCC. The clinical data of 216 elderly patients with advanced ccRCC in our hospital from January 2020 to January 2022 were retrospectively analysed. On the basis of different treatment regimens, patients were divided into the cabozantinib group (n = 111, receiving nivolumab and cabozantinib) and the sunitinib group (n = 105, receiving nivolumab and sunitinib). The overall survival time, disease control rates, health status, incidence of adverse events and identification of prognostic risk were compared between the two groups. The cabozantinib group had higher overall survival time, disease control rate and scores in the Functional Assessment of Cancer Therapy-Kidney Symptom Index and EuroQol-Five Dimensions-Three Levels Questionnaire than the sunitinib group. The incidence of adverse events in the cabozantinib group was lower than that in the sunitinib group (p < 0.001). However, no difference existed in the identification of prognostic risk between the two groups (p > 0.05). The effect of nivolumab plus cabozantinib on the treatment of elderly patients with advanced ccRCC is better than that of nivolumab plus sunitinib, with fewer adverse reactions and higher safety. However, the research results require further clinical studies to confirm and promote.

Belzutifan in patients with advanced clear cell renal cellcarcinoma (ccRCC): Subgroup analysis of the phase 2 LITESPARK-013 study.

4534 Background: In the randomized phase 2 LITESPARK-013 study (NCT04489771), the first-in-class HIF-2α inhibitor belzutifan showed comparable antitumor activity in patients with pretreated advanced ccRCC at 200 mg and 120 mg doses (objective response rate [ORR]: 23.1% vs 23.7%; 1-sided P= 0.5312). We present results of a post hoc analysis of the pooled population (200 mg and 120 mg arms) across patient subgroups based on prior therapy and IMDC risk group. Methods: Patients with advanced ccRCC, measurable disease per RECIST v1.1, a Karnofsky Performance Scale score of ≥70%, ≤3 prior systemic regimens for advanced ccRCC (including an anti–PD-(L)1 regimen), and disease progression during or after an anti–PD-(L)1 regimen were randomly assigned 1:1 to receive belzutifan 200 mg or 120 mg QD. End points in the pooled population and subgroups were ORR and duration of response per RECIST v1.1 by blinded independent central review. Data cutoff was February 10, 2023. Results: A total of 154 patients were enrolled (200 mg, n = 78; 120 mg, n = 76). In the pooled population, the median age was 64.0 years, 127 patients (82.5%) had intermediate/poor risk per IMDC criteria, 110 patients (71.4%) received 1-3 prior tyrosine kinase inhibitor (TKI) regimens, and 81 patients (52.6%) received 2 or 3 prior lines of therapy. As of the data cutoff date, 39 patients (25.3%) in the pooled population remained on treatment. Median follow-up was 20.1 months (range, 14.8-28.4). In the pooled population, ORR was 23.4% (95% CI, 16.9-30.9; 4 complete responses [CRs], 32 partial responses [PRs]) and median duration of response (DOR) was 16.1 months (range, 2.1+ to 23.5+). Additional efficacy analyses for subgroups are presented in the table. Conclusions: This post hoc analysis from the LITESPARK-013 study of patients with pretreated advanced ccRCC suggests that belzutifan has antitumor activity regardless of prior lines of therapies and prognostic risk category. These results further support belzutifan as a treatment option for advanced RCC. Clinical trial information: NCT04489771 . [Table: see text]

Health-related quality of life (HRQoL) with nivolumab (NIVO) subcutaneous (SC) or intravenous (IV) in patients (pts) with advanced or metastatic clear cell renal cell carcinoma (ccRCC) who have received prior therapy in the phase 3 CheckMate 67T trial.

4535 Background: NIVO IV has improved outcomes in multiple tumor types. Evolving treatment paradigms have created a need for administration options that address treatment burden and improve efficiencies of healthcare systems. In a phase 1/2 study (CheckMate 8KX), pts were highly satisfied with NIVO SC and preferred it over NIVO IV [Lonardi et al, ESMO 2022; Lonardi et al, SITC 2023]. CheckMate 67T (NCT04810078) is a multicenter, randomized, open-label, phase 3 study that demonstrated pharmacokinetic and objective response rate noninferiority of NIVO SC vs IV in pts with locally advanced or metastatic ccRCC [George et al, ASCO-GU 2024]. This exploratory analysis assessed non-inferiority of HRQoL between pts randomized to NIVO SC (n=248) vs NIVO IV (n=247) in CheckMate 67T. Methods: HRQoL was measured using patient-reported outcomes (PROs), FKSI-19 (kidney cancer-related HRQoL) and the EQ-5D-5L (pt’s health status). FKSI-19 total score (range 0-76, higher score better HRQoL)and EQ-5D-5L visual analogue scale (VAS) (range 0-100, higher score better health HRQoL) scores were evaluated longitudinally on-treatment visits with ≥10 pts per arm included in model [week 57]) using linear mixed models (constrained longitudinal data analysis), with least squares (LS) mean changes from baseline and differences in the LS mean between NIVO SC and NIVO IV assessed; non-inferiority of NIVO SC vs NIVO IV was evaluated by examining overall treatment differences for on-treatment visits relative to prespecified thresholds. Results: PRO data were available for 247 pts (99.6%) for NIVO SC and 245 pts (99.2%) for NIVO IV, with completion rates &gt;87% across instruments up to week 57 for both treatment arms. HRQoL was maintained over time for both NIVO arms for FKSI-19 total score and subscales and EQ-5D-5L VAS. NIVO SC was non-inferior to NIVO IV across FKSI-19 total score and subscales and EQ-5D-5L VAS (Table). Conclusions: These results demonstrate maintenance of HRQoL for pts with advanced or metastatic ccRCC while on treatment with NIVO, regardless of the mode of administration (SC or IV), supporting the use of NIVO SC as a new option to align with patient preferences. Clinical trial information: NCT04810078 . [Table: see text]

Belzutifan plus lenvatinib (len) for Chinese patients (pts) with previously treated advanced clear cell renal cell carcinoma (ccRCC): Preliminary results of cohort 1 of the phase 1 LITESPARK-010 study.

4537 Background: Belzutifan, a first-in-class HIF-2α inhibitor, alone or in combination with a VEGFR-TKI, has shown durable antitumor activity in first- and subsequent-line settings of advanced ccRCC. LITESPARK-010 (NCT05030506) is a phase 1, 2-cohort, open-label study of belzutifan + len, with or without pembrolizumab, in Chinese pts with advanced ccRCC. We present preliminary results cohort 1. Methods: Chinese adults with histologically confirmed ccRCC who had 1-3 prior treatment regimens received belzutifan 120 mg PO QD for 3 wk followed by belzutifan 120 mg + len 20 mg PO QD until intolerable toxicity, disease progression, or pt withdrawal. The study included a dose-limiting toxicity (DLT) phase of 21 days after the start of combination treatment. Dual primary end points were safety and PK. Secondary end points included ORR, DOR, and PFS per RECIST v1.1 by investigator assessment and OS. Results: As of August 29, 2023, 24 pts were enrolled in cohort 1 and 23 received combination treatment; 1 pt discontinued in the monotherapy period because of treatment with non-study anti-cancer therapy. Median age was 61 years, 17 pts (71%) were male, and 14 (58%) had intermediate/poor IMDC risk. 14 pts (58%) received 1 prior line of therapy and 10 (42%) received ≥2 prior lines. Five pts (21%) received prior therapy with a PD-(L)1 inhibitor. As of the data cutoff date, 11 pts (46%) remained on treatment. Median follow up was 14.4 mo (range, 1.6-22.1). Ten pts were evaluated in the DLT phase, and 1 experienced a DLT (grade 2 treatment-related transient ischemic attack). All 24 pts (100%) experienced a treatment-related AE (TRAE) of any grade, most commonly anemia (100%) and proteinuria (88%). Grade 3 or 4 TRAEs occurred in 17 pts (71%), most commonly anemia (29%) and hypertension (29%). One pt (4%) experienced grade 3 hypoxia. No pts died (grade 5) due to a TRAE. After a single dose of belzutifan monotherapy, median Tmax was 1.8 h (range, 0.6-8.0), geometric mean AUC0-24 was 22,400 h·ng/mL (90% CI, 19,600-25,500), and geometric mean Cmax was 1640 ng/mL (90% CI, 1490-1820). Steady-state concentration was reached after 14 days of belzutifan monotherapy treatment; the accumulation ratio of AUC0-24 was 1.7 (90% CI, 1.5-1.9). Belzutifan + len treatment had similar PK to belzutifan monotherapy. In all 24 pts, confirmed ORR was 50% (95% CI, 29-71; all PRs). Median DOR was not reached (NR; range, 3.5-20.4+ months); 50% of responders remained in response for ≥12 mo per Kaplan-Meir estimate. Median PFS was 13.7 mo (95% CI, 8-NR) and median OS was NR (95% CI, NR-NR). The 12-mo PFS and OS rates were 57% and 75%, respectively. Conclusions: Preliminary data from the belzutifan + len showed promising antitumor activity in Chinese pts with previously treated ccRCC. The safety of belzutifan 120 mg + len 20 mg was consistent with the safety profiles of the individual drugs. Clinical trial information: NCT05030506 .

Biomarker analysis of zanzalintinib in clear cell renal cell carcinoma from STELLAR-001.

4545 Background: Zanzalintinib (zanza) is a novel oral multi-targeted TKI that inhibits several receptors, including VEGFR, MET, and TAM kinases. In an expansion cohort of previously treated patients (pts) with clear cell renal cell carcinoma (ccRCC) from the phase 1b STELLAR-001 study (NCT03845166), single-agent zanza showed encouraging activity (ORR, 38%; disease control rate, 88%), with responses seen in VEGFR TKI–pretreated pts, and a manageable safety profile (Pal, IKCS NA 2023:Abs 1). Here, we investigate biomarkers associated with zanza from the STELLAR-001 ccRCC expansion cohort. Methods: Adult pts (N=32) with advanced ccRCC, ECOG ≤1, and 1–3 prior systemic anticancer therapies received zanza 100 mg once daily until unacceptable toxicity or no longer deriving clinical benefit. Circulating plasma biomarkers and immune cell populations in blood were assessed at baseline and on-study. IHC for AXL, c-Met, phosphorylated Met, and VEGFR2 was performed on archival tissue. Associations between response to zanza and biomarker levels (at baseline and treatment-related changes) were investigated by comparing zanza responders (CR/PR; n=10) and non-responders (SD/PD; n=19). The relation between baseline biomarker levels and prior exposure to VEGFR TKI was also evaluated. P values were determined using a Wilcoxon test ( P&lt;0.05 considered significant). Results: Zanza elicited significant changes in soluble biomarkers related to angiogenesis, tumor growth and metastasis, and immune modulation, including an increase in the circulating ligands VEGF ( P&lt;0.001) and GAS6 ( P&lt;0.001); decreases in ANG-1 ( P&lt;0.001) and ANG-2 ( P&lt;0.001), and the soluble angiogenic receptors, VEGFR2 ( P&lt;0.001) and TIE-2 ( P&lt;0.001). A decrease in levels of the chemokine, RANTES ( P&lt;0.001), and an increase in IFNγ ( P=0.039) and the pro-apoptotic protein, granzyme B ( P&lt;0.001) were also observed. An analysis of immune cell subsets showed that zanza raised activated cytotoxic T cell numbers ( P=0.002). Reductions in monocytes ( P=0.001), along with immunosuppressive subsets (total MDSCs [ P=0.013] and granulocytic MDSCs [ P=0.014]) were also observed. Response to zanza was associated with lower baseline levels of plasma biomarkers including CRP ( P=0.025) and HGF ( P=0.017), but not with any tissue biomarkers or zanza-mediated changes in immune cells or plasma biomarkers tested. Lower baseline levels of VEGFR2 were observed in pts with prior VEGFR TKI exposure ( P=0.042). Conclusions: Zanza in pts with advanced ccRCC leads to modulation of plasma biomarkers associated with angiogenesis and peripheral immune cell subsets consistent with its expected mechanism of action. The reduction in immunosuppressive immune cells and activation of effector immune cells by zanza support the rationale for combining zanza with immune checkpoint inhibitors. Given the small sample sizes, further investigation in larger studies is warranted. Clinical trial information: NCT03845166 .

Format-tuning of in vivo-launched bispecific T cell engager enhances efficacy against renal cell carcinoma

BackgroundAdvanced clear cell renal cell carcinoma (ccRCC) is a prevalent kidney cancer for which long-term survival rates are abysmal, though immunotherapies are showing potential. Not yet clinically vetted are bispecific...

Abstract CT163: FIT-001: A phase 1 clinical trial of the farnesyl transferase inhibitor KO-2806 alone or as part of combination therapy for advanced solid tumors

Abstract Background: Farnesyl transferase inhibitors (FTIs) block post-translational modification of RAS and other farnesylated proteins. HRAS-driven tumors are highly sensitive to FTI treatment. Recent clinical trials (NCT03719690, NCT02383927) of the FTI, tipifarnib, in patients with HRAS-mutant (HRAS-m) head and neck squamous cell carcinoma harboring high variant allele frequency mutations (VAF ≥20%), showed objective response rates of up to 50% and favorable long-term outcomes. KO-2806 is a next-generation FTI that has increased potency and improved pharmacokinetic properties. In preclinical studies, KO-2806 has been shown to: (1) enhance tumor growth inhibition of tyrosine kinase inhibitors, including cabozantinib, in multiple clear cell renal cell carcinoma (ccRCC) cell line- and patient-derived xenograft models; and (2) enhance activity of KRAS inhibitors, including adagrasib, in KRAS mutant non-small cell lung cancer (NSCLC), colorectal cancer (CRC), and pancreatic ductal adenocarcinoma (PDAC) mouse models. These preclinical data support clinical investigation of KO-2806 alone and in combination therapy. Study Design: FIT-001 is a first-in-human, multicenter, open-label clinical trial that will evaluate the safety, tolerability, pharmacokinetics, pharmacodynamics (Pd), and preliminary antitumor activity of KO-2806 as monotherapy or in combination therapy in advanced solid tumors (KO-2806-001; NCT06026410). Up to 270 patients will be enrolled in phase 1a and phase 1b combined across 50 sites. Phase 1a will have separate monotherapy and combination dose-escalation arms. As monotherapy, the study will enroll patients with N/K/HRAS alterations in specific solid tumor types, such as NSCLC, CRC, and PDAC, who are refractory to standard-of-care therapies. KO-2806 and cabozantinib will be combined in patients with advanced or metastatic ccRCC who progressed on ≥1 prior line of immunotherapy-based systemic therapy; KO-2806 and adagrasib will be combined in patients with KRAS-G12C mutant locally advanced or metastatic NSCLC who received ≥1 prior systemic therapy. On the basis of emerging data from phase 1a, two Pd cohorts (n≤12) with mandatory pre- and on-treatment tumor biopsies may be enrolled. In each Phase 1b dose expansion, patients will receive the recommended phase 2 dose [RP2D] of KO-2806 with cabozantinib (in ccRCC) or adagrasib (in NSCLC), or will be randomized by dose if 2 potential KO-2806 RP2Ds are identified for a combination. Other combination arms may also be considered. The study began accrual in October 2023. Citation Format: Glenn J. Hanna, Douglas R. Adkins, Jacob S. Thomas, Justine Y. Bruce, Manish R. Patel, Guru Sonpavde, Jason Henry, Nawal Bendris, Zijing Zhang, Amitava Mitra, Amaya Gascó, Andrew Saunders, Stephen Dale. FIT-001: A phase 1 clinical trial of the farnesyl transferase inhibitor KO-2806 alone or as part of combination therapy for advanced solid tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr CT163.

Abstract CT002: CTX130 allogeneic CRISPR-Cas9-engineered chimeric antigen receptor (CAR) T cells in patients with advanced clear cell renal cell carcinoma: Long-term follow-up and translational data from the phase 1 COBALT-RCC study

Abstract Background: The mainstay of therapy for clear cell renal cell carcinoma (ccRCC), the most prevalent subtype of kidney cancer, includes checkpoint inhibitors (CPIs) and tyrosine kinase inhibitors (TKIs). However, once patients progress on these drug classes, outcomes are poor. Here, we report durable response and stability observed in a Phase 1 dose-escalation study of CTX130™, a CD70-targeting allogeneic CAR T cell therapy in patients with ccRCC. Methods: In this phase I study, patients were recruited from sites in the United States, Europe and Australia. Key eligibility included advanced ccRCC with prior receipt of at least one CPI and TKI. After receipt of standard lymphodepletion with fludarabine and cyclophosphamide for 3 days (dosed at 30 mg/m2 and 500 mg/m2, respectively), patients received infusion of CTX130. Results: Among the 16 patients enrolled and treated in dose escalation, the median age was 63 (range, 53-77) and all were stage IV at the time of enrollment. Patients had received a median of 3 prior lines of therapy (range, 1-6). Doses ranging from 3 × 107 to 9 × 108 CAR T cells were administered, and no dose-limiting toxicities were encountered. Cytokine release syndrome (CRS) was observed in 8 patients (50%); all events were grade 1 or 2. Infections were observed in 4 patients (25%), all deemed to be unrelated to CTX130. No hemophagocytic lymphohistiocytosis, graft-versus host disease or treatment-related neurotoxicity was observed. As of Oct 9, 2023, 1 patient (6.3%) achieved a complete response (CR) (now extending over 36+ months) and 12 additional patients (75%) achieved stable disease (SD) (1 patient in excess of 18 months), reflecting a disease control rate (CR/partial response/SD) of 81.3%. Immunohistochemical staining of baseline and archival tissues show an initial median CD70 expression level of 100% (range, 1-100%), with no substantial antigenic loss at sequential biopsies performed at day 42. Using digital droplet PCR assays of the CAR construct, we assessed expansion. CTX130 was detected in 20 minutes after infusion, declined to a nadir 2-3 days later, followed by rapid expansion between days 7 and 15. In general, expansion increased at each dose level. Conclusions: Updated results from the COBALT-RCC study reinforce both the encouraging antitumor activity and exceptional safety profile of CTX130. The durable CR, now in excess of 3 years, reflects the first and longest seen with allogeneic CAR T cell therapy in refractory solid tumors. A study of CTX131™ (building on CTX130 with CRISPR edits to enhance potency and persistence) is ongoing. Citation Format: Sumanta Kumar Pal, Ben Tran, John B. Haanen, Michael Hurwitz, Adrian Sacher, Neeraj Agarwal, Nizar Tannir, Elizabeth Budde, Simon Harrison, Sebastian Klobuch, Sagar S. Patel, Mary-Lee Dequeant, Qiuling Ally He, Alissa Keegan, Henia Dar, Anna Ma, PK Morrow, Samer A. Srour. CTX130 allogeneic CRISPR-Cas9-engineered chimeric antigen receptor (CAR) T cells in patients with advanced clear cell renal cell carcinoma: Long-term follow-up and translational data from the phase 1 COBALT-RCC study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr CT002.

The effects of Gualou Qumai Wan combined with Sunitinib on VEGFA, HIF1A, and renal function in advanced clear cell renal cell carcinoma

[Objective:] To study the efficacy of Gualou Qumai Wan (GQW) combined with Sunitinib in the treatment of advanced clear cell renal cell carcinoma (ccRCC) and its effects on vascular endothelial growth factor A (VEGFA), hypoxia inducible factor 1A (HIF1A), and renal function. [Method:] A retrospective analysis was conducted on 20 patients with advanced ccRCC treated with GQW combined with Sunitinib at Shouguang Hospital of Traditional Chinese Medicine from January 2021 to January 2023. Analyze the patient's quality of life, serum VEGFA and HIF1A levels, renal function indicators, T lymphocyte subgroup levels, traditional Chinese medicine (TCM) symptom scores, and clinical efficacy. [Result:] The total effective rate of clinical efficacy in patients after treatment was 70%; The serum levels of VEGFA and HIF1A in patients were lower than before treatment, and the difference was statistically significant (P&lt;0.05); The levels of serum creatinine (Scr), blood urea nitrogen (BUN), and urinary albumin (ALB) in patients were lower than before treatment, and the differences were statistically significant (P&lt;0.05). Before and after treatment, there was no statistically significant difference in the levels of T lymphocyte subgroup among patients (P&gt;0.05). After treatment, the TCM symptom score and EORTC QoL-C30 score of the patients all decreased compared to before treatment, and the difference was statistically significant (P&lt;0.01). [Conclusion:] The combination of GQW and Sunitinib has a significant therapeutic effect on advanced ccRCC, and can effectively improve the levels of VEGFA, HIF1A, and renal function.

Abstract 38: AB-2100, a PSMA-inducible CA9-specific CAR T cell product for the treatment of ccRCC provides long-term tumor responses in preclinical mouse model

Abstract Common challenges of CAR-T cell therapies in solid tumors, such as clear cell renal cell carcinoma (ccRCC), include insufficient therapeutic potency and lack of tumor specificity. We have developed AB-2100, an autologous integrated circuit T (ICT) cell product, generated via CRISPR-mediated knock-in of a single transgene into a safe-harbor locus. AB-2100 encodes a transcriptionally regulated sequential AND gate that comprises a priming receptor (PrimeR) specific for PSMA and an inducible CAR targeting CA9 antigen, which is widely expressed on local and metastatic lesions. AB-2100’s sequential AND logic-gate confers tumor-specific activity by priming off of PSMA-expressing tumor vasculature to induce CA9 CAR expression. This unique feature of the logic gate is intended to increase the safety profile of AB-2100 given that PSMA and CA9 are predicted to have limited co-expression in normal tissues. Additional functionality includes short-hairpin RNAs (shRNA) against Fas and TGFBR designed to prevent tumor-mediated resistance, and a synthetic pathway activator (SPA) that drives constitutive STAT3 signaling and enhanced T cell cytotoxicity and expansion. Mechanism of action studies demonstrate that AB-2100 can prime off of PSMA-expressing endothelial cells and induce tumor-specific killing of CA9 tumor cells, leading to the eradication of ccRCC targets in vitro. AB-2100 also exhibited selective killing of dual antigen expressing tumors in vivo using a dual-flank subcutaneous xenograft model. Preclinical xenograft studies also demonstrated that TGFBR shRNA and SPA modules enhanced antitumor activity of ICTs. When AB-2100 potency was evaluated in the subcutaneous A498 xenograft model, treatment with AB-2100 resulted in complete and durable anti-tumor responses. In summary, preclinical data demonstrate that AB-2100 selectively targets tumors co-expressing PSMA and CA9, and can overcome multiple suppressive mechanisms in the tumor microenvironment. These results support the evaluation of AB-2100 in the clinic for the treatment of advanced or metastatic ccRCC. Citation Format: Suchismita Mohanty, Jeremy Chen, Alma Gomez, Angela Boroughs, Irene Scarfo, Laura Lim, Kevin Dang, Marvin Chew, Rakesh Sudhakah, Michelle Nguyen, Thomas J. Gardner, Beatriz Millare, James Zhang, Darrian Moskowitz, Stanley Zhou, Neroli H. Xie, Nickolas Attanasio, Amanda Fearon, Ivan Chan, Vibhavari Sail, Vince Thomas, Jennesa Smith, Jennifer McDevitt, Levi Gray-Rupp, Alba Gonzalez, Christopher Murriel, W. Nicholas Haining. AB-2100, a PSMA-inducible CA9-specific CAR T cell product for the treatment of ccRCC provides long-term tumor responses in preclinical mouse model [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 38.

CPA4 as a biomarker promotes the proliferation, migration and metastasis of clear cell renal cell carcinoma cells.

Clear cell renal cell carcinoma (ccRCC) is a commonly occurring and highly aggressive urological malignancy characterized by a significant mortality rate. Current therapeutic options for advanced ccRCC are limited, necessitating the discovery of novel biomarkers and therapeutic targets. Carboxypeptidase A4 (CPA4) is a zinc-containing metallocarboxypeptidase with implications in various cancer types, but its role in ccRCC remains unexplored. The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) databases were utilized in order to investigate the differential expression patterns of CPA4. The expression of CPA4 in ccRCC patients was further verified using immunohistochemical (IHC) examination of 24 clinical specimens. A network of protein-protein interactions (PPI) was established, incorporating CPA4 and its genes that were expressed differentially. Functional enrichment analyses were conducted to anticipate the contribution of CPA4 in the development of ccRCC. To validate our earlier study, we conducted real-time PCR and cell functional tests on ccRCC cell lines. Our findings revealed that CPA4 is overexpressed in ccRCC, and the higher the expression of CPA4, the worse the clinical outcomes such as TNM stage, pathological stage, histological grade, etc. Moreover, patients with high CPA4 expression had worse overall survival, disease-specific survival and progress-free interval than patients with low expression. The PPI network analysis highlighted potential interactions contributing to ccRCC progression. Functional enrichment analysis indicated the involvement of CPA4 in the regulation of key pathways associated with ccRCC development. Additionally, immune infiltration analysis suggested a potential link between CPA4 expression and immune response in the tumour microenvironment. Finally, cell functional studies in ccRCC cell lines shed light on the molecular mechanisms underlying the role of CPA4 in promoting ccRCC formation. Overall, our study unveils CPA4 as a promising biomarker with prognostic potential in ccRCC. The identified interactions and pathways provide valuable insights into its implications in ccRCC development and offer a foundation for future research on targeted therapies. Further investigation of CPA4's involvement in immune responses may contribute to the development of immunotherapeutic strategies for ccRCC treatment.

Efficacy, Safety, and Tolerability of Tivozanib in Heavily Pretreated Patients With Advanced Clear Cell Renal Cell Carcinoma.

Tivozanib has been approved as a third-line or later therapy for advanced renal cell carcinoma based on the TIVO-3 trial, which was conducted before immune checkpoint therapies (ICT), cabozantinib, and lenvatinib/everolimus became incorporated in the current sequential treatment paradigm for advanced clear cell RCC (ccRCC). We performed a retrospective study of patients with advanced ccRCC treated with tivozanib at MD Anderson Cancer Center during 6/2021-7/2023. A blinded radiologist assessed tumor response by RECIST v1.1. We assessed overall response rate (ORR), clinical benefit rate (CBR) [percentage of all treated patients who achieved radiologic response or stable disease (SD) for ≥ 6 months], progression-free survival (PFS), overall survival (OS), and safety. Of 30 analyzed patients, 23% had performance status ≥ 2; 47% had International Metastatic RCC Database Consortium (IMDC) poor-risk disease. Median number of prior therapies was 4 (range 1-8). All patients received prior ICT, 87% cabozantinib and 60% lenvatinib ± everolimus. Of 26 evaluable patients, 2 patients had confirmed partial response (ORR 7.7%); 5 patients had SD for ≥ 6 months (CBR 23.3%). Median PFS was 3.8 months (range 0.7-13.9); median OS was 14.1 months (range 0.3-28.5). Fifteen patients (50%) had ≥ 1 treatment-related adverse event (TRAE). There were 6 grade ≥ 3 TRAEs [hypertension, congestive heart failure (3), mucositis, and GI perforation (grade 5)]. In this cohort of heavily pretreated patients with advanced ccRCC, tivozanib yielded a modest clinical benefit in a minority of patients who received prior ICT, cabozantinib, and lenvatinib ± everolimus. TRAEs were consistent with previously published reports.

Upregulation of serine metabolism enzyme PSAT1 predicts poor prognosis and promotes proliferation, metastasis and drug resistance of clear cell renal cell carcinoma

Serine metabolic reprogramming is known to be associated with oncogenesis and tumor development. The key metabolic enzyme PSAT1 has been identified as a potential prognostic marker for various cancers, but its role in ccRCC remains unkown. In this study, we investigated expression of PSAT1 in ccRCC using the TCGA database and clinical specimens. Our results showed that PSAT1 exhibited lower expression in tumor tissue compared to adjacent normal tissue, but its expression level increased with advancing stages and grades of ccRCC. Patients with elevated expression level of PSAT1 exhibited an unfavorable prognosis. Functional experiments have substantiated that the depletion of PSAT1 shows an effective activity in inhibiting the proliferation, migration and invasion of ccRCC cells, concurrently promoting apoptosis. RNA sequencing analysis has revealed that the attenuation of PSAT1 can diminish tumor resistance to therapeutic drugs. Furthermore, the xenograft model has indicated that the inhibition of PSAT1 can obviously impact the tumorigenic potential of ccRCC and mitigate lung metastasis. Notably, pharmacological targeting PSAT1 by Aminooxyacetic Acid (AOA) or knockdown of PSAT1 increased the susceptibility of sunitinib-resistant cells. Inhibition of PSAT1 increased the sensitivity of drug-resistant tumors to sunitinib in vivo. Collectively, our investigation identifies PSAT1 as an independent prognostic biomarker for advanced ccRCC patients and as a prospective therapeutic target.

A phase 1 study of fianlimab (anti-LAG-3) in combination with cemiplimab (anti-PD-1) in patients with advanced ccRCC.

434 Background: Concurrent blockade of lymphocyte-activation gene 3 (LAG-3) may enhance efficacy of anti–programmed cell death protein 1 (PD-1) therapies. We present safety and clinical activity data from a Phase 1 study in patients with clear cell renal cell carcinoma (ccRCC) treated with anti–LAG-3 (fianlimab) + anti–PD-1 (cemiplimab). Methods: Patients with advanced or metastatic ccRCC who had received no more than 2 previous regimens of anti-angiogenic therapy who were anti–PD-1/PD-L1-naïve (cohort 3) or anti–PD-1/L1-experienced with most recent dose within 3 months prior to screening (cohort 4) were eligible. All patients were to receive fianlimab 1600 mg + cemiplimab 350 mg intravenously every 3 weeks for up to 24 months. Tumor measurements were performed by RECIST 1.1 every 6 weeks for 24 weeks, then every 9 weeks. Results: 15 patients (median age: 64 years) each in cohort 3 and 4 (total N=30) were enrolled and treated with fianlimab + cemiplimab as of 01 Nov 2022 data cutoff.For cohorts 3 and 4 respectively, 80% and 87% of patients were male, and 40% and 87% were White. All patients had prior cancer-related systemic therapy. 60% (9/15) and 93% (14/15) of patients in cohorts 3 and 4 had ≥2 lines of prior therapies, respectively. For cohorts 3 and 4, median treatment duration was 27 weeks and 18 weeks, and median follow-up was 13 months and 24 months, respectively. Grade ≥3 treatment-emergent adverse events (TEAEs) occurred in 53% and 33% of patients in cohorts 3 and 4, respectively. Serious TEAEs occurred in 33% and 13% of patients in cohorts 3 and 4, respectively. Treatment-related TEAEs (TRAEs) were reported in 80% of patients in cohorts 3 and 60% of patients in cohort 4. The most common TRAEs (any grade) were rash (27%) and infusion related reaction (grade 1 and 2) (27%) in cohort 3 and fatigue (20%) in cohort 4. Grade ≥3 TRAEs occurred in 27% of patients in cohorts 3. Treatment was discontinued due to any TEAE in 3 patients in cohort 3 and 1 patient in cohort 4. In cohort 3, there was one death. The patient was a 79-year-old woman with a history of antiphospholipid syndrome who died from complications of biopsy-proven ischemic colitis attributed to study treatment. RECIST 1.1-based investigator-assessed objective response rate (ORR) was 20% (3 partial responses [PRs]) in cohort 3 and 7% (1 PR) in cohort 4. The disease control rate (DCR) was 60% and 73% in cohorts 3 and 4, respectively. Kaplan–Meier estimation of median progression-free survival was 4 months (95% confidence interval [CI], 1–10) in cohort 3 and 4 months (95% CI, 1–7) in cohort 4 patients. Duration of responses were 4, 7, and 26 months in 3 responders in cohort 3; and 6 months in one responder in cohort 4. Conclusions: Fianlimab + cemiplimab demonstrated promising signs of clinical activity with durable responses among patients with anti–PD-1/PD-L1-naïve (cohort 3) and anti–PD-1/L1-experienced (cohort 4), with an acceptable safety profile. Clinical trial information: NCT03005782 .