Safety Biomarkers Research Articles

Asian Subgroup Analysis of the Randomized Phase 3 CROWN Study of First-Line Lorlatinib Versus Crizotinib in Advanced ALK-Positive NSCLC

IntroductionLorlatinib is a potent, third-generation inhibitor of ALK. In the planned interim analysis of the ongoing, phase 3, randomized, global CROWN trial (NCT03052608), lorlatinib resulted in significantly longer progression-free survival than crizotinib in patients with previously untreated, advanced, ALK-positive NSCLC. Here, we present a subgroup analysis of Asian patients in the CROWN study. MethodsPatients received lorlatinib 100 mg once daily or crizotinib 250 mg twice daily. The primary end point was progression-free survival assessed by blinded independent central review. Objective response rate (ORR), intracranial ORR, safety, and select biomarkers were secondary end points. ResultsAt data cutoff (September 20, 2021), 120 patients were included in the Asian intention-to-treat subgroup (lorlatinib n = 59; crizotinib n = 61). At 36 months, 61% (95% confidence interval [CI]: 47–72) and 25% (95% CI: 12–41) of patients in the lorlatinib and crizotinib groups, respectively, were alive without disease progression (hazard ratio for disease progression by blinded independent central review or death: 0.40; 95% CI: 0.23–0.71). ORR was 78% (95% CI: 65–88) versus 57% (95% CI: 44–70) for patients treated with lorlatinib and crizotinib, respectively. In patients with measurable, nonmeasurable, or both measurable and nonmeasurable brain metastases at baseline, intracranial ORR was 73% (95% CI: 39–94) versus 20% (95% CI: 4–48) for patients treated with lorlatinib and crizotinib, respectively. The definition of nonmeasurable brain metastases is: a brain lesion <5 mm provided gadolinium contrast enhanced magnetic resonance imaging is performed with contingent slices of 1 mm. Hypercholesterolemia, hypertriglyceridemia, and edema were the most frequently reported adverse events with lorlatinib. ConclusionsLorlatinib efficacy and safety in the Asian subgroup of CROWN were consistent with those in the overall population.

Clinical and biomarker analyses of sintilimab plus gemcitabine and cisplatin as first-line treatment for patients with advanced biliary tract cancer

The prognosis of biliary tract cancer (BTC) remains unsatisfactory. This single-arm, phase II clinical trial (ChiCTR2000036652) investigated the efficacy, safety, and predictive biomarkers of sintilimab plus gemcitabine and cisplatin as the first-line treatment for patients with advanced BTCs. The primary endpoint was overall survival (OS). Secondary endpoints included toxicities, progression-free survival (PFS), and objective response rate (ORR); multi-omics biomarkers were assessed as exploratory objective. Thirty patients were enrolled and received treatment, the median OS and PFS were 15.9 months and 5.1 months, the ORR was 36.7%. The most common grade 3 or 4 treatment-related adverse events were thrombocytopenia (33.3%), with no reported deaths nor unexpected safety events. Predefined biomarker analysis indicated that patients with homologous recombination repair pathway gene alterations or loss-of-function mutations in chromatin remodeling genes presented better tumor response and survival outcomes. Furthermore, transcriptome analysis revealed a markedly longer PFS and tumor response were associated with higher expression of a 3-gene effector T cell signature or an 18-gene inflamed T cell signature. Sintilimab plus gemcitabine and cisplatin meets pre-specified endpoints and displays acceptable safety profile, multiomics potential predictive biomarkers are identified and warrant further verification.

Abstract P3-06-02: TATEN TRIAL (SOLTI-1716) Targeting non-Luminal disease by PAM50 with pembrolizumab + paclitaxel in Hormone Receptor-positive/HER2-negative (HR+/HER2-) metastatic breast cancer (MBC): interim analysis

Abstract Background Within HR+/HER2- disease, patients with non-luminal subtypes of breast cancer (HER2-enriched [HER2-E] and Basal-like) have poorer prognosis than those with luminal subtypes, may be more sensitive to chemotherapy, and have higher expression of immune-related genes and tumor infiltrating lymphocytes (TILs). Here, we report the interim efficacy and safety data of the TATEN trial (NCT04251169), the first study designed to evaluate pembrolizumab and paclitaxel in HR+/HER2-negative, PAM50 non-luminal, metastatic breast cancer (MBC). Methods TATEN is a single-arm, multicenter phase II study evaluating pembrolizumab in combination with paclitaxel in patients with HR+/HER2-, PAM50 non-luminal, MBC. Key inclusion criteria include progression to prior CDK4/6 inhibitors, presence of measurable disease by RECIST V1.1, no prior chemotherapy for MBC, and ECOG 0-1. Patients receive pembrolizumab at 200 mg every 3 weeks (on D1 of each 21-day cycle, beginning at cycle 1) in combination with weekly paclitaxel at 80 mg/m2, beginning at cycle 2. The primary endpoint is to evaluate overall response rate (ORR), defined as the rate of complete (CR) and partial response (PR) according to RECIST V1.1. Secondary endpoints include clinical benefit rate (CBR; CR + PR + stable disease &amp;gt;24 weeks), progression free survival, overall survival, safety, and predictive biomarkers. Tumor samples collected during advanced/metastatic disease are mandatory to assess PAM50 and other translational endpoints. This study had a planned interim analysis after 15 patients were evaluable for ORR based on a Simon’s two stage design with 80% power and a type I error rate of 0.05. Stage I of the trial would be considered successful if at least 6 patients achieved a PR and/or CR. In that case, the trial would recruit up to 46 evaluable patients for a target ORR ≥ 41. Here we report results from the patients who received at least one dose of combination treatment and had a first, post-baseline, tumor assessment according to RECIST v1.1 (evaluable population). Results From July 2020 to December 2021, 119 patients were screened, and 25 PAM50 non-luminal tumors were identified (21%). From these, 17 (68%) patients were recruited, and 15 were evaluable for primary endpoint. Two patients discontinued the trial before the first dose of pembrolizumab and paclitaxel, because of clinical progressive disease (PD). Baseline patient characteristics were as follows: median age 53 years (range: 40-77), ECOG 0 52.9%, de novo MBC at diagnosis 29.4%, and visceral disease 64.7% (including 53.3% with liver metastasis). Ten patients had received paclitaxel treatment in the adjuvant setting. Regarding PAM50 intrinsic subtype, two patients had basal-like and 13 HER2-E tumors. At the time of data cut-off (May 17,2022), 8 patients (53.3%) had stopped their treatment because of PD and 2 (13.3%) due to toxicity. Five patients (33.3%) were still on treatment. The ORR was 53.3 % (8 of 15, 95% CI 26.6-78.7), meeting the pre-specified ORR for the first stage of the trial. The CBR was 86.6% (13 of 15, 95%CI 59.5-98.34), and median PFS was 7.5 months (95% CI: 5.6 – 10.2). Overall, all patients experienced treatment-related adverse events (TRAEs) of any grade, while 53.3% of patients experienced grade 3 TRAEs. No grade 4 or 5 TRAEs were reported in the evaluable population. Correlative analysis including gene expression analysis and centralized TILs scoring and PD-L1 IHC will be presented. Conclusions The first stage of TATEN combining pembrolizumab with paclitaxel after progression to CDK4/6 inhibitors in patients with HR+/HER2-negative, PAM50 non-luminal MBC met its pre-specified endpoint. Completion of the stage II part of the trial with the inclusion of up to 46 patients is warranted to assess the activity of this combination in this group of patients. Correlative studies to find predictive biomarkers of response to this regimen are ongoing and will be presented at the meeting. This study was funded by MSD. Citation Format: Aleix Prat, Tomás Pascual, Montserrat Muñoz, Cristina Hernando, Silvia Vazquez, Salvador Blanch, Manuel Alva, Mafalda Oliveira, Esther Sanfeliu, Lorea Villanueva, Fara Brasó-Maristany, Nuria Chic, Eva Ciruelos. TATEN TRIAL (SOLTI-1716) Targeting non-Luminal disease by PAM50 with pembrolizumab + paclitaxel in Hormone Receptor-positive/HER2-negative (HR+/HER2-) metastatic breast cancer (MBC): interim analysis [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-06-02.

Abstract P3-02-04: Phase II study of Pembrolizumab Maintenance treatment in patients with HER2-negative inflammatory breast cancer (IBC) and triple-negative breast cancer (TNBC) after response to chemotherapy

Abstract Accumulating physical and hematologic toxicities make the indefinite use of chemotherapy unfeasible for many patients with metastatic/recurrent HER2– IBC or TNBC. Whether maintenance immunotherapy has a role in the treatment of these patients is unclear. We conducted a single-arm phase II trial of pembrolizumab monotherapy in patients with metastatic/recurrent HER2– IBC or TNBC (regardless of their PD-L1 expression status) and report here the clinical data from this trial. Methods: Eligible patients were enrolled between 2015 and 2022 and had had a CR, a PR, or SD after a minimum of 3 cycles of chemotherapy for metastatic/recurrent disease. PD-L1 expression status was not used to determine eligibility. Patients received 200 mg of pembrolizumab every 3 weeks (q3w) until disease progression, intolerable toxicity, or 2 years. In late 2021, the study was amended to allow patients who had received ≥8 cycles of q3w therapy to transition to q6w dosing (400 mg), based on the FDA’s approval of both dosing regimens across all indications. The primary endpoint was the 4-month disease control rate (DCR); exploratory endpoints included safety and correlative biomarkers from tissue and blood to ascertain associations between clinical response and PD-L1 expression, T-cell clonality, and immune profiling. Results: Of 43 patients (median age, 54 years; range, 34-77 years), 11 had IBC (10 with triple-negative IBC and 1 with ER+ HER2– IBC), and 32 had TNBC. The 4-month DCR was 58.1% (95% CI: 43.4%-72.9%). During a median follow-up of 11.4 months, 25 patients died. The entire cohort’s median OS and PFS times were 26.0 months (95% CI: 11.0-33.5 months) and 4.8 months (95% CI: 3.0-7.1 months), respectively. The median OS times of the IBC and TNBC groups did not differ significantly, nor did those of the CR, PR, and SD groups. The median PFS times of the IBC group (2.2 months) and TNBC group (4.8 months) did not differ significantly (p = .12), but those of the CR, PR, and SD groups did (not reached, 10.3 months, and 3.4 months, respectively; p = .01). Among the 37 patients who are off study treatment, most patients (84%; n=31/37) discontinued treatment owing to disease progression rather than toxicities (n=2), and the toxicities overall were consistent with the known profile of single-agent anti-PD1. Five patients had grade 3 events; there were no grade 4 or 5 events. Three patients had irreversible endocrinopathies (thyroiditis and adrenal insufficiency) requiring hormone replacement, but only 1 patient discontinued pembrolizumab because of these events. One patient discontinued treatment because of optic neuritis requiring steroids. Four patients completed 2 years of treatment without disease progression. Conclusions: Pembrolizumab maintenance therapy achieves acceptable disease control after induction chemotherapy. The PFS in this trial compares favorably to the expected durations of response to later lines of therapy. The toxicity profile of pembrolizumab compares favorably with those of chemotherapy and ADCs, which may provide a rationale for the use of ICIs in this setting. However, whether pembrolizumab maintenance therapy is helpful in TNBC patients who have received concurrent pembrolizumab with neoadjuvant chemotherapy is unknown, as these patients were excluded from the trial. Acknowledgements: This trial was supported by Merck. Citation Format: Toshiaki Iwase, Angela Alexander, Vivian Chiv, Megumi Kai, Kumiko Kida, Charla Parker, Angela N. Marx, Evan Cohen, Hui Gao, James Reuben, Xiaoping Wang, Savitri Krishnamurthy, Diane Liu, Yu Shen, David Ramirez, Debu Tripathy, Daniel Booser, Clinton Yam, Vicente Valero, Bora Lim, Naoto T. Ueno, Jie S. Willey. Phase II study of Pembrolizumab Maintenance treatment in patients with HER2-negative inflammatory breast cancer (IBC) and triple-negative breast cancer (TNBC) after response to chemotherapy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-02-04.

DASL-HiCaP: A randomized, phase 3, double-blind trial of darolutamide with androgen-deprivation therapy and definitive or salvage radiation for localized very high-risk prostate cancer.

TPS396 Background: Radiation therapy (RT), plus androgen deprivation therapy (ADT) with a luteinizing hormone releasing hormone analogue (LHRHA), is a standard of care for patients with very high-risk localized prostate cancer (PC), or with very high-risk features and persistent PSA after radical prostatectomy (RP). Despite this, incurable distant metastases develop within 5 years in 15% of patients with very high-risk features. Darolutamide is a structurally distinct oral androgen receptor antagonist with low blood-brain-barrier penetration, a demonstrated favorable safety profile, and low potential for drug-drug interactions. Our aim is to determine the efficacy of adding darolutamide to ADT and RT used either as primary definitive therapy, or as salvage therapy, for very high-risk PC. Methods: This study is a randomized (1:1), phase 3, placebo-controlled, double-blind, international trial for patients planned for RT who have very high-risk localized PC on conventional imaging; or very high-risk features with PSA persistence or rise within one year following RP. The trial is stratified by previous RP; planned use of adjuvant docetaxel; clinical or pathological pelvic nodal involvement. 1100 participants will be randomized to receive darolutamide 600 mg or placebo twice daily for 96 weeks in combination with SOC (LHRHA for 96 weeks, plus RT starting week 8-24 from randomization). Participants are allowed nonsteroidal antiandrogen in addition to LHRHA for up to 90 days prior to randomization. Early treatment with up to 6 cycles of docetaxel completed at least 4 weeks prior to RT is permitted. The primary endpoint is metastasis-free survival, with secondary endpoints of overall survival, PC-specific survival, PSA-progression free survival, time to subsequent hormonal therapy, time to castration-resistance, frequency and severity of adverse events, health related quality of life, fear of recurrence. Tertiary endpoints include incremental cost-effectiveness, and identification of prognostic and/or predictive biomarkers of treatment response, safety, and resistance to study treatment. Clinical trial information: NCT04136353 .

A phase II trial of pembrolizumab combined with platinum-based chemotherapy as first-line systemic therapy in advanced penile cancer: HERCULES (LACOG 0218) trial.

TPS14 Background: Penile squamous cell carcinoma (PSCC) is an uncommon malignancy which accounts for 2,300 new cases and 400 deaths annually worldwide. However, in low-income countries from South America, Asia and Africa, incidence corresponds to 10-20% of all malignancies in men. Approximately 4% of PSCC patients present with metastatic disease at diagnosis. Also, even if diagnosed in early stages (localized disease), around 30% of patients will recur. No improvements have been achieved over the last three decades in platinum-based chemotherapy, which remains the standard-of-care; objective response rate (ORR), median progression-free survival (PFS) and overall survival (OS) are currently at 20-30%, 3-4 months and 7-15 months, respectively. HPV16 is the most important known risk factor for PSCC. Favorable results have been achieved with Pembrolizumab in other HPV-associated cancers, such as cervical and oropharyngeal cancer. HERCULES (LACOG 0218) aims to evaluate the efficacy of pembrolizumab combined with platinum-based chemotherapy as first-line treatment in advanced PSCC. Methods: HERCULES is a phase 2, single-arm, multicentric trial evaluating patients with histologically proven PSCC and metastatic disease (de novo or recurrent); or recurrent locally advanced disease not amenable to curative-intent therapy; or TanyN3M0 or T4NanyM0 (stage IV – AJCC 8th ed) not amenable to curative-intent therapy. Additional inclusion criteria were ECOG PS 0–1; measurable disease by RECIST 1.1; no prior systemic therapy for recurrent or metastatic disease (however, patients progressing after 12 months of neo/adjuvant chemotherapy completion are allowed). The primary endpoint is ORR up to week 24. Secondary endpoints are OS, PFS, clinical benefit rate, immune related response criteria, quality of life, safety, and predictive biomarkers of response/survival. Eligible subjects receive 5-FU 1000mg/m²/day IV D1-D4, cisplatin 70mg/m² or carboplatin AUC 5 IV D1 plus pembrolizumab 200mg IV D1 at each 3-week (Q3W) dosing cycle for 6 cycles, followed by Pembrolizumab 200mg IV Q3W maintenance. Patients without disease progression are allowed to continue pembrolizumab monotherapy until completing 34 cycles, disease progression or unacceptable toxicity, whichever comes first. Tumor evaluations are performed every 6 weeks until week 24. Sample size was calculated as 33 patients to detect an increase in ORR from 20% to 40% up to week 24 with 78.5% power and considering 10% drop-out. From Aug 2020 to Jul 2022, 33 patients were enrolled in 11 Brazilian research sites. Results are expected in 2023. NCT04224740. Clinical trial information: NCT04224740 .

Circulating microRNAs as promising testicular translatable safety biomarkers: current state and future perspectives.

Drug-induced testicular injury (DITI) is one of the often-observed and challenging safety issues seen during drug development. Semen analysis and circulating hormones currently utilized have significant gaps in their ability to detect testicular damage accurately. In addition, no biomarkers enable a mechanistic understanding of the damage to the different regions of the testis, such as seminiferous tubules, Sertoli, and Leydig cells. MicroRNAs (miRNAs) are a class of non-coding RNAs that modulate gene expression post-transcriptionally and have been indicated to regulate a wide range of biological pathways. Circulating miRNAs can be measured in the body fluids due to tissue-specific cell injury/damage or toxicant exposure. Therefore, these circulating miRNAs have become attractive and promising non-invasive biomarkers for assessing drug-induced testicular injury, with several reports on their use as safety biomarkers for monitoring testicular damage in preclinical species. Leveraging emerging tools such as 'organs-on-chips' that can emulate the human organ's physiological environment and function is starting to enable biomarker discovery, validation, and clinical translation for regulatory qualification and implementation in drug development.

The evolving role of investigative toxicology in the pharmaceutical industry.

For decades, preclinical toxicology was essentially a descriptive discipline in which treatment-related effects were carefully reported and used as a basis to calculate safety margins for drug candidates. In recent years, however, technological advances have increasingly enabled researchers to gain insights into toxicity mechanisms, supporting greater understanding of species relevance and translatability to humans, prediction of safety events, mitigation of side effects and development of safety biomarkers. Consequently, investigative (or mechanistic) toxicology has been gaining momentum and is now a key capability in the pharmaceutical industry. Here, we provide an overview of the current status of the field using case studies and discuss the potential impact of ongoing technological developments, based on a survey of investigative toxicologists from 14 European-based medium-sized to large pharmaceutical companies.

A multi-institutional, single-arm, phase II trial of neoadjuvant modified-FOLFIRINOX for resectable pancreatic ductal adenocarcinoma.

715 Background: Various peri-operative treatments have been tested to increase the survival of localized PDAC. Even with superior survival among various disease extent of PDAC, resectable PDAC still shows poor outcomes with surgery followed by adjuvant chemotherapy. We report the result of a multi-institutional phase II trial of modified-FOLFIRINOX as neoadjuvant treatment for resectable PDAC. Methods: Treatment naïve pts with histologically confirmed resectable PDAC were enrolled. Resectability was confirmed by both CT and MRI according to NCCN resectability criteria (no arterial tumor contact to celiac axis, SMA or CHA; no tumor contact with SMV or PV or ≤180° contact without vein contour irregularity) in multidisciplinary team meeting. Patients received oxaliplatin 85mg/m2 D1 + leucovorin 400mg/m2 D1 + irinotecan 150mg/m2 D1 + 5-FU 2,000mg/m2 46h continuous infusion, every other week for 6 cycles (12 weeks). Response assessments were performed every 6 weeks using the RECIST criteria version 1.1. Baseline MRI, PET-CT scan, and pre-surgery MRI after 6 cycles were mandatory. The primary endpoint was R0 resection rate. Secondary endpoints included survivals, ORR, safety, resection rate, and correlative biomarker exploration. (NCT05066802). Results: Total of 27 pts were enrolled between May 2020 and Feb 2022. Among total 27 pts, 24 pts underwent curative aim surgery after neoadjuvant treatment (resection rate 88.9%), and 23 pts showed R0 resection (23/27=85.2%), meeting the primary endpoint. Among 27 pts, 19 pts (70.4%) completed the neoadjuvant treatment per protocol. The reasons for neoadjuvant treatment discontinuation included progression of the disease (n=3, 11.1%) and pts withdrawal (n=5, 18.5%). Among 19 patients who underwent surgery per protocol, only one patient was R1 resected (R0 resection rate=94.7%). As of Sep 1, 2022 (median follow-up duration = 15.2 months) 6 pts recurred after surgery (6/19=31.6%). Median recur-free survival was 18.7 months (95%CI 13.6-NR) and median OS was not reached (95%CI 17.6-NR) for the per protocol treated pts. Treatment-related AE (≥G3) occurred in 10 pts (37.0%) including 7 (25.9%) with neutropenia G3-4. Conclusions: Three months of neoadjuvant mFOLFIRINOX was feasible and tolerable for resectable PDAC. Larger randomized trial is needed to validate the impact of neoadjuvant chemotherapy for resectable pancreatic cancer and to find subgroup of pts who would get benefit most from the neoadjuvant treatment. Post hoc genomic analyses with paired pre-neoadjuvant treatment and surgical tissues are ongoing. Clinical trial information: NCT05066802 .

A phase 1 study of E7386, a CREB-binding protein (CBP)/β-catenin interaction inhibitor, in patients (pts) with advanced solid tumors including colorectal cancer: Updated dose-escalation part.

106 Background: E7386 is a novel oral anticancer agent that inhibits the binding of β-catenin to its transcriptional co-activator, CBP, thereby modulating Wnt/β-catenin signaling. In preclinical studies, E7386 showed promising activity (eg, modulation of tumor angiogenesis, alteration of the immune microenvironment, and inhibition of tumor growth). At a prior cutoff point for the dose-escalation part of a phase 1 study of E7386 in pts with advanced solid tumors, we reported 2 dose-limiting toxicities (DLTs; both grade 3 decreased appetite) with E7386 160 mg twice daily (BID). Here we describe an update of the dose-escalation part of this phase 1 study—we mainly report updated safety, tolerability, and preliminary efficacy and biomarker results, which led to the inclusion of an additional dose level for investigation in the expansion part of this study. Methods: E7386 was administered orally in escalating doses on a BID continuous schedule in 28-day cycles. Adverse events (AEs) were graded using CTCAE v5.0. Tolerability was judged by DLTs during cycle 1 (C1). Tumor response was assessed every 8 weeks from C1 day (D) 1, or sooner if clinically indicated, and at the end of treatment by investigators using RECIST v1.1. Samples for pharmacokinetic analyses were collected on C1D1 and C1D8; samples for biomarker analyses were collected at protocol-defined time points. To determine the appropriate dose(s) for the expansion part of this study, additional investigation of the dose-escalation part was conducted. Results: As of the data cutoff (DCO) date (30 June 2022), 36 pts (24 men, 12 women; median age, 61.5 y) were enrolled in E7386 dose cohorts (10 to 160 mg BID). Doses were tolerable up to 120 mg BID. The most common treatment-related AEs (all grades; &gt; 10%) were nausea (80.6%), vomiting (58.3%), aspartate aminotransferase increased (16.7%), and alanine aminotransferase increased, decreased appetite, and diarrhea (13.9% each). Nausea and vomiting were well-controlled with antiemetics such as 5HT3 antagonists, except in the 160 mg BID cohort. Two pts with a Wnt-related adenomatous polyposis coli (APC)- mutation (small bowel adenocarcinoma and desmoid tumor) showed a partial response. As of the DCO date, 2 pts (who continued on-treatment as of that date) had received over 1.5 y of E7386 treatment. The preliminary PK analysis showed plasma exposure of E7386 generally increased with an increasing dose over the assessed dose range. FGF21 levels in plasma increased following E7386 administration. Conclusions: E7386 120 mg BID was tolerated and determined as the recommended dose for the expansion part. Based on additional analyses of the dose-escalation part of this study, further investigation of safety, preliminary efficacy, PK, and biomarker analyses of E7386 is ongoing using 2 dose levels (100 and 120 mg BID) in the expansion part. Clinical trial information: NCT03833700 .

Identifying multiscale translational safety biomarkers using a network-based systems approach

Animal testing is the current standard for drug and chemicals safety assessment, but hazards translation to human is uncertain. Human invitro models can address the species translation but might not replicate invivo complexity. Herein, we propose a network-based method addressing these translational multiscale problems that derives invivo liver injury biomarkers applicable to invitro human early safety screening. We applied weighted correlation network analysis (WGCNA) toa large rat liver transcriptomic dataset to obtain co-regulated gene clusters (modules). We identified modules statistically associated with liver pathologies, including a module enriched for ATF4-regulated genes as associated with theoccurrence of hepatocellular single-cell necrosis, and as preserved in human liver invitro models. Within the module, we identified TRIB3 and MTHFD2 as a novel candidate stress biomarkers, and developed and used BAC-eGFPHepG2 reporters in a compound screening, identifying compounds showing ATF4-dependent stress response and potential early safety signals.

Final efficacy and safety results and biomarker analysis of a phase 2 study of cabozantinib in Japanese patients with advanced renal cell carcinoma

BackgroundCabozantinib was established as the standard of care for the treatment of patients with renal cell carcinoma (RCC) whose disease had progressed after vascular endothelial growth factor receptor tyrosine kinase inhibitor (VEGFR-TKI) therapy in the global randomized trial METEOR. A phase 2 study was conducted to bridge the findings in METEOR to Japanese patients. Here, we report a biomarker analysis and update the efficacy and safety results of cabozantinib treatment.MethodsJapanese patients with RCC who received at least one prior VEGFR-TKI were enrolled and received cabozantinib 60 mg orally once daily. The primary endpoint was objective response rate. Secondary endpoints included progression-free survival, overall survival, and safety. Exploratory analyses included the relationship between plasma protein hepatocyte growth factor (HGF) levels and treatment responses.ResultsIn total, 35 patients were enrolled. The median treatment duration was 58.3 (range 5.1–131.4) weeks. The objective response rate was 25.7% (90% confidence interval [CI] 14.1–40.6). Kaplan–Meier estimate of median progression-free survival was 11.1 months (95% CI 7.4–18.4). The estimated progression-free survival proportion was 73.1% (95% CI 54.6–85.0) at 6 months. Median overall survival was not reached. Adverse events were consistent with those in METEOR and the safety profile was acceptable. Nonresponders to cabozantinib showed relatively higher HGF levels than responders at baseline.ConclusionsUpdated analyses demonstrate the long-term efficacy and safety of cabozantinib in Japanese patients with advanced RCC after at least one VEGFR-TKI therapy. Responders tended to show lower baseline HGF levels ClinicalTrials.gov Identifier: NCT03339219.

Early-Onset albuminuria and Associated Renal Pathology in Leucine-Rich Repeat Kinase 2 Knockout Rats.

Activating mutations of the leucine-rich repeat kinase 2 (LRRK2) gene are associated with Parkinson disease (PD), prompting development of LRRK2 inhibitors as potential treatment for PD. However, kidney safety concerns have surfaced from LRRK2 knockout (KO) mice and rats and from repeat-dose studies in rodents administered LRRK2 inhibitors. To support drug development of this therapeutic target, we conducted a study of 26 weeks' duration in 2-month-old wild-type and LRRK2 KO Long-Evans Hooded rats to systematically examine the performance of urinary safety biomarkers and to characterize the nature of the morphological changes in the kidneys by light microscopy and by ultrastructural evaluation. Our data reveal the time course of early-onset albuminuria at 3 and 4 months in LRRK2 KO female and male rats, respectively. The increases in urine albumin were not accompanied by concurrent increases in serum creatinine, blood urea nitrogen, or renal safety biomarkers such as kidney injury molecule 1 or clusterin, although morphological alterations in both glomerular and tubular structure were identified by light and transmission electron microscopy at 8 months of age. Diet optimization with controlled food intake attenuated the progression of albuminuria and associated renal changes.

ACT-13 DSP-0390, AN ORAL EMOPAMIL BINDING PROTEIN (EBP) INHIBITOR, IN PATIENTS WITH RECURRENT HIGH-GRADE GLIOMA: A FIRST-IN-HUMAN, PHASE 1 STUDY

Abstract Background The brain's cells are fully dependent on their own de novo biosynthesis of cholesterol as the blood-brain barrier prevents its uptake from the circulation. In normal glial cells, proper regulation of cholesterol synthesis depends on its cell density and is turned off when the cell density exceeds a certain level. On the other hand, gliomas maintain high levels of cholesterol synthesis to support abnormal growth under any condition. Upregulation of cholesterol synthesis genes is associated with decreased survival in patients with glioblastoma (GBM). Therefore, gliomas are potentially sensitive to cholesterol synthesis inhibition. DSP-0390 is an investigational small molecule inhibitor of EBP, an enzyme in one of the last steps of cholesterol biosynthesis. By inhibiting de novo cholesterol synthesis, cytotoxicity can be induced more selectively against hyperproliferative GBM cells. DSP-0390 has shown significant antitumor activity in orthotopic xenograft GBM models (data on file). Methods DSP-0390 will be evaluated in a phase 1 study in patients with recurrent high-grade glioma (NCT05023551). Key eligibility criteria: age ≥18 years; KPS score ≥70%; and adequate organ and hematologic function. Patients must not have multifocal disease, leptomeningeal metastasis, extracranial metastasis. In Dose Escalation, 21-30 patients with World Health Organization (WHO) grade III or IV malignant glioma who progressed after ≥1 prior therapy will be enrolled. Dose escalation will be guided by a Bayesian Logistic Regression Model until identification of the maximum tolerated dose or recommended dose for expansion. Dose Expansion will enroll approximately 20-40 patients with WHO grade IV GBM who progressed after primary therapy and have measurable disease. Study endpoints include safety (treatment-emergent adverse events [AEs], serious AEs, and dose-limiting toxicities), efficacy (6-month progression-free survival [PFS], objective response, PFS, duration of response, and 12-month overall survival), pharmacokinetics (PK), and pharmacodynamic biomarkers. This study is currently recruiting in the United States and Japan.

Dupilumab in daily practice for the treatment of pediatric atopic dermatitis: 28-week clinical and biomarker results from the BioDay registry.

Dupilumab has proven to be an effective and safe treatment for atopic dermatitis (AD) in pediatric patients in clinical trials. However, few daily practice studies are available. The aim of this study is to evaluate the effect of 28 weeks dupilumab treatment on effectiveness, safety, and serum biomarkers in pediatric patients with moderate-to-severe AD in daily practice. Patients visited the outpatient clinic at baseline, 4, 16, and 28 weeks of treatment. Disease severity was assessed by the Eczema Area and Severity Index (EASI), Investigator Global Assessment (IGA), Numeric Rating Scale (NRS)-pruritus and -pain, and the Patient-Oriented Eczema Measure (POEM). Side effects were evaluated. Nineteen severity-associated serum biomarkers were measured. Predicted-EASI (p-EASI) was calculated. Sixty-one patients were included. Respectively 75.4%, 49.2%, and 24.6% reached EASI-50, EASI-75, and EASI-90 and 36.1% achieved an IGA-score (almost) clear. Improvement of ≥4 points on POEM, NRS-pruritus, and NRS-pain was reached by 84.7%, 45.3%, and 77.4%, respectively. Most reported side effects were conjunctivitis (n= 10) and headache (n= 4). Biomarkers TARC, PARC, periostin, sIL-2Ra, and eotaxin-3 significantly decreased during treatment. The p-EASI showed a significant correlation with disease severity. Dupilumab treatment significantly improved disease severity and disease-associated symptoms and decreased severity-associated serum biomarkers in pediatric AD patients in daily practice.

The PIONEER Study: A Multi‐center, Randomized, Double‐blind, Placebo‐controlled Phase 2 Trial of the Effects of T3D‐959 on Safety, Cognition, Function and Plasma Biomarkers in Mild to Moderate Alzheimer’s Disease Subjects: Study Update.

AbstractBackgroundT3D‐959 is a novel (non‐amyloid/non‐tau‐directed) new chemical entity aimed at improving dysfunctional brain glucose energy and lipid metabolism in Alzheimer’s disease (AD). Dysfunctional brain metabolism in AD results from increasing resistance to insulin. Insulin resistance contributes to amyloid plaque formation, tau tangle formation and inflammation. T3D‐959, a brain‐penetrant, small molecule dual nuclear receptor agonist, acts as an insulin sensitizer to overcome insulin resistance to restore and maintain metabolic homeostasis.MethodPIONEER is a randomized, double‐blind, placebo‐controlled, Phase 2 trial involving 256 mild to moderate AD patients (MMSE = 14‐26) dosed orally once‐a‐day for 24‐weeks in 4 parallel arms (T3D‐959 15mg, 30mg, 45mg and placebo QD in a 1:1:1:1 ratio). Co‐primary outcome measures include the ADAS‐cog11 cognition and global function ADCS‐CGIC measures. Secondary outcome measures include DSCT and plasma Aβ 42/40 ratio. Exploratory outcome measures include plasma NfL tau, ptau217 and ptau181, apathy as measured by the NPI, expressive language function as measured by CFT, physical activity as measured by RAPA, plasma metabolomic and proteomic biomarkers and change in absolute regional, and whole brain, cerebral metabolic rate for glucose (CMRgl) as assayed by FDG‐PET.ResultPIONEER commenced in March 2021. The study is two‐thirds enrolled and ongoing [See ClinicalTrials.gov identifier NCT04251182]. Blinded, grouped, summary cognitive and functional endpoint data, as well safety data will be presented and discussed.ConclusionPIONEER is designed to evaluate the efficacy and safety of multiple dose strengths of T3D‐959 in patients with mild to moderate severity AD. Topline results are expected in 2023.

Transcriptomic Analysis of the Acute Skeletal Muscle Effects after Intramuscular DNA Electroporation Reveals Inflammatory Signaling.

Skeletal muscle is a promising tissue for therapeutic gene delivery because it is highly vascularized, accessible, and capable of synthesizing protein for therapies or vaccines. The application of electric pulses (electroporation) enhances plasmid DNA delivery and expression by increasing membrane permeability. Four hours after plasmid electroporation, we evaluated acute gene and protein expression changes in mouse skeletal muscle to identify regulated genes and genetic pathways. RNA sequencing followed by functional annotation was used to evaluate differentially expressed mRNAs. Our data highlighted immune signaling pathways that may influence the effectiveness of DNA electroporation. Cytokine and chemokine protein levels in muscle lysates revealed the upregulation of a subset of inflammatory proteins and confirmed the RNA sequencing analysis. Several regulated DNA-specific pattern recognition receptor mRNAs were also detected. Identifying unique molecular changes in the muscle will facilitate a better understanding of the underlying molecular mechanisms and the development of safety biomarkers and novel strategies to improve skeletal muscle targeted gene therapy.

Pharmacodynamic Biomarkers of Mosunetuzumab Efficacy and Safety in Patients with Relapsed/Refractory Non-Hodgkin Lymphoma: Results from a Phase I/II Study

Background: Mosunetuzumab (Mosun) is a CD20xCD3 bispecific antibody that engages T cells and B cells to induce a synthetic synapse leading to T-cell activation and production of cytokines involved in immune-directed B-cell killing. Mosun is being developed as a fixed-duration, off-the-shelf therapy for the treatment of non-Hodgkin lymphoma (NHL). A Phase I/II study (NCT02500407) is investigating Mosun monotherapy in patients (pts) with relapsed or refractory NHL (aggressive NHL [aNHL; n=278]: DLBCL, MCL, RS, transformed FL, FL3b; indolent NHL [iNHL; n=168]: FL, MZL, SLL) using fixed (Group A; n=33) and step-up (Group B; n=414) dosing schedules. We report exploratory pharmacodynamic (PD) biomarker analyses from this study across dosing cohorts and histologies in relation to mechanism of action, dose, safety, and clinical activity. Methods: In Group A, the target dose (TD) of intravenous Mosun was administered on Cycle (C) 1 Day (D) 1 (0.05-2.8mg). In Group B, step-up doses (SUD) were administered on C1D1 (0.4-1mg), C1D8 (1-2mg) and the TD on C1D15 (2.8mg-60mg). In both groups, TD was given on D1 of subsequent cycles (up to C8 for pts achieving a complete response or C17 for pts achieving partial response or stable disease). The recommended dose was confirmed as C1D1 (1mg), C1D8 (2mg), C1D15 and C2D1 (60mg) and C3D1-C8/C17 (30mg). Cytokines (IL-6, INF-γ, TNF-α, IL-2, IL-10) were measured by ELISA or SIMOA assays and peripheral blood (PB) immune-cell subsets by flow cytometry. Baseline (BL) tumor biopsies and on-treatment (on-Tx) biopsies collected between C1D15 and C3D1 were assessed by CD8 immunofluorescence (IF) and RNAseq. Results: In Group A, cytokine release was observed at Mosun doses of ≥0.4mg. Cytokine release was acute and transient, occurring early after Mosun administration and returning to BL levels by 24 hours. Despite a low to moderate correlation across cytokines at BL, a similar pattern of cytokine secretion was observed following administration of Mosun. High levels of cytokines were detected in pts who experienced cytokine release syndrome (CRS). In Group B, SUD was initiated as a CRS mitigating strategy, using the identified, pharmacodynamically active dose as the initial dose. Although a second cytokine peak was observed at C1D15 during SUD, with a trend towards higher peaks with increasing Mosun doses, significantly higher doses could be administered without corresponding cytokine release. While Mosun exhibited linear pharmacokinetics, dose-dependent PD relationships can be confounded by variables that affect target binding including residual anti-CD20 monoclonal antibodies from prior treatment. Taking CD20 receptor occupancy into account, exposure-response analyses using IL-6 or INF-γ confirmed that SUD ameliorates cytokine release to enable higher Mosun dosing to achieve clinically active exposure (Figure). T-cell margination, activation (CD69), and proliferation (Ki67) were observed in CD4+ and CD8+ T cells in a time-dependent manner that paralleled PD changes observed with cytokines in both aNHL and iNHL. CD4+ and CD8+ T-cell activation was observed after the initial Mosun dose and to a lesser extent with subsequent doses. In contrast, B-cell depletion was observed early after initial Mosun administration and was sustained throughout treatment. At BL, higher levels of PB B cells were associated with improved response in pts with aNHL. However, this may reflect prognostic features and prolonged time since prior therapy. On-Tx increases in activated T-cell subsets (% CD4+DR+GzB+ and % CD4/8 Tn DR+) were also associated with improved response. Changes in biomarker levels were observed predominantly with the first dose of Mosun; associations with response were primarily seen in pts with aNHL vs iNHL, possibly reflective of the distinct immune biology. Importantly, PD changes observed in PB were also observed in tumors. Increases in CD8+ T cells (CD8 IF) in on-Tx tumor biopsies were predominantly, but not exclusively, reported in pts who achieved a response. Consistent with PB observations, changes in RNA levels of CD8, cytokines and markers of T-cell activation (i.e. GZMB and TIM3) were also observed by RNAseq at the tumor site. Conclusions: PD biomarkers of Mosun in PB and tumor biopsies confirm immune-cell activity associated with Mosun treatment and demonstrate the benefit of SUD as a CRS mitigation strategy to enable administration of clinically active doses. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

CDX-301 prevents radiation-induced dysregulation of miRNA expression and biogenesis

Risks of radiation exposure necessitate the development ofradioprophylactic drugs. We have reported the efficacy of CDX-301, a recombinantly developed human protein form of Fms-related tyrosine kinase 3 ligand (Flt3L), as a radioprophylactic and radiomitigatory agent. Here, we performed global microRNA profiling to further understand the mechanism of action of CDX-301. We find that CDX-301 administration 24h prior to total body irradiation prevents radiation-induced dysregulation of microRNA biogenesis and expression in murine serum and spleen samples in a time- and tissue-dependent manner. Further analysis shows that activation of the HOTAIR regulatory pathway has a prominent function in radiation-induced injury responses, which is inhibited by pre-treatment with CDX-301. Moreover, CDX-301 attenuates radiation-induced dysregulation of several cellular functions such as inflammatory and immune responses. In corroboration, we also find that pre-treatment with CDX-301 restores the expression of bone marrow aplasia markers and inflammatory cytokines and growth factors, as well as the expression of genes associated with MAP kinase and TGF-β pathways that are altered by radiation. Our findings provide new insights into CDX-301-mediated molecular and cellular mechanisms and point to a possible novel radioprotective drug for the prevention of irradiation-induced injury and hematopoietic acute radiation syndrome.

Updated Results and Correlative Analysis: Autologous CD30.CAR-T-Cell Therapy in Patients with Relapsed or Refractory Classical Hodgkin Lymphoma (CHARIOT Trial)

Introduction Early results from the Pilot segment of a Phase 2 trial of autologous CD30.CAR-T in patients with relapsed/refractory (r/r) classical Hodgkin lymphoma (cHL) (NCT#04268706) demonstrated a favorable safety profile and excellent anti-tumor responses of CD30.CAR-T in patients with heavily pretreated r/r cHL (Ahmed et al., 2021). We report here updated clinical data and exploratory biomarker analysis from the Pilot segment. Methods This is a Phase 2 single arm, multi-center study, enrolling patients (12-75 years) with cHL progression after at least 3 lines of therapy, including chemotherapy, brentuximab vedotin, and anti-programmed cell death (PD)-1 antibodies. The pilot segment of this study has fully enrolled with safety as the primary endpoint and overall response rate (ORR) as assessed centrally according to Lugano Classification Revised Response System for malignant lymphoma (Cheson et al., 2014) as a secondary endpoint. The patients were treated with CD30.CAR-T cells, after lymphodepletion chemotherapy using bendamustine and fludarabine, with an allowable dose range of 2.0 to 2.7 × 108 CD30.CAR-T cells per m2. Second CD30.CAR-T infusion is allowed if the patients show progression after initial response to first CD30.CAR-T infusion. Exploratory objectives include assessment of expansion and persistence of autologous CD30.CAR-T, cytokine profiling, immunological parameters, circulating tumor DNA (ctDNA), and other biomarkers in blood and tumor tissue. Results As of 22 July 2022, 17 patients were screened and 15 patients enrolled in the Pilot segment (median age: 35 years [21-57], 66.7% male). The median number of prior therapies was 6 (range: 3-18). All 15 patients were treated with CD30.CAR-T single infusion, and 7 patients received a second CD30.CAR-T infusion. ORR after CD30.CAR-T single infusion was 73.3% (n=11) with complete response (CR) rate of 60% (n=9). ORR in 5 patients with available response assessment after the second infusion was 100%, with CR of 60% (n= 3). CD30.CAR-T treatment was well tolerated with one grade 1 Cytokine Release Syndrome (CRS) and no neurotoxicity. CD30.CAR-T cells in peripheral blood peaked at 7 days after first CAR-T infusion with median Cmax (peak exposure) of 6964.7 copies/µg DNA.There was no correlation observed between response and Cmax, or AUC (area under the curve) 0-42 days, 0-90 days, 0-180 days after the first CD30.CAR-T infusion. Biopsies obtained at the time of screening and relapse were reviewed by an independent pathologist with 100% concordance of CD30 positivity between local and central testing. HAMA (Human Anti-Mouse Antibody) in serum was negative after first and secondCD30.CAR-T infusion in all patients. An increase of the homeostatic cytokines interleukin (IL)-7 and IL-15 was detected after lymphodepletion chemotherapy. Serum CCL17 (Thymus and Activation Regulated Chemokine; TARC), a predictive marker of early response assessment in HL (Guidetti et al., 2017) was elevated before CD30.CAR-T infusion and had a dramatic decrease after treatment in responding patients. Conclusions Overall, CD30.CAR-T therapy was well tolerated with no unexpected safety signal and showed excellent anti-tumor efficacy with an ORR of 73.3% in heavily pretreated r/r cHL patients. The CD30.CAR-T cells showed good expansion and persistence after infusion. The efficacy, safety and exploratory biomarkers of CD30.CAR-T will be further evaluated in the Pivotal segment of this Phase 2 study.