Preliminary biomarker analysis in the phase III PIVOTAL study: Evidence for the mechanism of action of daromun in melanoma

BackgroundPIVOTAL (NCT02938299) is a randomized phase III trial studying the neoadjuvant use of intralesional Daromun, a combination of two antibody-cytokine fusions, in fully resectable locally advanced melanoma. The study completed the accrual of 256 patients (pts) in the EU and was recently reported to have met the primary endpoint of recurrence-free survival (RFS). Daromun treatment followed by surgery significantly improved RFS (HR=0.59; p=0.005) and distant metastasis-free survival (DMFS) (HR=0.60; p=0.029) compared to the surgery-only control arm. Preliminary translational studies were undertaken to explore Daromun’s mechanism of action in the tumor microenvironment (TME) and in blood.MethodsIn a cohort of 32 pts (15 in the Daromun arm; 17 in the control arm), H&E and IHC staining for CD4+, CD8+, NK and Treg cells was performed on surgical specimens. Total tumor infiltrating lymphocytes (TILs) and lymphocyte subpopulations were analyzed both manually and using a digitally-assisted method. In another subset of 33 pts (16 in the Daromun arm; 17 in the control arm), PBMCs were collected at 3 different time points in both study arms and changes in lymphocyte subpopulations were assessed by FACS analysis.ResultsThe H&E/IHC results showed a greater amount of TILs and a statistically significant higher influx in tumors of CD8+ T cells in Daromun-treated pts as compared to controls (unpaired t-test p<0.0001). To a lesser extent, also CD4+ T cells were increased (p<0.015). FACS analysis of PBMCs revealed a transient modest increase of Tregs and a trend to a decrease of MDSCs over time in Daromun treated pts. No differences were observed for CD4+, NK and CD8+ T cell but, for these last, an upregulation of CD25 (a marker of cytotoxic T cell activation) in Daromun-treated pts and significant downregulation in controls could be observed.ConclusionsAn increase in absolute amount and changes in the abundance of TILs and PBMCs subpopulations provide a rationale for the systemic anti-tumor immune response, indicated by a 40% reduction of the risk of distant relapse in the Daromun arm. These results will be discussed, also in relationship to prior treatment with systemic therapies or to post-surgery treatment with adjuvant therapy.Clinical trial identificationNCT02938299.Legal entity responsible for the studyPhilogen S.p.A.FundingPhilogen S.p.A.DisclosureP.A. Ascierto: Financial Interests, Personal, Other, Consultant and Advisory Role: BMS, Roche Genentech, Novartis, Merck Serono, Sun Pharma, Sanofi, Sandoz, Immunocore, Boehringer Ingelheim Ingelheim, Regeneron; Financial Interests, Personal, Other, Consultant, Advisory Role and Travel support: MSD, Pierre Fabre; Financial Interests, Personal, Other, Consultant and Advisory Role.Travel support: Pfizer/Array; Financial Interests, Personal, Other, Consultant Role: Italfarmaco; Financial Interests, Personal, Other, Consultant Role: Pfizer, Nouscom, Lunaphore; Financial Interests, Personal, Other, Consultant role: Medicenna; Financial Interests, Personal, Other, Consultant role and travel support: Bio-AI Health; Financial Interests, Personal, Advisory Board, Consultant and Advisory role: ValoTx; Financial Interests, Personal, Advisory Board, Consultant and Advisor role.Travel support: Replimmune; Financial Interests, Personal, Advisory Board, Advisor role: Bayer; Financial Interests, Personal, Other, Consultant and Advisory: Erasca; Financial Interests, Personal, Other, Consultant: Philogen; Financial Interests, Personal, Advisory Board: BionTech, Anaveon; Financial Interests, Institutional, Funding, Clinical trial and translational research: BMS; Financial Interests, Institutional, Funding, Clinical Trial: Roche Genentech, Pfizer/Array, Sanofi; Non-Financial Interests, Leadership Role, President since 2010: Fondazione Melanoma Onlus Italy; Non-Financial Interests, Leadership Role, President since 2014: Campania Society of ImmunoTherapy of Cancer (SCITO) Italy; Non-Financial Interests, Other, Member of Steering Committee since 2016: Society for Melanoma Research (SMR); Non-Financial Interests, Member of Board of Directors, November 2017 - December 2021: Society for Immunotherapy of Cancer (SITC); Non-Financial Interests, Member: ASCO, SITC, EORTC Melanoma Cooperative Group, AIOM, SMR. M. Ziemer: Financial Interests, Personal, Stocks or ownership: Sanofi; Financial Interests, Personal, Financially compensated role: BMS, Sanofi, Sun Pharma, Novartis, AstraZeneca, Kyowa Kirin, Therakos; Financial Interests, Personal, Advisory Role: BMS, Sun Pharma, Sanofi; Financial Interests, Institutional, Research Funding: Novartis; Financial Interests, Personal, Invited Speaker: Pierre Fabre, Sun Pharma. J.C. Hassel: Financial Interests, Personal, Invited Speaker: BMS, Novartis, Sanofi, MSD, SunPharma, Amgen, GSK, Pierre Fabre, Immunocore; Financial Interests, Personal, Advisory Board: MSD, Pierre Fabre, SunPharma, GSK, Onkowissen; Financial Interests, Institutional, Advisory Board: Novartis, BMS, Immunocore, Philogen, Sanofi; Financial Interests, Institutional, Research Grant: BMS, SunPharma; Financial Interests, Institutional, Local PI: Philogen, Genentech, 4SC, BioNTech, Idera, Iovance, Nektar, Pierre Fabre, Regeneron, Sanofi, Replimune; Financial Interests, Institutional, Coordinating PI: BMS, Immunocore, Novartis, Genmab; Financial Interests, Personal, Steering Committee Member: Immunocore, IO Biotech; Non-Financial Interests, Leadership Role: DeCOG; Non-Financial Interests, Member: ASCO. P. Rutkowski: Financial Interests, Personal, Invited Speaker, honoraria for lectures: MSD, BMS, Pierre Fabre; Financial Interests, Personal, Advisory Board: MSD, BMS, Pierre Fabre, Merck, Sanofi, Blueprint Medicines, Philogen; Financial Interests, Personal, Invited Speaker: Merck, Sanofi, Novartis, AstraZeneca; Financial Interests, Institutional, Research Grant, research grant for ISS: Pfzer; Financial Interests, Institutional, Funding, research grant for institution: BMS; Non-Financial Interests, Member of Board of Directors: Polish Society of Surgical Oncology; Non-Financial Interests, Member of Board of Directors, President: Polish Oncological Society. F. Meier: Financial Interests, Personal, Advisory Board: Bristol Myers Sqibb, Novartis, MSD, Sanofi, Philogen, Immunocore; Financial Interests, Personal, Invited Speaker: Sanofi, Immunocore. L. Flatz: Financial Interests, Personal, Stocks or ownership: Hookipa Pharma; Financial Interests, Personal, Advisory Role: Philogen; Financial Interests, Personal, Research Funding: Hookipa Pharma, Mundipharma; Financial Interests, Personal, Royalties: Hookipa Pharma; Financial Interests, Personal, Invited Speaker: Hookipa Pharma. C. Gaudy Marqueste: Financial Interests, Personal, Advisory Role: Pierre Fabre; Financial Interests, Personal, Invited Speaker: Pierre Fabre, BMS, MSD Oncology; Financial Interests, Personal, Financially compensated role: BMS, Pierre Fabre; Financial Interests, Institutional, Local PI: BMS, Pfizer, Amgen, GSK, Roche, Novartis, Pierre Fabre, Replimmune, MSD, Janssen, Kartos, IFX, Huyabio, Astex, Regeneron, IO Biotech, Philogen, Sotio, Kinnate, AstraZeneca. I. von Wasielewski: Financial Interests, Personal, Advisory Role: BMS, MSD, Sanofi; Financial Interests, Personal, Speaker’s Bureau: Novartis, BMS, MSD, Sanofi, Stemline, Kyowa Kirin; Financial Interests, Personal, Invited Speaker: Novartis, BMS, MSD, Sanofi, Stemline, Kyowa Kirin. T.K. Eigentler: Financial Interests, Personal, Stocks or ownership: CureVac; Financial Interests, Personal, Advisory Role: Merck, BMS, MSD, Novartis, Sanofi, Anaveon; Financial Interests, Institutional, Research Funding: Genentech, CureVac. M. Maio: Financial Interests, Personal, Advisory Board: BMS, Roche, GSK, Sanofi, Alfasigma, Amgen, Sciclone, Eli Lilly, MSD, Incyte, Pierre Fabre, AstraZeneca, Pfizer, Merck Serono; Financial Interests, Personal, Stocks/Shares: EPIGEN, Theravance. I. Zalaudek: Financial Interests, Personal, Advisory Role: Sun Pharma, Philogen, Sanofi Genzyme; Financial Interests, Institutional, Research Funding: Sun Pharma, Philogen, Regeneron; Financial Interests, Personal, Invited Speaker: Sun Pharma, Novartis. S. Haferkamp: Financial Interests, Personal, Advisory Role: BMS, Novartis, Amgen, Roche, Pierre Fabre, MSD; Financial Interests, Personal, Financially compensated role: Novartis, BMS, Amgen. P. Quaglino: Financial Interests, Personal, Advisory Board: BMS, MSD, Pierre Fabre; Financial Interests, Institutional, Research Funding: BMS, MSD; Financial Interests, Personal, Invited Speaker: BMS, MSD, Pierre Fabre. C. Garbe: Financial Interests, Personal, Advisory Board: CeCaVa, MSD, NeraCare, Philogen; Non-Financial Interests, Leadership Role, President: European Association of Dermato-Oncology (EADO). K.C. Kähler: Financial Interests, Personal, Financially compensated role: BMS, MSD, Sanofi-Aventis, Immunocore, Philogen; Financial Interests, Personal, Advisory Role: BMS, MSD, Piere Fabre, Philogen; Financial Interests, Institutional, Research Funding: Novartis; Financial Interests, Personal, Invited Speaker: BMS, MSD, Novartis, Roche, Pierre Fabre. C. Robert: Financial Interests, Personal, Other, Consultancy fees: BMS, Roche, Pierre Fabre, Novartis, Sanofi, MSD, AstraZeneca, Pfizer, Sun Pharma. A. Hauschild: Financial Interests, Personal, Advisory Board: BMS, MSD, Philogen, Pierre Fabre, Regeneron, Roche, Sanofi, Novartis, Eisai, Immunocore, Replimune, Seagen, Dermagnostix, Neracare, IO Biotech, Incyte, Highlight Therapeutics, Agenus, Xenthera; Financial Interests, Personal, Invited Speaker: Merck, Pfizer; Financial Interests, Institutional, Local PI: BMS, MSD, Pierre Fabre, Amgen, Roche, Agenus; Financial Interests, Institutional, Coordinating PI: Regeneron, Novartis. D. Schadendorf: Financial Interests, Personal, Invited Speaker: BMS, MSD, Merck Serono, Sanofi, Neracare, SunPharma; Financial Interests, Personal, Advisory Board: BMS, Novartis, MSD, Immunocore, Pierre Fabre, Sanofi/Regeneron, Pfizer, Philogen, Neracare, InFlarX, BioAlta, Daiichi Sanyko, NoviGenix, Anaveon, AstraZeneca, PamGene, BioNTech, Immatics, CureVac, Erasca, Formycon, Replimune, Seagen, SunPharma, Ultimovacs; Financial Interests, Personal, Steering Committee Member: Novartis, BMS, MSD; Financial Interests, Institutional, Coordinating PI: Novartis, BMS, MSD, Pierre Fabre; Financial Interests, Institutional, Research Grant: BMS, MSD; Financial Interests, Institutional, Local PI: Sanofi, Philogen; Non-Financial Interests, Member of Board of Directors: EORTC-MG; Non-Financial Interests, Leadership Role, Founding member and SC chair: European Melanoma Registry (EuMelaReg). All other authors have declared no conflicts of interest.