Immunotherapy with nivolumab after progression on lenvatinib in advanced hepatocellular carcinoma: A real-world Indian experience

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Background: Firstline treatment of advanced hepatocellular carcinoma (HCC) till recently has been sorafenib or lenvatinib. Lenvatinib, due to its better tolerability and efficacy (in PFS) over sorafenib, is our preferred first line treatment. Nivolumab, with an objective response rate (ORR) of 14.3% and median duration of response of 16.6 months, was approved by FDA on the basis of the CheckMate-040 trial in patients who progressed or were intolerant to sorafenib. There is very limited data of immunotherapy on progression with lenvatinib. Methods: This is a single center, retrospective analysis of patients with advanced HCC who progressed on first line lenvatinib and received treatment with nivolumab. The endpoints were objective response rate (ORR), progression free survival (PFS), overall survival (OS) and toxicity. Results: 15 patients who progressed on lenvatinib, received nivolumab at 3 mg/kg, 2 weekly as second line therapy between July 2019 to July 2021. There were 2 females and 13 males. Median age was 66 years (37-77 years). All patients were BCLC stage C. AFP was elevated in 11 patients. Child Pugh score was A in 10 patients, and B in 5 patients. 7 patients had background of hepatitis B and 1 had hepatitis C. The number of cycles of nivolumab ranged from 2 to 13 cycles. 3 patients (20%) had partial response, 2 had stable disease and 10 (66.6%) had progressive disease by recist criteria. The ORR was 20% and median PFS was 3 months. Median OS was 8 months. The common side effects were hypothyroidism in 7 (46.6%), fatigue in 4 (26.6%) and skin rashes in 3 (20%) patients. Conclusions: Immunotherapy with nivolumab showed limited efficacy in our patients of HCC who have progressed on lenvatinib. There were few patients who showed durable response, but there are no biomarkers to choose these patients. The immune related side effects were manageable. With the first line approval of combination therapy with atezolizumab and bevacizumab, single agent second line immunotherapy with its limited efficacy, may have a reduced role in HCC management.

Real-World Experience with Nivolumab in Metastatic Renal Cell Carcinoma Patients Who Have Progressed on Prior Therapies: A Single-Center Study from India

Introduction Nivolumab monotherapy is approved for the treatment of metastatic renal cell carcinoma (mRCC) patients who have progressed on prior therapies based on the pivotal Checkmate-025 trial. There is limited literature on the efficacy and safety profile of usage of nivolumab in the treatment of mRCC in India in a real-world setting.

Methods A retrospective analysis was performed of patients who received nivolumab monotherapy for mRCC after having progressed on prior therapies. Tumor response was graded according to RECIST v1.1 and Kaplan–Meier survival analysis was used to estimate progression-free survival (PFS) and overall survival (OS). Immune-related adverse events (irAEs) were documented and graded according to CTCAE v5.0.

Results Between 2016 and 2019, 35 patients received nivolumab for mRCC at our center after progression on prior therapies. A majority of the patients (n = 30, 85.7%) received it in a second-line setting, and the remaining in the third line and beyond setting. Clear cell was the most common histology (n = 26, 74.3%). There were 18 patients (51.42%) who belonged to IMDC intermediate risk, while 17 (48.58%) patients were at poor risk. The overall response rate was 60%, with complete response (CR) in 11.4%. Median duration of response was not reached among responders. Median PFS was 5 months (95% confidence interval [CI]: 3.06–6.93) and median OS was 26 months (95% CI: 1.90–50.09). Ongoing survival of 47, 42, 34, and 22 months was noted in four patients with CR, respectively. In our study, 23 patients (65.71%) experienced any grade of irAE. Grade 3 irAEs was seen in four patients (11.42%). Most common irAE was thyroid dysfunction seen in 12 patients (34.2%). Treatment discontinuation due to irAEs occurred in three patients (8.57%).

Conclusion Nivolumab showed good efficacy with high response rates and an OS comparable to the pivotal Checkmate-025 trial. It was well tolerated with safety profile in terms of irAE consistent with those reported in literature.

Combination of immunotherapy and tyrosine kinase inhibitor in first-line metastatic renal cell carcinoma: A real-world Indian experience

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Background: Immuno-oncology (IO) agents in combination with oral tyrosine kinase inhibitors (TKIs) has become a standard first line therapy in metastatic renal cell carcinoma (mRCC) patients. Various combinations such as pembrolizumab + axitinib, avelumab + axitinib, nivolumab + cabozantinib and pembrolizumab + lenvatinib have all shown better results than sunitinib. There is very limited data about this from India. Methods: This is a single center, retrospective study of mRCC patients, who received first line treatment was nivolumab or pembrolizumab with axitinib or lenvatinib. The endpoints were objective response rate (ORR), progression free survival (PFS), overall survival (OS) and adverse events (AE). Results: Between Jan 2019 to Jan 2021, 22 patients were treated with IO + TKI combination. 12 patients received axitinib, and 10 lenvatinib. Age range was 35 to 78 years with 18 males and 4 females. IMDC risk stratification showed 3 favorable (13.6%), 13 intermediate (59%) and 6 poor risk (27.2%) patients. 2 patients (9%) achieved complete response(CR), 13 (59%) partial response (PR), 4 (18.2%) had stable disease and 3 (13.6%) progressed. The ORR was 68%. Median PFS was 22 months (1 month- 24 months). OS at 1 year was 92%, and median OS was not reached. Grade 3/4 immune related adverse events (AEs) were seen in 3 (14.2%) patients (1 colitis,1 pneumonitis,1 encephalitis), for whom the IO was discontinued. TKI related grade 3/4 AEs were seen in 8 patients (38%), and were managed with dose reductions. Conclusions: Combination IO + TKI is a very effective first line therapy in mRCC. An ORR of 68%, median PFS of 22 months and 1 year OS of 92% is the best we have seen in our patients. The efficacy of this combination is seen in all IMDC subgroups. The combination is well tolerated, and the TKI AEs are comfortably managed with dose reduction. IO combinations should be preferred over single agent TKIs (sunitinib or pazopanib) as first line therapy.