Faculty Bibliography

Background Despite improved outcomes in advanced (unresectable or metastatic) melanoma, many patients progress after ICI,1-3 and have low response rates to subsequent therapy.4-7 Lifileucel, a one-time autologous TIL cell therapy, demonstrated an investigator-assessed ORR of 36% in Cohort 2 (C2), which enrolled 66 patients who progressed post-ICI and appropriate targeted therapy.8,9 We now report outcomes of 153 patients enrolled across C2 and C4 (NCT02360579), representing the largest phase 2 study of cell therapy in melanoma. Methods Eligibility criteria were identical for C2 and C4. Patients had >=1 lesion(s) resected (~1.5 cm in diameter postresection) and shipped to a central GMP facility for 22-day lifileucel manufacturing. All patients received a nonmyeloablative lymphodepletion (NMA-LD) regimen, a single lifileucel infusion, and up to 6 doses of high-dose IL-2. Primary endpoint was IRC-assessed ORR (RECIST v1.1). Results The full analysis set included 153 patients (C2: n=66; C4: n=87) treated with lifileucel, with a median of 3 prior lines of therapy (range: 1-9) and substantial baseline disease burden (>3 target and non-target lesions: 76%; median target lesion SOD: 97.8 mm; LDH >ULN: 54%). ORR was 31% (95% CI: 24.1%-39.4%) (C2: 35%; C4: 29%), with 8 CRs and 40 PRs (figure 1). At median study follow-up of 27.6 months, median DOR was not reached (NR). Forty-two percent of responses extended >=18 months, and 40% (19/48) of responses were ongoing at time of datacut (figure 2). In multivariable analyses adjusted for ECOG PS, elevated LDH and target lesion SOD >median were independently correlated with ORR (p=0.008); normal LDH and SOD < median were associated with higher odds of response than either (OR=2.08) or both (OR=4.42) risk factors. The median OS was 13.9 months (95% CI: 10.6-17.8. In an analysis of survival by response at first assessment (1.5 months post-lifileucel infusion), median OS in responders was NR (95% CI: 22.5 months-NR). The most common (>=30%) G3/4 TEAEs were thrombocytopenia (77%), anemia (50%), and febrile neutropenia (42%). TEAEs were consistent with known safety profiles of NMA-LD and IL-2, and their incidence decreased within the first 2 weeks post-lifeucel infusion, characteristic of onetime treatment. Conclusions Lifileucel demonstrated clinically meaningful and durable activity (ORR: 31%; mDOR: NR) in heavily pretreated patients with advanced melanoma and high tumor burden after ICI (and targeted therapy, where appropriate). Favorable safety profile and sustained responses support the potential benefit of one-time lifileucel TIL cell therapy as a novel treatment option for patients without approved therapies post-ICI. (Table Presented)

BACKGROUND:Adjuvant therapy for high-risk resected melanoma with programmed cell-death 1 blockade results in a median relapse-free survival (RFS) of 5 years. The addition of low dose ipilimumab (IPI) to a regimen of adjuvant nivolumab (NIVO) in CheckMate-915 did not result in increased RFS. A pilot phase II adjuvant study of either standard dose or low dose IPI with NIVO was conducted at two centers to evaluate RFS with correlative biomarker studies. METHODS:Patients with resected stages IIIB/IIIC/IV melanoma received either IPI 3 mg/kg and NIVO 1 mg/kg (cohort 4) or IPI 1 mg/kg and NIVO 3 mg/kg (cohorts 5 and 6) induction therapy every 3 weeks for 12 weeks, followed by maintenance NIVO. In an amalgamated subset of patients across cohorts, peripheral T cells at baseline and on-treatment were assessed by flow cytometry and RNA sequencing for exploratory biomarkers. RESULTS:High rates of grade 3-4 adverse events precluded completion of induction therapy in 50%, 35% and 7% of the patients in cohorts 4, 5 and 6, respectively. At a median of 63.9 months of follow-up, 16/56 patients (29%) relapsed. For all patients, at 5 years, RFS was 71% (95% CI: 60 to 84), and overall survival was 94% (95% CI: 88 to 100). Expansion of CD3+CD4+CD38+CD127-GARP- T cells, an on-treatment increase in CD39 expression in CD8+ T cells, and T-cell expression of phosphorylated signal-transducer-and-activator-of-transcription (STAT)2 and STAT5 were associated with relapse. CONCLUSIONS:Adjuvant IPI/NIVO at the induction doses used resulted in promising relapse-free and overall survival, although with a high rate of grade 3-4 adverse events. Biomarker analyses highlight an association of ectoenzyme-expressing T cells and STAT signaling pathways with relapse, warranting future validation. TRIAL REGISTRATION NUMBER:NCT01176474 and NCT02970981.

Background: Lifileucel showed durable responses in patients (pts) with advanced (unresectable/metastatic) melanoma in the post anti-PD-1 setting, with an ORR of 36% (Sarnaik JCO 2021). The recent approval of relatlimab (anti-LAG3 antibody) + nivolumab provides a new option for first-line (1L) treatment of advanced melanoma; however, ORR after exposure to this novel combination has been reported only for anti-CTLA-4-based therapies (11%; Menzies NEJM 2022).
Method(s): In the phase 2, C-144-01 study (NCT02360579), pts with advanced melanoma were previously treated with immune checkpoint inhibitor(s) (ICI) and BRAF +/- MEK inhibitors (if BRAF V600 mutation-positive). We performed a retrospective exploratory analysis to assess efficacy and safety of lifileucel in pts enrolled in C-144-01 who progressed on/after anti-LAG3-containing therapy. ORR was assessed by investigators per RECIST v1.1.
Result(s): Thirteen pts received prior anti-LAG3 (12 with anti-PD-1; 1 with anti-PD-1 + anti-CTLA-4), with a median of 3 prior therapies. Anti-LAG3 was the last therapy prior to TIL therapy in 7 pts; 6 pts had other therapies after anti-LAG3 (eg, chemotherapy, ICI, targeted therapy). Anti-LAG3 was used in 1L in 4 pts; 9 pts received it post-progression. Median duration of anti-LAG3 therapy was 3.3 mo (range, 0.03-9.2 mo). ORR for lifileucel was 38.5% (5 partial responses); 3 responders had primary and 2 acquired resistance to anti-LAG3 + anti-PD-1. Responses were durable, with 60% of responses extending beyond 12 mo. Safety profile was consistent with prior reports; most common (>=30%) grade 3/4 treatment-emergent adverse events were anemia (85%), thrombocytopenia (85%), febrile neutropenia (39%), leukopenia (31%), neutropenia (31%), and lymphopenia (31%).
Conclusion(s): Lifileucel showed an encouraging 38.5% ORR in pts with advanced melanoma refractory to prior anti-LAG3 + anti-PD-1 +/- anti-CTLA-4. Similar to prior observations in pts after anti-PD-1 therapy, both primary and acquired anti-LAG3-resistant pts responded to lifileucel, suggesting that lifileucel outcomes may not be affected by prior anti-LAG3 therapy. Clinical trial identification: NCT02360579. Editorial acknowledgement: Medical writing support was provided by Second City Science (Vaniam Group, LLC) and funded by Iovance Biotheraputics, Inc. Legal entity responsible for the study: Iovance Biotherapeutics, Inc.
Funding(s): Iovance Biotherapeutics, Inc. Disclosure: J. Larkin: Financial Interests, Personal, Other, Honoraria: Eisai, Novartis, Incyte, Merck, touchIME, touchEXPERTS, Pfizer, Royal College of Physicians, Cambridge Healthcare Research, RGCP, VJOncology, Agence Unik, BMS, Pierre Fabre, Ipsen, Roche, EUSA Pharma, Aptitude, AstraZeneca, GSK, Calithera, Ultimovacs, Seagen, eCancer, Inselgruppe, Goldman Sachs, MSD; Financial Interests, Personal, Advisory Role, Consulting: iOnctura, Apple Tree, Merck, BMS, Eisai, Debipharm, Incyte; Financial Interests, Institutional, Research Grant: Achilles, BMS, MSD, Nektar, Novartis, Pfizer, Roche, Immunocore, Aveo, Pharmacyclics. S. Dalle: Financial Interests, Institutional, Research Grant: BMS, MSD; Financial Interests, Personal, Other, Travel expenses: BMS; Financial Interests, Institutional, Advisory Board: MSD. M.F. Sanmamed: Financial Interests, Institutional, Research Grant: Roche; Financial Interests, Personal, Advisory Role, Consulting: Numab, BMS; Financial Interests, Personal, Other, Honoraria: MSD; Financial Interests, Personal, Advisory Board: Numab. J.C. Hassel: Financial Interests, Institutional, Research Grant: Clinical Trial Agreement. H. Kluger: Financial Interests, Institutional, Research Grant: Apexigen, BMS, Merck; Non-Financial Interests, Personal, Other, Unpaid relationship: Celldex. M. Orloff: Financial Interests, Personal, Advisory Role, Consulting: Trisalus, Ideaya, Immunocore; Financial Interests, Personal, Advisory Board: Trisalus, Ideaya, Immunocore. J.S. Weber: Financial Interests, Personal, Funding, supports an IIT: BMS; Financial Interests, Personal, Stocks/Shares: Biond, Evaxion, Neximmune, Instil Bio, OncoC4; Financial Interests, Personal, Other, Honoraria: BMS, Merck, Pfizer, AstraZeneca, Regeneron, Incyte, Genentech, Iovance, OncoC4, Sellas, Biond, Instil Bio, Evaxion; Financial Interests, Personal, Advisory Role: BMS, Merck, Pfizer, AstraZeneca, Regeneron, Incyte, Genentech, Iovance, OncoC4, Sellas, Biond, Instil Bio, Evaxion; Financial Interests, Personal, Royalties, named on a CTLA4 biomarker and a TIL growth patent: Moffitt; Financial Interests, Personal, Royalties, named on a PD-1 biomarker patent: Biodesix; Financial Interests, Personal, Other, Travel: BMS. F. Graf Finckenstein: Financial Interests, Personal, Full or part-time Employment: Iovance Biotherapeutics, Inc.; Financial Interests, Personal, Stocks/Shares: Iovance Biotherapeutics, Inc. P. Hari: Financial Interests, Personal, Full or part-time Employment: Iovance Biotherapeutics, Inc.; Financial Interests, Personal, Stocks/Shares: Iovance Biotherapeutics, Inc. M. Jagasia: Financial Interests, Personal, Full or part-time Employment: Iovance Biotherapeutics, Inc.; Financial Interests, Personal, Stocks/Shares: Iovance Biotherapeutics, Inc. H. Yin: Financial Interests, Personal, Full or part-time Employment: Iovance Biotherapeutics, Inc.; Financial Interests, Personal, Stocks/Shares: Iovance Biotherapeutics, Inc. W. Shi: Financial Interests, Personal, Full or part-time Employment: Iovance Biotherapeutics, Inc.; Financial Interests, Personal, Stocks/Shares: Iovance Biotherapeutics, Inc. G. Sulur: Financial Interests, Personal, Full or part-time Employment: Iovance Biotherapeutics, Inc.; Financial Interests, Personal, Stocks/Shares: Iovance Biotherapeutics, Inc. X. Wu: Financial Interests, Personal, Full or part-time Employment: Iovance Biotherapeutics, Inc.; Financial Interests, Personal, Stocks/Shares: Iovance Biotherapeutics, Inc. V. Gontcharova: Financial Interests, Personal, Full or part-time Employment: Iovance Biotherapeutics, Inc.; Financial Interests, Personal, Stocks/Shares: Iovance Biotherapeutics, Inc. K. Lewis: Financial Interests, Personal, Advisory Role: Array BioPhar, Merck, Roche, Regeneron, Sanofi, Iovance Biotherapeutics, nektar, Merck; Financial Interests, Personal, Other, Travel: Roche/Genentech, Regeneron, Neon Therapeutics, alkermes; Financial Interests, Personal, Other, Honoraria: Array BioPharma, Iovance Biotherapeutics; Financial Interests, Institutional, Funding: Roche/Genentech, Merck, Array BioPharma, Incyte, Nektar, Iovance Biotherapeutics, Bristol Myers Squibb, Kartos Therapeutics, OncoSec, Regeneron, alkermes, Neon Therapeutics, Ultimovacs, Senhwa Biosciences, Replimune, Amgen, Seattle Genetics; Non-Financial Interests, Personal, Other, Uncompensated Relationships: Roche/Genentech, Regeneron. All other authors have declared no conflicts of interest.
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PURPOSE/OBJECTIVE:Metastatic melanoma is a tumor amenable to immunotherapy in part due to the presence of antigen-specific tumor-infiltrating lymphocytes (TIL). These T cells can be activated and expanded for adoptive cell transfer (ACT), which has resulted in relatively high rates of clinical responses. Similarly, immune checkpoint inhibitors, specifically PD-1 blocking antibodies, augment antitumor immunity and increase the influx of T cells into tumors. Thus, we hypothesized that addition of PD-1 inhibition may improve the outcomes for patients undergoing ACT with TIL. PATIENTS AND METHODS/METHODS:Stage III/IV metastatic melanoma patients with unresectable disease who were anti-PD-1 treatment-naïve were enrolled. TIL were generated in the presence of anti-4-1BB antibody in vitro and expanded for ACT. Patients in Cohort 1 received TIL infusion followed by nivolumab. Patients in Cohort 2 also received nivolumab prior to surgical harvest and during TIL production. RESULTS:A total of 11 patients were enrolled, all of whom were evaluated for response, and nine completed ACT. Predominantly CD8+ TIL were successfully expanded from all ACT-treated patients and were tumor-reactive in vitro. The trial met its safety endpoint, as there were no protocol-defined dose-limiting toxicity events. The objective response rate was 36% and median progression-free survival was 5 months. Two non-responders who developed new metastatic lesions were analyzed to determine potential mechanisms of therapeutic resistance, which included clonal divergence and intrinsic TIL dysfunction. CONCLUSIONS:Combination therapy with TIL and nivolumab was safe and feasible for metastatic melanoma patients and provides important insights for future therapeutic developments in ACT with TIL.

Helper (CD4⁺) T cells perform direct therapeutic functions and augment responses of cells such as cytotoxic (CD8⁺) T cells against a wide variety of diseases and pathogens. Nevertheless, inefficient synthetic technologies for expansion of antigen-specific CD4⁺ T cells hinders consistency and scalability of CD4⁺ T cell-based therapies, and complicates mechanistic studies. Here we describe a nanoparticle platform for ex vivo CD4⁺ T cell culture that mimics antigen presenting cells (APC) through display of major histocompatibility class II (MHC II) molecules. When combined with soluble co-stimulation signals, MHC II artificial APCs (aAPCs) expand cognate murine CD4⁺ T cells, including rare endogenous subsets, to induce potent effector functions in vitro and in vivo. Moreover, MHC II aAPCs provide help signals that enhance antitumor function of aAPC-activated CD8⁺ T cells in a mouse tumor model. Lastly, human leukocyte antigen class II-based aAPCs expand rare subsets of functional, antigen-specific human CD4⁺ T cells. Overall, MHC II aAPCs provide a promising approach for harnessing targeted CD4⁺ T cell responses.

PURPOSE/OBJECTIVE:Ipilimumab and nivolumab have each shown treatment benefit for high-risk resected melanoma. The phase III CheckMate 915 trial evaluated adjuvant nivolumab plus ipilimumab versus nivolumab alone in patients with resected stage IIIB-D or IV melanoma. PATIENTS AND METHODS/METHODS:In this randomized, double-blind, phase III trial, 1,833 patients received nivolumab 240 mg once every 2 weeks plus ipilimumab 1 mg/kg once every 6 weeks (916 patients) or nivolumab 480 mg once every 4 weeks (917 patients) for ≤ 1 year. After random assignment, patients were stratified by tumor programmed death ligand 1 (PD-L1) expression and stage. Dual primary end points were recurrence-free survival (RFS) in randomly assigned patients and in the tumor PD-L1 expression-level < 1% subgroup. RESULTS:= .269) or in patients with PD-L1 expression < 1% (hazard ratio, 0.91; 95% CI, 0.73 to 1.14). In all patients, 24-month RFS rates were 64.6% (combination) and 63.2% (nivolumab). Treatment-related grade 3 or 4 adverse events were reported in 32.6% of patients in the combination group and 12.8% in the nivolumab group. Treatment-related deaths were reported in 0.4% of patients in the combination group and in no nivolumab-treated patients. CONCLUSION/CONCLUSIONS:Nivolumab 240 mg once every 2 weeks plus ipilimumab 1 mg/kg once every 6 weeks did not improve RFS versus nivolumab 480 mg once every 4 weeks in patients with stage IIIB-D or stage IV melanoma. Nivolumab showed efficacy consistent with previous adjuvant studies in a population resembling current practice using American Joint Committee on Cancer eighth edition, reaffirming nivolumab as a standard of care for melanoma adjuvant treatment.

PURPOSE:Adjuvant immunotherapy produces durable benefit for patients with resected melanoma, but many develop recurrence and/or immune-related adverse events (irAE). We investigated whether baseline serum autoantibody (autoAb) signatures predicted recurrence and severe toxicity in patients treated with adjuvant nivolumab, ipilimumab, or ipilimumab plus nivolumab. EXPERIMENTAL DESIGN:This study included 950 patients: 565 from CheckMate 238 (408 ipilimumab versus 157 nivolumab) and 385 from CheckMate 915 (190 nivolumab versus 195 ipilimumab plus nivolumab). Serum autoAbs were profiled using the HuProt Human Proteome Microarray v4.0 (CDI Laboratories, Mayaguez, PR). Analysis of baseline differentially expressed autoAbs was followed by recurrence and severe toxicity signature building for each regimen, testing of the signatures, and additional independent validation for nivolumab using patients from CheckMate 915. RESULTS:In the nivolumab independent validation cohort, high recurrence score predicted significantly worse recurrence-free survival [RFS; adjusted HR (aHR), 3.60; 95% confidence interval (CI), 1.98-6.55], and outperformed a model composed of clinical variables including PD-L1 expression (P < 0.001). Severe toxicity score was a significant predictor of severe irAEs (aHR, 13.53; 95% CI, 2.59-86.65). In the ipilimumab test cohort, high recurrence score was associated with significantly worse RFS (aHR, 3.21; 95% CI, 1.38-7.45) and severe toxicity score significantly predicted severe irAEs (aHR, 11.04; 95% CI, 3.84-37.25). In the ipilimumab plus nivolumab test cohort, high autoAb recurrence score was associated with significantly worse RFS (aHR, 6.45; 95% CI, 1.48-28.02), and high severe toxicity score was significantly associated with severe irAEs (aHR, 23.44; 95% CI, 4.10-212.50). CONCLUSIONS:Baseline serum autoAb signatures predicted recurrence and severe toxicity in patients treated with adjuvant immunotherapy. Prospective testing of the signatures that include datasets with longer follow-up and rare but more severe toxicities will help determine their generalizability and potential clinical utility. See related commentary by Hassel and Luke, p. 3914.

Tilsotolimod, an oligodeoxynucleotide TLR9 agonist, administered intra-tumorally, has been clinically evaluated. This compound has demonstrated the ability to induce changes within the tumor microenvironment, to convert non-inflamed cold tumors into inflamed hot tumors, with the hope that these tumors will be more responsive to immune checkpoint blockade.

BACKGROUND:Recent data suggest that patients with stage III melanoma are at high risk for developing central nervous system (CNS) metastases. Because a subset of patients with stage II melanoma experiences worse survival outcomes than some patients with stage III disease, the authors investigated the risk of CNS metastasis in stage II melanoma to inform surveillance guidelines for this population. METHODS:test, the cumulative incidence, and Cox multivariable regression analyses were performed to evaluate the association between baseline characteristics and the development of CNS metastases. RESULTS:Patients with stage III melanoma had a higher rate of developing brain metastases than those with stage II melanoma (100 of 468 patients [21.4%] vs. 82 of 586 patients [14.0%], respectively; p = .002). However, patients who had stage IIC melanoma had a significantly higher rate of isolated first recurrences in the CNS compared with those who had stage III disease (12.1% vs. 3.6%; p = .002). The risk of ever developing brain metastases was similarly elevated for patients who had stage IIC disease (hazard ratio [HR], 3.16; 95% CI, 1.77-5.66), stage IIIB disease (HR, 2.83; 95% CI, 1.63-4.91), and stage IIIC disease (HR, 2.93; 95% CI, 1.81-4.74), and the risk was highest in patients who had stage IIID disease (HR, 8.59; 95% CI: 4.11-17.97). CONCLUSIONS:Patients with stage IIC melanoma are at elevated risk for first recurrence in the CNS. Surveillance strategies that incorporate serial neuroimaging should be considered for these individuals until more accurate predictive markers can be identified.

PURPOSE/OBJECTIVE:Nivolumab was approved as adjuvant therapy for melanoma based on data from CheckMate 238, which enrolled patients per American Joint Committee on Cancer version 7 (AJCC-7) criteria. Here, we analyse long-term outcomes per AJCC-8 staging criteria compared with AJCC-7 results to inform clinical decisions for patients diagnosed per AJCC-8. PATIENTS AND METHODS/METHODS:In a double-blind, phase 3 trial (NCT02388906), patients aged ≥15 years with resected, histologically confirmed AJCC-7 stage IIIB, IIIC, or IV melanoma were randomised to receive nivolumab 3 mg/kg every 2 weeks or ipilimumab 10 mg/kg every 3 weeks for 4 doses and then every 12 weeks, both intravenously ≤1 year. Recurrence-free survival (RFS) and distant metastasis-free survival (DMFS) were assessed in patients with stage III disease, per AJCC-7 and AJCC-8. RESULTS:Per AJCC-7 staging, 42.4% and 57.3% of patients were in substage IIIB and IIIC, respectively; per AJCC-8, 1.1%, 30.4%, 62.8%, and 5.0% were in IIIA, IIIB, IIIC, and IIID. After 4 years' minimum follow-up, the AJCC-7 superior efficacy of nivolumab over ipilimumab in patients with resected stage III melanoma was preserved per AJCC-8 analysis. No statistically significant difference in RFS between stage III substage hazard ratios was observed per AJCC-7 or -8 staging criteria (interaction test: AJCC-7, P = 0.8115; AJCC-8, P = 0.1051; P = 0.8392 ((AJCC-7) and P = 0.8678 (AJCC-8) for DMFS). CONCLUSIONS:CheckMate 238 4-year RFS and DMFS outcomes are consistent per AJCC-7 and AJCC-8 staging criteria. Outcome benefits can therefore be translated for patients diagnosed per AJCC-8.