ICI Treatment Research Articles

Abstract P049: Phase II trial of TRC102 (methoxyamine HCl) in combination with temozolomide (TMZ) in patients with advanced non-small cell lung cancer

Abstract Background: TRC102 binds to abasic sites in DNA, inhibiting the base excision repair (BER) pathway, which is implicated in resistance to alkylating agents. Preclinical xenograft studies in mice demonstrated a synergistic anti-tumor effect when TRC102 was combined with alkylating agents. TRC102 given in combination with temozolomide in a phase 1 trial demonstrated acceptable toxicity and antitumor activity in patients (pts) with colorectal cancer (CRC), non-small cell lung cancer (NSCLC, squamous cell carcinoma) and granulosa cell ovarian cancer (Oncotarget 2020). Pharmacodynamic (PD) analysis revealed treatment-induced induction of nuclear Rad51 signal, indicating DNA damage repair (DDR) response and tumor biopsy data indicated MGMT methylation correlated with tumor response in CRC (Cancer Cell, 2020). Here we report data from a phase II expansion cohort of this combination in pts with NSCLC. Methods: We conducted a single arm open label trial in a pt cohort with advanced NSCLS, who had received at least one line of therapy in the metastatic setting. Pts who received immunotherapy (ICI) and/or molecularly targeted therapy were eligible. Pts received 125 mg TRC102 (100 mg for BSA < 1.6) and 150 mg/m2 TMZ given orally daily for days 1-5 of 28-day cycle (C). Restaging CT scans were carried out after every 2 C and evaluated using RECIST 1.1. Blood from all pts was analyzed for circulating tumor cells (CTCs) at baseline and the beginning of each C. A two-stage design was employed, with at least 2 objective responses needed among the first 16 pts treated on study in order to proceed to the second stage. Results: Sixteen pts with NSCLC (12 adenocarcinoma, 4 squamous) were enrolled between 11/2016 and 6/2021; 12 men and 4 women, median age of 69 yrs (range 33-80), 1 Hispanic, 3 Asian, 2 Black/African American, and 10 Caucasian. Pts received a median of 3 prior lines of therapy (range 1-7), including ICI in all but 1 pt. Twelve pts were evaluable for response. Three pts experienced clinical progression before completing C 2, and 1 pt withdrew consent before completing C 2. Median number of Cs received by pts was 3 (range 1-14); 9 pts experience stable disease (SD) as best response lasting median of 12 wks (range 8-56 wks), and 4 pts experienced prolonged SD lasting greater than 6 Cs (24 wks). Treatment-related grade 3 adverse events reported include lymphopenia (4) and anemia (1). No grade 4 or 5 events were noted. Conclusion: TRC102 in combination with temozolomide was well tolerated with notable efficacy. Although no objective tumor responses were observed in this heavily pretreated population, 9 of 15 pts experienced SD, lasting ≥ 24 wks in 4 pts. Given the limited options for NSCLC treatment following ICI and TKI treatment, this regimen merits further evaluation. Analysis of CTCs is ongoing, as well as additional biomarker evaluation in other treatment cohorts. Funded by NCI Contract No. HHSN261200800001E Citation Format: Mohamad A. Salkeni, Geraldine O’Sullivan Coyne, Jennifer Zlott, Naoko Takebe, Ning Ma, Larry Rubinstein, Richard Piekarz, Jared Foster, Brandon Miller, Ralph Parchment, Abdul R. Naqash, Andrea Voth, James Doroshow, Alice Chen. Phase II trial of TRC102 (methoxyamine HCl) in combination with temozolomide (TMZ) in patients with advanced non-small cell lung cancer [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2021 Oct 7-10. Philadelphia (PA): AACR; Mol Cancer Ther 2021;20(12 Suppl):Abstract nr P049.

Predictive value of mRNA expression and dynamic changes from immune related biomarkers in liquid biopsies before and after start of pembrolizumab in stage IV non-small cell lung cancer (NSCLC).

BackgroundThe aim of this study was to determine whether mRNA expressions and dynamic changes of immune-related genes before and after starting first-line treatment with the PD-1 inhibitor pembrolizumab in patients with NSCLC were of predictive value.MethodsCD3, CD8, PD-1, PD-L1 and CTLA-4 mRNA expression levels were measured from peripheral blood before and after three weeks of treatment with the PD-1 inhibitor. Univariate and multivariate analyses were performed retrospectively. Response, progression-free survival (PFS) and overall survival (OS) were determined.ResultsIn univariate analysis an increase of CD3 and CD8 mRNA expression after the first cycle of pembrolizumab were each associated with improved PFS and OS. In contrast, patients with no change or with a decrease in CD3 and CD8 mRNA expression showed significantly worse outcome. CD8 mRNA increase remained an independent predictive factor for PFS and OS in the multivariate analysis with p values of 0.011 and 0.006, respectively.ConclusionsAn increase of CD8 mRNA expression predicts favorable outcome after first line monotherapy with pembrolizumab, while no change or decrease might serve as an indicator of poor outcome and might give cause for early treatment escalation for instance by addition of chemotherapy or additional ICI treatment, e.g., against CTLA-4.

Health-related quality of life in cancer patients treated with immune checkpoint inhibitors in randomised controlled trials: A systematic review and meta-analysis

BackgroundImmune checkpoint inhibitors (ICIs) have revolutionised clinical practice in oncology in the last years, leading to a survival benefit in several tumour types. To investigate whether these benefits are associated with improved quality of life, we conducted a systematic review and meta-analysis comparing patient-reported outcomes (PROs) between ICIs and standard chemotherapy (CT) in patients with advanced solid tumours. MethodsClinical trials comparing the efficacy of ICIs (either programmed death receptor-1 and programmed death-ligand 1 inhibitors or cytotoxic T-lymphocyte antigen 4 inhibitors, as single agent or in combination) versus CT were included. Trials evaluating treatment with ICIs plus CT versus CT alone were also included, whereas studies in which the control arm included other anticancer agents (such as targeted therapy and other ICIs) or placebo alone were excluded. The aim of our meta-analysis was to compare PROs in subjects treated with ICIs or ICIs plus CT (intervention) with those reported by patients receiving CT (control). The co-primary endpoints were time from baseline to first deterioration in PROs, defined as the time from baseline to the first clinically significant deterioration in PROs, and the changes in PROs from baseline to follow-up between ICI and CT treatment groups (PROSPERO registration number CRD42021247440). ResultsA total of 8341 patients from 17 randomised trials of ICI versus CT were included in the analysis. Treatment with ICI delayed clinical deterioration over standard CT in Global Health Status/QoL EORTC QLQ-C30 (hazard ratio [HR] 0.81; 95% confidence interval [CI], 0.74–0.89), and in both EQ-5D utility index (HR 0.65; 95% CI, 0.52–0.82) and EQ-5D visual analogue scale (VAS; HR 0.70; 95% CI, 0.61–0.80). The difference in mean change between the ICI-treated group and the CT-treated group was 5.82 (95% CI, 4.11–7.53) in favour of ICI. Similarly, in the EQ-5D, the mean change differences favoured treatment with ICIs in both Utility Index and VAS, with differences of 0.05 (95% CI, 0.03–0.07) and 5.41 (95% CI, 3.39–7.43), respectively. ConclusionsICIs are associated with higher levels of quality of life and longer time to clinical deterioration on several PROs scales compared with CT in different types of solid tumours.

Pan-cancer landscape of CD274 (PD-L1) rearrangements in 283,050 patient samples, its correlation with PD-L1 protein expression, and immunotherapy response

BackgroundImmune checkpoint inhibitors (ICIs) benefit patients with multiple cancer types, however, additional predictive biomarkers of response are needed. CD274 (programmed cell death ligand-1, PD-L1) gene rearrangements are positively associated with...

Long-term outcomes in extensive disease small cell lung cancer patients treated without immune checkpoint inhibitors.

Immune checkpoint inhibitors (ICIs) combined with chemotherapy have been approved as first-line treatment for patients with untreated extensive disease-small cell lung cancer (ED-SCLC). However, there are few reports about the long-term outcomes in patients with ED-SCLC treated without ICIs. Thus, we analyzed the long-term outcomes in patients with ED-SCLC. We retrospectively examined the medical records of patients with SCLC who were treated at our hospital between September 2002 and September 2019. The main inclusion criteria were as follows: (i) histological or cytological confirmation of SCLC, (ii) diagnosed with ED-SCLC and (iii) received chemotherapy, not including ICIs, as the first-line treatment. To assess the trends of treatment outcomes, we compared the survival outcomes between 2002-2010 (early) and 2011-2019 (late) groups. A total of 314 patients were included in this study. Patient characteristics at the time of first-line treatment were as follows: median age was 69years; 82% of the patients were male and 70% had a performance status of 0 or 1. The median follow-up time of overall survival (OS) was 7.4years, and 89% of the patients died. The median progression-free survival and survival time were 4.9 and 12.1months, respectively. Five-year survival rate was 2%. There was no significant difference in survival between the early and late groups. We found that the long-term outcomes in ED-SCLC patients treated without ICIs were poor. Prior to the approval of ICI treatment for ED-SCLC, there was no improvement in the OS for ~20years.

Immune checkpoint inhibitors in patients with pre-existing psoriasis: safety and efficacy

BackgroundImmune checkpoint inhibitors (ICIs) are approved to treat multiple cancers. Retrospective analyses demonstrate acceptable safety of ICIs in most patients with autoimmune disease, although disease exacerbation may occur. Psoriasis vulgaris...

Sonodynamic therapy complements PD-L1 immune checkpoint inhibition in a murine model of pancreatic cancer.

The emergence of immune checkpoint inhibitors (ICI's) in the past decade has proven transformative in the area of immuno-oncology. The PD-1/PD-L1 axis has been particularly well studied and monoclonal antibodies developed to block either the receptor (anti PD-1) or its associated ligand (anti PD-L1) can generate potent anti-tumour immunity in certain tumour models. However, many "immune cold" tumours remain unresponsive to ICI's and strategies to stimulate the adaptive immune system and make these tumours more susceptible to ICI treatment are currently under investigation. Sonodynamic therapy (SDT) is a targeted anti-cancer treatment that uses ultrasound to activate a sensitiser with the resulting generation of reactive oxygen species (ROS) causing direct cell death by apoptosis and necrosis. SDT has also been shown to stimulate the adaptive immune system in a pre-clinical model of colorectal cancer. In this manuscript, we investigate the ability of microbubble mediated SDT to control tumour growth in a bilateral tumour mouse model of pancreatic cancer by treating the target tumour with SDT and observing the effects at the off-target untreated tumour. The results demonstrated a significant 287% decrease in tumour volume when compared to untreated animals 11 days following the initial treatment with SDT, which reduced further to 369% when SDT was combined with anti-PD-L1 ICI treatment. Analysis of residual tumour tissues remaining after treatment revealed increased levels of infiltrating CD4+ and CD8+ T-lymphocytes (respectively 4.65 and 3.16-fold more) in the off-target tumours of animals where the target tumour was treated with SDT and anti-PD-L1, when compared to untreated tumours. These results suggest that SDT treatment elicits an adaptive immune response that is potentiated by the anti-PD-L1 ICI in this particular model of pancreatic cancer.

Telomere Shortening in Peripheral Leukocytes Is Associated With Poor Survival in Cancer Patients Treated With Immune Checkpoint Inhibitor Therapy.

BackgroundImmune checkpoint inhibitor (ICI) therapy represents a new standard of care for an increasing number of malignancies. Nevertheless, response rates and outcome of ICI treatment vary between individuals and the identification of predictive markers or hints towards immune cell exhaustion during therapy has remained a major challenge. Leukocyte telomere length is an established predictive biomarker of replicative aging and cellular proliferative potential in various hematological diseases. However, its relevance in the context of ICI therapy has not been investigated to date. Here, we analyze the age-adapted delta telomere length (ΔTL) of peripheral leukocytes as a potential predictive and prognostic marker in patients undergoing ICI therapy.MethodsAge-adapted delta telomere length (ΔTL) of 84 patients treated with ICIs for solid malignancies was measured via quantitative real-time PCR. ΔTL was correlated with outcome and clinical data.ResultsΔTL was not significantly altered between patients with different tumor entities or tumor stages and did not predict tumor response to ICI therapy. However, ΔTLs at initiation of treatment were a prognostic marker for overall survival (OS). When using a calculated ideal cut-off value, the median OS in patients with shorter ΔTL was 5.7 months compared to 18.0 months in patients showing longer ΔTL. The prognostic role of age-adapted ΔTL was further confirmed by uni- and multivariate Cox-regression analyses.ConclusionIn the present study, we demonstrate that shorter telomere lengths in peripheral blood leukocytes are associated with a significantly impaired outcome in patients receiving ICI therapy across different malignancies. We explain our findings by hypothesizing an older replicative age in peripheral leukocytes of patients with an impaired overall survival, reflected by a premature TL shortening. Whether this association is ICI-specific remains unknown. Further follow-up studies are needed to provide insights about the exact mechanism of how shortened telomeres eventually affect OS and could help guiding therapeutic decisions in future.

Outcome of immune checkpoint inhibitors in metastatic renal cell carcinoma across different treatment lines

BackgroundImmune checkpoint inhibitors (ICIs) have led to a paradigm change in the management of metastatic renal cell carcinoma (mRCC). Prospective trials have focused on ICI treatment in the first or second line. The aim of this analysis is to evaluate the benefit of ICI across different treatment lines.Patients and methodsThis is a single-center retrospective study that included mRCC patients who received ICIs in various treatment lines. Objective response rates (ORR), progression-free survival (PFS) and overall survival (OS) were evaluated.ResultsNinety-four patients were eligible for full evaluation. Patients were classified as International mRCC Database Consortium (IMDC) risk group categorization as good, intermediate and poor risk in 26.8%, 61.6% and 14.8% of cases, respectively. They were treated with ICI monotherapy, dual ICI therapy and ICI + tyrosine kinase inhibitor in 59%, 20% and 21% of cases, respectively. ORR, median PFS and OS for the entire cohort was 39.4%, 9.67 months [95% confidence interval (CI) 6.9-12.4 months] and 23.6 months (95% CI 13.3-33.9 months), respectively. The ORR by treatment line was 33% in first, 40.4% in the second, 35% in the third and 43.5% in the fourth line and beyond. Median PFS by treatment line was 8.6, 10.3, 7.9 and 7.23 months, respectively. The median OS was not reached in first-line treatment and was 26.2, 18.1 and 20.7 months in the second, third and fourth line and beyond, respectively.ConclusionsICIs or ICI combinations are active in all treatment lines and should also be offered in heavily pretreated patients. Patient selection based on tumor and patient factors allows for maximal benefit from ICI-based therapies.

Abstract 471: Reference materials for tumor mutational burden transcriptome profiling

Abstract Immune Checkpoint Inhibitor (ICI) therapies continue to revolutionize treatment of advanced malignancies. However, identification of individuals who respond to ICI treatment remains challenging. Along with programmed death ligand 1(PD-L1 aka CD274) expression and microsatellite instability, tumor mutational burden (TMB), defined as the number of nonsynonymous mutations per megabase of genome, has emerged as a promising biomarker for differentiating responders from non-responders, especially in non-small cell lung cancer. Although promising, TMB is not a perfect biomarker for ICI efficacy with some individuals responding conversely to expectations. The imperfection of TMB as a prognostic biomarker may result from it being a proxy measurement of potential neoantigens. Indeed, all mutations that contribute to TMB will not be expressed as neoantigens and not all neoantigens will illicit immune responses. In refining ICI response prediction, tumor abundance of nonsynonymous mutations has aided in neoantigen prediction. In order to begin development of quality reference materials for neoantigen prediction, we have characterized the transcriptomes of four tumor cell lines that were previously used to formulate TMB reference materials. Sequencing libraries were prepared with the TruSeq Stranded Total RNA with Illumina Ribo-Zero Plus rRNA Depletion Kit and Invitrogen Collibri Stranded RNA Library Prep Kit from Illumina with Collibri H/M/R rRNA Depletion Kit. The resultant transcriptome libraries were sequenced on an Illumina NextSeq2000 platform and relative transcript counts were determined. Broad ranges of expression were observed among transcripts containing nonsynonymous mutations in each of the tumor cell lines tested. These datasets will serve as benchmarks for others attempting to combine TMB and tumor abundance in predicting neoantigen potential. Citation Format: Matthew G. Butler, Yves Konigshofer, Jessica Dickens, Bharathi Anekella. Reference materials for tumor mutational burden transcriptome profiling [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 471.

Abstract 1606: Potentiating effect of olaparib on anti-PD-1 treatment in colorectal cancer

Abstract Immune checkpoint inhibitors (ICIs) are approved for microsatellite unstable colorectal cancer (CRC), however, microsatellite stable (MSS) CRC that make up the majority of tumors in clinical practice have not seen any benefit with ICI. This is in part due to the lack of sufficient tumor infiltrating immune cells, particularly CD8+ T cells, in the milieu. Immunogenic cell death (ICD) is a particular form of cell death that elicits robust cross-priming of CD8 T cells against antigens expressed by dying cells in the absence of exogenous adjuvants. ICD-inducing drugs such as poly (ADP-ribose) polymerase inhibitors (PARPis) are poised to enhance cancer cell killing, boost tumor immunogenicity, increase in vivo immune infiltration, and thereby accelerate a tumor response to ICI treatment. Here, we tested the combinatorial therapeutic efficacy of a PARPi, olaparib (OLA), and an ICI, anti-PD-1, in in vitro and in vivo conditions. Combined treatment of OLA and anti-mouse PD-1 reduced tumor growth and increased survival in an immunocompetent, syngeneic animal model of BALB/c carrying allograft CT26 tumor that is MSS. Flow cytometry analysis revealed that the combo treatment significantly reduced percentages of anti-inflammatory macrophages and increased inflammatory monocytes. There was no significant difference in dendritic cell populations. We observed increased anti-tumor lymphocyte response via activation of CD4 and CD8 T cell populations upon combo treatment with OLA and anti-mouse PD-1. In addition, we noticed an increased association of expression of PD-L1 and its receptor PD-1 with OLA treatment in CRC cell lines and CT26 tumors. Our preliminary data suggests altered expressions of the CD8+ T cell exhaustion marker TIM-3 and its ligands galectin-9 and high mobility group protein 1 (HMGB1), an indicator of ICD. The pilot studies also revealed increased levels of STING-dependent type I interferon signaling initiator cGAS upon treatment with OLA in vivo. Mechanistically, OLA might induce DNA damage among tumor cells and trigger innate immune signaling including NF-κB activation and STING-dependent type I interferon signaling, both of which contribute to the maturation of myeloid antigen-presenting cells and subsequent activation of T cells. In conclusion, OLA potentiated the antitumor efficacy of anti-PD-1 in CT26 induced syngeneic CRC mouse model. Our findings indicate that OLA might trigger tumor immunogenicity, and enable a potential targeted-immunotherapeutic angle for exercising ICD and activating cytotoxic T lymphocytes in CT26 syngeneic CRC mouse model; however, further studies are needed to elucidate the mechanism. Despite ICD markers' identification as immuno-stimulating characteristics of dead cells, whether ICD-associated molecules can be used as a prognostic biomarker or therapeutic target, and the rational for such markers on tumor cells in eliciting antitumor immunity are still under investigation. Citation Format: Chintal Bhavsar, Peter John, Magnolia Abreu, Laura Bencosme, Radhashree Maitra, Sanjay Goel, Titto Augustine. Potentiating effect of olaparib on anti-PD-1 treatment in colorectal cancer [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 1606.

Both combined or sequential use with immune checkpoint inhibitors on cetuximab-treated patients with recurrent or metastatic head and neck squamous cell carcinoma improve the overall survival

BackgroundAfter the introduction of ICI treatment, data about feasibility and activity of a cetuximab-containing first-line therapy in patients with recurrent and/or metastatic head and neck cancer (R/M HNSCC) are still not available. We sought to analyze the clinical outcomes in the real-world setting. Material MethodsThis retrospective study was conducted at two tertiary medical centers in Taiwan. Patients with R/M HNSCC receiving cetuximab-containing first-line therapy were included between January 2017 and July 2019. The study endpoints were the response, Progression-Free Survival (PFS), and Overall Survival (OS). Subgroup analyses were conducted to evaluate survival outcomes by platinum resistance and the use of immunotherapy. ResultsWe identified 290 patients treated with cetuximab-containing first-line therapy. The most primary tumor site was oral cavity cancer (59.3%). 44% of patients were resistant to platinum. The median PFS and OS were 5.0 months and 9.1 months, respectively, for the total population. In patients with platinum resistance, the median OS was 10.4 months with ICIs versus 6.3 months without ICIs; p = 0.01. In patients with platinum sensitivity, the median OS was 20.6 months with ICIs versus 9.1 months without ICs; p < 0.01. OS benefit with ICIs was similar between patients who received ICIs after progression on Cetuximab and receiving Cetuximab in combination with ICIs. Independent favorable prognostic factors for OS were platinum-sensitive, better response to cetuximab, and ICIs use. ConclusionICIs are indicated to improve OS in R/M HNSCC receiving cetuximab-containing first-line therapy, even in platinum-resistant populations. The reduction in risk of death with ICIs was similar regarding the combination or sequencing of cetuximab.

Evaluation of liver enzyme elevations and hepatotoxicity in patients treated with checkpoint inhibitor immunotherapy.

Background and aimsImmune checkpoint inhibitors (ICI) are increasingly used in cancer therapy. Elevated liver enzymes frequently occur in patients treated with ICI but evaluation is poorly described. We sought to better understand causes of liver enzyme elevation, investigation and management.MethodsPatients treated with anti-PD-1, PDL-1 or CTLA-4 therapy in Phase I/II clinical trials between August 2012 and December 2018 were included. Clinical records of patients with significant liver enzyme elevations were retrospectively reviewed.ResultsOf 470 ICI-treated patients, liver enzyme elevation occurred in 102 (21.6%), attributed to disease progression (56; 54.9%), other drugs/toxins (7; 6.9%), other causes (22; 21.6%) and ICI immunotoxicity (17; 16.7%; 3.6% of total cohort). Immunotoxicity was associated with higher peak ALT than other causes of enzyme elevation (N = 17; M = 217, 95% CI 145–324 for immunotoxicity, N = 103; M = 74, 95% CI 59–92 for other causes; ratio of means 0.34, 95% CI 0.19–0.60, p = <0.001) and higher ALT:AST ratio (M = 1.27, 95% CI 0.78–2.06 for immunotoxicity, M = 0.69, 95% CI 0.59–0.80 for other causes, ratio of means 0.54, 95% CI 0.36–0.82, p = 0.004). Immunotoxicity was more often seen in patients with prior CPI exposure (41.2% of immunotoxicity vs 15.9% of patients without, p = 0.01), anti-CTLA-4 –containing ICI treatments (29.4% of immunotoxicity vs 6.8% of patients without, p = <0.001) and other organ immunotoxicity (76.5% of immunotoxicity vs 19.2% of patients without, p = <0.001). Cause for enzyme elevation was established in most patients after non-invasive investigation. Liver biopsy was reserved for four patients with atypical treatment response.ConclusionsLiver enzyme elevation is common in patients receiving ICI, but often has a cause other than immunotoxicity. A biochemical signature with higher ALT and ALT/AST ratio, a history of prior ICI exposure and other organ immunotoxicities may help to identify patients at a higher likelihood of immunotoxicity. Liver biopsy can be safely deferred in most patients. We propose an approach to diagnostic evaluation in patients with liver enzyme elevations following ICI exposure.

Identification of a predictive metabolic signature of response to immune checkpoint inhibitors in non-small cell lung cancer: METABO-ICI clinical study protocol

BackgroundImmune checkpoints inhibitors (ICI) are becoming new standards of care for the treatment of non-small cell lung cancer (NSCLC), both as first (alone or in association with chemotherapy) and second line. However, no powerful predictive biomarker of therapeutic response to ICI has been found to date. It has been recently shown that microbiota composition could influence the ability of patients to respond to ICI. Indeed, the microbiota produces circulating metabolites that will subsequently act on immune system, the investigators hypothesized that plasma metabolic signature, reflecting a global microbiota function, could represent a predictive biomarker of response to ICI. MethodsMonocentric prospective study. Primary objective is to identify baseline metabolic signature (metabolomics analysis by mass spectrometry) associated to ICI response. Secondary objectives are to link metabolic signature with microbiota composition (metagenomics analysis RNA 16S) and immune profile, and altogether with clinic response to ICI. The study will include 60 NSCLC patients treated by ICI in 1st, 2nd or 3rd line of treatment at the Grenoble Alpes University hospital (CHUGA) in 18 months. Patients that have received antibiotic or steroid treatment, 2 or 4 weeks before ICI initiation, respectively, will be excluded. Blood and feces will be collected prior to, at 2 months after ICI treatment initiation, and at 6 months or at progression. Expected resultsWe expect to highlight a metabolic profile predictive of response to ICI. By identifying factors associated with early progression, we could avoid to treat potential non-responding patients. Moreover, by restoring a favorable microbiota, patients’ ability to respond to these treatments might be restored.

Male fertility during and after immune checkpoint inhibitor therapy: A cross-sectional pilot study

BackgroundImmune checkpoint inhibitors (ICIs) are widely used and may induce long-term survival in various types of cancer. Yet, there is scarce evidence on potential effects on patient fertility and the necessity of cryopreservation before treatment onset. The aim of our study was to assess the prevalence of male infertility after initiation of ICI treatment. MethodsThis is a monocenter, cross-sectional pilot study. Fertility was investigated by spermiogram, analysis of sexual hormones and questionnaires on sexual function and sexual activity. Male patients under the age of 60 years previously or currently treated with ICI for cutaneous malignancies or uveal melanoma were included. ResultsTwenty-five patients were included, with a median age of 49 years. Eighteen of 22 (82%) available spermiograms showed no pathologies, all patients reported a normal sexual function and sexual activity. Of four patients with pathological spermiogram, three patients were diagnosed with azoospermia and one with oligoasthenoteratozoospermia. Three patients had significant confounding factors (previous inguinal radiotherapy, chemotherapy and chronic alcohol abuse, and bacterial orchitis). One patient with normal spermiogram before ICI treatment presented 1 year after initiation with azoospermia, showing an asymptomatic, inflammatory infiltrate with predominantly neutrophil granulocytes, macrophages and T-lymphocytes in the ejaculate. Infectious causes were ruled out; andrological examination was unremarkable. A second case with reduced sperm counts during treatment may be ICI-induced also. ConclusionsMost patients had no restrictions in fertility, yet an inflammatory loss of spermatogenesis seems possible. Cryopreservation should be discussed with all patients with potential future desire for children before treatment.

Association Between FSIP2 Mutation and an Improved Efficacy of Immune Checkpoint Inhibitors in Patients With Skin Cutaneous Melanoma.

BackgroundImmune checkpoint inhibitors (ICIs) have shown remarkable success in treating skin cutaneous melanoma (SKCM); however, the response to treatment varies greatly between patients. Considering that the efficacy of ICI treatment is influenced by many factors, we selected the Fibrosheath interacting protein 2 (FSIP2) gene and systematically analyzed its potential to predict the efficacy of ICI treatment.MethodsPatient data were collected from an ICI treatment cohort (n = 120) and a The Cancer Genome Atlas (TCGA)-SKCM cohort (n = 467). The data were divided into an FSIP2-mutant (MT) group and FSIP2-wild-type (WT) group according to FSIP2 mutation status. In this study, we analyzed the patients’ overall survival rate, tumor mutational burden (TMB), neoantigen load (NAL), copy number variation (CNV), cell infiltration data and immune-related genes. We used gene set enrichment analysis (GSEA) to delineate biological pathways and processes associated with the efficacy of immunotherapy.ResultsThe efficacy of ICI treatment of SKCM patients with FSIP2 mutation was significantly better than that of patients without FSIP2 mutation. The patients in the FSIP2-MT group had higher tumor immunogenicity and lower regulatory T cell (Treg) infiltration. Results of GSEA showed that pathways related to tumor progression (MAPK and FGFR), immunomodulation, and IL-2 synthesis inhibition were significantly downregulated in the FSIP2-MT group.ConclusionOur research suggests that the FSIP2 gene has the potential to predict the efficacy of ICI treatment. The high tumor immunogenicity and low Treg levels observed may be closely related to the fact that patients with FSIP2-MT can benefit from ICI treatment.

Prevalence of hyperprogressive disease (HPD) mutations and correlations to immune-related biomarkers in a large pan-cancer Chinese cohort.

2649 Background: Immune checkpoint blockade (ICI) therapies have demonstrated inspiring clinical efficacy in multiple types of cancer. However, a subset of patients suffered rapid tumor growth after ICI treatment, which is known as hyperprogressive disease (HPD). Although the mechanism of HPD has not been fully elucidated, some genomic alterations, such as CDKN2A/CDKN2B loss and MDM2/MDM4 amplification were reported to occur in tumors with ICI-related HPD. We analyzed the prevalence of these four “HPD mutations” and their association with PD-L1 expression, TMB, and occurrence of driver gene mutations in a large pan-cancer Chinese cohort. Methods: Patients whose tumor tissues were subjected to molecular profiling using targeted next-generation sequencing from January 2017 – November 2020 were included. Single nucleotide variants (SNV), copy number variants (CNV), insertion/deletions (indels) and fusions were called. PD-L1 expression was stratified by CPS 5. Fisher’s exact test were conducted to compare the frequencies of biomarkers and Mann-Whitney U test was used to compare the TMB level between the “HPD mutations” group and their wild-type counterpart. Results: 45,785 patients of 22 types of cancer were queried. Across all 22 cancers, CDKN2A loss and CDKN2B loss were most commonly seen in ESCA (23.3%, 19.8%), while with the lowest frequency in PRAD (0.18%, 0.18%). MDM2 gain and MDM4 gain occurred most frequently in SARC (14.6%) and BRCA (3.3%), respectively, with the lowest frequency in COAD (0.05%, 0.07%). PD-L1 positive (CPS≥5) rates were similar in CDKN2A/B loss, MDM2/4 amp and wild-type groups in the whole cohort (26.1%, 25%, 27.7%). Enrichment of PD-L1 positivity was not observed in HPD-mutant groups in a specific cancer type. Compared with wild-type group, CDKN2A/B loss significantly correlated with higher TMB levels in NSCLC and SARC (p &lt; 0.05) while MDM2/4 amp correlated with lower TMB levels in NSCLC, BTC, and STAD (p &lt; 0.05). In NSCLC, SNV in EGFR, TP53, KEAP1, NFE2L2, STK11, PIK3CA, and SMARCA4 genes were significantly enriched in the CDKN2A/B loss group, while SNV in EGFR, RBM10, AR, KDR genes, and fusion in RET were significantly enriched in MDM2/4 amp group. Conclusions: HPD mutations were significantly associated with TMB level and occurrence of some driver genes, but were not correlated with PD-L1 expression. Our results revealed the immune-related molecular characteristics in tumors with HPD mutations, providing more insights into the exploration for mechanism of HPD.

Correlation of microsatellite-instable (MSI) status and genomic characteristics in 12,000 Chinese lung cancer patients.

e21019 Background: Microsatellite-instable-high (MSI-H) is a strong biomarker for favorable response to immune checkpoint blockade (ICI) therapies. The objective response rate was 30%̃40% in advanced MSI-H solid tumors receiving ICI treatment, while MSI status is rarely considered in lung cancer in setting of ICI treatment. MSI-H occurred in 0.8%̃2% lung cancer patients tested by PCR method. Immune microenvironment of MSI-H lung cancer had not been studied on a large scale. We explored the association of MSI status, genetic profile and PD-L1 expression in a large Chinese lung cancer cohort to elucidate the molecular characteristics of MSI-H lung cancer. Methods: MSI status was determined by PCR test in tumor tissue and by an in-house algorithm in blood specimen. The tumor samples were sequenced by next-generation sequencing to call single nucleotide variants (SNVs) and copy number variants (CNVs). PD-L1 expression was evaluated by TPS. Results: 67 pts were determined as MSI-H in total of 12,485 pts, namely the frequency of MSI-H was 0.5% in Chinses lung cancer. 26 MSI-H pts were harboring EGFR mutations, including Ex19del in 10 pts, L858R in 6 pts, T790M in 5 pts, EGFR gain in 4 pts, and other uncommon mutations such as C797, L861Q. Interestingly, no EGFR Ex20ins was detected. In the other 41 non-EGFR-mutant pts, RET fusion were detected in 2 pts, FGFR2/3 SNV were detected in 5 pts, KRAS activating SNVs were detected in 5 pts, and PIK3CA SNV/amplification were detected in 8 pts. No ICI response negative alterations (CDKN2A/B loss, MDM2/4 gain) were detected in MSI-H patients. 125 genes, including MSH6, MLH1, BRCA2, NOTCH1, TGFBR2, ACVR2A and etc, had higher frequency in MSI-H lung cancers than MSS lung cancers in our cohort. Moreover, only MAP3K1 gene SNV occurred more frequently in MSS lung cancers (4.5% vs 7.7%, p &lt; 0.001). MSI-H lung cancer had a trend for enrichment of PD-L1 positivity (TPS &gt; 1%) but no significance (58% vs 43%, p = 0.205). Conclusions: About 50% MSI-H lung cancers harbored actionable mutations for targeted agents (EGFR TKIs or other TKIs), while EGFR Ex20ins might exist mutually exclusively with MSI-H. MSI-H lung cancer had much more mutational genes than MSS lung cancer, which was consistent with previous studies. On the other hand, MAP3K1 was the only gene with lower mutational frequency in MSI-H lung cancer. Our results revealed the genetic mutational characteristics of MSI-H lung cancer and provided suggestions for treatment decisions of this patient population.

Efficacy of weekly paclitaxel-bevacizumab combination in advanced nonsquamous non-small cell lung cancer (NSCLC): AVATAX, a retrospective multicentric study.

e21086 Background: With the growing role of immunotherapy (ICI) as first-line setting for advanced NSCLC, strategies must be redefined after failure. The combination paclitaxel-bevacizumab showed in the ULTIMATE trial a significant superiority versus docetaxel as second or third-line treatment. Limited restropective studies has demonstrated unexpected efficacy of chemotherapy after prior progression on ICI. This combination could be use as salvage treatment following ICI. Methods: This multi-centric retrospective study identifies patients treated with the combination paclitaxel-bevacizumab in metastatic non-squamous NSCLC as second-line therapy or beyond. Main objectives were to describe safety and efficacy of this combination, with a special attention to the sub-group treated just after ICI. Results: From January 2010 to February 2020, 314 patients started the paclitaxel-bevacizumab combination : 55% male, with a median age of 60 years, 27% with a performance status ≥2, 45% with brain metastases. A majority of patients were treated in second (20%) and third-line (39%), and 28% were treated just after ICI failure (88/314). Objective response rate (ORR) was 40% and disease control rate was 77 %. Median progression-free survival (PFS) and overall survival (OS) were 5,7 months [IQ,3,2–9,6] and 10,8 months [IQ,5,3–19,6] respectively. All grades adverse events concerned 82% of patients, including 53% asthenia and 39% neurotoxicity, and 25% of patients continued a monotherapy alone due to toxicity. Median PFS for patients treated after ICI failure (ICI+) was significantly superior compare to those not previously treated with ICI (ICI-) : 7,0 months [IQ,4,2–11,0] vs 5,2 months [IQ,2,9–8,8] p (log-rank) = 0,01. There was not statistically significant difference in term of OS between this two groups. In multivariate analysis, factors associated with superior PFS were previous ICI treatment (ICI+) and performance status. Conclusions: This study confirms an acceptable toxicity profile associated with interesting efficacy of the combination paclitaxel-bevacizumab as second-line treatment or beyond for non–squamous NSCLC patients, particularly after progression with ICI.

Improving tumor mutational burden calibration in non-European patients.

1559 Background: Tumor mutational burden (TMB), has been recently granted FDA approval as a biomarker for ICI treatment in tumors with a high mutation load (≥ 10/MB). To leverage this biomarker in the clinical setting, it is necessary to evaluate its application in diverse patient populations. In particular, tumor-only sequencing may overestimate TMB in non-EUR populations for which reference panels are small or unavailable, and thus have poorer predictive performance. Herein, we investigate the effect of TMB overestimation in non-EURs on patient diagnosis and clinical outcomes in a real world patient cohort. Methods: TMB was computed using a tumor-only NGS platform (Oncopanel) for 8349 cancer patients (pts) of 7 cancer types (Table). Genetic ancestry was inferred directly from tumor sequencing data and confirmed for a subset of pts using germline SNP arrays. TMB was compared using Wilcoxon rank-sum test between European (EUR) and non-EUR pts. TMB percentile rank by ancestral group (East Asian, African, European) and tumor histology was computed. In non-EUR pts, TMB was calibrated by reassigning its value to the corresponding percentile rank in EUR pts having the same cancer (AH-TMB). Tumors with raw TMB ≥ 10/MB were assigned as TMB-high (TMBH; with the rest referred to as TMBL for TMB-low) and those with calibrated AH-TMB ≥ 10/MB as AH-TMBH. A subset of pts treated with ICIs at DFCI and of EUR ancestry were analyzed. TMB was intentionally mis-calibrated in EURs (MC-TMB), to mimic the TMB overestimation observed in non-EURs. Associations between TMBH status and overall survival (OS) was assessed using Cox regression. Results: Uncalibrated TMB was significantly higher in tumors from non-EUR pts overall (p &lt;0.0001, Table) as anticipated, whereas this difference was not observed in tumors with matched germline filtering. We reassigned non-EUR pts into low/high groups using calibrated AH-TMB, which changed the assignment of 67/670 non-EURs, most of which (65/67) were downgraded from TMBH to AH-TMBL. In the ICI-treated cohort, there was a strong association between TMBH status and OS (p = 2e-11, HR = 0.6) whereas MC-TMBH (mimicking the miscalibration in non-EUR samples) had a weaker association with OS (p = 0.0013, HR = 0.8). Importantly, pts assigned to TMB-H due to miscalibration (90 TMB-L/MC-TMBH pts) had shorter OS compared to the true TMBH group (p = 3e-6, HR = 1.9). Conclusions: In this analysis, we showed that tumor-only sequencing platforms can overestimate TMB in non-EUR pts, impacting treatment decisions and outcomes. Replacing raw TMB counts with an ancestry-adjusted measure could optimize TMB application in the clinical setting when germline sequencing is not available. Accurate ancestry inference can be performed using tumor-only sequencing.[Table: see text]