EUROPEAN UROLOGY OPEN SCIENCE 40 (2022) 38–45 available at www.sciencedirect.com journal homepage: www.eu-openscience.europeanurology.com Kidney Cancer Ilixadencel, a Cell-based Immune Primer, plus Sunitinib Versus Sunitinib Alone in Metastatic Renal Cell Carcinoma: A Randomized Phase 2 Study Magnus Lindskog a,*, Anna Laurell b, Anders Kjellman c, Bohuslav Melichar d, Pablo Maroto Rey e, Henryk Zieliński f, Felipe Villacampa g, Pierre Bigot h, Bajory Zoltan i, Omi Parikh j, David Vazquez Alba k, Ðsa Jellvert l, Tibor Flaskó m, Enrique Gallardo n, Maria José Ribal Caparrós o, Gunta Purkalne p, Peter Suenaert q, Alex Karlsson-Parra q,r, Börje Ljungberg s a Department of Immunology, Genetics and Pathology, Uppsala University Hospital, Uppsala University, Uppsala, Sweden; b Department of Oncology, Akademiska University Hospital, Uppsala, Sweden; c Department of Urology, CLINTEC, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; d Department of Urology and Urological Oncology, Wojewodzki Szpital Specjalistyczny im. Stefana Kardynaûçûçla Wyszyńskiego, Lublin, Poland; e Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; f Clinical Urology, Military Institute of Medicine, Warsaw, Poland; g Urology Service, Hospital Unversitario 12 Octubre, Madrid, Spain; h Department of Urology, Centre Hospitalier Universitaire d’Angers, Angers Cedex, France; i Szent-Györgyi Albert Klinikai Központ, Szegedi Tudomanyegyetem Altalanos Ovostudomanyi Kar Urologiai Klinika, Szeged, Hungary; j Rosemere Cancer Centre, Royal Preston Hospital, Preston, UK; k Servicio de Urología, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain; l Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; m Department of Urology, Medical School, University of Debrecen, Debrecen, Hungary; n Oncology Department, Parc Taulí Hospital Universitari, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain; o Department of Urology, Hospital Clínic Barcelona, Barcelona, Spain; p Oncology Clinic, Pauls Stradins Clinical University Hospital, Rıga, Latvia; q Immunicum AB, Stockholm, Sweden; r Department of Immunology, Genetics and Pathology, Section of Clinical Immunology, Uppsala University, Uppsala, Sweden; s Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden Article info Abstract Article history: Background: The prognosis of patients with synchronous metastatic renal cell car- Accepted March 30, 2022 cinoma (mRCC) is poor. Whereas single-agent tyrosine kinase inhibition (TKI) is clearly insufficient, the effects can be enhanced by combinations with immune Associate Editor: checkpoint inhibitors. Innovative treatment options combining TKI and other M. Carmen Mir immune-stimulating agents could prove beneficial. Objective: To evaluate the clinical effects on metastatic disease when two doses of Keywords: allogeneic monocyte-derived dendritic cells (ilixadencel) are administrated Allogeneic dendritic cells intratumorally followed by nephrectomy and treatment with sunitinib compared Ilixadencel Intratumoral administration with nephrectomy and sunitinib monotherapy, in patients with synchronous Metastatic renal cell carcinoma mRCC. Off the shelf Design, setting, and participants: A randomized (2:1) phase 2 multicenter trial Phase 2 trial enrolled 88 patients with newly diagnosed mRCC to treatment with the combina- Randomized tion ilixadencel/sunitinib (ILIXA/SUN; 58 patients) or sunitinib alone (SUN; 30 Sunitinib patients). * Corresponding author. Department of Immunology, Genetics and Pathology, Uppsala University Hospital, Uppsala University, Akademiska sjukhuset, Entrance 100/101, 751 85 Uppsala, Sweden. Tel. +46 (0) 768434455. E-mail address: magnus.lindskog@igp.uu.se (M. Lindskog). https://doi.org/10.1016/j.euros.2022.03.012 2666-1683/Ó 2022 The Author(s). Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). EUROPEAN UROLOGY OPEN SCIENCE 40 (2022) 38–45 39 Outcome measurements and statistical analysis: The primary endpoints were 18- mo survival rate and overall survival (OS). A secondary endpoint was objective response rate (ORR) assessed up to 18 mo after enrollment. Statistic evaluations included Kaplan-Meier estimates, log-rank tests, Cox regression, and stratified Cochran-Mantel-Haenszel tests. Results and limitations: The median OS was 35.6 mo in the ILIXA/SUN arm versus 25.3 mo in the SUN arm (hazard ratio 0.73, 95% confidence interval 0.42–1.27; p = 0.25), while the 18-mo OS rates were 63% and 66% in the ILIXA/SUN and SUN arms, respectively. The confirmed ORR in the ILIXA/SUN arm were 42.2% (19/45), including three patients with complete response, versus 24.0% (six/25) in the SUN arm (p = 0.13) without complete responses. The study was not adequately powered to detect modest differences in survival. Conclusions: The study failed to meet its primary endpoints. However, ilixadencel in combination with sunitinib was associated with a numerically higher, nonsignif- icant, confirmed response rate, including complete responses, compared with suni- tinib monotherapy. Patient summary: We studied the effects of intratumoral vaccination with ilix- adencel followed by sunitinib versus sunitinib only in a randomized phase 2 study. The combination treatment showed numerically higher numbers of confirmed responses, suggesting an immunologic effect. Ó 2022 The Author(s). Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY license (http://creativecommons. org/licenses/by/4.0/). 1. Introduction hepatocellular carcinoma (HCC) treated with intratumoral injections of ilixadencel [14] showed an increased fre- Metastatic renal cell carcinoma (mRCC) remains a clinical quency of interferon-gamma–producing CD8+ T cells challenge despite recent developments in oncologic treat- specific for the HCC-associated tumor antigens hTERT ment option. In particular, improved treatment is urgently and/or AFP. The initial phase 1 data in 12 patients with needed for the 17–20% individuals diagnosed with syn- newly diagnosed synchronous mRCC suggested that ilix- chronous metastases and classified as poor- or adencel treatment before nephrectomy followed by stan- intermediate-risk patients according to the International dard sunitinib treatment after nephrectomy was feasible Metastatic Renal Cell Carcinoma Database Consortium [15]. Based on these results, we designed a randomized, (IMDC) [1,2]. phase 2, open-label, multicenter trial comparing intratu- Tyrosine kinase inhibitors (TKIs) targeting vascular moral ilixadencel before nephrectomy followed by suni- endothelial growth factor (VEGF) and related tyrosine tinib with standard of care sunitinib monotherapy after kinases have been the cornerstone of medical treatment nephrectomy, in patients with synchronous mRCC in the for mRCC until recently [3,4]. However, most patients trea- first-line setting. ted with a TKI agent as monotherapy ultimately develop resistance. The era of immune checkpoint inhibitors (ICIs) 2. Patients and methods has recently opened new treatment perspectives, and com- bination treatments with ICIs with or without a TKI are now 2.1. Study design recommended as first-line treatment [5–10]. Patients were randomized in a 2:1 ratio to ilixadencel (two intratumoral Ilixadencel is a cell-based, off-the-shelf investigational doses of ilixadencel in the primary tumor before nephrectomy) followed drug product based on allogeneic monocyte-derived inflam- by sunitinib after nephrectomy (ILIXA/SUN group) or after nephrectomy matory cells aimed to prime an adaptive anticancer sunitinib monotherapy (SUN group). Sunitinib treatment was initiated immune response by recruiting and activating endogenous 5–8 wk after nephrectomy. Patients were followed on for 18 mo from cross-presenting dendritic cells (DCs) when injected intra- randomization unless early discontinuation due to disease progression, tumorally [11–13]. Preclinical in vitro studies with ilix- intolerance to therapy, death, or withdrawal of consent. After study sur- adencel have shown that ilixadencel produces factors that vival follow-up, with no other data collection, is ongoing and extends to induce phenotypic maturation of allogeneic bystander DCs 5 yr after study or until the date of death, whichever occurs first. The and enhances their ability to cross-present cell-associated minimum follow-up time was 36.2 mo for patients still alive. The last antigens to CD8+ T cells [12,13]. Moreover, local subcuta- follow-up was performed in January 2021. The trial was conducted at neous injection of allogeneic mouse-ilixadencel in mice 26 sites in the Czech Republic, France, Hungary, Latvia, Poland, Spain, has been shown to induce migration of endogenous DCs Sweden, the UK, and the USA. The trial was approved by the institutional to draining lymph nodes and systemic activation of review board of each participating center. This study is registered with antigen-specific CD8+ T cells [11]. In line with these preclin- the European Clinical Trials (EudraCT) database (2014-004510-28) and ical data, the majority of evaluable patients (11/15) with the ClinicalTrials.gov (NCT02432846). 40 EUROPEAN UROLOGY OPEN SCIENCE 40 (2022) 38–45 2.2. Patients (HRs) with corresponding 95% confidence intervals (CIs). Between-group differences in the percentage of patients with an objective response were Eligible patients were 18 yr of age or older with newly diagnosed syn- evaluated with a stratified Cochran-Mantel-Haenszel test. A p value of chronous mRCC with at least one computed tomography (CT)-verified 0.05 was considered significant. metastasis (10 mm in the longest diameter) for whom complete metastasectomy was not considered feasible. All patients had Eastern 3. Results Cooperative Oncology Group (ECOG) performance status (PS) of 0–2 and adequate end-organ and bone marrow function, and were without any significant comorbidities. Patients with known brain metastases fol- 3.1. Patient characteristics lowing metastasis-directed local treatment were eligible provided that From April 2014 to January 2017, 88 patients (58 ILIXA/SUN there were no indications of either clinical or radiological progression and 30 SUN) were assigned (safety analysis population). before the initiation of the study. Two of the patients initially assigned to the ILIXA/SUN The patients provided written informed consent. arm were excluded from the full analysis due to withdrawal prior to the first dose of ilixadencel. The intention-to-treat 2.3. Randomization population consisted of 56 patients (16 poor-risk and 40 Patients were stratified according to the IMDC criteria (high vs interme- intermediate-risk patients) for the ILIXA/SUN group and diate risk) and randomized in a 2:1 ratio to receive either ilixadencel 30 patients (eight poor-risk and 22 intermediate-risk plus sunitinib or sunitinib alone. Treatment allocation was not masked, patients) in the SUN group. The overall trial profile is and patients received information about study design and the allocated depicted in Fig. 1. treatment. Overall, the treatment groups were balanced with respect to baseline demographic and disease characteristics 2.4. Procedures (Table 1). In the ILIXA/SUN group (n = 56), ten patients never Cryo-preserved ilixadencel [12], provided by Immunicum AB (Stock- received sunitinib and one patient did not undergo holm, Sweden), was injected intratumorally (ultrasound or CT guided) follow-up CT. In the SUN group, five patients never received into the primary kidney tumor twice, 2 wk apart, with 10 million viable, sunitinib. Death within 2 mo after surgery was the most HLA-DR–expressing cells per dose, followed by nephrectomy at least 3 d frequent reason for not starting sunitinib (five patients in after the second vaccine dose and within 56 d from randomization. Suni- the ILIXA/SUN arm and three in the SUN arm). Additional tinib was administered orally using the standard regimen once per day at a dose of 50 mg for 4 wk, followed by a 2-wk break. Adverse events reasons included disease progression (n = 3), withdrawal (AEs) were managed with treatment interruptions or dose reductions. (n = 1), different diagnosis at laparotomy (n = 1), start of Sunitinib dose could be reduced to 37.5 and 25 mg. CT scans for central another treatment after nephrectomy (n = 1), and with- assessment of tumor response were performed at screening, sunitinib drawal of consent (n = 1). The safety population included start (ie, 5–8 wk after nephrectomy [baseline]), each sunitinib follow- all 88 randomized patients. up visit (6, 12, 24, 36, 48, and 60 wk), and end-of-study visit (18 mo; Supplementary Fig. 1). Response assessment was based on an indepen- 3.2. Efficacy dent blinded central review and response evaluation criteria in solid The 18-mo median OS rate (95% CI) was 63% (49–74%) in tumors version 1.1 (RECIST 1.1) [16]. Treatment was continued until dis- ease progression, intolerance to therapy, or withdrawal of consent. the ILIXA/SUN arm (n = 56) and 66% (46–80%) in the SUN arm (n = 30; p = 0.81). In high-risk patients, the 18-mo sur- 2.5. Outcomes vival rates were 30% in the ILIXA/SUN arm and 38% in the SUN arm (p = 0.72). In intermediate-risk patients, the 18- The coprimary endpoints were 18-mo survival rate and overall survival mo survival rates were 77% in the ILIXA/SUN arm and 76% (OS), both for intention-to-treat and separately by IMDC risk groups. OS in the SUN arm (p = 0.97). was defined as the time from the date of randomization to the time of After a minimum survival follow-up of 36.2 mo, the death from any cause or to the last follow-up for alive patients. The median OS (95% CI) was 35.6 (14.2–not available [NA]) mo key secondary endpoints were objective response rate (ORR; indepen- in the ILIXA/SUN arm and 25.3 (7.7–40.8) mo in the SUN dent blinded central review), confirmed ORR (amended post hoc analysis arm (HR 0.73, 95% CI 0.42–1.27; p = 0.25; Fig. 2). In the based on independent blinded central review data), and progression-free per-protocol population, the median OS (95% CI) was 41.8 survival (PFS), defined as the time from sunitinib start to the time of pro- (26.6–NA) mo in the ILIXA/SUN arm and 33.9 (11.3–45.2) gressive disease according to RECIST 1.1 [16] or death following suni- mo in the SUN arm (HR 0.70, 95% CI 0.38–1.29; p = 0.24). tinib initiation from any cause, whichever occurred first. Safety At the last survival follow-up, the number of patients assessment included all randomized patients. Safety data were moni- still alive in the ILIXA/SUN arm was 22 of 55 (40.0%), com- tored by an independent data and safety monitoring committee. pared with nine of 30 patients in the SUN arm (30.0%; odds ratio 2.0, 95% CI 0.8–5.1; p = 0.14). One additional patient 2.6. Statistical analysis was alive at 18 mo but was lost to subsequent survival As this study was exploratory, sample size was not based on power cal- follow-up. culation for confirming efficacy. Statistical hypothesis testing was used The median OS (95% CI) for intermediate-risk patients in the context of exploratory analysis for the primary and secondary was 41.7 (28.0–NA) mo in the ILIXA/SUN arm and 36.1 endpoints. Time to event endpoints (OS, PFS, and time to response) were (7.7–44.9) mo in the SUN arm (HR 0.62, 95% CI 0.31–1.2; evaluated with Kaplan-Meier estimates, and differences analyzed using p = 0.16). In poor-risk patients, the median OS was reached log-rank test and Cox regressions were applied to estimate hazard ratios at 10.6 (5.0–22.4) mo in the ILIXA/SUN arm and 9.3 EUROPEAN UROLOGY OPEN SCIENCE 40 (2022) 38–45 41 Fig. 1 – Overall trial profile. During enrollment, 111 patients were assessed for eligibility; 29 patients were screening failures and 88 were randomized. Patients were stratified according to the Heng criteria (high and intermediate risk). Fifty-eight patients (17 high-risk and 41 intermediate-risk patients) were allocated to receive ilixadencel (ILIXA) before nephrectomy and sunitinib (SUN) after nephrectomy (defined as the ILIXA/SUN group), whereas 30 patients (eight high-risk and 22 intermediate-risk patients) were allocated to sunitinib (SUN) alone after nephrectomy (defined as the SUN group). (1.3–NA) mo in the SUN arm (HR 0.98, 95% CI 0.37–2.58; was 38.5% for the ILIXA/SUN arm and 33.3% for the SUN p = 0.96; Supplementary Fig. 1). arm (p = 0.83). In the intermediate-risk group, the corre- The median PFS from the start of sunitinib treatment in sponding rates were 43.8% in the ILIXA/SUN arm and the ILIXA/SUN arm was 11.8 mo, as compared with 11.1 21.1% in the SUN arm, respectively (p = 0.1). mo in the SUN arm (p = 0.55). The confirmed ORR was 42.2% (19/45) in the ILIXA/SUN 3.3. Sunitinib treatment: median duration, drug dose arm, including three patients with complete response (CR; reduction, or interruption Table 2). Among the three patients with a confirmed CR, The median duration of sunitinib treatment in the ILIXA/ the sum of tumor diameter in the target lesions were 22 SUN arm was 6.9 (95% CI 6.0–9.3) mo, and it was 7.8 (95% mm (adrenal), 43 mm (lung  2, muscle, and lymph node), CI 5.8–10.4) mo in the SUN arm. Dose reductions for suni- and 22 mm (lung  2), prior to treatment. Two additional tinib due to toxicity occurred in 17.4% (eight/46) of the patients in the ILIXA/SUN arm developed a CR at the last ILIXA/SUN patients versus 24% (six/25) of the SUN patients, follow-up CT scan at 18 mo; one had stable disease until as shown in Supplementary Table 1. Of the ILIXA/SUN the CR and the other had a partial response after 3 mo until patients, 17.4% (eight/46) interrupted sunitinib temporarily the CR was recorded at 18 mo. The ORR in the SUN arm was and 19.6% (nine/46) discontinued it definitively due to tox- 24.0% (six/25; p = 0.13) with no confirmed CR. One patient icity, compared with 16% (four/25) and 20% (five/25) in the in the SUN arm had a CR observed at the last 18-mo CT SUN arm, respectively (Supplementary Table 1). follow-up. The five ILIXA/SUN patients who achieved a CR (three 3.4. Adverse events confirmed and two nonconfirmed) were all alive at the lat- est survival follow-up, while the SUN patient with noncon- AEs were reported in 93.1% (54/58) of ILIXA/SUN patients firmed CR died. In high-risk patients, the confirmed ORR and in 90% (27/30) in the SUN arm. In total, 692 unique 42 EUROPEAN UROLOGY OPEN SCIENCE 40 (2022) 38–45 Table 1 – Baseline demographics and clinical characteristics Table 2 – Antitumor activity in IMDC intermediate- and high-risk patients after the start of sunitinib ILIXA/SUN SUN (n = 56) (n = 30) ILIXA/SUN group SUN group Gender, n (%) (n = 45a) (n = 25) Male 43 (76.8) 21 (70) Confirmed objective response 19 (42.2) 6 (24.0) Female 13 (23.2) 9 (30) rate (%) Age (yr) Complete response 3 (6.7) 0 (0.0) Median 63 64 Partial response 16 (35.6) 6 (24.0) Range 41–76 49–86 Stable disease 11 (24.4) 10 (40.0) Ethnic origin, n (%) Progressive disease 7 (15.6) 2 (8.0) Caucasian 55 (98.2) 28 (93.3) Unable to determine or not 9 (20.0) 7 (28.0) Unknown 1 (1.8) 2 (6.7) reported ECOG performance status Time to response (mo), 2.9 (2.6–6.5) 4.2 (2.9–9.6) (screening), n (%) median (95% CI) 0 33 (58.9) 17 (56.6) CI = confidence interval; ILIXA = ilixadencel; IMDC = International Meta- 1 23 (41.1) 12 (40) static Renal Cell Carcinoma Database Consortium; SUN = sunitinib. 2 0 (0) 1 (3.3) a One patient was not evaluable for response evaluation due to which Time from diagnosis to screening (mo) 0.6 0.8 no evaluation by imaging was performed. Tumor type, n (%) RCC histology 51 (91.1) 27 (90.0) RCC with clear cell component 49 (87.5) 25 (83.3) RCC without clear cell component 1 (1.8)a 0 (0) Non-RCC histology 1 (1.8)b 1 (3.3)c ment were fatigue, diarrhea, and nausea (see Table 3). Clinical and radiological RCC/no 4 (7.1) 2 (6.7) nephrectomy due to rapid Grade 3 anemia was slightly more common in patients progression/no histology in the ILIXA/SUN arm (5.2%) than in those in the SUN arm IMDC risk category, n (%) (3.3%). Anemia was not related to any vaccination proce- Intermediate 40 (71.4) 22 (73.3) Poor 16 (28.6) 8 (26.6) dures, but was judged due to disease progression (n = 2) ECOG = Eastern Cooperative Oncology Group; ILIXA = ilixadencel; and sunitinib treatment (n = 1) in the ILIXA/SUN arm and IMDC = International Metastatic Renal Cell Carcinoma Database Consor- postoperative anemia in one patient in the SUN arm. tium; RCC = renal cell carcinoma; SUN = sunitinib. Grade 3 AEs occurred in 48 of all 88 patients enrolled a Chromophobe RCC. b Sarcoma. (54.5%), 31 in the ILIXA/SUN arm and 17 in the SUN arm. c Urothelial cancer. Nine patients (10.2%) experienced a grade 4 AE, six in the ILIXA/SUN arm and three in the SUN arm. Overall, two patients (2.3%) discontinued the study due to an AE of any cause, one patient in the ILIXA/SUN arm and one in the AEs were reported, that is, AE of a certain type was counted SUN arm. Twelve patients (13.6%) discontinued due to only once in each patient. In both groups, the most common death during the study, seven patients in the ILIXA/SUN AEs of any cause and the most common AEs related to treat- arm and five in the SUN arm. Fig. 2 – Kaplan-Meier estimate of survival for all patients. Survival probability (all patients) is displayed graphically using Kaplan-Meier, including summaries of the number of events (marked as a black star) and censored observations (marked as black circles). The red line represents ilixadencel and sunitinib strata (high and intermediate risk), and the blue line represents sunitinib strata (high and intermediate risk). The patients at risk for each stratum are indicated below the figure. CR = complete response. EUROPEAN UROLOGY OPEN SCIENCE 40 (2022) 38–45 43 Table 3 – Adverse events Any AE ILIXA/SUN (N = 58) SUN (N =30) Preferred terma Patients with occurrence, n (%) Any grade Grade 3 or 4 Any grade Grade 3 or 4 Fatigue 14 (24.1) 1 (1.7) 8 (26.7) 0 (0) Diarrhea 14 (24.1) 0 (0) 7 (23.3) 2 (6.7) Nausea 14 (24.1) 1 (1.7) 7 (23.3) 0 (0) Anemia 14 (24.1) 3 (5.2) 4 (13.3) 1 (3.3) Hypertension 12 (20.7) 4 (6.9) 6 (20.0) 0 (0) Asthenia 11 (19.0) 2 (3.5) 5 (16.7) 2 (6.7) Pyrexia 11 (19.0) 2 (3.5) 4 (13.3) 0 (0) Decreased appetite 10 (17.2) 0 (0) 5 (16.7) 0 (0) Vomiting 14 (24.1) 2 (3.5) 0 (0) 0 (0) Dysgeusia 9 (15.5) 0 (0) 5 (16.7) 0 (0) Back pain 10 (17.2) 1 (1.7) 3 (10.0) 0 (0) Stomatitis 6 (10.3) 1 (1.7) 6 (20.0) 0 (0) Hypothyroidism 8 (13.8) 0 (0) 3 (10.0) 0 (0) Palmar-plantar erythrodysesthesia syndrome 7 (12.1) 0 (0) 3 (10.0) 0 (0) Blood creatinine increased 6 (10.3) 1 (1.7) 4 (13.3) 1 (3.3) Constipation 7 (12.1) 0 (0) 2 (6.7) 0 (0) Headache 7 (12.1) 0 (0) 1 (3.3) 0 (0) Urinary tract infection 6 (10.3) 1 (1.7) 2 (6.7) 0 (0) Arthralgia 5 (8.6) 1 (1.7) 3 (10.0) 0 (0) Mucosal inflammation 6 (10.3) 0 (0) 1 (3.3) 0 (0) Pain in extremity 5 (8.6) 0 (0) 2 (6.7) 0 (0) Epistaxis 5 (8.6) 0 (0) 2 (6.7) 1 (3.3) Abdominal pain upper 4 (6.9) 1 (1.7) 3 (10.0) 0 (0) Dry skin 4 (6.9) 0 (0) 2 (6.7) 0 (0) Hypercalcemia 4 (6.9) 1 (1.7) 2 (6.7) 2 (6.7) Dyspnea 4 (6.9) 0 (0) 2 (6.7) 0 (0) Oral pain 3 (5.2) 0 (0) 3 (10.0) 0 (0) Dizziness 3 (5.2) 0 (0) 3 (10.0) 0 (0) Procedural pain 3 (5.2) 0 (0) 3 (10.0) 1 (3.3) Thrombocytopenia 5 (8.6) 1 (1.7) 0 (0) 0 (0) Anxiety 5 (8.6) 0 (0) 0 (0) 0 (0) Neutropenia 4 (6.9) 0 (0) 1 (3.3) 0 (0) Cough 4 (6.9) 0 (0) 1 (3.3) 0 (0) Hypotension 4 (6.9) 0 (0) 1 (3.3) 0 (0) Abdominal pain 3 (5.2) 0 (0) 2 (6.7) 0 (0) Platelet count decreased 2 (3.4) 1 (1.7) 3 (10.0) 1 (3.3) AE = adverse event; ILIXA = ilixadencel; SUN = sunitinib. a Preferred term used. Adverse events that occurred of any cause and occurred in 5% of patients in the treated population as per safety analysis. N = total number of patients in the group, used as the denominator for calculating percentage. Table 4 – Treatment-related adverse events of grade 3a Grade AE related to ILIXA/SUN (N = 58) SUN (N = 30) Total (N = 88) n (%) n (%) n (%) 3 SUN 13 (22.4) 5 (16.7) 18 (20.5) ILIXA 2 (3.4) NA 2 (2.3) 4 SUN 1 (1.7) 2 (6.7) 3 (3.4) ILIXA 0 (0.0) NA 0 (0.0) 5 SUN 0 (0.0) 1 (3.3) 1 (1.1) ILIXA 0 (0.0) NA 0 (0.0) AE = adverse event; ILIXA = ilixadencel; NA = not available; SUN = sunitinib. a Common Terminology Criteria for Adverse Events version 5.0. Treatment-related AEs of any grade occurred in 62 of 88 (3.4%; see Table 4). Two patients developed a grade 3 patients (70.5%). Sunitinib-related events of any grade AE that was attributed to ilixadencel, whereas five occurred in 36 of 58 patients (62.1%) in the ILIXA/SUN patients had a grade 3 AE that was considered related arm and in 20 of the 30 patients (66.7%) in the SUN arm. to sunitinib. One patient in the SUN arm died due to sep- Ilixadencel-related AEs of any grade occurred in 13 of 58 tic shock of abdominal origin that was attributed by the patients (22.4%) in the ILIXA/SUN arm. investigator to the treatment of sunitinib (1.1%). There Sunitinib-related grade 3 events occurred in 18 of 88 were no grade 4 and 5 events related to treatment with patients (20.5%) and grade 4 events in three patients ilixadencel. 44 EUROPEAN UROLOGY OPEN SCIENCE 40 (2022) 38–45 4. Discussion ered to detect modest differences in survival. The present study population of patients with synchronous metastases This trial was a randomized, phase 2, open-label study com- could possibly have diminished sensitivity, in particular paring intratumoral ilixadencel followed by sunitinib with since both arms included a substantial number of sunitinib monotherapy (standard of care at the time of the high-risk patients who may not have benefitted from the study), in patients with synchronous mRCC in the first- treatment approach with upfront nephrectomy [18,19]. line setting. Upfront nephrectomy was performed in both Moreover, since patient survival was the only postprogres- groups (following ilixadencel vaccination in the experimen- sion parameter recorded, potential differences in second- tal arm). The drug combination did not improve OS com- line treatment between the groups cannot be excluded. In pared with sunitinib alone. These statistically negative OS addition, the standard of care has evolved since the time data are in line with the data from a recently published this trial was conceived, and sunitinib monotherapy is cur- phase 3 study in a patient population with synchronous rently recommended only as first-line medical therapy in mRCC using autologous monocyte-derived DCs loaded with intermediate- and poor-risk mRCC patients who cannot mRNA from the autologous tumor plus sunitinib versus receive or tolerate immune checkpoint inhibition [7]. The sunitinib alone, where no improvement in median OS was present study was limited to synchronous mRCC due to observed [17]. the study design, indicating that most patients would have Nevertheless, ilixadencel in combination with sunitinib remained unbenefited even with positive study results. was associated with a numerically higher rate of confirmed Nevertheless, patients with synchronous metastatic RCC responses (42.2%) including 6.7% CR (all alive at the last represent a vulnerable group of RCC patients in whom good follow-up) compared with 24% with a confirmed response treatment options were largely lacking, motivating our trial (none with a confirmed CR) in patients treated with suni- design. Future trials of ilixadencel in mRCC should therefore tinib monotherapy. The observed responses seemed to be use ICI-based combinations as backbone regimens. Based on driven mainly by intermediate-risk patients. The short sur- the results of the present study, The US Food and Drug vival of poor-risk patients in both arms is consistent with Administration has recently supported further development more recent finding from phase 3 randomized clinical trials, of the ilixadencel and sunitinib combination with a Regen- indicating that upfront nephrectomy should be avoided in erative Medicine Advanced Therapy designation [24]. this subgroup due to the risk of rapidly progressive disease [18,19]. Of possible interest, while the OS rate at 18 mo was comparable in both arms, the OS curves separated there- 5. Conclusions after. This might indicate a possibility of late responses with prolonged duration in the ILIXA/SUN arm. Indeed, remark- In conclusion, despite that this trial failed to meet its pri- ably late CRs (18 mo) were noted in two patients treated mary endpoints, it showed the combination of ilixadencel with the combination. Furthermore, the nearly two-fold with sunitinib to be safe and associated with promising higher rate of confirmed objective responses in the ILIXA/ overall and CR rates, compared with sunitinib alone. Future SUN patients, as compared with sunitinib alone, may be investigations of ilixadencel with regimens combining ICIs clinically meaningful. Our hypothesis is that ilixadencel and TKIs in the study population are warranted. induces a systemic and sustained activation of tumor- specific T cells and that the subsequent blockade of different Author contributions: Magnus Lindskog had full access to all the data in VEGF-dependent immunosuppressive mechanisms by suni- the study and takes responsibility for the integrity of the data and the tinib will unleash the full antitumor potential of an accuracy of the data analysis. ilixadencel-induced systemic and sustained tumor- specific, T-cell response. Such a proposed synergistic mech- anism is supported by data from others showing that suni- Study concept and design: Lindskog, Suenaert, Karlsson-Parra, Ljungberg. tinib works in concert with immune primers and anticancer Acquisition of data: Lindskog, Laurell, Kjellman, Melichar, Rey, Zieliński, vaccines, including DC-based vaccines in preclinical tumor Villacampa, Bigot, Zoltan, Parikh, Alba, Jellvert, Flaskó, Gallardo, models [20–22]. Caparrós, Purkalne, Suenaert, Karlsson-Parra, Ljungberg. The addition of ilixadencel to sunitinib did not increase Analysis and interpretation of data: Lindskog, Suenaert, Karlsson-Parra, toxicity, and the safety profile was consistent with previous Ljungberg. experience with ilixadencel in combination with TKIs in Drafting of the manuscript: Lindskog, Suenaert. mRCC [15], HCC [14], and gastrointestinal stromal tumors Critical revision of the manuscript for important intellectual content: Lind- [23]. The schedule of sunitinib was in line with previous skog, Suenaert, Karlsson-Parra, Ljungberg. randomized trials with sunitinib [5,9]. The incidence of Statistical analysis: Lindskog, Suenaert, Karlsson-Parra, Ljungberg. grade 3 and 4 events was similar in both arms, whereas Obtaining funding: None. no treatment-related deaths occurred in the ILIXA/SUN arm. Administrative, technical, or material support: Lindskog, Suenaert, Karlsson-Parra. The present study has several limitations, including a Supervision: Lindskog, Suenaert, Karlsson-Parra, Ljungberg. small sample size and absence of blinding, as expected for Other: None. a phase 2 trial using an interventional procedure. A non- negligible proportion did not proceed to sunitinib treat- ment, introducing a potential selection bias. Moreover, Financial disclosures: Magnus Lindskog certifies that all conflicts of inter- exploratory in its design, the trial was not adequately pow- est, including specific financial interests and relationships and affiliations EUROPEAN UROLOGY OPEN SCIENCE 40 (2022) 38–45 45 relevant to the subject matter or materials discussed in the manuscript checkpoint inhibitor–based combination therapies for treatment- (eg, employment/affiliation, grants or funding, consultancies, honoraria, naive metastatic clear-cell renal cell carcinoma are standard of care. Eur Urol 2021;80:393–7. stock ownership or options, expert testimony, royalties, or patents filed, [8] Choueiri TK, Powles T, Burotto M, et al. Nivolumab plus received, or pending), are the following: Alex Karlsson-Parra and Peter cabozantinib versus sunitinib for advanced renal-cell carcinoma. Suenaert report ownership of stocks in Immunicum AB. Alex Karlsson- N Engl J Med 2021;384:829–41. Parra is an Immunicum employee, and Peter Suenaert is an Immunicum [9] Rini BI, Plimack ER, Stus V, et al. Pembrolizumab plus axitinib consultant. All other authors report no conflict of interest. versus sunitinib for advanced renal-cell carcinoma. N Engl J Med 2019;380:1116–27. [10] Motzer R, Alekseev B, Rha SY, et al. Lenvatinib plus pembrolizumab or everolimus for advanced renal cell carcinoma. N Engl J Med Funding/Support and role of the sponsor: The research reported is spon- 2021;384:1289–300. sored by Immunicum AB. [11] Fotaki G, Jin C, Kerzeli IK, et al. Cancer vaccine based on a combination of an infection-enhanced adenoviral vector and pro- inflammatory allogeneic DCs leads to sustained antigen-specific Ethics statement: This study was approved by the Independent Ethics immune responses in three melanoma models. Oncoimmunology Committee and the Institutional Review Board prior to inclusion of 2018;7:e1397250. patients. Patients provided written informed and signed consent before [12] Karlsson-Parra A, Kovacka J, Heimann E, et al. Ilixadencel—an allogeneic cell-based anticancer immune primer for intratumoral participation. administration. Pharm Res 2018;35:156. [13] Fotaki G, Jin C, Ramachandran M, et al. Pro-inflammatory allogeneic DCs promote activation of bystander immune cells and thereby Data sharing: No identifiable data will be shared and should not be license antigen-specific T-cell responses. Oncoimmunology 2018;7: requested. The datasets used and/or analyzed during the current study e1395126. are available from the corresponding author on reasonable request. [14] Rizell M, Sternby Eilard M, Andersson M, Andersson B, Karlsson- Parra A, Suenaert P. Phase 1 trial with the cell-based immune primer ilixadencel, alone, and combined with sorafenib, in Acknowledgments: We thank the patients who participated in this study advanced hepatocellular carcinoma. Front Oncol 2019;9:19. 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