Combination Of Immune Checkpoint Inhibitors Research Articles

Abstract 1167: Prospective analysis of pretreatment circulating CD4 memory T cell features associated with severe immunotherapy toxicity

Abstract Introduction: Immune checkpoint inhibitors (ICIs) have revolutionized melanoma treatment, significantly improving outcomes. Nevertheless, too many melanoma patients undergoing ICI treatment experience severe and often debilitating immune-related adverse events (irAEs). In a retrospective melanoma cohort treated with ICIs, we previously found that elevated baseline levels of circulating CD4 effector memory T (TEM) cells were associated with the development of severe irAEs, irrespective of the affected organ system (Lozano et al., Nature Medicine, 2022). Here, we present data from an extended prospective validation cohort from 47 patients across two academic medical centers. Methods: Of 47 patients, 26 received combination anti-PD1/anti-CTLA4 ICIs, 3 combination anti-PD1/anti-LAG3 ICIs, 17 anti-PD1 ICI, and 1 anti-CTLA4 ICI. Peripheral blood mononuclear cells (PBMCs) were prepared from pretreatment (Cycle 1 Day 1) blood samples obtained from all patients. We performed mass cytometry (CyTOF) on PBMCs using a 38-marker panel to deeply profile immune subsets. We further leveraged bulk RNA-seq from 24 patients to (i) deconvolve CD4 memory T cell abundance using CIBERSORTx and (ii) determine T cell receptor (TCR) diversity using Shannon entropy following MiXCR clonotype assembly. irAEs were graded on a 5-point scale using the Common Terminology Criteria for Adverse Events v5. Results: After treatment initiation, 14 patients experienced severe irAEs (grade 3+) at a median of 12.1 weeks (range 4-54), including 4 with life-threatening (grade 4) irAEs. CyTOF revealed elevated circulating CD4 TEM cells in patients that developed severe irAEs (P<0.0001; AUC=0.87), including those treated with combination ICIs (P=0.0001; AUC=0.89). We further observed a continuous relationship between increasing CD4 TEM levels and irAE grade (P=3e-6, Jonckheere-Terpstra test). We then combined CD4 memory T cell abundance and TCR diversity derived from bulk RNA-seq on 24 of these patients using logistic regression (trained on data from Lozano et al.) to yield a composite model score. The pretreatment composite model score was strongly associated with severe irAE development (P=0.0009, AUC=0.88), and in a median split, identified patients with shorter time to severe irAE development (3 months vs. not reached; P=0.006; HR=10.5). Notably, composite model features and the overall score had no significant association with immunotherapy benefit. Conclusion: In this prospective study, both circulating CD4 TEM levels determined by CyTOF and a composite model score measured by RNA-seq were strongly associated with severe irAE development, independent of response status. These findings hold promise for future pretreatment risk stratification of ICI therapy. Citation Format: Abul Usmani, Noah Earland, Wubing Zhang, Peter K. Harris, Antonietta Bacchiocchi, Chloe M. Sachs, Aishwarya Nene, David Y. Chen, Mario Sznol, Ruth Halaban, Aaron M. Newman, Aadel A. Chaudhuri. Prospective analysis of pretreatment circulating CD4 memory T cell features associated with severe immunotherapy toxicity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1167.

Abstract 3327: L-pampo™, a TLR2/3 agonist, enhances anti-tumor immune responses and synergistically improves the anti-tumor efficacy of immune checkpoint inhibitors in cold tumors

Abstract Introduction: Immunotherapy is a promising therapeutic approach for a wide range of cancers. However, some tumors called "cold tumors" lack infiltrating T-cells and are not responsive to immune checkpoint inhibitors (ICIs), leading to worse clinical outcomes. This study demonstrates that L-pampo, a novel TLR2/3 agonist, promotes an anti-tumor immune response in cold tumors. Also, combining L-pampo with ICIs can improve the anti-tumor efficacy more safely than standard-of-care (SoC) chemotherapies. Method: We utilized syngeneic tumor models using CT26 colon cancer and 4T1 triple-negative breast cancer (TNBC). L-pampo was administered alone or in combination with ICIs such as anti-PD-1 (aPD-1) and anti-CTLA-4 (aCTLA-4) antibodies to tumor-bearing mice (n=8/group). Tumor size was measured every three days, and the survival rate was monitored until day 60. On day 21 or 27 after transplantation, we analyzed the tumor weight and tumor-infiltrating immune cells. Furthermore, we assessed the respective anti-tumor efficacies and safety of L-pampo and SoC chemotherapies (FOLFOX and paclitaxel). Result: In the CT26 colon cancer model, L-pampo effectively reduced the tumor size compared to the vehicle group (83.7%). The combination of L-pampo and ICI reduced tumor size by 86.1% (with aCTLA4) and 90.5% (with aPD-1), while the ICI alone did not effectively inhibit tumor growth (aPD-1; 17.3%, aCTLA-4; 23.6%). Notably, the triple concurrent treatment with L-pampo, aPD-1 and aCTLA-4 reduced tumor size by 96.6% and induced completed tumor regression in 1 out of 8. In the 4T1 TNBC model, L-pampo reduced tumor size by 64.2% compared to the vehicle treatment, and combined treatment with L-pampo and a-PD-1 suppressed tumor growth compared to aPD-1 alone (9.6% vs. 61.5%). Additionally, L-pampo improved median overall survival in each tumor model (CT26; 25.5 vs. 35.5, 4T1; 29.5 vs. 53.5 days). To compare the anti-tumor efficacy of L-pampo and conventional cytotoxic chemotherapy, we treated tumor-bearing mice with FOLFOX or paclitaxel as SoC regimen, respectively. Compared with each chemotherapy, L-pampo revealed comparable antitumor efficacies (Tumor growth inhibition CT26; 75.6% vs. 70.6%, 4T1; 65.5% vs. 58.8%). Interestingly, L-pampo inhibited tumor growth without significant adverse effects. In contrast, conventional chemotherapies induced acute hematological side effects such as leukopenia/neutropenia/thrombocytopenia and rapid weight loss. Furthermore, L-pampo increased the active cytotoxic T-cells infiltration through antigen-presenting cells stimulation within the tumors. Conclusion: This study suggests that L-pampo, a novel TLR2/3 agonist, can be a potent anti-tumor agent, improving the anti-tumor efficacy of ICIs in cold tumors with enhanced anti-tumor immunity and minimal toxicities than conventional chemotherapies. Citation Format: Guentae Kim, Yoonki Heo, Hye Jung Kim, Sejung Park, Byung Cheol Ahn, Won Suk Lee, Chan Kim, Hong Jae Chon, Eunyoung Chun, Jung Sun Yum. L-pampo™, a TLR2/3 agonist, enhances anti-tumor immune responses and synergistically improves the anti-tumor efficacy of immune checkpoint inhibitors in cold tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3327.

Abstract 922: Comparison of adverse effects of different combination therapies of immune checkpoint inhibitors and radiotherapy: A systematic review and meta-analysis

Abstract Background: Numerous ongoing trials are investigating cancer treatment combinations based on the combination of radiotherapy and immune checkpoint inhibitors. Understanding the toxicity profile of treatment-related adverse events is crucial. The purpose of this study is to comprehensively investigate the incidence and overview of treatment-related adverse events in different combination therapies involving radiotherapy and immune checkpoint inhibitors. Methods: We conducted a systematic review and meta-analysis of different combination therapies involving radiotherapy and immune checkpoint inhibitors. We searched English-language articles published between January 1, 2000, and May 31, 2023, in Pubmed, Embase, and the Cochrane database, investigating globally approved therapies based on PD-1, PD-L1 inhibitors, or CTA-4. Only prospective trials reporting overall incidence rates or lists of treatment-related adverse events data were included, and studies recruiting fewer than 10 patients were excluded. Retrospective studies were also excluded to minimize the risk of bias. The primary outcomes were the overall incidence and overview of treatment-related adverse events of all grades and grade 3 or higher. Heterogeneity among studies was assessed using the I2 statistic. The summary measure for primary outcomes was incidence rate (95% CI). This protocol is registered in PROSPERO (CRD42023390147). Results: We identified 1300 records, of which 50 studies (1655 patients) met the inclusion criteria. The incidence of treatment-related adverse reactions in the concurrent group was 76.0% (95% CI 73.5-78.4), and the incidence of grade 3 or higher adverse events was 23.5% (21.1-25.9). In the sequential group, the incidence of treatment-related adverse reactions was 75.9% (70.8-80.6), and the incidence of grade 3 or higher adverse events was 22.5% (18.0-27.5). In the induction group, the incidence of treatment-related adverse reactions was 72.8% (65.0-79.8), and the incidence of grade 3 or higher adverse events was 37.1% (29.4-45.3). The most common specific adverse event in the concurrent group was Fatigue (27.8% [25.2-30.6]); in the sequential group, it was Fatigue (43.3% [33.3-53.7]); in the induction group, it was Fatigue (71.4% [56.7-83.4]). Grade 3 or higher adverse events in the concurrent group was Lymphocyte Count Decreased (7.2% [5.4-9.4]); in the sequential group, it was Pneumonitis (11.1% [5.7-19.0]); in the induction group, it was Fatigue (10.5% [5.6-17.7]). Conclusion: Our study provides comprehensive data on treatment-related adverse events in different combination therapies involving radiotherapy and immune checkpoint inhibitors. Our results provide an essential reference of toxicity profiles of radiotherapy combined with immune checkpoint inhibitors for clinicians in routine practice of cancer care. Citation Format: Haiyu Zhou, Zefeng Guo, Ting Wang, Liyu Cai, Peimeng You. Comparison of adverse effects of different combination therapies of immune checkpoint inhibitors and radiotherapy: A systematic review and meta-analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 922.

Abstract 1208: Plasma proteomics-based models for predicting therapeutic benefit and immune-related adverse events in non-small cell lung cancer patients treated with immunotherapy

Abstract Background: Immune checkpoint inhibitors (ICIs) have significantly improved outcomes for patients with metastatic non-small cell lung cancer (NSCLC). However, clinical management is challenging. The PD-L1 biomarker does not optimally guide the choice between ICI monotherapy and combination ICI-chemotherapy, and there are currently no biomarkers to predict immune-related adverse events (irAEs). Here, we describe a versatile platform based on plasma proteomics and machine learning for generating predictive tools to support treatment decisions. Methods: Pre-treatment plasma samples were collected from 616 NSCLC patients receiving ICI-based therapy (NCT04056247). Clinical benefit (CB) data and irAEs were recorded. Proteomic profiling of plasma samples was performed using the SomaScan® assay, covering ~7000 proteins per sample. Proteins associated with Clinical Benefit (progression-free survival at 12 months) were classified as resistance-associated proteins (RAPs). Proteins associated with grade ≥3 irAEs occurring within the first 100 days of treatment were classified as toxicity-associated proteins (TAPs). RAPs and TAPs were integrated into two separate machine learning-based models, yielding CB and irAE probabilities, respectively. The CB model used a CB probability threshold to assign patients a PROphet-positive or PROphet-negative result. Bioinformatic analysis was performed on RAPs and TAPs. Results: CB and irAE models displayed strong predictive performance with a high correlation between predicted probability and observed CB or irAE rate (CB model: R2=0.98; p-value<0.0001; irAE model: R2= 0.92; p-value <0.0001). In the CB model, patients classified as PROphet-positive achieved significantly longer overall survival (OS) than PROphet-negative patients, with a median OS of 25.9 vs. 10.8 months (hazard ratio, HR = 0.51; p-value<0.001). Furthermore, patients with PD-L1 ≥50% tumors and a PROphet-negative result had significantly longer OS with ICI-chemotherapy in comparison to ICI monotherapy (HR=0.23, p-value = 0.0003), suggesting that combination therapy is preferable for such patients despite high PD-L1 levels. Bioinformatic analysis showed that RAPs related to immune regulation, angiogenesis, chemo-resistance, and other potential resistance mechanisms displayed higher expression levels in patients who did not benefit from treatment. Neutrophil- and inflammation-related proteins were significantly enriched in patients who experienced irAEs. Conclusions: We describe two machine-learning based predictive tools that may be used separately or in combination to inform treatment decisions based on the patient’s likelihood to benefit from ICI therapy and to develop serious irAEs. Our findings also provide biological insights related to treatment resistance and immune-related toxicity. Citation Format: Michal Harel, Petros Christopoulos, Igor Puzanov, Jair Bar, Iris Kamer, Niels Reinmuth, Ina Koch, Mor Moskovitz, Adva Levy-Barda, Alona Zer, Michal Lotem, David Farrugia, Rivka Katzenelson, Gillian Price, Abed Agbarya, Helen Cheley, Adam Hassani, Mahmoud Abu-Amna, Tom Geldart, Anirban Chatterjee, Andreas Polychronis, Maya Gottfried, Yanyan Lou, Tatiana Harkovsky, Alison Brewster, Ido Wolf, Ella Tepper, Ben Yellin, Itamar Sela, Coren Lahav, Yehonatan Elon, Raya Leibowitz, Adam P. Dicker, Young Kwang Chae, Ryan J. Sullivan, David Carbone, David Gandara, Jarushka Naidoo. Plasma proteomics-based models for predicting therapeutic benefit and immune-related adverse events in non-small cell lung cancer patients treated with immunotherapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1208.

Abstract 229: Molecular-genomic characterization of metastatic gastric cancer organoids and establishment of organoid-immune cell co-culture model

Abstract Advanced gastric cancer (AGC) showed marked molecular heterogeneity with aggressive behavior and treatment resistance, especially AGC with ascites from peritoneal metastasis. Tumor organoids are valuable in vitro model for mimicking organ characteristics and are used for developing therapeutic strategies. Therefore, we aimed to understand the characteristics of organoids established from AGC patient-derived fluids. Also, we are in progress of setting up an organoid-immune cell co-culture model for drug screening of immune checkpoint inhibitors (ICI) for AGC. All established organoids from peritoneal and pleural fluid of AGC patients were authenticated through short tandem repeat (STR) profiling, comparing with their matched PBMCs. We compared the morphological characteristics using Operetta High Content Imaging (Perkin Elmer). Also, the in house targeted sequencing and RNA sequencing data were obtained from the genome database of the Song-Dang Institute for Cancer Research and it was verified using molecular methods. Then, we co-cultured organoids with healthy donor PBMCs that were pre-activated using anti-human CD3/CD28 Dynabeads (Gibco). 3D spheroids, rather than single cells, and the PBMCs were co-cultured in matrigel (Corning Inc.) for more than 3 days. The overall success rate of the organoid establishment was 53.8% (78/145), with different sources of peritoneal (54%, 61/113) and pleural fluids (53.1%, 17/32). The organoid success rate was various as in EBV positive (66.7%, 2/3) and dMMR (0%, 0/4). Based on the analysis of 91 patients eligible for histopathology, the success rate of HER2-negative (57.5%, 46/80) is higher than that of HER2-positive (36.4%, 4/11). The organoids were observed in a variety of morphologies categorized in 3 groups such as grape-like, compact and glandular structure. Based on genomic data of 31 organoids, we could subgrouping for TCGA subtypes and EMT subtype. RTKs were amplified in 10 organoids, including the amplification of ERBB2 (n=2), MET (n=4) and FGFR (n=4). And KRAS alterations including amplification (n=2) and G12A/D (n=2) mutation were also detected. Then, we established the condition for organoid-immune co-culture model with PBMCs with Dynabead activation for 3-10 days. We confirmed that higher dose of PBMCs killed the tumor cells with reduction of organoid size and partial disintegration. We established the proper PBMC dose and characterization to maintain the organoids co-culture for further drug (ICI) sensitivity testing. In conclusion, we evaluated phenotypic and molecular characteristics of gastric cancer organoids established from malignant peritoneal and pleural effusion. The established organoid-immune cell co-culture models can be utilized to evaluate a variety of drug screenings, including ICI and various combinations, helping in the selection of drugs for individual patient. Citation Format: Han Byeol Mun, juin Park, Jinsoo Jang, Jingmin Che, Tae Soo Kim, Woo Sun Kwon, Hyun Cheol Chung, Sun Young Rha. Molecular-genomic characterization of metastatic gastric cancer organoids and establishment of organoid-immune cell co-culture model [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 229.

Abstract 1186: Moving beyond conventional autoimmune thyroiditis autoantibodies to predict immune checkpoint inhibitor induced hypothyroidism

Abstract INTRODUCTION: Treatment emergent adverse events (TEAEs) thyroiditis/thyrotoxicosis and hypothyroidism occur in up to 40% of patients treated with immune checkpoint inhibitors (ICIs). Conventional autoimmune thyroiditis autoantibodies (AutoAbs) (thyroglobulin (TG); thyroid peroxidase (TPO)) do not predict these TEAEs. We previously reported that pretreatment serum AutoAb profiles were associated with all severe TEAEs for melanoma patients treated with ICIs. Herein, we test if pre-existing AutoAbs could predict ICI induced hypothyroidism (TEAE ThyDis). METHODS: NYU Melanoma Program patients with stage IV metastatic melanoma treated with ICIs (Ipilumumab, Pembrolizumab, Nivolumab, or Combination) who had TEAE ThyDis (N = 14) or No TEAE (N = 11) were included. The HuProtTM human proteome microarray was used to profile proteins on cell surfaces or preferentially in extracellular spaces (N = 1061) in pretreatment and posttreatment (within ~4 months of ICI start) serum. Wilcoxon Rank Sum test was used to determine statistical significance (p < 0.05). RESULTS: 17 pretreatment pre-existing AutoAbs were detected (Table). All were higher in patients with TEAE ThyDis versus those with No TEAE. The pre-existing AutoAbs impacted immune cells (41%), extracellular matrix (ECM) (65%), or both (24%). P3H4 (p = 0.01) and ABCA2 (p = 0.01) were the only pre-existing AutoAbs that were statistically different posttreatment and were >10x higher in patients with TEAE ThyDis. They are both associated with intracellular vesicles but can be found in plasma membranes and extracellular spaces. No pre-existing AutoAbs were higher in patients with No TEAE ThyDis compared to those with TEAE ThyDis. However, posttreatment there was an increase in CSF1 AutoAbs that were not pre-existing (p = 0.05). CONCLUSIONS: Our data suggest that serum AutoAbs beyond TG and TPO can predict ICI TEAE ThyDis. Larger studies in other cancers (e.g., Breast) are required to validate these results. Pretreatment VS Posttreatment Pretreatment Pre-Existing Autoantibody Gene Name Impact TEAE ThyDis Present_median (N=14) TEAE ThyDis Absent_median (N=11) p-value COL14A1 ECM 17.35 7.99 0.01 DKK3 Cancer cells/ECM 14.74 3.75 0.01 LRFN1 Neurons 9.87 3.54 0.01 ABI3BP ECM 2.80 1.69 0.02 SELPLG Immune Cells 6.26 3.39 0.02 SMPDL3B Immune Cells/ECM 3.52 1.82 0.02 P3H4 Fibroplasts/ECM 13.41 6.29 0.02 C1QTNF2 Adipocytes/ECM 10.81 5.01 0.03 EMP1 Apoptosis 6.61 3.58 0.03 TMEF1 Neurons 6.44 3.03 0.03 CAPNS1 Cytoskeleton/ECM 3.27 2.13 0.04 FGFR2 Cancer Cells/ECM 2.96 1.62 0.04 GZMH Immune Cells 2.46 1.45 0.04 FSTL1 Immune Cells (autoantigen)/ECM 5.76 3.17 0.04 ABCA2 Immune Cells 11.81 7.00 0.05 ENPP1 Immune Cells/ECM 2.00 1.33 0.05 FGL2 Immune Cells/ECM 4.17 2.21 0.05 Posttreatment P3H4 Fibroplasts/ECM 61.82 6.09 0.01 ABCA2 Immune Cells 106.97 6.69 0.01 CSF1 Immune Cells 4.89 10.31 0.05 Citation Format: Kim Blenman, Ondrej Blaha, Courtney Gibson, Sherry Qiu, Holly Rushmeier, Milad Ibrahim, Shi Qiu, Michelle Krosgsgaard, Iman Osman. Moving beyond conventional autoimmune thyroiditis autoantibodies to predict immune checkpoint inhibitor induced hypothyroidism [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1186.

Abstract 3729: Association between clinical characteristics and treatment outcome of immune checkpoint inhibitor with or without chemotherapy in elderly non-small cell lung cancer patients with high PD-L1 expression

Abstract Background and Aim: The proportion of elderly patients diagnosed with advanced stage lung cancer has been increasing owing to the aging of the population. Thus, formulating a treatment strategy for elderly non-small cell lung cancer (NSCLC) patients is essential. For NSCLC with programmed cell death ligand-1 (PD-L1) tumor proportion score (TPS) ≧ 50%, both immune checkpoint inhibitor monotherapy (ICI mono) and combination therapy of ICI and chemotherapy (ICI/Chemo) have been established as standard treatment options. However, evidence based on the clinical trials specifically for elderly patients is limited, and it is not clear whether ICI mono or ICI/Chemo should be used in elderly NSCLC patients with PD-L1 TPS ≧ 50%. This study aimed to clarify which clinical population will benefit from ICI/Chemo in elderly NSCLC patients with PD-L1 TPS ≧ 50%. Method: We retrospectively analyzed 199 NSCLC patients aged ≧ 70 years of Eastern Cooperative Oncology Group performance status (ECOG PS) 0-1 with PD-L1 TPS ≧ 50% who were treated with ICI mono or ICI/Chemo. We analyzed the association between treatment outcome and baseline patient characteristics in each group. Comparing the treatment outcome, propensity score matching was used to reduce bias. Results: Of the 199 patients, 131 received ICI mono, and 68 received ICI/Chemo. The median overall survival (OS; 25.0 vs. 42.2 months, P = 0.116) and median progression-free survival (PFS; 10.9 vs. 11.8 months, P = 0.231) did not significantly differ between the ICI mono and ICI/Chemo groups. Multivariate analysis revealed the factors independently associated with OS: smoking history in the ICI mono group (smoking history/non-smoking history, hazard ratio [HR] 0.36, 95% confidence interval [CI] 0.16-0.78, P = 0.048), and ECOG PS (ECOG PS 1/PS 0, HR 3.84, 95% CI 1.44-10.20, P = 0.007) and histology type in the ICI/Chemo group (Non-squamous cell carcinoma/squamous cell carcinoma, HR 0.17, 95% CI 0.06-0.44, P < 0.001). For patients with ECOG PS 0 (OS: 26.1 months vs. not reached, P = 0.0031, PFS: 6.5 vs. 21.7 months, P = 0.0436) or non-squamous cell carcinoma (OS: 23.8 months vs. not reached, P = 0.0038, PFS: 10.9 vs. 17.3 months, P = 0.0383) in the ICI/Chemo group, PFS and OS were significantly longer than in the ICI mono group. Discussion and Conclusion: In elderly NSCLC patients with high PD-L1 expression, this study suggested that ECOG PS and histological type may be predictive clinical factor when choosing ICI mono or ICI/Chemo treatment. Citation Format: Hayato Kawachi, Shota Takei, Tadaaki Yamada, Motohiro Tamiya, Yoshiki Negi, Yasuhiro Goto, Akira Nakao, Shinsuke Shiotsu, Takayuki Takeda, Asuka Okada, Taishi Harada, Koji Date, Yusuke Chihara, Isao Hasegawa, Nobuyo Tamiya, Takashi Kijima, Koichi Takayama. Association between clinical characteristics and treatment outcome of immune checkpoint inhibitor with or without chemotherapy in elderly non-small cell lung cancer patients with high PD-L1 expression [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3729.

Abstract 6646: Investigating the combination of radiation and subsequent immune checkpoint inhibitor treatment in head and neck squamous cell carcinoma models

Abstract Purpose: Head and neck squamous cell carcinoma (HNSCC) is often marked by an immunosuppressive tumor microenvironment, which contributes to the dismal 10-20% response rate to immune checkpoint inhibitor (ICI) therapy in HNSCC patients. Radiotherapy (RT) is a currently standard of care and frontline therapy for HNSCC, yet resistance is common. We sought to examine the combination therapy of RT followed by ICI therapy to test if RT induces an in situ vaccination which enhances the efficacy of subsequent ICI. Methods: We utilized SCC cell lines derived from K15.KrasG12D/Smad4−/− SCCs, which mimic the progression of HPV-unrelated HNSCC, and transplanted SCC cells into immune-competent C57BL/6J mouse recipients. Mice were subjected to RT followed by anti-PD-L1/anti-TGFb therapy. CD8+ splenic T cells of responder or non-responder mice were examined by paired single-cell VDJ sequencing and single cell RNA sequencing (TCR/sc-RNAseq) to look for adaptations of the cytotoxic T cell compartment following combination therapy. Responder and non-responder tumor lines or tumors were treated with RT alone in vitro and in vivo, respectively, to examine major histocompatibility complex I (MHC-I) levels on tumor cells. Results: Responders to this combination therapy exhibited complete tumor eradication while non-responders displayed rapid tumor progression. When re-challenged with same HNSCCs cells, responders rejected implanted tumor cells while naïve recipients rapidly developed HNSCCs. Single-cell TCR sequencing of splenic CD8+ T cells revealed that responders, but not naïve recipients exhibited multiclonal CD8+ T cell expansion specifically of memory cell populations. Responder tumor cells exhibited greater levels of MHC-I protein level presentation than non-responders when stimulated with RT. Conclusions: Our data suggest that 1) elevated MHC-I by SCC tumor cells presentation driven by RT and ICI combination therapy facilitate a systemic expansion of memory CD8+ T cell clonotypes which drive anti-tumor immunity and 2) MHC-I expression at baseline or when induced by RT may serve as a predictive marker for therapeutic response to RT and ICI combination therapy in HNSCCs. Citation Format: Hanne Lind, Alexander Strait, Spencer Hall, Jack B. Goon, John D. Aleman, Samantha Chen, Philip Owens, Jing H. Wang, Christian Young, Xiao-Jing Wang. Investigating the combination of radiation and subsequent immune checkpoint inhibitor treatment in head and neck squamous cell carcinoma models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6646.

Spatial relationships in the urothelial and head and neck tumor microenvironment predict response to combination immune checkpoint inhibitors

Immune checkpoint inhibitors (ICI) can achieve remarkable responses in urothelial cancer (UC), which may depend on tumor microenvironment (TME) characteristics. However, the relationship between the TME, usually characterized by immune cell density, and response to ICI is unclear. Here, we quantify the TME immune cell densities and spatial relationships (SRs) of 24 baseline UC samples, obtained before pre-operative combination ICI treatment, using multiplex immunofluorescence. We describe SRs by approximating the first nearest-neighbor distance distribution with a Weibull distribution and evaluate the association between TME metrics and ipilimumab+nivolumab response. Immune cell density does not discriminate between response groups. However, the Weibull SR metrics of CD8+ T cells or macrophages to their closest cancer cell positively associate with response. CD8+ T cells close to B cells are characteristic of non-response. We validate our SR response associations in a combination ICI cohort of head and neck tumors. Our data confirm that SRs, in contrast to density metrics, are strong biomarkers of response to pre-operative combination ICIs.

Memory/Active T-Cell Activation Is Associated with Immunotherapeutic Response in Fumarate Hydratase-Deficient Renal Cell Carcinoma.

Fumarate hydratase-deficient renal cell carcinoma (FH-deficient RCC) is a rare and lethal subtype of kidney cancer. However, the optimal treatments and molecular correlates of benefits for FH-deficient RCC are currently lacking. A total of 91 patients with FH-deficient RCC from 15 medical centers between 2009 and 2022 were enrolled in this study. Genomic and bulk RNA-sequencing (RNA-seq) were performed on 88 and 45 untreated FH-deficient RCCs, respectively. Single-cell RNA-seq was performed to identify biomarkers for treatment response. Main outcomes included disease-free survival (DFS) for localized patients, objective response rate (ORR), progression-free survival (PFS), and overall survival (OS) for patients with metastasis. In the localized setting, we found that a cell-cycle progression signature enabled to predict disease progression. In the metastatic setting, first-line immune checkpoint inhibitor plus tyrosine kinase inhibitor (ICI+TKI) combination therapy showed satisfactory safety and was associated with a higher ORR (43.2% vs. 5.6%), apparently superior PFS (median PFS, 17.3 vs. 9.6 months, P = 0.016) and OS (median OS, not reached vs. 25.7 months, P = 0.005) over TKI monotherapy. Bulk and single-cell RNA-seq data revealed an enrichment of memory and effect T cells in responders to ICI plus TKI combination therapy. Furthermore, we identified a signature of memory and effect T cells that was associated with the effectiveness of ICI plus TKI combination therapy. ICI plus TKI combination therapy may represent a promising treatment option for metastatic FH-deficient RCC. A memory/active T-cell-derived signature is associated with the efficacy of ICI+TKI but necessitates further validation.

Peripheral blood biomarkers associated with combination of immune checkpoint blockade plus chemotherapy in NSCLC.

Biomarkers predicting clinical outcomes of treating non-small cell lung cancer (NSCLC) with combination of immune checkpoint inhibitors (ICIs) and chemotherapy would be valuable. This study aims to seek predictors of combination of ICI/chemotherapy response in NSCLC patients using peripheral blood samples. Patients diagnosed with advanced NSCLC between July 2019 and May 2021 receiving combination of ICI/chemotherapy were included and assessed for partial responses (PR), stable disease (SD) or progressive disease (PD). We measured circulating immune cells, plasma cytokines and chemokines. Nineteen patients were enrolled. The proportions of circulating natural killer (NK) cells within CD45 + cells, programmed death 1 (PD-1) + Tim-3 + T cells within CD4 + cells, and the amount of chemokine C-X-C ligand (CXCL10) in the plasma were significantly elevated in PR relative to SD/PD patients (median 8.1%-vs-2.1%, P= 0.0032; median 1.2%-vs-0.3%, P= 0.0050; and median 122.6pg/ml-vs-76.0pg/ml, P= 0.0125, respectively). Patients with 2 or 3 elevated factors had longer progression-free survival than patients with 0 or only one (not reached-vs-5.6months, P= 0.0002). We conclude that NK cells, CD4 + PD-1 + Tim-3 + T cells, and CXCL10 levels in pre-treatment peripheral blood may predict the efficacy of combination of ICI/chemotherapy in NSCLC.

Biomimetic Tertiary Lymphoid Structures with Microporous Annealed Particle Scaffolds for Cancer Postoperative Therapy.

Immunotherapy plays a vital role in cancer postoperative treatment. Strategies to increase the variety of immune cells and their sustainable supply are essential to improve the therapeutic effect of immune cell-based immunotherapy. Here, inspired by tertiary lymphoid structures (TLSs), we present a microfluidic-assisted microporous annealed particle (MAP) scaffold for the persistent recruitment of diverse immune cells for cancer postoperative therapy. Based on the thermochemical responsivity of gelatin methacryloyl (GelMA), the MAP scaffold was fabricated by physical cross-linking and sequential photo-cross-linking of GelMA droplets, which were prepared by microfluidic electrospraying. Due to the encapsulation of liquid nitrogen-inactivated tumor cells and immunostimulant, the generated MAP scaffold could recruit a large number of immune cells, involving T cells, macrophages, dendritic cells, B cells, and natural killer cells, thereby forming the biomimetic TLSs in vivo. In addition, by combination of immune checkpoint inhibitors, a synergistic anticancer immune response was provoked to inhibit tumor recurrence and metastasis. These properties make the proposed MAP scaffold-based artificial TLSs of great value for efficient cancer postoperative therapy.

Cytoreductive nephrectomy in the era of immune checkpoint inhibitors: a US Food and Drug Administration pooled analysis.

This pooled analysis of patient-level data from trials evaluated the clinical outcomes of patients with metastatic renal cell carcinoma with or without cytoreductive nephrectomy before a combination of immune checkpoint inhibitor and antiangiogenic therapy. Data from 5 trials of immune checkpoint inhibitors plus antiangiogenic therapy were pooled. Only patients with stage 4 disease at initial diagnosis were included to ensure that nephrectomy was performed for cytoreductive purposes and not to previously treat an earlier stage of disease. The effect of cytoreductive nephrectomy before immune checkpoint inhibitor therapy on outcomes was evaluated using the Kaplan-Meier method and a Cox proportional hazards regression model, adjusted for age, sex, risk group, performance status, and the presence of sarcomatoid differentiation. A total of 981 patients were included. The estimated median progression-free survival with and without nephrectomy was 15 and 11 months, respectively; the adjusted hazard ratio was 0.71 (95% confidence interval = 0.59 to 0.85). The estimated median overall survival with and without nephrectomy was 46 and 28 months, respectively; the adjusted hazard ratio was 0.63 (95% confidence interval = 0.51 to 0.77). Objective response was 60% of patients with vs 46% of patients without cytoreductive nephrectomy. Patients with metastatic renal cell carcinoma who undergo cytoreductive nephrectomy before immune checkpoint inhibitor plus antiangiogenic therapy had improved outcomes compared with patients without cytoreductive nephrectomy. Selection factors for cytoreductive nephrectomy may be prognostic and could not be fully controlled for in this retrospective analysis. Prospective determination of and stratification by prior cytoreductive nephrectomy may be considered when designing clinical trials to assess the impact of this factor on prognosis.

Targeted Combination of Poly(ADP-ribose) Polymerase Inhibitors and Immune Checkpoint Inhibitors Lacking Evidence of Benefit: Focus in Ovarian Cancer.

The emergence of targeted therapeutics in ovarian cancer, particularly poly (ADP-ribose) polymerase inhibitors (PARPi's), has created additional opportunities for patients seeking frontline and recurrent disease management options. In particular, PARPi's have shown clinical benefits in BRCA mutant and/or homologous recombination deficient (HRD) ovarian cancer. Until recently, response was thought to be limited in BRCA wild-type, homologous recombination proficient (HRP) cancers. Therefore, attempts have been made at combination therapy involving PARPi to improve patient outcomes. Additionally, immune checkpoint inhibitors (ICIs) have demonstrated underwhelming results involving ovarian cancer. Many are searching for reliable biomarkers of immune response to increase efficacy of ICI therapy involving ovarian cancer. In this review, we examine the evidence supporting the combination of PARPi and ICIs in ovarian cancer, which is still lacking.

Neoadjuvant therapy with chemotherapy and immune checkpoint inhibitor for laryngeal function preservation in locally advanced hypopharyngeal cancer.

To evaluate the efficacy and laryngeal function preservation of neoadjuvant treatment with chemotherapy and immune checkpoint inhibitor for locally advanced hypopharyngeal cancer (LAHPC). We retrospectively collected LAHPC patients who were diagnosed between February 2022 and June 2023. The patients received a combination of chemotherapy and immune checkpoint inhibitors as the neoadjuvant therapy. The response to treatment, laryngeal function preservation rate, and short-term survival were assessed. A total of 20 patients were included. Of these patients, 17 (85.0%) had stage IVA-B disease. Ten (50%) and four (20%) patients achieved pathological complete response (PCR) and major pathological response (MPR) to the primary tumor, respectively. In addition, 6 patients had incomplete pathological response (IPR). In the neck, 19 patients had node-positive disease before treatment, and only 5 patients (26.4%) had PCR to regional lymph nodes. Pathologically positive lymph nodes were still observed in 14 (73.6%) patients. Significant downgrading on narrow-band imaging assessment in primary tumors was associated with a higher probability of PCR or MPR than those with IPR (92.9% vs. 33.3%, P=0.014). The overall rate of laryngeal preservation was 95.0%. No severe perioperative complications or perioperative death were found. All patients completed the recommended postoperative radiotherapy/chemoradiotherapy. The median follow-up period was 12.1 months. The 1-year progression-free survival and overall survival were 94.1% and 92.9%, respectively. During the follow-up period, all 19 patients who underwent laryngeal preservation surgery had their laryngeal function preserved. The addition of an immune checkpoint inhibitor to neoadjuvant chemotherapy effectively preserves laryngeal function without increasing complications related to surgery and postoperative radiotherapy in LAHPC.

Immunotherapy or Chemoimmunotherapy in Older Adults With Advanced Non–Small Cell Lung Cancer

Immune checkpoint inhibitor (ICI) plus chemotherapy combination treatment (ICI-chemotherapy) is now a standard treatment for non-small cell lung cancer (NSCLC) without targetable oncogene alterations, but there are few data on ICI-chemotherapy for patients 75 years and older. To inform the choice of first-line drugs in clinical practice and assess the safety and efficacy of ICI-chemotherapy combination treatment in older adult patients with previously untreated advanced NSCLC. This retrospective cohort study included 58 centers in Japan. The cohort consisted of patients 75 years and older with clinical stage IIIB, IIIC, IV, postoperative or radiotherapy recurrent NSCLC. Patients started first-line systemic therapy between December 2018 and March 2021. Those receiving first-line molecular targeted drugs were excluded. The data were analyzed from February 2022 to October 2022. Systemic therapy. The main outcomes were overall survival (OS), progression-free survival (PFS), and safety. A total of 1245 patients (median [range] age, 78 [75-95] years; 967 [78%] male) with NSCLC were included in the cohort. Programmed death ligand-1 (PD-L1) expression of less than 1% occurred in 268 tumors (22%); 1% to 49% in 387 tumors (31%); 50% and higher in 410 tumors (33%), and unknown expression in 180 tumors (14%). Median OS was 20.0 (95% CI, 17.1-23.6) months for the 354 patients receiving ICI-chemotherapy (28%); 19.8 (95% CI, 16.5-23.8) months for the 425 patients receiving ICI alone (34%); 12.8 (95% CI, 10.7-15.6) months for the 311 patients receiving platinum-doublet chemotherapy (25%); and 9.5 (95% CI, 7.4-13.4) months for the 155 patients receiving single-agent chemotherapy (12%). After propensity score matching, no differences in OS and PFS were found between the patients receiving ICI-chemotherapy vs ICI alone. Each group consisted of 118 patients. For PD-L1 expression of 1% and higher the OS hazard ratio (HR) was 0.98 (95% CI, 0.67-1.42; P = .90), and the PFS HR was 0.92 (95% CI, 0.67-1.25; P = .59). Significance was also not reached when separately analyzed for lower or higher PD-L1 expression (1%-49% or ≥50%). However, grade 3 or higher immune-related adverse events occurred in 86 patients (24.3%) treated with ICI-chemotherapy and 76 (17.9%) with ICI alone (P = .03). In this study, ICI-chemotherapy combination treatment did not improve survival and increased the incidence of grade 3 and higher immune-related adverse events compared with ICI alone in patients 75 years and older. Based on these results, ICI alone may be recommended for older adult patients with PD-L1-positive NSCLC.

Unraveling the Therapeutic Benefit of Sequenced Chemo-immunotherapy.

Combination immune-checkpoint inhibition with chemotherapy is a clinical standard, yet concurrent administration may limit the full benefit of immunotherapy by blunting the proliferation and differentiation of CD8 T cells. Identifying patients in whom sequential chemo-immunotherapy or immunotherapy alone is feasible should be a priority to optimize long-term outcomes. See related article by Mariniello et al., p. 1833.

Neoadjuvant systemic therapy for hepatocellular carcinoma.

Surgical resection and liver transplant remain the only curative therapies for most patients with hepatocellular carcinoma (HCC). Systemic therapy options have typically been ineffective, but recent advances, such as the combination of immune checkpoint inhibitors and targeted therapies, have shown great promise. Neoadjuvant systemic therapy in resectable or locally advanced HCC is under active investigation with encouraging results in small, early-phase trials. Many of these completed and ongoing trials include combinations of systemic therapy (e.g. immune checkpoint inhibitors, tyrosine kinase inhibitors), transarterial therapies, and radiation. Despite early successes, larger trials with evaluation of long-term oncologic outcomes are needed to determine the role of neoadjuvant systemic therapy in patients with HCC who may be eligible for curative intent surgery or transplant.

The Role of Tumor and Host Microbiome on Immunotherapy Response in Urologic Cancers

Introduction & Objective: The role of the microbiome in the development and treatment of genitourinary malignancies is just starting to be appreciated. Accumulating evidence suggests that the microbiome can modulate immunotherapy through signaling in the highly dynamic tumor microenvironment. Nevertheless, much is still unknown about the immuno-oncology-microbiome axis, especially in urologic oncology. The objective of this review is to synthesize our current understanding of the microbiome’s role in modulating and predicting immunotherapy response to genitourinary malignancies. Methods: A literature search for peer-reviewed publications about the microbiome and immunotherapy response in bladder, kidney, and prostate cancer was conducted. All research available in PubMed, Google Scholar, clinicaltrials.gov, and bioRxiv up to September 2023 was analyzed. Results: Significant differences in urinary microbiota composition have been found in patients with genitourinary cancers compared to healthy controls. Lactic acid-producing bacteria, such as Bifidobacterium and Lactobacillus genera, may have value in augmenting BCG responsiveness to bladder cancer. BCG may also be a dynamic regulator of PD-L1. Thus, the combination of BCG and immune checkpoint inhibitors may be an effective strategy for bladder cancer management. In advanced renal cell carcinoma, studies show that recent antibiotic administration negatively impacts survival outcomes in patients undergoing immunotherapy, while administration of CBM588, a live bacterial product, is associated with improved progression-free survival. Specific bacterial taxa, such as Streptococcus salivarius, have been linked with response to pembrolizumab in metastatic castrate-resistant prostate cancer. Fecal microbiota transplant has been shown to overcome resistance and reduce toxicity to immunotherapy; it is currently being investigated for both kidney and prostate cancers. Conclusions: Although the exact mechanism is unclear, several studies identify a symbiotic relationship between microbiota-centered interventions and immunotherapy efficacy. It is possible to improve immunotherapy responsiveness in genitourinary malignancies using the microbiome, but further research with more standardized methodology is warranted.

Avelumab Plus Intermittent Axitinib in Previously Untreated Patients with Metastatic Renal Cell Carcinoma. The Tide-A Phase 2 Study

Background and ObjectiveCombinations of VEGFR-TKIs plus ICI against PD1/PD-L1 are the standard first-line therapy for patients with mRCC, irrespective of the prognostic class. This study aims to investigate the feasibility and safety of withdrawing the VEGFR-TKI but continuing the anti- PD1/PD-L1 in patients who achieve response to their combination. MethodsThis was a single-arm phase 2 trial in patients with treatment naïve mRCC with prior nephrectomy, without symptomatic/bulky disease and no liver metastases. Enrolled patients received axitinib+avelumab, after 36 weeks of therapy those who achieved tumor response interrupted axitinib and continued avelumab maintenance until disease progression. The primary endpoint was the rate of patients without progression eight weeks after the axitinib interruption. Secondary endpoints were the median value for progression free (mPFS) and overall survival (mOS) and the safety in the overall population. Key Findings and Limitations79 patients were enrolled and 75 evaluated for efficacy. A total of 29 (38%) patients had axitinib withdrawn, as per the study design, with 72% of them having no progression after eight weeks and thus achieving the primary endpoint. The mPFS of the overall population was 24 months while the mOS was not reached. The ORR was 76% (12% CR, 64% PR), with 19% of patients having stable disease. In the patients who discontinued axitinib, the incidence of AEs of any grade was 59% and 3% for grade 3 or 4. This study was limited by the lack of the comparative arm. Conclusions and Clinical ImplicationsThe TIDE-A study demonstrates that the withdrawal of VEGFR-TKI with ICI maintenance is feasible for selected mRCC patients with evidence of response to the VEGFR-TKI+ICI combination employed in first-line therapy. Axitinib interruption with avelumab maintenance led to decreased side effects and should be further investigated as a new strategy to delay tumor progression.