# Genomic and Molecular Associations with Preoperative Immune Checkpoint Inhibition in Patients with Stage III Clear Cell Renal Cell Carcinoma

## TL;DR

This study explores how pre-surgery immune checkpoint treatment affects kidney cancer tumors, finding that while it changes the tumor environment, it doesn't always improve patient outcomes.

## Contribution

The study identifies four genes (GZMK, GZMA, ITGAL, IL7R) associated with immune checkpoint treatment and improved survival in kidney cancer patients.

## Key findings

- Preoperative immune checkpoint inhibition altered the tumor microenvironment to resemble treatment-naïve patients without recurrence.
- Higher expression of GZMK, GZMA, ITGAL, and IL7R was associated with better overall survival in TCGA cohorts.
- CD8+ T effector and central memory cells were less prevalent in treatment-naïve patients who experienced recurrence.

## Abstract

Existing clinical data regarding immune checkpoint inhibition around the time of surgery in patients with stage III clear cell RCC are conflicting. To better understand the effects of immune checkpoint inhibition on the tumor microenvironment, we performed differential expression analysis of proteins and RNA in surgical specimens from patients with stage III clear cell RCCs. We found that while preoperative immune checkpoint inhibition altered the tumor microenvironment to resemble that of treatment-naïve patients without recurrence, these changes did not necessarily translate to improved oncologic outcomes. Specifically, prevalence of CD8+ T effector and central memory cells appeared lower in the treatment-naïve patients who had recurrence. Upon external validation, we identified the genes GZMK, GZMA, ITGAL, and IL7R as being associated with both exposure to immune checkpoint inhibition and improved survival. When expression of these four genes was assessed in cohorts from The Cancer Genome Atlas (TCGA), higher expression levels were associated with better overall survival. These genes should be further investigated as potential predictors for benefit from immune checkpoint blockade.

Background and Objective: Patients with stage III clear cell renal cell carcinoma (ccRCC) have a high risk for disease recurrence post-nephrectomy. To mitigate overtreatment, there is a pressing need to determine who benefits from immune checkpoint inhibition (ICI) around the time of surgical resection. We performed digital spatial analysis of both gene and protein expression in stage III ccRCC tumors, some of which had preoperative ICI exposure. Methods: Nephrectomy specimens from stage III ccRCC patients were analyzed using the Nanostring GeoMx Digital Spatial Profiler. Differential expression analysis was performed and validated using NCT02210117 trial data to identify genes associated with both ICI and clinical response. A gene score was then generated to predict overall survival in patients from The Cancer Genome Atlas (TCGA). Key Findings and Limitations: In a small cohort of 19 patients, RNA expression significantly differed based on preoperative ICI exposure and recurrence status—CD8+ effector and central-memory T-cell signatures were less prevalent in the treatment-naïve with recurrence group. Three out of four patients with preoperative immune checkpoint inhibition recurred. External validation yielded a four-gene set (GZMK, GZMA, ITGAL, and IL7R), where higher expression levels predicted better overall survival in the TCGA cohort (p = 0.005). Conclusions and Clinical Implications: Preoperative ICI favorably altered the tumor microenvironment to resemble that of treatment-naïve patients without recurrence but did not translate to improved survival. Upon external validation, the genes GZMK, GZMA, ITGAL, and IL7R were modifiable with ICI and associated with improved overall survival. Further investigation is needed to assess if patients with low baseline expression of these genes may benefit from ICI around the time of surgery.