Immunotherapy in Adrenocortical Carcinoma: Predictors of Response, Efficacy, Safety, and Mechanisms of Resistance

Abstract

Adrenocortical carcinoma (ACC) is a rare endocrine malignancy with limited treatment options in the advanced stages. Immunotherapy offers hope for altering the orthodox management of cancer, and its role in advanced ACC has been investigated in different studies. With the aim clarifying the role of immunotherapy in ACC we performed a comprehensive review about this topic focusing on the predictors of response, efficacy, safety, and the mechanisms of resistance. Five clinical trials with four immune checkpoint inhibitors (pembrolizumab, avelumab, nivolumab, and ipilimumab) have investigated the role of immunotherapy in advanced ACC. Despite, the different primary endpoints used in these studies, the reported rates of overall response rate and progression free survival were generally poor. Three main potential markers of response to immunotherapy in ACC have been described: Expression of PD-1 and PD-L1, microsatellite instability and tumor mutational burden. However, none of them has been validated in prospective studies. Several mechanisms of ACC immunoevasion may be responsible of immunotherapy failure, and a greater knowledge of these mechanisms might lead to the development of new strategies to overcome the immunotherapy resistance. In conclusion, although currently the role of immunotherapy is limited, the identification of immunological markers of response and the implementation of strategies to avoid immunotherapy resistance could improve the efficacy of this therapy.

Keywords: adrenocortical carcinoma; anti-PD-L1; immunotherapy; pembrolizumab.

Figure 1

Molecular alterations in adrenocortical carcinoma. IGF2: Insulin-like growth factor 2; LOH: Loss of heterozygosity; PKA: Protein kinase A; WGD: Whole-genome doubling.

Figure 2

Mechanism of action of programmed death-1 (PD-1)/PD-L1 and CTLA-4 immuno checkpoint inhibitors used for adrenocortical carcinoma treatment. Immunotherapy targeting CTLA-4 (ipilimumab), PD-1 (nivolumab, pembrolizumab), and PD-L1 (avelumab) block immune checkpoints (CTLA-4, PD-1, and PD-L1, respectively) and restore antitumor immune response, resulting in tumor cell death via release of cytolytic molecules (e.g., granzyme B, TNF-a, INF-g). APC: professional antigen presenting; TCR: MHC-T cell receptor.