Companion Diagnostic Research Articles

Landscape of Biomarkers and Actionable Gene Alterations in Adenocarcinoma of GEJ and Stomach-A Real World Data Analysis.

Simple SummaryMolecular tumor signatures are becoming increasingly important in the treatment of metastatic adenocarcinomas of the gastroesophageal junction (GEJ) and stomach (GC). There are few studies available analyzing data from the Caucasian population regarding molecular signatures and biomarkers. In the presented study, we investigated the distribution of gene variants in outpatients with advanced disease at the onset of diagnosis and correlated them with clinically relevant biomarkers according to ESCAT levels. In addition, we compared the results of conventional diagnostics (IHC/ISH) with NGS findings of gene amplifications. We were able to detect clinically relevant biomarkers according to ESCAT level I in approximately one-third of our patients, which have immediate therapeutic implications. The study highlights the importance of comprehensive molecular profiling for precision treatment of GEJ/GC and indicates that a biomarker evaluation should be performed for all patients with metastatic adenocarcinomas before the initiation of first-line treatment and during second-line or subsequent treatment.After several years of negative phase III trials in gastric and esophageal cancer, a significant breakthrough in the treatment of metastatic adenocarcinomas of the gastroesophageal junction (GEJ) and stomach (GC) is now becoming evident with the emerging of precision oncology and implementation of molecular targets in tumor treatment. In addition, new generation studies such as umbrella and basket trials are focused on these molecular targets, which makes an early molecular diagnosis based on IHC/ISH and NGS necessary. The required companion diagnostics of Her2neu overamplification or PD-L1 expression is based on immunohistochemistry (IHC) or additionally in situ hybridization (ISH) in case of an IHC Her2neu score of 2+. However, there are investigator-dependent differences in the assessment of Her2neu amplification and different PD-L1 scoring systems obtained by IHC/ISH. The use of high-throughput technologies such as next-generation sequencing (NGS) holds the potential to standardize the analysis and thus make them more comparable. In the presented study, real-world multigene sequencing data of 72 Caucasian patients diagnosed with metastatic adenocarcinomas of GEJ and stomach were analyzed. In the clinical companion diagnostics, we found ESCAT level I molecular targets in one-third of our patients, which directly determined the therapy. In addition, we found potential targets in 14/72 patients (19.4%) who potentially qualify for precision therapies in corresponding molecular studies. The study highlights the importance of comprehensive molecular profiling for precision treatment of GEJ/GC and indicates that a biomarker evaluation should be performed for all patients with metastatic adenocarcinomas before the initiation of first-line treatment and during second-line or subsequent treatment.

The Role of the Global Central Laboratory in Successful Companion Diagnostic Development

Clinical OMICsVol. 8, No. 5 Sponsored ContentFree AccessThe Role of the Global Central Laboratory in Successful Companion Diagnostic DevelopmentMeeting companion diagnostic co-development program expectations with a spectrum of technologies, globallyPublished Online:13 Oct 2021https://doi.org/10.1089/clinomi.08.05.22AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail William A. Haseltine, PhD, President, Haseltine, Foundation; Founder, Chairman, and President of ACCESS InternationalSince the approval of the first companion diagnostic (CDx), HER2, in 1998, precision medicine has embraced companion diagnostics as one way to ensure that targeted therapies can be appropriately administered to the right patient with some degree of assurance following clinical validity within clinical trials.The clinical validity of the companion diagnostic tends to be the final piece before the assay is submitted for PMA in the US. Long before that, translational science investigations sought to determine which biomarkers might be used for patient selection in the context of safety and/or efficacy. For these biomarkers, they have tended to fall into four main technology categories: Immuno-histochemistry (IHC), fluorescent in situ hybridisation (FISH), molecular via PCR and next generation sequencing (NGS). Although more recently, flow cytometry and immunoassay approaches are being considered for CDx.Oncology remains the dominant therapeutic area, and indeed, most solid tumor clinical development patient selection is built into the clinical trial. Lymphoma and leukaemia indications increasingly have biomarker analysis built into their clinical development plans. Given that each of these technology approaches requires pathology review (typically confirmation of diagnosis and assessment of tissue containing cells of sufficient quantity and quality), it's imperative that these pathologists are integral within the global central laboratory set up. Often, these pathologists will serve as principal investigators. At Q2 Solutions, this forms the foundation for much of what the laboratory provides to support global CDx.Successful partnerships between therapeutic sponsors, global central laboratories, and in vitro diagnostic companies (IVD) are critical to moving these CDx programs through clinical development. At Q2 Solutions, we work closely with IVD companies to ensure we have the appropriate equipment and instrumentation, plus adequately trained staff.Regulatory and ethics compliance are key to ensuring these CDx studies are conducted in accordance with national and local guidelines. Accordingly, it's important to have personnel who can work with ethics and regulatory bodies. For studies involving China, Q2 Solutions ensures that appropriate HGRAC and NMPA guidelines are adhered to and provides reassurance to its pharma and IVD partners given its long experience with these bodies. Many oncology global phase III studies involve clinical sites in China, and given the regulations limiting or prohibiting the export of biological samples, having a local solution in China is a prerequisite.Providing biomarker results to clinical trial sites within fast turnaround times is almost a ubiquitous requirement given that patients may have the option of several clinical trials and that often, their disease management requires results quickly as therapeutic options are approved or investigational methods are being assessed. Q2 Solutions' default position is to provide results back to clinical sites within five business days of sample receipt.Increasingly, more and more biomarker data is available locally with patients at clinical sites. Often, this local data is being used for the biomarker selection criteria in the clinical study. In our experience, lab data collected at different labs with different quality systems, often using different technologies, is not ideal and more often, sponsors require confirmation within a central laboratory.The global central laboratory continues to provide crucial laboratory data, often to support the decision to place a patient on an investigative therapy in a clinical trial. With the crucial elements discussed, the global central laboratory will continue to be a critical player in the pursuit of precision medicines for the patients who need them most.For more information: www.q2labsolutions.comFiguresReferencesRelatedDetails Volume 8Issue 5Sep 2021 InformationCopyright © GEN PublishingTo cite this article:The Role of the Global Central Laboratory in Successful Companion Diagnostic Development.Clinical OMICs.Sep 2021.35-35.http://doi.org/10.1089/clinomi.08.05.22Published in Volume: 8 Issue 5: October 13, 2021PDF download

A New Player in Companion Diagnostics

A New Player in Companion Diagnostics

How are we evaluating the cost-effectiveness of companion biomarkers for targeted cancer therapies? A systematic review

BackgroundDespite the increasing economic assessment of biomarker-guided therapies, no clear agreement exists whether existing methods are sufficient or whether different methods might produce different cost-effectiveness results. This study aims to examine current practices of modeling companion biomarkers when assessing the cost-effectiveness of targeted cancer therapies. It investigates the current methods in modeling the characteristics of companion diagnostics based on existing economic evaluations of biomarker-guided therapies in cancer.MethodsA literature search was performed using Medline, Embase, EconLit, Cochrane library for economic evaluations of biomarker-guided therapies with companion diagnostics in cancer. Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Studies were selected using pre-specified eligibility criteria based on the PICO framework. To make the included studies more comparable, we qualitatively synthesized the data under nine domains of methods where consensus was deemed lacking.ResultsOnly four of the twenty-two studies included in this review were found to be of good quality with respect to incorporating the characteristics of companion biomarkers in economic evaluations. However, many evaluations focused on a pre-selected patient group rather than including all patients regardless of their biomarker status. Companion biomarker characteristics captured in evaluations were often limited to the cost or the accuracy of the test. Often, only the costs of biomarker testing were modelled. Clinical outcomes and health state utilities were often not included due to the limited data generated by clinical trials. Methods of economic evaluation were not applied consistently in assessments of companion cancer biomarkers for targeted therapies. It was also shown that conflicting cost-effectiveness results were likely depending on what comparator arm was chosen and what comparison structure was designed in the model.ConclusionWe found no consistent approach applied in assessing the value of companion biomarker tests and including the characteristics of biomarkers in an economic evaluation of targeted oncology therapies. Currently, many economic evaluations fail to capture the full value of companion biomarkers beyond sensitivity/specificity and cost related to biomarker testing.

Building the Bridge: Molecular Imaging Biomarkers for 21st Century Cancer Therapies.

Precision medicine, where the molecular underpinnings of the disease are assessed for tailored therapies, has greatly impacted cancer care. In parallel, a new pillar of therapeutics has emerged with profound success, including immunotherapies such as checkpoint inhibitors and cell-based therapies. Nonetheless, it remains essential to develop paradigms to predict and monitor for therapeutic response. Molecular imaging has the potential to add substantially to all phases of cancer patient care: predicative, companion diagnostics can illuminate therapeutic target density within a tumor, and pharmacodynamic imaging biomarkers can complement traditional modalities to judge a favorable treatment response. This "Focus on Molecular Imaging" article discusses the current role of molecular imaging in oncology and highlights an additional step in clinical paradigm termed a "therapeutic biomarker," which serves to assess whether next generation drugs reach their target to elicit a favorable clinical response.

Development of a DELFIA method to detect oncofetal antigen ROR1-positive exosomes

Receptor tyrosine kinase-like orphan receptor 1 (ROR1) is highly expressed in a wide variety of hematological and solid cancers, but is low or absent in adult tissues. Here, we show that ROR1 is released with exosomes from ROR1-positive cancer cells. We also developed a simple dissociation-enhanced lanthanide fluorescence immunoassay (DELFIA) to detect cancer-derived ROR1-positive exosomes, which are captured by two anti-ROR1 antibodies and detected by the fluorescence of free chelating europium. This new DELFIA method can detect cancer-derived ROR1-positive exosomes in the cell supernatant and serum with a wide range and rapidly compared with the conventional Western blot assay. This method may be useful as a companion diagnostics for ROR1-positive cancers.

A Practical Guide to Modeling and Conducting a Cost-Effectiveness Analysis of Companion Biomarker Tests for Targeted Therapies Using R: Tutorial Paper.

Despite the increasing number of potential biomarkers identified in laboratories and reported in much literature, the adoption of biomarkers routinely available in clinical practice to inform treatment decisions is very limited. Reimbursement decisions for new health technologies are often informed by economic evaluations; however, economic evaluations of diagnostics/testing technologies, such as companion biomarker tests, are far less frequently reported than drugs. Furthermore, few countries provide the health economic evaluation methods guide specific to co-dependent technologies such as companion diagnostics or precision medicines. Therefore, this paper aims to guide the process of the development of cost-effectiveness models of cancer biomarkers for targeted therapies, focusing on companion diagnostics. This tutorial paper provides practical guidance on how to conduct economic evaluations of cancer biomarkers and how to model the characteristics of the biomarker tests as part of the value for money of corresponding targeted therapies. This paper presents a brief introduction to the methods and data requirements, a step-by-step guide to constructing a health economic model of companion cancer biomarkers, and a discussion of issues that arise in their application to healthcare decision making. This practical guidance is provided in R, and worked examples are provided in this paper with R codes in the accompanying electronic supplementary material.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40273-021-01069-8.

Co-Development of Oncology Drugs and Companion Diagnostics: Analyses of Approval Lags and Drug Development Periods in Recently Approved Cases in Japan.

The utilization of biomarkers has become increasingly active to enhance efficiency of clinical development. This study evaluated the current situation and quantitative impact of co-development of companion diagnostics (CDx) on the oncology drug development in Japan. Based on publicly available information about the oncology drugs and CDx approved in Japan in 2010-2020, we evaluated the approval lag time between drugs and CDx, and the duration between the pivotal study start date and the new drug application submission date (the time to application). Influences of multiple factors including the use of CDx on the time to application were also analyzed. A diagnostic test was mostly used from an early development phase such as phase1/2 study, and the median approval lag has tended to decrease when approved CDx were used (- 507 vs. - 25days for newly developed CDx). The shorter median times to application were observed in Drugs with CDx (1204days) compared to Targeted therapies without CDx (1423days) or Other drugs without CDx (1853days), although both the cancer types and the implementation of multi-regional clinical trials have a larger impact on the time to application compared to the use of CDx. The use of CDx from the early development phase and the global development strategy could have a positive contribution on the development period of oncology drugs, which will facilitate patients' earlier access to the optimal treatment.

From Passive Targeting to Personalized Nanomedicine: Multidimensional Insights on Nanoparticles' Interaction with the Tumor Microenvironment.

Nanomedicine is revolutionizing the treatment of cancer and has achieved unprecedented outcomes over the past decades. The accumulation of Nanoparticles (NPs) in different tumors relies mainly on the Enhanced Permeability and Retention (EPR) effect benefiting from the wide fenestrae of the tumor vasculature and the lack of lymphatic drainage. However, the EPR effect is recognized as a heterogeneous phenomenon resulting in heterogeneous outcomes of clinical trials. Extensive efforts are exerted to enhance the outcomes of nanomedicine in a larger cohort of patients by employing active targeting strategies. However, actively targeted NPs accumulate in tumors by the EPR effect and hence fail to achieve convincing therapeutic outcomes. These obstacles are gradually being removed by improving the understanding of the Tumor Microenvironment (TME) and the mechanistic interaction of the NPs with its different components. In this review, we provide detailed insights into the past concerns of drug targeting, the current trends of TME reengineering, and the future implications for overcoming past hurdles. Strategies explored in this regard included the use of companion diagnostics and the modulation of the protein corona associated with the systemic administration of NPs and their interaction with biological macromolecules.

Regulatory Aspects of Personalised Medicines

: The advent of big data analysis, genetic engineering and epigenetics has transformed the healthcare system by shifting the strategy for diagnosis, prevention and treatment of diseases from “one-size-fits-all” approach to “personalised” approach. Identification of biomarkers from molecular diagnosis has made tailoring of the medical treatment possible. Optimization of treatment decreases the costs related to the ineffective treatments and helps in avoiding possible side effects and adverse drug reactions. The efficient development of personalised medicine is largely dependent on the tools, sequencing techniques used and regulatory policies related to the personalised medicine products, tests and companion diagnostics. The uncertainties in the regulations governing personalised medicine should be eliminated and specific guidelines should be laid down by the respective regulatory authorities to bridge the emerging tools and technologies with the regulatory policies. Also, proper regulatory approval pathways for companion diagnostics will resolve the complications of organized development of therapeutic products and diagnostic tests.

Systematic Review of PD-1/PD-L1 Inhibitors in Oncology: From Personalized Medicine to Public Health.

BackgroundTo review and summarize all U.S. Food and Drug Administration (FDA) approvals of programmed death (PD)‐1 and PD‐ligand 1 blocking antibodies (collectively referred to as PD‐[L]1 inhibitors) over a 6‐year period and corresponding companion/complementary diagnostic assays.Materials and MethodsTo determine the indications and pivotal trials eligible for inclusion, approval letters and package inserts available on Drugs@FDA were evaluated for approved PD‐[L]1 inhibitors to identify all new indications granted from the first approval of a PD‐[L]1 inhibitor on September 4, 2014, through September 3, 2020. The corresponding FDA drug and device reviews from the marketing applications for the approved indications were identified through FDA internal records. Two reviewers independently extracted information for the endpoints, efficacy data, basis for approval, type of regulatory approval, and corresponding in vitro diagnostic device test. The results were organized by organ system and tumor type.ResultsOf 70 Biologic Licensing Application or supplement approvals that resulted in new indications, 32 (46%) were granted based on response rate (ORR) and durability of response, 26 (37%) on overall survival, 9 (13%) on progression‐free survival, 2 (3%) on recurrence‐free survival, and 1 (1%) on complete response rate. Most ORR‐based approvals were granted under the accelerated approval provisions and were supported with prolonged duration of response. Overall, 21% of approvals were granted with a companion diagnostic. Efficacy results according to tumor type are discussed.ConclusionPD‐[L]1 inhibitors are an effective anticancer therapy in a subset of patients. This class of drugs has provided new treatment options for patients with unmet need across a wide variety of cancer types. Yet, the modest response rates in several tumor types signal a lack of understanding of the biology of these diseases. Further preclinical and clinical investigation may be required to identify a more appropriate patient population, particularly as drug development continues and additional treatment alternatives become available.Implications for PracticeThe number of PD‐[L]1 inhibitors in drug development and the associated companion and complementary diagnostics have led to regulatory challenges and questions regarding generalizability of trial results. The interchangeability of PD‐L1 immunohistochemical assays between PD‐1/PD‐L1 drugs is unclear. Furthermore, robust responses in some patients with low levels of PD‐L1 expression have limited the use of PD‐L1 as a predictive biomarker across all cancers, particularly in the setting of diseases with few alternative treatment options. This review summarizes the biomarker thresholds and assays approved as complementary and companion diagnostics and provides regulatory perspective on the role of biomarkers in oncology drug development.

Tissue Multiplex Analyte Detection in Anatomic Pathology - Pathways to Clinical Implementation.

Background: Multiplex tissue analysis has revolutionized our understanding of the tumor microenvironment (TME) with implications for biomarker development and diagnostic testing. Multiplex labeling is used for specific clinical situations, but there remain barriers to expanded use in anatomic pathology practice.Methods: We review immunohistochemistry (IHC) and related assays used to localize molecules in tissues, with reference to United States regulatory and practice landscapes. We review multiplex methods and strategies used in clinical diagnosis and in research, particularly in immuno-oncology. Within the framework of assay design and testing phases, we examine the suitability of multiplex immunofluorescence (mIF) for clinical diagnostic workflows, considering its advantages and challenges to implementation.Results: Multiplex labeling is poised to radically transform pathologic diagnosis because it can answer questions about tissue-level biology and single-cell phenotypes that cannot be addressed with traditional IHC biomarker panels. Widespread implementation will require improved detection chemistry, illustrated by InSituPlex technology (Ultivue, Inc., Cambridge, MA) that allows coregistration of hematoxylin and eosin (H&E) and mIF images, greater standardization and interoperability of workflow and data pipelines to facilitate consistent interpretation by pathologists, and integration of multichannel images into digital pathology whole slide imaging (WSI) systems, including interpretation aided by artificial intelligence (AI). Adoption will also be facilitated by evidence that justifies incorporation into clinical practice, an ability to navigate regulatory pathways, and adequate health care budgets and reimbursement. We expand the brightfield WSI system “pixel pathway” concept to multiplex workflows, suggesting that adoption might be accelerated by data standardization centered on cell phenotypes defined by coexpression of multiple molecules.Conclusion: Multiplex labeling has the potential to complement next generation sequencing in cancer diagnosis by allowing pathologists to visualize and understand every cell in a tissue biopsy slide. Until mIF reagents, digital pathology systems including fluorescence scanners, and data pipelines are standardized, we propose that diagnostic labs will play a crucial role in driving adoption of multiplex tissue diagnostics by using retrospective data from tissue collections as a foundation for laboratory-developed test (LDT) implementation and use in prospective trials as companion diagnostics (CDx).

A Companion Diagnostic With Significant Clinical Impact in Treatment of Breast and Gastric Cancer.

The development of trastuzumab (Herceptin®) was one of the most significant cancer drug development projects of the 20th century. Not only was it a scientific and medical achievement but it also paved the way for the drug-diagnostic codevelopment model, where a predictive biomarker assay is developed in parallel to the drug. One of the challenges in the development of trastuzumab was to select the right patient population likely to respond and here, it was critical to have access to an accurate, robust and reliable assay for detection of HER2 overexpression in tumors. In the clinical development of trastuzumab, a clinical trial assay (CTA), developed by Genentech, was used for selection of HER2 positive patients. However, during the phase III trial with trastuzumab, a new optimized IHC assay, HercepTest™ was designed and developed by Dako. In the final stage of its development, a comparative study with the CTA was conducted in order to show concordance between the two assays. In September 1998, the Food and Drug Administration (FDA) simultaneously granted approval to trastuzumab and HercepTest™. The assay has been used for patient selection in a number of significant breast cancer clinical trials such as the HERA, CLEOPATRA, EMILIA and more. In these trials, HercepTest™ demonstrated its clinical utility in the neoadjuvant, adjuvant, and metastatic setting as well as in relation to different types of HER2 targeted therapies. Likewise, the assay was used for selection of HER2 positive gastric cancer patients in the important ToGA trail. HercepTest™ was the first companion diagnostic ever approved by the FDA, and more than 20 years of use has documented its clinical impact.

Pharmacogenomic-Guided Therapy in Colorectal Cancer.

Approximately 20 drugs have been shown to be effective for the treatment of colorectal cancer (CRC). These drugs are from several classes of agents and include cytotoxic drugs, therapeutics that target cell signaling pathways at the extracellular and/or intracellular levels, and combination therapies that contain multiple targeted agents and/or cytotoxic compounds. Targeted therapeutics can include monoclonal antibodies, fusion proteins, and small molecule drugs. The first introduced into clinical use was 5-fluorouracil in the early 1960s and remains the foundation for most CRC treatments in both adjuvant therapy and in advanced (metastatic) treatment regimens. As with other cancers, the consideration of biomarkers has the potential to improve CRC therapy through patient stratification. The biomarkers can include germline genetic markers, tumor-specific genetic markers, immune markers, and other biomarkers that can predict antitumor efficacy or the likelihood of toxicity prior to administration of a specific drug. Consistent with the benefit of considering biomarkers in treatment, many newer targeted therapies are developed and approved simultaneously with a companion diagnostic test to determine efficacy. This review will focus on biomarkers that have demonstrated clinical utility in CRC treatment; however, it is noted that many additional biomarkers have been theorized to contribute to drug response and/or toxicity based on known biological pathways but thus far have not attained widespread use in the clinic. The importance of pretreatment biomarker testing is expected to increase as future drug development will likely continue to focus on the concurrent development of companion diagnostics.

Abstract 2707: NGS-based murine pan-cancer gene expression panel reveals high resolution for immuno-oncology and tumor microenvironment studies

Abstract Background: Immunotherapies have made a significant contribution in the treatment of cancer; however, the interaction between tumor, treatment and immune response remains complex. To fully understand the interactions between cancer and immunity in a tumor microenvironment (TME), experimental murine models, derived from a variety of biological technologies, are essential preclinical systems utilized before clinical studies. Next-generation sequencing (NGS) technologies have been demonstrated to be superior to microarray-based methods in assessing molecular features on omics levels. Here we describe a robust and efficient NGS-based gene expression panel to characterize murine tumor-immune interactions. Methods: We developed a murine gene expression panel (NGSmIO) with ~1100 immune-associated marker genes and immuno-oncology (I/O) signaling genes. Oligonucleotide-based hybridization/capture techniques analogous to exome sequencing, and targeting specific regions, are well established on Illumina NovaSeq and BGI MGISEQ platforms. These methods were applied to the murine I/O panel assay, with accuracy and reproducibility verified across these two sequencing platforms. Tumor, blood and spleen tissues derived from MC38 and Hepa 1-6 tumor models with anti-PD-1 and anti-CD4 treatment were collected for both our NGS panel assay and the NanoString PanCancer Mouse IO 360™ Panel (NanoStringIO). The results were compared in parallel with historical cell cytometry, RNA-Seq (transcriptomics) and proteomics data in the same experimental conditions. Results: By systematic comparison of NGSmIO and NanoStringIO panels, we observed high correlation (mean R=0.856) and high consistency in common gene signature expression across 12 paired samples derived from different tissues and therapeutic conditions. To determine the performance of both panels, we used FACS, RNA-Seq and proteomics data in the same therapeutic conditions as previous studies for reference, and demonstrated that NanoStringIO systematically over-detects low expressed genes in different samples/conditions. Furthermore, NGSmIO detected gene expression changes under treatment, whereas NanoStringIO was unable to differentiate expression between control and treatment. Conclusions: We have established a murine-I/O NGS panel to efficiently characterize tumor-immune interactions in a robust manner for preclinical studies. Compared to the NanoStringIO panel, NGSmIO provides enhanced insight into the TME, and has the potential to both translate preclinical studies more effectively to the clinic as well as guide the design of immunotherapy companion diagnostics. Citation Format: Jia Xue, Xiaobo Chen, Henry Q. Li, Sheng Guo. NGS-based murine pan-cancer gene expression panel reveals high resolution for immuno-oncology and tumor microenvironment studies [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2707.

Non-invasive molecular imaging of kidney diseases.

In nephrology, differential diagnosis or assessment of disease activity largely relies on the analysis of glomerular filtration rate, urinary sediment, proteinuria and tissue obtained through invasive kidney biopsies. However, currently available non-invasive functional parameters, and most serum and urine biomarkers, cannot capture intrarenal molecular disease processes specifically. Moreover, although histopathological analyses of kidney biopsy samples enable the visualization of pathological morphological and molecular alterations, they only provide information about a small part of the kidney and do not allow longitudinal monitoring. These limitations not only hinder understanding of the dynamics of specific disease processes in the kidney, but also limit the targeting of treatments to active phases of disease and the development of novel targeted therapies. Molecular imaging enables non-invasive and quantitative assessment of physiological or pathological processes by combining imaging technologies with specific molecular probes. Here, we discuss current preclinical and clinical molecular imaging approaches in nephrology. Non-invasive visualization of the kidneys through molecular imaging can be used to detect and longitudinally monitor disease activity and can therefore provide companion diagnostics to guide clinical trials, as well as the safe and effective use of drugs.

TRK Inhibitors: Tissue-Agnostic Anti-Cancer Drugs.

Recently, two tropomycin receptor kinase (Trk) inhibitors, larotrectinib and entrectinib, have been approved for Trk fusion-positive cancer patients. Clinical trials for larotrectinib and entrectinib were performed with patients selected based on the presence of Trk fusion, regardless of cancer type. This unique approach, called tissue-agnostic development, expedited the process of Trk inhibitor development. In the present review, the development processes of larotrectinib and entrectinib have been described, along with discussion on other Trk inhibitors currently in clinical trials. The on-target effects of Trk inhibitors in Trk signaling exhibit adverse effects on the central nervous system, such as withdrawal pain, weight gain, and dizziness. A next generation sequencing-based method has been approved for companion diagnostics of larotrectinib, which can detect various types of Trk fusions in tumor samples. With the adoption of the tissue-agnostic approach, the development of Trk inhibitors has been accelerated.

Prohibitin Expression Level As a Companion Diagnostic Marker in Cytogenetically Normal Acute Myeloid Leukemia

Background: Cytogenetically normal acute myeloid leukemia (CN-AML) accounts for almost half of all AML and shows significantly heterogeneous clinical outcomes. Despite the advancements in the molecular pathophysiology of CN-AML, clinical outcome of this leukemia remains unsatisfactory. The recent studies of close relationship between mitochondrial alterations and pathologies of various tumors and degenerative diseases suggested that mitochondria have been an important target for the identification and development of novel companion diagnostic and prognostic marker. These findings prompted us to investigate whether mitochondrial markers could serve as a potential diagnostic, prognostic and therapeutic target in CN-AML patients.Patients and Methods: The proteome analysis of the mitochondria enriched cytoplasmic fractions in primary CN-AML and counterpart normal cells was performed using 2-DE and MALDI-TOF/TOF mass spectrometry. For the development of anti-leukemic drug candidates targeting PHB in CN-AML cells, we synthesized potent chemical substances that can alkylate identified biomarkers. Quantitative reverse transcriptase-polymerase chain reaction and immunohistochemical staining (IHCS) on paraffin-embedded bone marrow sections were performed in order to obtain clinicopathological implications of candidate biomarkers. To assess the functional significance of identified biomarkers, we investigated the effect of β-catenin accumulation on the expression of identified biomarkers because accumulation of β-catenin in the nucleus has been identified in leukemic cells.Results: Prohibitin (PHB /gi4505773) was highly expressed in primary CN-AML cells compared with normal cells. PHB2 protein expression using IHCS was assessed in 133 CN-AML patients. Patients with PHB2 overexpression showed inferior OS (23.7% vs 50.0%; P =0.026) and high hazard ratio (1.808; P = 0.028) compared to PHB2 expression negative patients in CN-AML. Quantitative expression of PHB1 g ene (ddCt) was higher in the control group; 0.31 to 28.32 (mean 4.40, median 2.16) in control group versus 0.22 to 6.52 (mean 1.83, median 1.56) in patient group. Meanwhile, PHB 2 gene expression was higher in the patient group; 0.0 to 0.46 (mean 0.16, median 0.15) in control group versus 0.15 to 3.49 (mean 0.80, median 3.49) in patient group. As a result of linear discrimination analysis, a linear equation (y = 0.5857 * x1 - 4.7252 * x2 - 0.18652; x1 was ddCt of PHB1 , x2 was ddCt of PHB 2) was derived. Estimating the prevalence of AML as 0.003%, the sensitivity of newly developed algorithm was 88.0%, specificity was 87.0%, negative predictive value (NPV) was 99.9% and positive predictive value (PPV) was 2.0%. The elevated level of PHB in CN-AML cells was the result of Wnt signals that were up-regulated in AML cells. PHB is a direct target of β-catenin, and TCF-4/LEF-1 binding motif, CATCTG, appears in the promoter region of PHB by site-directed mutagenesis and ChIP assay. This β-catenin-mediated activation of PHB expression is independent of c-MYC activation which is also a product of Wnt signaling. Potent chemical substances that can alkylate PHB in AML cells, cyclohexylphenyl-chloroethyl urea (CCEU) and iodophenyl-chloroethyl urea (ICEU). Proliferation suppression was observed in leukemic cell lines, THP-1, K-562 and Kasumi-1, which were treated with CCEU and ICEU in time and dose dependent manner. Moreover, notable morphological transformation of leukemic cells was observed when treated with 50 - 200 umol of CCEU and ICEU for 24 hours. Cell cycle analysis of CCEU-and-ICEU-treated- THP-1 and Kasumi-1 cell lines showed a remarkable increase of the sub-G1 phase.Conclusions: Overexpression of PHB2 protein was associated with poor prognosis in CN-AML. Newly developed algorithm using quantitative data of PHB1 and PHB2 mRNA expressions also showed the possibility as rapid diagnostic tools for leukemic cell identification, and novel alkylating chemotherapeutics, CCEU and ICEU, targeting PHB for selective killing of leukemic cells have been developed. PHB2 expression status can provide clinically valuable results for the diagnosis, prediction of the prognosis, detection of minimal residual disease and therapeutic targeting of AML with normal karyotype. High expression of PHB was served as a companion diagnostic marker in cytogenetically normal acute myeloid leukemia. DisclosuresNo relevant conflicts of interest to declare.

PCN185 Identification of Gaps and Opportunities for Provincial Reimbursement of Oncology Companion Diagnostics in Canada

Companion diagnostics (CDx) are administered prior to treatment with a therapeutic. Within oncology, CDx detect single biomarkers or genes. The Canadian Agency for Drugs and Technologies in Health (CADTH) review process incorporates CDx, with guidance on inclusion in economic evaluations for therapeutics, though it does not provide funding recommendations. Funding decisions for genetic tests are made provincially. This research aims to identify where in the reimbursement pathway of CADTH-participating provinces do gaps exist in patient access to oncology therapeutics and the associated CDx.

Models that combine transcriptomic with spatial protein information exceed the predictive value for either single modality

Immunotherapy has reshaped the field of cancer therapeutics but the population that benefits are small in many tumor types, warranting a companion diagnostic test. While immunohistochemistry (IHC) for programmed death-ligand 1 (PD-L1) or mismatch repair (MMR) and polymerase chain reaction (PCR) for microsatellite instability (MSI) are the only approved companion diagnostics others are under consideration. An optimal companion diagnostic test might combine the spatial information of IHC with the quantitative information from RNA expression profiling. Here, we show proof of concept for combination of spatially resolved protein information acquired by the NanoString GeoMx® Digital Spatial Profiler (DSP) with transcriptomic information from bulk mRNA gene expression acquired using NanoString nCounter® PanCancer IO 360™ panel on the same cohort of immunotherapy treated melanoma patients to create predictive models associated with clinical outcomes. We show that the combination of mRNA and spatially defined protein information can predict clinical outcomes more accurately (AUC 0.97) than either of these factors alone.