
==== Front
Immunotherapy
Immunotherapy
Immunotherapy
1750-743X
1750-7448
Taylor & Francis

39264730
10.1080/1750743X.2024.2359359
2359359
Version of Record
Research Article
Research Article
A phase 1 study of the CD40 agonist MEDI5083 in combination with durvalumab in patients with advanced solid tumors
https://orcid.org/0000-0001-9124-354X
Tran Ben * a
Voskoboynik Mark b c
Bendell Johanna ‡ d
Gutierrez Martin e
Lemech Charlotte f g
Day Daphne c h
Frentzas Sophia c h
Garrido-Laguna Ignacio i
Standifer Nathan § j
Wang Fujun k
Ferte Charles l
Wang Yue l
Das Mayukh l
Carneiro Benedito A m
a Peter MacCallum Cancer Centre, Melbourne, 8006, Australia
b Nucleus Network, Melbourne, 3004, Australia
c Monash University, Melbourne, 3004, Australia
d Sarah Cannon Research Institute/Tennessee Oncology, Nashville, TN 37203, USA
e Hackensack University Medical Center, Hackensack, NJ 07601, USA
f Scientia Clinical Research, Randwick, 2031, Australia
g The University of New South Wales, Sydney, 2052, Australia
h Monash Medical Centre, Clayton, 3800, Australia
i Huntsman Cancer Institute, Salt Lake City, UT 84132, USA
j Integrated Bioanalysis, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, South San Francisco, CA 94080, USA
k Oncology Biometrics, AstraZeneca, Gaithersburg, MD 20878,USA
l AstraZeneca, Gaithersburg, MD 20878,USA
m Legorreta Cancer Center at Brown University, Lifespan Cancer Institute, Providence, RI 02903,USA
* CONTACT: Tel.: 03 8559 5000; ben.tran@petermac.org
‡ Current affiliation: Research and Early Development, Roche Pharma, Basel, Switzerland

§ Current affiliation: Translational Science, Tempest Therapeutics, Brisbane, CA, USA

12 9 2024
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© 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.

Aim: This first-in-human study evaluated safety and efficacy of CD40 agonist MEDI5083 with durvalumab in patients with advanced solid tumors.

Methods: Patients received MEDI5083 (3–7.5 mg subcutaneously every 2 weeks × 4 doses) and durvalumab (1500 mg every 4 weeks) either sequentially (N = 29) or concurrently (N = 9). Primary end point was safety; secondary end points included efficacy.

Results: Thirty-eight patients received treatment. Most common adverse events (AEs) were injection-site reaction (ISR; sequential: 86%; concurrent: 100%), fatigue (41%; 33%), nausea (20.7%; 55.6%) and decreased appetite (24.1%; 33.3%). Nine patients had MEDI5083-related grade ≥3 AEs with ISR being the most common. Two patients experienced dose limiting toxicities (ISR). One death occurred due to a MEDI5083-related AE. MEDI5083 maximum tolerated dose was 5 mg. Objective response rate was 2.8% (1 partial response and 11 stable disease).

Conclusion: MEDI5083 toxicity profile limits its further development.

Plain Language Summary

MEDI5083 is a molecule that was designed as a potential anticancer medication. Once inside the body, MEDI5083 connects to specific proteins found on the surface of immune cells and cancer cells. It can boost the immune system of the body in multiple ways to help kill cancer cells. In this clinical study, 38 patients with various types of cancers (bladder, breast, colon, head and neck, kidney, lung, and pancreas) were treated with MEDI5083 together with another anticancer medicine called durvalumab. MEDI5083 was given to patients as an injection under the skin once every 2 weeks. Durvalumab was given to patients as an infusion once every 4 weeks. The study monitored whether treatment caused unwanted side effects and whether MEDI5083 was able to shrink the size of tumors.

A total of 34 of 38 patients who received treatment experienced unwanted reactions at the site of MEDI5083 treatment injection. These symptoms were long lasting and did not go away with an applied steroid treatment. A total of 5 of 38 patients experienced extreme tiredness and 4 of 38 patients experienced fever. Of 38 patients enrolled, 6 discontinued treatment because of a MEDI5083-related side effect. Only one patient had a decrease in the size of their cancer mass with treatment. Because of safety concerns, this study was not completed. The injectable form of MEDI5083 is not being further tested in patients with cancer.

Summary points

CD40 is widely expressed in multiple solid tumor types and activation of the CD40 pathway is an attractive approach to boost antitumor immune responses.

MEDI5083 is a homodimeric fusion protein composed of a single chain fusion of three single-chain CD40L domains and an IgG4P domain fragment crystallizable linked by 9-glycine-serine linker regions, containing a mutated residue 194 (unpaired cysteine).

MEDI5083 was designed to have better potency with prolonged exposure and less systemic toxicities.

This multicenter, open-label, phase 1 study evaluated the safety and clinical activity of MEDI5083, administered sequentially or concurrently with durvalumab in adult patients with advanced solid tumors.

Limited efficacy has been observed with the combination across cancer types evaluated.

The most common MEDI5083-related adverse events were injection-site reaction, fatigue, and pyrexia.

MEDI5083 demonstrated mobilization of B-cells and increased proliferating T-cell in peripheral blood.

The toxicity profile of MEDI5083, when administered subcutaneously alone or in combination with durvalumab, did not support further development of this formulation.

Keywords: 

CD40
CD40L
cancer
efficacy
fusion protein
safety
AstraZeneca United States 10.13039/100021316 This study was supported by AstraZeneca.
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pmc1. Introduction

CD40 is a member of the TNF receptor superfamily expressed in a variety of cell types, including immune and tumor cells [1]. The interaction between CD40 and its ligand, CD40L, plays an important role in activating the adaptive immune response [1,2]. CD4+ T-cells can be primed via the interaction between CD40 on APCs and CD40L on CD4+ T-cells (Supplementary Figure S1) [3–5]. Activation of APCs like dendritic cells, macrophages, and B-cells induces cytokine production (including IL-12 by dendritic cells), upregulates cell surface costimulatory molecule production, facilitates antigen presentation and promotes maturation, and indirectly facilitates cytotoxic T-cell activation [2,6–9].

In addition to its expression in a wide variety of normal immune and non-immune cells, CD40 is widely expressed in multiple solid tumor types [10–15]. The intracellular downstream effect of CD40 agonism is dependent on the cell type involved and the tumor microenvironment. For most solid tumors, CD40 activation by its ligand is expected to cause direct apoptotic cell death [16]. However, in certain lymphomas, CD40 activation can result in enhancement of tumor progression via the activation of endothelial cells [16]. Accordingly, activation of the CD40 pathway represents an attractive approach for boosting antitumor immune responses, especially in solid tumors. However, the use of agonistic antibodies can be associated with significant systemic toxicities, limiting the development of these molecules.

MEDI5083 is a homodimeric fusion protein composed of a single chain fusion of three single-chain CD40L domains and an IgG4P domain fragment crystallizable (Fc) linked by 9-glycine-serine linker regions, containing a mutated residue 194 (unpaired cysteine) (Supplementary Figure S1) [17]. MEDI5083 was designed as a trimerized IgG fusion protein to mimic the native ligand for better potency and was formulated for subcutaneous (sc.) injection to prolong exposure and minimize systemic toxicities. The molecular weight (MW) of MEDI5083 is 148 kDa, which is similar to the MW of a monoclonal antibody (∼150 kDa). MEDI5083 has six binding sites compared with the two binding sites of a standard monoclonal antibody. MEDI5083 activates the CD40 pathway and bridges the innate and adaptive immune systems via three distinct mechanisms: (i) direct apoptosis of tumor cells; (ii) CD8+ cytotoxic T-cell mediated indirect tumor killing; and (iii) tumor microenvironment activation via M1 polarization (data on file, AstraZeneca, Gaithersburg, MD).

In preclinical studies, MEDI5083 activated the CD40 pathway in APCs, potently upregulated co-stimulation molecules on monocyte-derived dendritic cells, and induced secretion of pro-inflammatory cytokines in a viral antigen re-stimulating assay [17]. In addition, an sc. administered murine surrogate of MEDI5083 (mCD40L-Fc) demonstrated antitumor activity in mice, which was further enhanced when used in combination with PD-L1 and/or CTLA-4 [17]. The priming effect of MEDI5083 may also enhance tumor sensitivity to chemotherapy, depending upon the timing at which the treatments are administered [18]. Because the upregulation of PD-L1 on tumor-infiltrating monocytes and macrophages is recognized as a resistance mechanism of agonistic anti-CD40 treatment [19], we hypothesized that combining MEDI5083 with durvalumab may activate the adaptive immune response through complementary mechanisms and lead to enhanced targeting of tumor cells.

In preclinical studies, a rapid systemic clearance and short half-life (t1/2; <24 h) of MEDI5083 were observed following either intravenous (iv.) or sc. administration (data on file, AstraZeneca, Gaithersburg, MD).

Durvalumab is a selective, high-affinity, engineered human IgG1 monoclonal antibody that blocks PD-L1 from binding to PD-1 and CD80, facilitating T-cell activation and tumor cell elimination [20]. Accordingly, the combination of durvalumab and MEDI5083 has the potential to activate the adaptive immune system through complementary mechanisms, leading to enhanced targeting of tumor cells.

This multicenter, open-label, phase 1 study evaluated the safety and clinical activity of the CD40 agonist MEDI5083 administered sequentially or concurrently with durvalumab in adult patients with advanced solid tumors (NCT03089645).

2. Methods

2.1. Study population

Patients aged ≥18 years were eligible if they had metastatic or recurrent solid tumors progressing on, or refractory to, prior therapy. Eligible patients also: had an Eastern Cooperative Oncology Group (ECOG) performance status of 0–1; had at least 1 measurable lesion according to RECIST version 1.1; consented to provide archival tumor tissue and pre/on-treatment biopsies; had adequate organ and marrow function (defined as hemoglobin ≥9 g/dl, absolute neutrophil count ≥1500 μl and platelet count ≥100,000/μl (none of which could be met with ongoing or recent blood transfusions ≤14 days of starting the first dose or required growth factor support within ≤28 days of starting the first dose); total bilirubin ≤1.5 × upper limit of normal (ULN) except for patients with documented Gilbert's syndrome [>3 × ULN]; ALT and AST ≤2.5 × ULN [AST/ALT could be up to 5 × ULN in the presence of liver metastasis or hepatocellular carcinoma, but could not be associated with elevated bilirubin]; and creatinine clearance of ≥50 ml/min, as determined by the Cockcroft–Gault formula using actual body weight or 24-h urine creatinine clearance).

Patients who had received prior immunotherapy regimens containing CTLA-4, PD-L1 or PD-1 antagonists were eligible if all of the following applied: the last dose of immunotherapy was administered ≥28 days prior to the planned first dose of study drug; they had not experienced a toxicity that led to discontinuation on prior immunotherapy; all adverse events (AEs) while receiving prior immunotherapy had resolved to grade <1 or baseline prior to screening; they had not experienced a grade >3 AE or neurologic AE of any grade while receiving prior immunotherapy; they must not have required the use of additional immunosuppression, other than corticosteroids, for the management of an AE; and they must not have experienced recurrence of an AE if rechallenged or required a maintenance dose of >10 mg prednisone or equivalent per day.

Key exclusion criteria included: receipt of any systemic anticancer therapy within 28 days prior to the first dose of MEDI5083 or durvalumab; concurrent enrollment in another clinical study; active or prior autoimmune or inflammatory disorders; a history of immunodeficiency, solid organ transplant or tuberculosis; known allergy/hypersensitivity to study drug or components; untreated central nervous system metastatic disease, leptomeningeal disease or cord compression; and current or prior use of immunosuppressive medication within 14 days prior to the first dose of MEDI5083 or durvalumab.

2.2. Study design

This open-label, multicenter, phase 1 study of MEDI5083 administered sequentially or concurrently with durvalumab was conducted at eight centers in the USA and Australia from 24 March 2017 to 18 August 2020 (data cutoff date). Patients were enrolled from March 2017 to June 2020. The study was conducted in accordance with the ethical principles originating in the Declaration of Helsinki and consistent with the International Conference on Harmonisation/Good Clinical Practice and applicable regulatory requirements. A waiver for the institutional review board requirements under 21 CFR Part 56 was granted by the US FDA. The study was not blinded. All patients provided written informed consent before study participation. The study was registered with Clinicaltrials.gov, number NCT03089645.

The study design is summarized in Supplementary Figure S2. In the sequential-treatment cohort, MEDI5083 was administered sc. every 2 weeks for 4 doses, followed by a 4-week washout and durvalumab 1500 mg iv. every 4 weeks (Q4W). Patients in this cohort were enrolled in sequential cohorts of increasing dose levels of MEDI5083 (3, 4, 5 or 7.5 mg) until disease progression, initiation of alternative cancer therapy, unacceptable toxicity, withdrawal of consent, or treatment discontinuation. In the concurrent-treatment cohort, MEDI5083 was administered sc. every 2 weeks for four doses concurrently with durvalumab 1500 mg iv. Q4W for two doses, followed by durvalumab 1500 mg iv. Q4W until disease progression, initiation of alternative cancer therapy, unacceptable toxicity, withdrawal of consent or treatment discontinuation. The starting dose of single site injection MEDI5083 was at least two dose levels below the highest tolerated dose explored in the sequential treatment and was chosen based on emerging pharmacokinetic (PK)/pharmacodynamic (PD)/safety/efficacy data and at the discretion of the sponsor. Dose escalation in the concurrent cohort could proceed up to, but not exceed the MEDI5083 monotherapy maximum tolerated dose (MTD) identified in the sequential cohort. On days when both treatments were administered, MEDI5083 was administered first and iv. infusion of durvalumab was started after an observation period of 30–60 min. This interval after administration of MEDI5083 was used to observe the patient for (and manage) any emerging AE (e.g., cytokine release syndrome).

The dose-escalation cohorts followed a modified toxicity probability interval (mTPI-2) algorithm that utilized a simple beta-binomial Bayesian model for dose finding. Decision rules were based on the unit probability mass (UPM) calculated on equal-length intervals. The three types of dosing intervals (proper dosing intervals, underdosing intervals, overdosing intervals) are associated with three different dose-escalation decisions. The under-dosing intervals correspond to a dose escalation (E), overdosing intervals correspond to a dose de-escalation (D) and proper dosing intervals correspond to staying at the current dose (S). Given an interval and a probability distribution, the UPM of that interval is defined as the probability of the interval divided by the length of the interval. The mTPI-2 design calculates the UPMs for each of equal-length dosing intervals. A dose level was considered unsafe, with no additional patients enrolled at that dose level, if it had an estimated 95% or more probability of exceeding the target dose-limiting toxicity (DLT) rate of 30% (i.e., P [DLT >30% data] >95%) with at least three patients treated at that dose level. In this study, dose-escalation to the next dose-level was determined by using a modified mTPI-2 algorithm, with a target DLT rate of 30% and an equivalence interval of 25–35% [21]. Dose escalation was continued to the next higher dose level after all available safety data and any available (PK/PD) data from patients in that dose level and prior dose levels had been reviewed by a study-specific dose escalation committee. The DLT assessment period was 28 days from the administration of the first dose of MEDI5083. A DLT was defined as any grade 3 or higher toxicity occurring during the DLT evaluation period, defined as the period from the first dose of MEDI5083 plus 28 days, except for toxicity that was clearly and directly related to the primary disease or another etiology. The following were considered as DLTs: any grade 4 immune-related AE; any grade ≥3 uveitis; any grade ≥3 noninfectious colitis; any grade ≥3 noninfectious pneumonitis irrespective of duration; any grade 3 immune-related AE, excluding colitis, uveitis or pneumonitis, that did not downgrade to grade 2 within 3 days after onset of the event, despite optimal medical management including systemic corticosteroids or did not downgrade to grade ≤1 or baseline within 14 days; any grade 2 noninfectious pneumonitis that did not resolve to grade ≤1 within 7 days of the initiation of maximum supportive care; any grade 3 or 4 hematologic AE as described in the Supplementary Table S1; isolated ALT or AST >8 × ULN or isolated total bilirubin >5 × ULN regardless of duration or reversibility; and any grade ≥3 non-immune-related AE, except for the exclusions listed in Supplementary Table S2. Immune-related AEs were defined as AEs of an immune nature (i.e., inflammatory) in the absence of an alternative etiology. In the absence of a clinically significant abnormality, repeat laboratory testing was conducted to confirm significant laboratory findings prior to designation as a DLT.

2.3. End points

The primary end point of the study was safety. Secondary end points were objective response rate (ORR), progression-free survival (PFS) at 6 months, disease control (complete response, partial response [PR] or stable disease [SD] ≥24 weeks), duration of response based on investigator-assessed Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, overall survival (OS), and PD variables including reduction in peripheral blood CD19+B-cells. Evaluation of the activation of T-cells in peripheral blood was an exploratory end point.

2.4. Safety

Safety was assessed by monitoring DLTs during the first 28 days from the first dose of MEDI5083 and evaluating AEs and serious AEs (SAEs) at screening (within 28 days of first dose), through end-of-treatment (14 days post last dose), at day 30, day 120 and every 12 weeks of follow-up. Safety was further assessed via physical examination and assessment of ECOG performance status, vital signs and laboratory tests, at screening (within 28 days of the first dose), on day 1, day 15, day 29, day 43, day 57 and at end-of-treatment (14 days post last dose). Laboratory tests were also performed on day 71+Q4W and at day 30 of follow-up in addition to the above mentioned days. AEs were assessed by the investigator for relationship to the investigational product and severity. AEs were coded by the Medical Dictionary for Regulatory Activities and preferred term, and AEs and laboratory values were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03.

2.5. Efficacy

Efficacy analyses used RECIST version 1.1 [22] applied to investigator-assessed tumor measurements of CT/MRI scans at screening, every 8 weeks, at end-of-treatment (14 days post last dose and every 8 weeks) and at day 120.

2.6. Pharmacodynamics

Circulating lymphocyte populations, including T-, B- and NK-cells and proliferating T-cell subsets, were monitored using two bioanalytically validated, flow cytometry-based immunophenotyping assays, as described previously [23]. Fresh whole blood specimens were collected in CytoChex® and acid citrate dextrose collection tubes at screening (within 28 days of the first dose) and at days 1, 2, 3, 8, 15, 29, 43, 44, 45, 50, 57 and 71. Predose samples were collected ≥30 min prior to MEDI5083 administration. Samples were shipped overnight to regional testing laboratories, at which blood was added to antibody cocktails and incubated for 20 min at room temperature in the dark. Erythrocytes were lysed using ammonium chloride potassium solution and T-, B-, NK-cells were immediately enumerated on BD FACSCanto II™ cytometers with a standard 4–2–2 optical configuration. Proliferating T-cell counts were determined using fluorochrome-labeled anti-Ki67 antibodies. Proliferating T-cell counts were calculated by multiplying the percentage of Ki67+ T-cell population by the absolute count of T-cells derived from the T-, B- and NK-cell assay.

2.7. Statistical analyses

In the dose escalation phase of the sequential-treatment cohort, a number of 12 patients were enrolled for each dose level, with up to 60 patients planned for enrollment. The mTPI-2 design was used to guide dose escalation decisions [21]. Dose-escalation to the next dose-level was determined by using a modified mTPI-2 algorithm, with a target DLT rate of 30% and an equivalence interval of 25–35%. The MTD was determined by isotonic regression analysis applied to DLT rates observed during the dose-escalation phase.

The safety and efficacy analyses were based on the as-treated population, defined as patients who received any dose of either investigational drug. The response-evaluable population included patients from the as-treated population who had a baseline disease assessment and either had at least one post-baseline disease assessment and/or discontinued treatment due to disease progression. Categorical data were summarized by the number and percentage of patients in each category and continuous variables were summarized by descriptive statistics. SAS version 9.4 (SAS Institute Inc., Cary NC) was used for statistical analyses.

3. Results

3.1. Patient demographics & clinical characteristics

As of 18 August 2020, 38 patients were treated. Twenty-nine patients received sequential treatment: 4 patients received MEDI5083 3.0 mg, 4 received MEDI5083 4.0 mg, 18 received MEDI5083 5.0 mg and 3 received MEDI5083 7.5 mg. Nine patients received concurrent treatment: three patients received a dose of MEDI5083 3.0 mg and six patients received MEDI5083 4.0 mg. Tumor types included bladder cancer (n = 3), breast cancer (n = 2), colon cancer (n = 5), NSCLC (n = 5), renal cancer (n = 3), pancreatic cancer (n = 4), squamous cell carcinoma of the head and neck (SCCHN; n = 3). Thirty-eight patients were included in the as-treated population, 31 patients were included in the DLT-evaluable population and 36 patients were included in the response-evaluable population. Patient demographics and baseline disease characteristics are summarized in Table 1. Patients in the sequential cohort had a median of 2 (range: 1,19) prior treatments, while patients in the concurrent cohort had a median of 4 (range: 2, 8) prior treatments. Twenty-six (89.7%) patients in the sequential cohort and 9 (100%) patients in the concurrent cohort had received prior systemic therapy. Prior treatments are summarized in Table 1.

Table 1. Patient demographics and baseline disease characteristics.

Parameter	Sequential-treatment cohort	Concurrent-treatment cohort	
MEDI5083
3.0 mg + durvalumaba (n = 4)	MEDI5083
4.0 mg + durvalumaba (n = 4)	MEDI5083
5.0 mg + durvalumaba (n = 18)	MEDI5083
7.5 mg + durvalumaba (n = 3)	total (N = 29)	MEDI5083
3.0 mg + durvalumaba (n = 3)	MEDI5083
4.0 mg + durvalumaba (n = 6)	total (N = 9)	
Age (years), median (min, max)	67.5 (56, 71)	66.0 (38, 78)	62.5 (32, 75)	66.0 (21, 77)	64.0 (21, 78)	55.0 (47, 66)	67.5 (59, 71)	66.0 (47, 71)	
Sex, n (%)	 	 	 	 	 	 	 	 	
  Female	1 (25.0)	1 (25.0)	6 (33.3)	1 (33.3)	9 (31.0)	1 (33.3)	2 (33.3)	3 (33.3)	
  Male	3 (75.0)	3 (75.0)	12 (66.7)	2 (66.7)	20 (69.0)	2 (66.7)	4 (66.7)	6 (66.7)	
Raceb, n (%)	 	 	 	 	 	 	 	 	
  American Indian or
  Alaskan Native	
0	
0	
1 (5.6)	
0	
1 (3.4)	
0	
0	
0	
  Asian	1 (25.0)	1 (25.0)	1 (5.6)	1 (33.3)	4 (13.8)	0	0	0	
  White	3 (75.0)	2 (50.0)	16 (88.9)	2 (66.7)	23 (79.3)	3 (100)	6 (100)	9 (100)	
  Other	0	1 (25.0)	0	0	1 (3.4)	0	0	0	
ECOG PS, n (%)	 	 	 	 	 	 	 	 	
  0	2 (50.0)	1 (25.0)	7 (38.9)	1 (33.3)	11 (37.9)	2 (66.7)	2 (33.3)	4 (44.4)	
  1	2 (50.0)	3 (75.0)	11 (61.1)	2 (66.7)	18 (62.1)	1 (33.3)	4 (66.7)	5 (55.6)	
Number of prior treatments, n (%)	 	 	 	 	 	 	 	
  1	3 (75.0)	1 (25.0)	4 (22.2)	0	8 (27.6)	0	0	0	
  2	1 (25.0)	2 (50.0)	3 (16.7)	1 (33.3)	7 (24.1)	1 (33.3)	1 (16.7)	2 (22.2)	
  3	0	0	1 (5.6)	1 (33.3)	2 (6.9)	1 (33.3)	1 (16.7)	2 (22.2)	
  4	0	0	1 (5.6)	1 (33.3)	2 (6.9)	0	2 (33.3)	2 (22.2)	
  ≥5	0	1 (25.0)	9 (50.0)	0	10 (34.5)	1 (33.3)	2 (33.3)	3 (33.3)	
Median treatments (min, max)	1 (1, 2)	2 (1, 8)	4.5 (1, 19)	3 (2, 4)	2 (1, 19)	3 (2, 6)	4 (2, 8)	4 (2, 8)	
Prior systemic therapy, n (%)	3 (75.0)	4 (100.0)	16 (88.9)	3 (100.0)	26 (89.7)	3 (100.0)	6 (100.0)	9 (100.0)	
Prior treatment types, n (%)	 	 	 	 	
  Systemic therapy	3 (75.0)	4 (100)	16 (88.9)	3 (100)	26 (89.7)	3 (100)	6 (100)	9 (100)	
  Radiation	2 (50.0)	3 (75.0)	11 (61.1)	2 (66.7)	18 (62.1)	1 (33.3)	3 (50.0)	4 (44.4)	
  Cancer-related surgery	1 (25.0)	3 (75.0)	15 (83.3)	1 (33.3)	20 (69.0)	2 (66.7)	5 (83.3)	7 (77.8)	
a Durvalumab dose was 1500 mg.

b Each race category counted patients who selected only that category.

ECOG PS: Eastern Cooperative Oncology Group performance status; max: Maximum; min: Minimum.

3.2. Safety

The most common AEs are summarized in Supplementary Table S3. The most common MEDI5083-related AEs were injection-site reaction (ISR; sequential cohort: 86.2%; concurrent cohort: 100%), fatigue (sequential cohort: 13.8%; concurrent cohort: 11.1%) and pyrexia (sequential cohort: 10.3%; concurrent cohort: 11.1%) (Table 2). Seven (24.1%) patients in the sequential cohort and two (22.2%) patients in the concurrent cohort had at least one MEDI5083-related grade ≥3 AE. ISR was the most common grade 3/4 MEDI5083-related AE, occurring in six patients: five patients in the sequential cohort (MEDI5083 4.0 mg: 25.0%; MEDI5083 5.0 mg: 11.1%; MEDI5083 7.5 mg: 66.7%) and one patient in the concurrent cohort (MEDI5083 4.0 mg: 16.7%) (Table 3 & Supplementary Figure S3). The first patient on this study developed a grade 2 ISR that escalated from grade 1 on day 3 to grade 2 on day 7. This patient did not receive topical steroids until day 15, resulting in a prolonged recovery, which led to discontinuation of MEDI5083. For subsequent patients, the use of topical diprosone 0.5% cream was encouraged upon the development of a grade 1 ISR. Despite the early use of topical steroids, ISRs were observed. A summary of the time to onset and duration of ISRs observed in the study are summarized in Supplementary Table S4. Overall, the median number of days (min, max) to the onset of an ISR was 3.0 (1, 17) days in part 1 and 5.0 (2, 18) days in part 2.

Table 2. MEDI5083-related adverse events of any grade occurring in patients in either part, as-treated population.

Preferred terma, n (%)	Sequential-treatment cohort	Concurrent-treatment cohort	
MEDI5083
3.0 mg + durvalumabb (n = 4)	MEDI5083
4.0 mg + durvalumabb (n = 4)	MEDI5083
5.0 mg + durvalumabb (n = 18)	MEDI5083
7.5 mg + durvalumabb (n = 3)	Part 1 total (N = 29)	MEDI5083
3.0 mg + durvalumabb (n = 3)	MEDI5083
4.0 mg + durvalumabb (n = 6)	Part 2 total (N = 9)	
Patients with ≥1 AE	3 (75.0)	4 (100)	18 (100)	3 (100)	28 (96.6)	3 (100)	6 (100)	9 (100)	
Lymph node pain	–	–	–	1 (33.3)	1 (3.4)	–	–	–	
Diarrhea	–	–	1 (5.6)	–	1 (3.4)	–	–	–	
Nausea	–	–	–	–	–	–	1 (16.7)	1 (11.1)	
Asthenia	–	–	–	–	–	–	1 (16.7)	1 (11.1)	
Death	–	–	–	–	–	–	1 (16.7)	1 (11.1)	
Fatigue	1 (25.0)	1 (25.0)	2 (11.1)	–	4 (13.8)	–	1 (16.7)	1 (11.1)	
Injection-site erythema	–	1 (25.0)	1 (5.6)	–	2 (6.9)	–	–	–	
Injection-site induration	–	–	–	–	–	–	1 (16.7)	1 (11.1)	
Injection-site inflammation	–	–	–	–	–	1 (33.3)	–	1 (11.1)	
Injection-site pain	–	–	3 (16.7)	–	3 (10.3)	–	–	–	
Injection-site rash	–	–	1 (5.6)	–	1 (3.4)	–	–	–	
Injection-site reaction	3 (75.0)	3 (75.0)	16 (88.9)	3 (100)	25 (86.2)	3 (100)	6 (100)	9 (100)	
Injection-site scar	–	–	–	1 (33.3)	1 (3.4)	–	–	–	
Injection-site swelling	–	–	1 (5.6)	–	1 (3.4)	–	–	–	
Non-cardiac chest pain	–	–	1 (5.6)	–	1 (3.4)	–	–	–	
Edema, peripheral	–	–	1 (5.6)	–	1 (3.4)	–	–	–	
Pyrexia	1 (25.0)	–	2 (11.1)	–	3 (10.3)	–	1 (16.7)	1 (11.1)	
C-reactive protein increased	1 (25.0)	–	–	–	1 (3.4)	–	–	–	
WBC count decreased	–	–	1 (5.6)	–	1 (3.4)	–	–	–	
Presyncope	–	–	1 (5.6)	–	1 (3.4)	–	–	–	
Acute kidney injury	–	–	1 (5.6)	–	1 (3.4)	–	–	–	
Erythema	–	–	1 (5.6)	–	1 (3.4)	–	–	–	
Hyperhidrosis	–	1 (25.0)	–	–	1 (3.4)	–	–	–	
Night sweats	1 (25.0)	–	–	–	1 (3.4)	–	–	–	
Rash maculopapular	–	–	–	1 (33.3)	1 (3.4)	–	–	–	
Decreased appetite	–	–	–	–	–	–	1 (16.7)	1 (11.1)	
Data are presented as n (%).

a Patients were counted once for each preferred term, regardless of the number of events and sorted by decreasing frequency in total (MedDRA v22.0).

b Durvalumab dose was 1500 mg.

AE: Adverse event; MedDRA: Medical Dictionary for Regulatory Activities; WBC: White blood cell.

Table 3. Grade 3/4 MEDI5083-related adverse events, as-treated population.

Preferred terma, n (%)	Sequential-treatment cohort	Concurrent-treatment cohort	
MEDI5083
3.0 mg + durvalumabb (n = 4)	MEDI5083
4.0 mg + durvalumabb (n = 4)	MEDI5083
5.0 mg + durvalumabb (n = 18)	MEDI5083
7.5 mg + durvalumabb (n = 3)	Part 1 total (N = 29)	MEDI5083
3.0 mg + durvalumabb (n = 3)	MEDI5083
4.0 mg + durvalumabb (n = 6)	Part 2 total (N = 9)	
Patients with ≥1 MEDI5083-related AE	0	1 (25.0)	4 (22.2)	2 (66.7)	7 (24.1)	0	2 (33.3)	2 (22.2)	
Injection-site reaction	0	1 (25.0)	2 (11.1)	2 (66.7)	5 (17.2)	0	1 (16.7)	1 (11.1)	
Pyrexia	0	0	1 (5.6)	0	1 (3.4)	0	0	0	
WBC count decreased	0	0	1 (5.6)	0	1 (3.4)	0	0	0	
Acute kidney injury	0	0	1 (5.6)	0	1 (3.4)	0	0	0	
Death	0	0	0	0	0	0	1 (16.7)	1 (11.1)	
a Patients were counted once for each preferred term, regardless of the number of events (MedDRA v22.0).

b Durvalumab dose was 1500 mg.

AE: Adverse event; MedDRA: Medical Dictionary for Regulatory Activities; WBC: White blood cell.

Other grade 3/4 MEDI5083-related AEs were observed in the sequential cohort, including pyrexia (MEDI5083 5.0 mg: 5.6%), decreased white blood cell count (MEDI5083 5.0 mg: 5.6%) and acute kidney injury (MEDI5083 5.0 mg: 5.6%). Besides ISR, no additional grade 3/4 MEDI5083-related AEs were observed in the concurrent cohort.

Of 38 patients in the as-treated population, 6 (15.8%) patients discontinued treatment due to MEDI5083-related AEs, 4 of whom had received sequential treatment (MEDI5083 4.0 mg, n = 1, ISR; MEDI5083 5.0 mg, n = 3 ISR) and 2 of whom had received concurrent treatment (MEDI5083 4.0 mg, n = 2; ISR and death). Patients in both cohorts had received a median of three doses of MEDI5083. Twenty-eight (96.6%) patients in the sequential-treatment cohort and 9 patients in the concurrent-treatment cohort received 90–110% relative dose intensity of MEDI5083. The median duration of durvalumab treatment was 13.7 weeks for the sequential-treatment cohort and 8.1 for both the 3.0 mg and 4.0 mg concurrent-treatment cohorts.

There was one MEDI5083-related death due to an AE that occurred within 30 days of the last dose (cause unknown) in the 4.0 mg concurrent-treatment cohort. In the sequential-treatment cohort, three patients (10.3%) died due to SAEs (small intestinal obstruction, cerebral infarction, and hypoxia), including one SAE that occurred within 30 days after the last dose of study medication. These three deaths were considered by the investigator to be unrelated to MEDI5083 or durvalumab.

Eight (44.4%) patients in the sequential-treatment cohort and four (44.4%) patients in the concurrent-treatment cohort experienced at least one durvalumab-related AE. The most common durvalumab-related AEs in the sequential-treatment cohort were fatigue, diarrhea, hypothyroidism, arthralgia and pruritus (each 11.1%). The most common durvalumab-related AEs in the concurrent-treatment cohort were fatigue (22.2%), diarrhea, nausea, asthenia, injection-site inflammation, ISR, decreased appetite and peripheral sensory neuropathy (each 11.1%). Durvalumab-related grade ≥3 AEs occurred in two (11.1%) patients in the sequential-treatment cohort (grade 3 diarrhea; grade 4 acute kidney injury). One patient in the sequential-treatment cohort (MEDI5083 7.5 mg) experienced immune system AEs (treatment-emergent seasonal allergies and contrast media reaction).

3.3. DLTs & MTD

Two patients in the MEDI5083 7.5 mg sequential-treatment cohort experienced study-drug-related DLTs. One patient experienced a grade 3 ISR, which occurred on day 4 following one dose of MEDI5083 (despite application of topical corticosteroids on day 2) and led to the omission of three subsequent doses of MEDI5083. This patient also experienced a grade 1 AE of lymph node pain on day 8 after one dose of MEDI5083. These DLTs did not lead to study drug discontinuation; ISR resolved after 68 days (changed to grade 2 on day 22 and grade 1 on day 29 prior to resolving completely) and the lymph node pain resolved after 2 days. The second patient experienced a grade 3 ISR on day 4 following one dose of MEDI5083 (despite application of topical corticosteroids on day 2), which led to the omission of one dose of MEDI5083. The DLT did not lead to discontinuation of treatment and resolved after 124 days. However, this patient died on day 206 due to an AE of a small bowel obstruction. The median time to DLT was 4.0 days. The MTD for MEDI5083 was 5.0 mg. Due to the unexpected high incidence of ISRs observed at low doses of MEDI5083 in the sequential-treatment cohort, that part of the study was discontinued and patients in the concurrent-treatment cohort were treated with doses of MEDI5083 3 and 4 mg.

3.4. Efficacy

In the response-evaluable population (N = 36), the ORR was 2.8% (95% CI: 0.1–14.5%) (Table 4). A confirmed PR was observed in one patient with SCCHN lip and oral cavity (anti-PD-1 naive, p16+ve) treated in the sequential-treatment cohort (MEDI5083 3.0 mg); the time to response for this patient was 5.7 months (Table 4 & Figure 1). Eleven (30.6%) patients had SD (including one patient with unconfirmed PR): seven in the sequential-treatment cohort and four in the concurrent-treatment cohort (Table 4). Eight (22.2%; 95% CI, 10.1–39.2%) patients had disease control (CR + PR + SD ≥24 weeks; Table 4 & Figure 2). Median duration of response was 7.3 months. Change in tumor size from baseline (Figure 2) and duration of exposure and response (Supplementary Figure S4) are presented. At the 5.0 mg dose of MEDI5083, median PFS was 1.8 months and median OS was 15.3 months (Supplementary Figure S5).

Figure 1. Best percent change in tumor size from baseline (RECIST v1.1) in (A) the sequential-treatment cohort and (B) the concurrent-treatment cohort (as-treated population).

D: Durvalumab; M: MEDI5083; NE: Not evaluable; PD: Progressive disease; PR: Partial response; RECIST: Response Evaluation Criteria in Solid Tumors; SD: Stable disease.

Figure 2. Change in tumor size from baseline in (A) the sequential-treatment cohort and (B) concurrent-treatment cohort (response-evaluable population).

D: Durvalumab; M: MEDI5083.

Table 4. Disease response per RECIST v1.1, response-evaluable population.

Parameter	N = 36a	
Best overall response, n (%)
  CR
  PR
  SD
    Unconfirmed PR
  Progressive disease
  Not evaluable	
0
1 (2.8)
11 (30.6)
1 (2.8)
20 (55.6)
4 (11.1)	
Objective response (CR + PR), n (%)
  95% CI	1 (2.8)
0.1–14.5	
CR + PR + SD ≥24 weeks (disease control), n (%)
  95% CI	8 (22.2)
10.1–39.2	
a Represents all cancer types combined.

CR: Complete response; PR: Partial response; RECIST: Response Evaluation Criteria in Solid Tumors; SD: Stable disease.

3.5. Pharmacodynamics

MEDI5083 PD activities on circulating immune cells were assessed using flow cytometry-based immunophenotyping assays. Previous studies have demonstrated that CD40 activation results in B-cell mobilization from the circulation [24–26]. We observed MEDI5083-induced reductions in baseline-normalized B-cells on days 2 and 3 post-dose (Figure 3A & B). The greatest reductions in peripheral B-cells were observed in patients receiving 7.5 mg either as monotherapy or with durvalumab. B-cells returned to approximate baseline levels on day 8 and thereafter (Figure 3A & B). MEDI5083 also induced elevations in circulating, baseline-normalized quantities of proliferating CD8+Ki67+ T-cells on day 8 in both cohorts; however, this response was not dose-dependent (Figure 3C & D). Peak elevation magnitudes and durations of the increases were higher in patients receiving MEDI5083 and durvalumab concurrently compared with those receiving MEDI5083 alone. CD8+Ki67+ T-cell quantities subsequently returned to near baseline levels on day 43 (Figure 3B).

Figure 3. Mobilization of B-cells in peripheral blood in response to MEDI5083 treatment in the sequential-treatment (A) and concurrent-treatment (B) cohorts. Baseline-normalized CD8+Ki67+ T-cells over time in sequential-treatment (C) or concurrent-treatment (D) cohorts. (C & D), error bars represent 25th and 75th percentiles.

M: MEDI5083.

4. Discussion

The rationale for investigating the combination of MEDI5083 with the PD-L1 inhibitor durvalumab was based on preclinical models demonstrating that CD40 activation induces PD-L1 expression, which is recognized as a resistance mechanism to CD40-targeted treatment [19]. This phase 1 study evaluated the safety and clinical activity of MEDI5083 when administered sequentially and concurrently with durvalumab. The safety profile of durvalumab was consistent with the previous studies and no unexpected AEs were observed [27]. Two patients in the MEDI508 3–7.5 mg sequential-treatment cohort had treatment-related grade 3/4 DLTs. There were three deaths due to SAEs in the sequential-treatment cohort, none of which were treatment related.

Grade 3/4 MEDI5083-related ISRs occurred in 6/38 (15.8%) patients; 5 patients in the sequential-treatment cohort (MEDI5083 4.0 mg, n = 1; MEDI5083 5.0 mg, n = 2; MEDI5083 7.5 mg, n = 2) and 1 patient in the concurrent-treatment cohort (MEDI5083 4.0 mg). Despite mitigation strategies, including the early use of topical corticosteroids, ISRs persisted and resulted in two DLTs. As patients could not be treated with a biologically efficacious dose of MEDI5083, the study was discontinued. There was one MEDI5083-related death due to an AE (cause unknown) in the 4.0 mg concurrent-treatment cohort.

While the reason for the high rates of ISRs observed in this study are unknown, it is possible that the sc. formulation of MEDI5083 elicited a more immediate immune response (e.g., immune complex deposits, FCyR-mediated inflammation or aggregate formation of MEDI5083 involving CD40 expressing cells in the vicinity of the injection site) compared with the iv. formulation. The onset of ISRs occurred relatively early – with a median time to onset of 3.0 days (part 1) or 5.0 days (part 2) from injection of MEDI5083. Patients who did not experience early MEDI5083-related ISRs were unlikely to present with injection site reaction symptoms later during the course of the study. Although ISR symptoms can often be managed conservatively, in this trial, many patients' clinical course was adversely impacted.

In a large study of patient reported outcomes, ISRs were reported in 3–15% of patients treated with biological agents administered sc. [28]. However, the pathophysiology of ISRs with biological agents remains less well described. In addition, preclinical studies lack the modeling data required to consistently predict characteristics in patients. It remains possible that alternative approaches (e.g., intra-tumoral delivery or additional FC protein engineering) may help to overcome the safety limitations observed with MEDI5083.

Systemic toxicities have been observed in clinical trials of CD40 agonists administered iv., with CRS being the most common AE. In phase 1b trials of selicrelumab, CRS was reported in 80% or more of patients, with most cases being mild to moderate (grade ≤3) and often resolving with supportive care [29,30]. Other AEs that are frequently observed with CD40 monoclonal antibody treatments included liver test abnormalities (AST and ALT) and thrombocytopenia; both transient and mild in most cases [29–32]. In the current study, there were no MEDI5083-related increases in ALT and AST, thrombocytopenia or CRS reported. The sc. administration of a CD40 agonist has been shown to delay and reduce the maximum serum concentration [33,34], potentially reducing acute and systemic immune-related AEs. However, we observed that sc. administration of MEDI5083 is associated with high rates of ISRs. Notably, in a phase 1 study, sc. administration of the CD40 agonist recombinant human soluble CD40 ligand (rhuCD40L) did not result in ISRs, but [35] grade 3–4 transaminase elevations were observed in 14%, 28% and 57% of patients at rhuCD40L doses of 0.05, 0.10 and 0.15 mg/kg/d, respectively.

In the current study, only one PR was observed in a patient with SCCHN. Potential explanations for limited antitumor activity include: (i) a large proportion of patients had non-IO-sensitive tumor types (e.g., CRC, breast cancer, pancreatic cancer); (ii) high prevalence of ISRs limited dosing of MEDI5083, which may have been compounded by MEDI5083 rapid systemic clearance and short half-life (t1/2;<24 h), as suggested in preclinical studies. In the current study, a large number of PK samples were below the limit of quantification for a credible non-compartmental analysis, precluding the determination of half-life and clearance for MEDI5083.

We observed MEDI5083-induced PD changes as demonstrated by reductions in circulating B-cells (regardless of tumor type), which are consistent with the proposed mechanism of action of CD40 pathway activation and increased B-cell mobilization to tumor sites [24–26]. Reductions in circulating B-cell populations may also be associated with the formation of tertiary lymphoid structures (TLSs). TLSs are organized aggregates of immune cells that can form near tumors and may serve as antigen presentation sites for the activation of naive T-cells [36,37]. Treatment with monoclonal CD40 antibodies has been associated with increased frequency and size of TLSs [36]. In a previous study, tumors from patients with advanced melanoma that responded to immune checkpoint blockade developed TLSs that were enriched with B-cells characterized by a unique gene signature [38]. Additionally, gene expression analysis demonstrated that the tumors from patients with cutaneous melanoma were enriched with B-cells and this enrichment was associated with increased tumor infiltration of CD8+ T-cells and longer OS [38]. Additional study is needed to determine whether the reductions in circulating B-cells observed in this study may be associated with the development of TLSs.

In the current study, CD8+Ki67+ T-cell elevations were observed on day 8, which suggests an immune stimulatory role for MEDI5083. The magnitude of elevations was consistent with that observed in patients treated with durvalumab monotherapy (∼100% increases on average, depending upon indication) [39]. In patients receiving durvalumab plus MEDI5083, the elevations in CD8+Ki67+ T-cell populations were prolonged compared with patients receiving durvalumab monotherapy [39]. This may reflect an additive effect of MEDI5083 in combination with durvalumab in these patients, as this cell population is a key PD biomarker for durvalumab [23]. Although statistical testing was not performed for PD assessments due to the small number of patients and exploratory nature of these assays, the PD data suggest that, even at doses limited by ISRs, MEDI5083 was capable of generating an immune response.

Despite limited responses with monotherapy, clinical studies have demonstrated that the use of CD40 agonists in combination with other therapies (e.g., APX005M with chemotherapy and nivolumab, CDX-1140 with pembrolizumab or chemotherapy) represents a promising avenue of exploration [30,40–42]. Combination trials have shown preliminary efficacy results with ORRs ranging from 20-54% [29–32]. AEs resulting from combination therapies have generally been tolerable, without worsening of toxicities associated with monotherapy [30,31,40]. In a phase 1 study, the investigational nonfucosylated IgG1 CD40 agonist (SEA-CD40) in combination with nab-paclitaxel and pembrolizumab demonstrated a tolerable safety profile and evidence of immune activation [43]. CD40 agonists have also been studied for the treatment of hematological malignancies; however, unlike in solid tumors, CD40 antibodies induce direct cytotoxic activity in patients with hematological malignancies [44,45]. Subsequently, the clinical focus for these agents remains primarily for the treatment of solid tumors.

The structure of MEDI5083, a homodimeric fusion protein covalently linked to an IgG Fc domain, is distinct from other CD40 agonists, which often require crosslinking [17,30]. Because of the bivalent nature of anti-CD40 antibodies, crosslinking is needed to exert significant antitumor activity. However, crosslinking of trimerized receptor complexes may result in hyperclustering and uncontrolled overstimulation leading to exhaustion of immune cells and increased systemic toxicities. An advantage of MEDI5083 is that it is composed of a trivalent, but single-chain CD40L-receptor-binding domain and generates a hexavalent molecule by linking to human IgG; this higher-order hexavalent approach enables for signal transduction in a more well-defined manner [46]. The structure of MEDI5083 allows the molecule to bridge the innate and adaptive immune systems by activating CD40 expressed on APCs, including B-cells, dendritic cells, monocytes and macrophages (data on file, AstraZeneca, Gaithersburg, MD). While the results of this phase 1 dose-escalation study do not support further development of MEDI5083, continued clinical exploration of CD40 with immune checkpoint inhibitors may be warranted [17], particularly given the consistent PD effects seen with MEDI5083 and other CD40 targeted therapies. Lastly, CRS management and mitigation strategies may improve over time [47], impacting the ability to further develop CD40 targeted drugs. Future development of CD40 agonists should focus on optimizing drug delivery, the inclusion of PD end points to explore the impact CD40 agonism on peripheral immune cells and center on the use of combination therapies.

5. Conclusion

The distinct structure of the CD40 agonist MEDI5083 allows it to activate both the innate and adaptive immune systems. In this phase 1 study, limited clinical response was observed with sc. administration of MEDI5083 in combination with durvalumab. A high incidence of ISRs was observed at low doses of MEDI5083 and resulted in study discontinuation. Nevertheless, CD40 agonists are still a promising therapeutic approach and future development of these drugs should focus on optimizing drug delivery, improving efficacy and minimizing AEs.

Supplementary Material

Supplementary Figures S1-S5 and Tables S1-S4

Acknowledgments

The authors thank the patients, their families and study-site personnel for their participation. We also thank Christopher Del Nagro for his early contributions to pharmacodynamic biomarker assay development and data interpretation.

Supplemental material

Supplemental data for this article can be accessed at https://doi.org/10.1080/1750743X.2024.2359359

Author contributions

BT did the study design. BT, NS and MV did the data acquisition. BT, NS and MV did the data analysis and interpretation. All authors wrote, reviewed and edited.

Financial disclosure

This study was supported by AstraZeneca. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Competing interests disclosure

BT received grants and personal fees from Amgen, grants and personal fees from AstraZeneca, grants from Astellas, grants and personal fees from BMS, grants and personal fees from Janssen, grants and personal fees from Pfizer, grants and personal fees from MSD, grants and personal fees from Ipsen, personal fees from IQVIA, personal fees from Sanofi, personal fees from Tolmar, personal fees from Novartis and grants and personal fees from Bayer outside the submitted work.

MV has received personal fees from AstraZeneca and MSD outside the submitted work. Research funding (institutional) from AstraZeneca, MSD, Alpine Immune Sciences, Virocure, Hinova Pharmaceuticals, Atridia/Hengrui, Antengene and Beigene.

JB has received research funding (institutional) from: Gilead, Genentech/Roche, BMS, Five Prime, Lilly, Merck, MedImmune, Celgene, EMD Serono, Taiho, Macrogenics, GSK, Novartis, OncoMed, LEAP, TG Therapeutics, AstraZeneca, BI, Daiichi Sankyo, Bayer, Incyte, Apexigen, Koltan, SynDevRex, Forty Seven, AbbVie, Array, Onyx, Sanofi, Takeda, Eisai, Celldex, Agios, Cytomx, Nektar, ARMO, Boston Biomedical, Ipsen, Merrimack, Tarveda, Tyrogenex, Oncogenex, Marshall Edwards, Pieris, Mersana, Calithera, Blueprint, Evelo, FORMA, Merus, Jacobio, Effector, Novocare, Arrys, Tracon, Sierra, Innate, Arch Oncology, Prelude Oncology, Unum Therapeutics, Vyriad, Harpoon, ADC, Amgen, Pfizer, Millennium, Imclone, Acerta Pharma, Rgenix, Bellicum, Gossamer Bio, Arcus Bio, Seattle Genetics, TempestTx, Shattuck Labs, Synthorx, Inc., Revolution Medicines, Inc., Bicycle Therapeutics, Zymeworks, Relay Therapeutics, Scholar Rock, NGM Biopharma, Stemcentrx, Beigene, CALGB, Cyteir Therapeutics, Foundation Bio, Innate Pharma, Morphotex, OncXerna, NuMab, AtlasMedx, Treadwell Therapeutics, IGM Biosciences, Mabspace, Hutchinson MediPharma, REPARE Therapeutics, NeoImmune Tech, Regeneron and PureTech Health; Consulting/advisory role (institutional) for: Gilead, Genentech/Roche, BMS, Five Prime, Lilly, Merck, MedImmune, Celgene, Taiho, Macrogenics, GSK, Novartis, OncoMed, LEAP, TG Therapeutics, AstraZeneca, BI, Daiichi Sankyo, Bayer, Incyte, Apexigen, Array, Sanofi, ARMO, Ipsen, Merrimack, Oncogenex, FORMA, Arch Oncology, Prelude Therapeutics, Phoenix Bio, Cyteir, Molecular Partners, Innate, Torque, Tizona, Janssen, Tolero, Amgen, Seattle Genetics, Moderna Therapeutics, Tanabe Research Laboratories, Beigene, Continuum Clinical, Agios, Bicycle Therapeutics, Relay Therapeutics, Evelo, Pfizer, Samsung Bioepios and Fusion Therapeutics; Travel and food accommodations from: Gilead, Genentech/Roche, BMS, Lilly, Merck, MedImmune, Celgene, Taiho, Novartis, OncoMed, BI, ARMO, Ipsen, Oncogenex and FORMA.

MG has received research funding (institutional) from: BMS, Merck, Incyte, NextCure, Pfizer, Roche/Genentech, Boehringer Ingelheim, GSB Pharmaceuticals, Moderna Therapeutics, Eisai, Silenseed, Seattle Genetics, Regeneron, Sanofi, Johnson & Johnson, MedImmune, Checkpoint Therapeutics, Acerta Pharmaceuticals, Arcus Biosciences, Array Biopharma, Bayer, Celgene, Compass Therapeutics, Constellation Pharmaceuticals, Cyteir, EMD Serano, Fate Therapeutics, GlaxoSmithKline, Infinity Pharmaceuticals, Pharmacyclics, Synlogic, Tesaro, Vedanta Biosciences, Millennium, Memorial Sloan-Kettering Cancer Center, Rapa Therapeutics, Turning Point Therapeutics, VelosBio, Vincerx Pharmaceuticals, Verstem, Hackensack Meridian Health, Erasca, Inc., Imugene, Incyte Biosciences International, iTeos Therapeutics, KSQ Therapeutics, Nimbus Saturn, Inc.,Georgetown University, Janssen, Mirati Therapeutics, Adlai Nortye, Bellicum Pharmaceuticals, Cullinan MICA Corporation and Daiichi Sankyo Company.

CL has nothing to disclose. DD has received Institutional research support: Beigene, Pfizer, EpimAb Biotherapeutics, Harbour BioMed, Maxinovel, PharmAbcine, Olema, Roche, MSD and Bristol-Myers Squibb. SF Honoraria/expenses: Amgen; Consulting/Advisory Boards: Akeso BioPharma. IG-L Institutional research support: Revolution Medicine, BridgeBio, Pfizer, Bayer, MedImmune, Sumitomo, Repare Therapeutics, Amgen, Novartis, Lilly, BMS, RedHill, Incyte, OncoMed. Honoraria for DSMC: SOTIO. Consulting: Jazz Pharmaceuticals, Kanaph, Sumitomo, OncXerna. NS was an employee of AstraZeneca and may own stock or stock options. FW is an employee of AstraZeneca and may own stock or stock options. CF was an employee of AstraZeneca at the time the study was conducted. MD is an employee of AstraZeneca and may own stock or stock options. BAC Institutional research support: AstraZeneca, AbbVie, Bayer, Pfizer, Daiichi Sankyo, Dragonfly Therapeutics, Actuate Therapeutics, Astellas, Repare Therapeutics. Ad boards: Foundation Medicine, Seagen. The authors have no other competing interests or relevant affiliations with any organization or entity with the subject matter or materials discussed in the manuscript apart from those disclosed.

Writing disclosure

Medical writing and editorial support, conducted in accordance with Good Publication Practice (GPP3) and the International Committee of Medical Journal Editors (ICMJE) guidelines, were provided by Eli Berdougo, PhD, of Oxford PharmaGenesis Inc., Newtown, PA and was funded by AstraZeneca, Gaithersburg, MD.

Ethical conduct of research

The study was conducted in accordance with the ethical principles originating in the Declaration of Helsinki and consistent with the International Conference on Harmonisation/Good Clinical Practice and applicable regulatory requirements. A waiver for the institutional review board requirements under 21 CFR Part 56 was granted by the US Food and Drug Administration. The study was not blinded. All patients provided written informed consent before study participation. The study was registered with Clinicaltrials.gov, number NCT03089645.

Data availability statement

Data underlying the findings described in this manuscript may be obtained in accordance with AstraZeneca's data sharing policy described at: https://astrazenecagrouptrials.pharmacm.com/ST/Submission/Disclosure. Data for studies directly listed on Vivli can be requested through Vivli at www.vivli.org. Data for studies not listed on Vivli could be requested through Vivli at https://vivli.org/members/enquiries-about-studies-not-listed-on-the-vivli-platform/. AstraZeneca Vivli member page is also available outlining further details: https://vivli.org/ourmember/astrazeneca/.
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References

Papers of special note have been highlighted as: • of interest; •• of considerable interest

1. Elgueta R, Benson MJ, de Vries VC, et al. Molecular mechanism and function of CD40/CD40L engagement in the immune system. Immunol Rev. 2009;229 :152–172. doi:10.1111/j.1600-065X.2009.00782.x 19426221
2. Chand Dakal T, Dhabhai B, Agarwal D, et al. Mechanistic basis of co-stimulatory CD40-CD40L ligation mediated regulation of immune responses in cancer and autoimmune disorders. Immunobiology. 2020;225 :151899. doi:10.1016/j.imbio.2019.151899 31899051
3. Bennett SR, Carbone FR, Karamalis F, et al. Help for cytotoxic-T-cell responses is mediated by CD40 signalling. Nature. 1998;393 :478–480. doi:10.1038/30996 9624004
4. Ridge JP, Di Rosa F, Matzinger P. A conditioned dendritic cell can be a temporal bridge between a CD4+ T-helper and a T-killer cell. Nature. 1998;393 :474–478. doi:10.1038/30989 9624003
5. Schoenberger SP, Toes RE, van der Voort EI, et al. T-cell help for cytotoxic T lymphocytes is mediated by CD40-CD40L interactions. Nature. 1998;393 :480–483. doi:10.1038/31002 9624005
6. Caux C, Massacrier C, Vanbervliet B, et al. Activation of human dendritic cells through CD40 cross-linking. J Exp Med. 1994;180 :1263–1272. doi:10.1084/jem.180.4.1263 7523569
7. Fillatreau S. B-cells and their cytokine activities implications in human diseases. Clin Immunol. 2018;186 :26–31. doi:10.1016/j.clim.2017.07.020 28736271
8. Iwata Y, Matsushita T, Horikawa M, et al. Characterization of a rare IL-10-competent B-cell subset in humans that parallels mouse regulatory B10 cells. Blood. 2011;117 :530–541. doi:10.1182/blood-2010-07-294249 20962324
9. Duddy M, Niino M, Adatia F, et al. Distinct effector cytokine profiles of memory and naive human B-cell subsets and implication in multiple sclerosis. J Immunol. 2007;178 :6092–6099. doi:10.4049/jimmunol.178.10.6092 17475834
10. Altenburg A, Baldus SE, Smola H, et al. CD40 ligand-CD40 interaction induces chemokines in cervical carcinoma cells in synergism with IFN-gamma. J Immunol. 1999;162 :4140–4147.10201939
11. Baxendale AJ, Dawson CW, Stewart SE, et al. Constitutive activation of the CD40 pathway promotes cell transformation and neoplastic growth. Oncogene. 2005;24 :7913–7923. doi:10.1038/sj.onc.1208929 16091748
12. Hakkarainen T, Hemminki A, Pereboev AV, et al. CD40 is expressed on ovarian cancer cells and can be utilized for targeting adenoviruses. Clin Cancer Res. 2003;9 :619–624.12576427
13. van den Oord JJ, Maes A, Stas M, et al. CD40 is a prognostic marker in primary cutaneous malignant melanoma. Am J Pathol. 1996;149 :1953–1961.8952530
14. Slobodova Z, Ehrmann J, Krejci V, et al. Analysis of CD40 expression in breast cancer and its relation to clinicopathological characteristics. Neoplasma. 2011;58 :189–197. doi:10.4149/neo_2011_03_189 21391734
15. Ishikawa K, Miyamoto M, Yoshioka T, et al. Up-regulation of CD40 with juxtacrine activity in human nonsmall lung cancer cells correlates with poor prognosis. Cancer. 2008;113 :530–541. doi:10.1002/cncr.23618 18548529
16. Korniluk A, Kemona H, Dymicka-Piekarska V. Multifunctional CD40L: pro- and anti-neoplastic activity. Tumour Biol. 2014;35 :9447–9457. doi:10.1007/s13277-014-2407-x 25117071
• Depending on the cancer type, CD40 ligands can either enhance or inhibit tumor growth and progression. Therefore, they should be carefully considered when designing therapeutic strategies for various cancers.

17. Turman S, McGlinchey K, Wang Y, et al. MEDI5083, a novel CD40L-Fc fusion protein, activates the CD40 pathway on antigen presenting cells and promotes a robust anti-tumor immune response in a B16F10 murine tumor model. Cancer Res. 2019;79 :1534. doi:10.1158/1538-7445.Am2019-1534
18. Long KB, Gladney WL, Tooker GM, et al. IFNgamma and CCL2 cooperate to redirect tumor-infiltrating monocytes to degrade fibrosis and enhance chemotherapy efficacy in pancreatic carcinoma. Cancer Discov. 2016;6 :400–413. doi:10.1158/2159-8290.CD-15-1032 26896096
19. Zippelius A, Schreiner J, Herzig P, et al. Induced PD-L1 expression mediates acquired resistance to agonistic anti-CD40 treatment. Cancer Immunol Res. 2015;3 :236–244. doi:10.1158/2326-6066.CIR-14-0226 25623164
20. Stewart R, Morrow M, Hammond SA, et al. Identification and characterization of MEDI4736, an antagonistic anti-PD-L1 monoclonal antibody. Cancer Immunol Res. 2015;3 :1052–1062. doi:10.1158/2326-6066.CIR-14-0191 25943534
21. Guo W, Wang SJ, Yang S, et al. A Bayesian interval dose-finding design addressing Ockham's razor: mTPI-2. Contemp Clin Trials. 2017;58 :23–33. doi:10.1016/j.cct.2017.04.006 28458054
22. Eisenhauer EA, Therasse P, Bogaerts J, et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer. 2009;45 :228–247. doi:10.1016/j.ejca.2008.10.026 19097774
23. Kelley RK, Sangro B, Harris W, et al. Safety, efficacy and pharmacodynamics of tremelimumab plus durvalumab for patients with unresectable hepatocellular carcinoma: randomized expansion of a phase I/II study. J Clin Oncol. 2021;39 :2991–3001. doi:10.1200/JCO.20.03555 34292792
24. Irenaeus SMM, Nielsen D, Ellmark P, et al. First-in-human study with intratumoral administration of a CD40 agonistic antibody, ADC-1013, in advanced solid malignancies. Int J Cancer. 2019;145 :1189–1199. doi:10.1002/ijc.32141 30664811
•• The results of this phase 1 study indicated that intratumoral administration of the CD40 agonist ADC-1013 was well tolerated and associated with pharmacodynamic responses in patients with advanced solid tumors.

25. Vonderheide RH, Flaherty KT, Khalil M, et al. Clinical activity and immune modulation in cancer patients treated with CP-870,893, a novel CD40 agonist monoclonal antibody. J Clin Oncol. 2007;25 :876–883. doi:10.1200/JCO.2006.08.3311 17327609
•• Patients with advanced solid tumors were administered a single dose of the CD40 agonist mAb CP-870,893, which was well tolerated and associated with antitumor activity. The most common adverse event was cytokine release syndrome.

26. Johnson P, Challis R, Chowdhury F, et al. Clinical and biological effects of an agonist anti-CD40 antibody: a Cancer Research UK phase I study. Clin Cancer Res. 2015;21 :1321–1328. doi:10.1158/1078-0432.CCR-14-2355 25589626
27. Imfinzi® (Durvalumab) [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; 2020.
28. Choquette D, Bessette L, Brown J, et al. Injection Site Reaction Associated with Subcutaneous Biologic Agents and Methotrexate. Analysis from the Rhumadata® Clinical Database and Registry [abstract]. Arthritis Rheumatol. 2018;70 (Suppl. 9 ). https://acrabstracts.org/abstract/injection-site-reaction-associated-with-subcutaneous-biologic-agents-and-methotrexate-analysis-from-the-rhumadata-clinical-database-and-registry/
29. Beatty GL, Torigian DA, Chiorean EG, et al. A phase I study of an agonist CD40 monoclonal antibody (CP-870,893) in combination with gemcitabine in patients with advanced pancreatic ductal adenocarcinoma. Clin Cancer Res. 2013;19 :6286–6295. doi:10.1158/1078-0432.CCR-13-1320 23983255
30. Vonderheide RH. CD40 agonist antibodies in cancer immunotherapy. Annu Rev Med. 2020;71 :47–58. doi:10.1146/annurev-med-062518-045435 31412220
• CD40 activation enhances T-cell infiltration into tumors, thus sensitizing them to checkpoint inhibition.

31. Bajor DL, Mick R, Riese MJ, et al. Long-term outcomes of a phase I study of agonist CD40 antibody and CTLA-4 blockade in patients with metastatic melanoma. Oncoimmunology. 2018;7 :e1468956. doi:10.1080/2162402X.2018.1468956 30288340
• The combination of CD40 agonist and CTLA-4 blocker was associated with T-cell activation and increased tumor T-cell infiltration in the absence of therapeutic PD-1/PD-L1 blockade in patients with melanoma. The combination had an acceptable toxicity profile.

32. Nowak AK, Cook AM, McDonnell AM, et al. A phase 1b clinical trial of the CD40-activating antibody CP-870,893 in combination with cisplatin and pemetrexed in malignant pleural mesothelioma. Ann Oncol. 2015;26 :2483–2490. doi:10.1093/annonc/mdv387 26386124
33. Smith KE, Deronic A, Hagerbrand K, et al. Rationale and clinical development of CD40 agonistic antibodies for cancer immunotherapy. Expert Opinion Biological Therapy. 2021;21 (12 ):1635–1646. doi:10.1080/14712598.2021.1934446
•• CD40 agonists are emerging therapies that increase response rates of cancer immunotherapies by activating dendritic cells and enhancing antigen cross-presentation to CD8+ T-cells; however, further research is needed to determine optimal dose regimens, safety and pharmacodynamic profiles, combination agents and responsive cancer types.

34. Melero I, Castanon E, Alvarez M, et al. Intratumoural administration and tumour tissue targeting of cancer immunotherapies. Nat Rev Clin Oncol. 2021;18 :558–576. doi:10.1038/s41571-021-00507-y 34006998
35. Vonderheide RH, Dutcher JP, Anderson JE, et al. Phase I study of recombinant human CD40 ligand in cancer patients. J Clin Oncol. 2001;19 :3280–3287. doi:10.1200/jco.2001.19.13.3280 11432896
36. van Hooren L, Vaccaro A, Ramachandran M, et al. Agonistic CD40 therapy induces tertiary lymphoid structures but impairs responses to checkpoint blockade in glioma. Nat Commun. 2021;12 :4127. doi:10.1038/s41467-021-24347-7 34226552
• Systemic exposure to αCD40 impaired T-cell responses and promoted the expansion of suppressive CD11b+ B-cells, but also enhanced formation of tertiary lymphoid structures in the brain, which may be associated with improved immunotherapy response.

37. Lauss M, Donia M, Svane IM, et al. B cells and tertiary lymphoid structures: friends or foes in cancer immunotherapy? Clin Cancer Res. 2022;28 :1751–1758. doi:10.1158/1078-0432.CCR-21-1130 34965949
38. Helmink BA, Reddy SM, Gao J, et al. B-cells and tertiary lymphoid structures promote immunotherapy response. Nature. 2020;577 :549–555. doi:10.1038/s41586-019-1922-8 31942075
39. Antonia S, Goldberg SB, Balmanoukian A, et al. Safety and antitumour activity of durvalumab plus tremelimumab in non-small cell lung cancer: a multicentre, phase 1b study. Lancet Oncol. 2016;17 :299–308. doi:10.1016/S1470-2045(15)00544-6 26858122
40. Vonderheide RH. Abstract I12: CD40 immunotherapy for pancreatic cancer. Cancer Res. 2019;79 :I12. doi:10.1158/1538-7445.Panca19-i12
41. O'Hara M, O'Reilly E, Mick R, et al. A Phase Ib study of CD40 agonistic monoclonal antibody APX005M together with gemcitabine (Gem) and nab-paclitaxel (NP) with or without nivolumab (Nivo) in untreated metastatic ductal pancreatic adenocarcinoma (PDAC) patients. Cancer Res. 2019;79 (Suppl. 13 ):CT004. doi:10.1158/1538-7445.SABCS18-CT004
42. Clinicaltrials.gov. A study of CDX-1140 (CD40) as monotherapy or in combination in patients with advanced malignancies. 2020. https://clinicaltrials.gov/study/NCT03329950?term=CDX-1140&rank=
43. Bajor DL, Gutierrez M, Vaccaro GM, et al. Preliminary results of a phase 1 study of sea-CD40, gemcitabine, nab-paclitaxel and pembrolizumab in patients with metastatic pancreatic ductal adenocarcinoma (PDAC). J Clin Oncol. 2022;40 (Suppl. 4 ):559. doi:10.1200/JCO.2022.40.4_suppl.559
44. Beatty GL, Li Y, Long KB. Cancer immunotherapy: activating innate and adaptive immunity through CD40 agonists. Expert Rev Anticancer Ther. 2017;17 :175–186. doi:10.1080/14737140.2017.1270208 27927088
•• This comprehensive review discussed the potential of CD40 agonists to restore both innate and adaptive immunity and how identification of biomarkers is crucial for monitoring and predicting anti tumor responses.

45. Horton HM, Bernett MJ, Peipp M, et al. Fc-engineered anti-CD40 antibody enhances multiple effector functions and exhibits potent in vitro and in vivo antitumor activity against hematologic malignancies. Blood. 2010;116 :3004–3012. doi:10.1182/blood-2010-01-265280 20616215
46. Richards DM, Sefrin JP, Gieffers C, et al. Concepts for agonistic targeting of CD40 in immuno-oncology. Hum Vaccin Immunother. 2020;16 :377–387. doi:10.1080/21645515.2019.1653744 31403344
47. Morris EC, Neelapu SS, Giavridis T, et al. Cytokine release syndrome and associated neurotoxicity in cancer immunotherapy. Nat Rev Immunol. 2022;22 :85–96. doi:10.1038/s41577-021-00547-6 34002066
