Severe Immune-related Adverse Events Research Articles

Risk factors for severe immune-related pneumonitis after nivolumab plus ipilimumab therapy for non-small cell lung cancer.

The efficacy of anti-CTLA-4 antibody (ipilimumab) plus anti-programmed cell death 1 antibody (nivolumab) in treating advanced non-small cell lung cancer (NSCLC) is impeded by an elevated risk of severe immune-related adverse events. However, our understanding of associations among pre-existing fibrosis, emphysematous changes, and objective indicators as predictive factors is limited for severe pneumonitis in NSCLC patients receiving this combination therapy. Thus, we retrospectively investigated these associations, including overall tumor burden, before treatment initiation in the Japanese population. We focused on patients (n = 76) with pre-existing interstitial lung disease (ILD) to identify predictors of severe pneumonitis. Variables included age, sex, smoking status, programmed cell death ligand 1 expression, overall tumor burden, chest computed tomography-confirmed fibrosis, serum markers, and respiratory function test results. Severe pneumonitis was more frequent in patients with squamous cell carcinoma, fibrosis, low diffusing capacity for carbon monoxide (%DLCO), and high surfactant protein D (SP-D) level. Notably, squamous cell carcinoma, baseline %DLCO, and SP-D level were significant risk factors. Our findings revealed the nonsignificance of tumor burden (≥85 mm) in predicting severe pneumonitis, emphasizing the importance of pre-existing ILD. Conversely, in cases without pre-existing fibrosis, severe pneumonitis was not associated with %DLCO or SP-D level (93.2% vs. 91.9%, and 63.3 vs. 40.9 ng/mL, respectively) and was more common in patients with a large overall tumor burden (97.5 vs. 70.0 mm). Vigilant monitoring and early intervention are crucial for patients with squamous cell carcinoma, high SP-D level, or low %DLCO undergoing ipilimumab plus nivolumab therapy.

Correlation of patient HLA class I genotypes with severe immune-related adverse events: A retrospective study in Chinese population.

10586 Background: Immune checkpoint inhibitors (ICIs) are effective in multiple tumors. However, about 10% of immune-related adverse events (irAEs) are severe and can have serious or even life-threatening consequences for patients. We investigated whether Human leukocyte antigen (HLA) genes predispose to and thus hold a predictive role of developing of severe irAEs in Chinese population. Methods: In a case/control study, we collected data from patients with metastatic cancer treated with ICIs and developed severe irAEs (Grade ≥3 and required hospitalization). Patients treated with ICIs without any irAEs were used as controls. Data was collected from15th Nov, 2019 until 10th Oct, 2023. HLA typing was performed via next generation sequencing. Results: We enrolled 83 patients with severe irAEs and 286 patients treated with ICIs without any irAEs. We found HLA-B*15:27 (OR=9.1, X21,95 = 7.2, P = 0.008) and HLA-C*04:01 (OR=2.5, X21,95 = 7.0, P =0.008) were significantly associated with severe overall irAEs risk. When assessing irAE individually, a significant association between HLA-B*13:02 and serious myocarditis (OR = 3.4, X21,95 = 6.2, P =0.01) as well as striking enrichment for HLA-A*02:03 haplotypes in severe adrenal insufficiency (OR = 10.0, X21,95 = 19.1, P<0.0001) were observed. Conclusions: Specific HLA alleles were associated with severe irAEs. Consideration of pre-prescription HLA typing and vigilance for serious reactions to ICIs are warranted.

Phenotyping Hepatic Immune-Related Adverse Events in the Setting of Immune Checkpoint Inhibitor Therapy.

We present and validate a rule-based algorithm for the detection of moderate to severe liver-related immune-related adverse events (irAEs) in a real-world patient cohort. The algorithm can be applied to studies of irAEs in large data sets. We developed a set of criteria to define hepatic irAEs. The criteria include: the temporality of elevated laboratory measurements in the first 2-14 weeks of immune checkpoint inhibitor (ICI) treatment, steroid intervention within 2 weeks of the onset of elevated laboratory measurements, and intervention with a duration of at least 2 weeks. These criteria are based on the kinetics of patients who experienced moderate to severe hepatotoxicity (Common Terminology Criteria for Adverse Events grades 2-4). We applied these criteria to a retrospective cohort of 682 patients diagnosed with hepatocellular carcinoma and treated with ICI. All patients were required to have baseline laboratory measurements before and after the initiation of ICI. A set of 63 equally sampled patients were reviewed by two blinded, clinical adjudicators. Disagreements were reviewed and consensus was taken to be the ground truth. Of these, 25 patients with irAEs were identified, 16 were determined to be hepatic irAEs, 36 patients were nonadverse events, and two patients were of indeterminant status. Reviewers agreed in 44 of 63 patients, including 19 patients with irAEs (0.70 concordance, Fleiss' kappa: 0.43). By comparison, the algorithm achieved a sensitivity and specificity of identifying hepatic irAEs of 0.63 and 0.81, respectively, with a test efficiency (percent correctly classified) of 0.78 and outcome-weighted F1 score of 0.74. The algorithm achieves greater concordance with the ground truth than either individual clinical adjudicator for the detection of irAEs.

The survival benefits and the risk of severe renal injury of immune checkpoint inhibitors in patients with cancer: The real-world evidence from the National Clinical Cohort Collaborative (N3C).

e24142 Background: The survival benefits and the risks of severe immune-related adverse events (sirAEs) of Immune checkpoint inhibitors (ICI) vary dramatically among cancer patients. Among sirAEs, acute kidney injury (AKI) incidences are rising, often cause sustained renal damage, and are responsible for the deterioration of patients’ overall health and quality of life. There is an urgent need to support oncologists and nephrologists in choosing the right ICI drugs for the right patients. We aim to comprehensively scrutinize the tradeoff between the survival benefits and the severe AKI risk for ICI patients by leveraging the national electronic medical records (EMR) from the National Clinical Cohort Collaborative (N3C) registry. Our work provides real-world evidence for clinical decisions on ICI use. Methods: Cancer patients treated with ICI are followed up for at least 6 months using N3C data (01/01/2018 - 01/19/2024). Primary outcomes included severe AKI within 6 months of initiation or mortality up to the last follow-up. We fit multivariable Cox proportional hazards models to evaluate the effect of various ICI types, adjusting for age, gender, race, cancer types, smoking status, and comorbidities. Results: Our study cohort included 55,767 patients who received an ICI, with 25,197 deaths and 6,458 severe AKI events. The most common ICI used were PD-1 inhibitors (74.3%), PD-L1 inhibitors (16.6%), CTLA-4 inhibitors (0.3%), and combination treatments of PD-1 and CTLA-4 inhibitors (8.8%). Observed long-term severe AKI incidences exceeded prior reports, with 96%, 92%, 88%, and 71% at 1, 3, 6, and 36 months. Survival benefits of PD-1, CTLA-4 and their combinations versus PD-L1 inhibitors were comparable (HR: 0.94 [95%CI: 0.91–0.97]; HR: 0.81 [95%CI: 0.63–1.02]; HR: 1.09 [95%CI: 1.04–1.15]). Severe AKI risks were higher with CTLA-4 and combination therapy (HR: 1.48 [95%CI: 0.96–2.28]; HR: 1.96 [95%CI: 1.78–2.16]) compared to PD-L1 inhibitors, with PD-1 inhibitors also showing increased risk (HR: 1.15 [95%CI: 1.07–1.23]). We also scrutinize risk factors associated with significant AKI risk, including a history of AKI, congestive heart failure, dementia, complicated diabetes, hypertension, liver disease, other immunocompromised diseases, and cancers of the gynecologic type, prostate cancer, and gastrointestinal cancers, and being of Black race. Conclusions: Our work provides up-to-date and comprehensive real-world evidence of the survival benefits and severe renal injury risks for clinical decisions of ICI therapy. PD-L1 inhibitors are associated with a lower risk of severe AKI compared to PD-1, CTLA-4 inhibitors, and their combination. Future research should focus on identifying patient subgroups that may benefit from specific ICI therapies while minimizing adverse outcomes.

Stage IV renal cell carcinoma achieves pathologic complete response after two ipilimumab plus nivolumab courses despite severe immune-related adverse events: a case report

BackgroundIpilimumab (Ipi) plus nivolumab (Nivo) is the recommended first-line treatment for renal cell carcinoma (RCC). This report describes a case where pancreatic metastases disappeared after only two courses of Ipi + Nivo therapy. The primary tumor was cured by surgery, and a pathological Complete Response (pCR) was observed despite multiple serious immune-related Adverse Events (irAEs).Case presentationA 54-year-old woman with RCC and pancreatic metastasis at stage IV, diagnosed with intermediate risk according to the International Metastatic RCC Database Consortium classification, underwent initiation of Ipi + Nivo therapy. On day 26, she developed hyperthyroidism accompanied by tachycardia, leading to the commencement of metoprolol tartrate treatment. Following the resolution of tachycardia, a second course of Ipi + Nivo therapy was administered on day 50. By day 70, the patient exhibited Grade 3 hepatic dysfunction, followed by the onset of hypothyroidism on day 75, necessitating treatment with steroids and levothyroxine. After positive treatment, a Grade 3 skin disorder emerged on day 87 while tapering steroids, prompting treatment with methylprednisolone (mPSL) pulse therapy. The skin disorder responded to steroids, allowing for tapering. However, on day 113, a recurrence of Grade 3 skin disorder occurred, necessitating another mPSL pulse. The patient responded well to treatment, exhibiting improvement in her condition. On day 131, she presented at the hospital with complaints of respiratory distress, prompting a Computed Tomography (CT) scan that revealed interstitial pneumonia. By day 272, subsequent CT imaging showed the disappearance of pancreatic metastasis and shrinkage of the primary tumor. On day 294, she underwent a laparoscopic left nephrectomy. Pathological analysis confirmed a pCR in the primary tumor, indicating successful eradication of RCC through surgical intervention.ConclusionsThis case report presents a scenario where multiple severe irAEs appeared in a patient, yet metastases disappeared after only two courses of Ipi + Nivo therapy. The patient was ultimately cured by surgery and achieved a pCR. This case highlights that despite the occurrence of severe irAEs during RCC treatment with Ipi + Nivo therapy, they can be managed appropriately to maximize the therapeutic effects of checkpoint inhibitors.

Safe Stop IPI-NIVO trial: early discontinuation of nivolumab upon achieving a complete or partial response in patients with irresectable stage III or metastatic melanoma treated with first-line ipilimumab-nivolumab – study protocol

BackgroundPatients with irresectable stage III or metastatic melanoma presenting with poor prognostic factors are usually treated with a combination of immune checkpoint inhibitors (ICIs), consisting of ipilimumab and nivolumab. This combination therapy is associated with severe immune related adverse events (irAEs) in about 60% of patients. In current clinical practice, patients are usually treated with ICIs for up to two years or until disease progression or the occurrence of unacceptable AEs. The incidence of irAEs gradually increases with duration of treatment. While durable tumour responses have been observed after early discontinuation of treatment, no consensus has been reached on optimal treatment duration. The objective of the Safe Stop IPI-NIVO trial is to evaluate whether early discontinuation of ICIs is safe in patients with irresectable stage III or metastatic melanoma who are treated with combination therapy.MethodsThe Safe Stop IPI-NIVO trial is a nationwide, multicentre, prospective, single-arm, interventional study in the Netherlands. A total of 80 patients with irresectable stage III or metastatic melanoma who are treated with combination therapy of ipilimumab-nivolumab and have a complete or partial response (CR/PR) according to RECIST v1.1 will be included to early discontinue maintenance therapy with anti-PD-1. The primary endpoint is the rate of ongoing response at 12 months after start of ICI. Secondary endpoints include ongoing response at 24 months, disease control at different time points, melanoma specific and overall survival, the incidence of irAEs and health-related quality of life.DiscussionFrom a medical, healthcare and economic perspective, overtreatment should be prevented and shorter treatment duration of ICIs is preferred. If early discontinuation of ICIs is safe for patients who are treated with the combination of ipilimumab-nivolumab, the treatment duration of nivolumab could be shortened in patients with a favourable tumour response.Trial registrationClinicalTrials.gov ID NCT05652673, registration date: 08–12-2022.

Immune checkpoint inhibitor therapy in patients with cancer and pre-existing systemic sclerosis

ObjectiveImmune checkpoint inhibitor (ICI) therapies have dramatically improved outcomes in multiple cancers. ICI's mechanism of action involves immune system activation to augment anti-tumor immunity. Patients with pre-existing autoimmune diseases, such as systemic sclerosis (SSc), were excluded from initial ICI clinical trials due to concern that such immune system activation could precipitate an autoimmune disease flare or new, severe immune related adverse events (irAE). In the present study, we report our experience with ICIs in patients with pre-existing SSc. MethodsPatients with SSc who received ICI therapy for cancer were identified from the Johns Hopkins Scleroderma Center Research Registry. Through chart review and prespecified definitions, we identified whether patients experienced worsening SSc activity or new irAEs. SSc disease activity worsening was pre-defined as an increase in modified Rodnan skin score (mRSS), new scleroderma renal crisis, progression of interstitial lung disease (ILD) on CT scan, increased Raynaud's phenomenon frequency or severity, new pulmonary hypertension, or myositis flare. IrAEs also included active inflammatory arthritis and dermatitis. ResultsEight patients with SSc who received ICI therapy for cancer were included. Overall, SSc symptoms remained stable during and after ICI therapy. None of the patients with long-standing sine or limited cutaneous SSc (lcSSc) had progressive skin thickening after ICI therapy. One patient, who was early in his diffuse cutaneous SSc (dcSSc) disease course, experienced worsening skin thickening and renal crisis. Three patients (38 %) experienced a total of five irAEs (grade 2: diarrhea, mucositis and dermatitis; grade 3: pneumonitis, and grade 4: nephritis). The patient with grade 4 nephritis developed scleroderma renal crisis and immune checkpoint related nephritis simultaneously. There were no deaths due to irAEs. ConclusionIn this study, ICI therapy was well tolerated in patients with longstanding, sine or lcSSc. IrAE were common but generally manageable. Patients with early, active SSc may be at greater risk from ICI therapy, but more research is needed.

Noncovalently particle-anchored cytokines with prolonged tumor retention safely elicit potent antitumor immunity.

Preclinical studies have shown that immunostimulatory cytokines elicit antitumor immune responses but their clinical use is limited by severe immune-related adverse events upon systemic administration. Here, we report a facile and versatile strategy for noncovalently anchoring potent Fc-fused cytokine molecules to the surface of size-discrete particles decorated with Fc-binding peptide for local administration. Following intratumoral injection, particle-anchored Fc cytokines exhibit size-dependent intratumoral retention. The 1-micrometer particle prolongs intratumoral retention of Fc cytokine for over a week and has minimal systemic exposure, thereby eliciting antitumor immunity while eliminating systemic toxicity caused by circulating cytokines. In addition, the combination of these particle-anchored cytokines with immune checkpoint blockade antibodies safely promotes tumor regression in various syngeneic tumor models and genetically engineered murine tumor models and elicits systemic antitumor immunity against tumor rechallenge. Our formulation strategy renders a safe and tumor-agnostic approach that uncouples cytokines' immunostimulatory properties from their systemic toxicities for potential clinical application.

Abstract 6681: Altered microbial community stability and increases in circulating B cells are associated with the development of severe immune related adverse events during ICI-immunotherapy

Abstract Background: Immune related adverse events (irAEs) are a major hurdle to the success of immune checkpoint inhibitor (ICI) immunotherapy. There is increasing evidence that the gut microbiota influences irAE development, however the microbe-immune crosstalk underpinning this remains cryptic. Methods: Paired pre- & post-treatment (baseline/week 6) stool samples from 129 Australian and Dutch melanoma patients treated on trial with neo-adjuvant combination anti-PD1/anti-CTLA4 immunotherapy were analyzed with 16S rRNA gene sequencing. Matched PBMCs at both timepoints were analyzed using mass cytometry (n=71). Results: ICI immunotherapy resulted in changes in the relative abundance of specific bacterial groups in the faecal microbiota, however the microbial community as a whole remained relatively stable. In particular enhanced oralization of the gut microbiome was observed with treatment, including a significant increase in the relative abundance of oral Streptococcus species in the gut (P=0.0004). These changes were particularly evident in patients whose microbial communities were Bacteroidaceae (Ba)-dominated at baseline, and those who developed severe (grade 3+) irAEs. Indeed, Ba-dominated microbiomes were linked with comparatively higher rates of severe irAEs compared to patients with Ruminococcaceae (Ru)-dominated gut microbiomes (P= 0.0440). Furthermore, Ba patients developed severe irAEs earlier during treatment, prior to week 6 (P=0.0016). A significant reduction in transitional B cells (CD24+ CD38hi CD27-) (P<0.0001) and an increase in activated B cells subsets (CD27- CD38- CD24- populations) (P=0.0022) were observed between baseline and week 6 across all patients who developed or went on to develop severe irAEs. Most notably, Ba patients who developed early, severe irAEs specifically had significantly higher frequencies of overall circulating B cells (P=0.0018) and lower frequencies of ICOS+ Tregs at week 6 post treatment (P=0.0005), which was not observed in Ru-dominated irAE patients. Conclusions: Higher risk of early, severe irAEs were associated with Bacteroidaceae-dominated gut microbiomes, reduced microbial community stability, and increases in activated circulating B cells during treatment. We postulate that differing baseline microbial community assemblages are associated with altered pre-established intestinal homeostasis influencing the likelihood of irAE development. Together, the data highlights a potential relationship between B cells, the gut microbiota and irAE development which may point to early steps in the induction of irAEs during ICI immunotherapy. Citation Format: Rebecca C. Simpson, Erin R. Shanahan, Ines P. Silva, Irene L. Reijers, Judith M. Versluis, Alexander M. Menzies, Gonzalez Maria, Umaimainthan Palendira, James S. Wilmott, Christian Blank, Richard A. Scolyer, Georgina V. Long. Altered microbial community stability and increases in circulating B cells are associated with the development of severe immune related adverse events during ICI-immunotherapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6681.

Abstract 2712: Development of GB268, a tri-specific antibody targeting PD-1/CTLA-4/VEGF, with enhanced anti-tumor efficacy and reduced toxicity in pre-clinical studies

Abstract Background: Immunotherapy using immune checkpoint modulators such as anti-PD1/PD-L1 have been widely used in cancer therapy. Combination of checkpoint inhibition using anti-PD1 and anti-CTLA4 has improved therapeutic efficacy but is also accompanied by severe immune related adverse events (irAEs) which limited their clinical use. Bi-specific antibody targeting PD-1/CTLA-4 such as cadonilimab has shown improved clinical benefits with reduced irAEs in cervical cancer. Vascular endothelial growth factor (VEGF) is overexpressed in various solid tumors and anti-VEGF agents inhibit neovascularization and shrink tumor with time. Combined application of bevacizumab and PD-1/PD-L1 blockade displays durable and improved anti-tumor effects. We have recently developed a novel tri-specific antibody GB268, specifically targeting PD-1, CTLA-4 and VEGF with fine-tuned activity & potency for each arm to simultaneously block PD-1/CTLA-4 mediated immune-suppression and VEGF mediated tumor angiogenesis. Methods: GB268 is a hexavalent antibody with symmetrical structure, composed of anti-PD-1 VHH antibody, anti-CTLA-4 VHH antibody, and anti-VEGF conventional antibody. The Fc part is silenced by introducing L234A/L235A mutations. Comprehensive in vitro and in vivo characterization of GB268 have been carried out. Along with in vivo efficacy studies, toxicity has also been evaluated with a murine arthritis model in hPD1/hCTLA4 double-KI mice to assess immune related AEs. Results: GB268 specifically bound to PD-1, VEGF, and CTLA-4 with high affinity and completely blocked PD-1 and VEGF pathways in reporter systems. To reduce the CTLA4 inhibition-induced AEs, the CTLA-4 arm was intentionally designed to only partially block the interaction of CTLA4 to its ligands CD80/CD86, and furthermore, the blockade of CTLA-4 was highly dependent on PD-1 expression. GB268 displayed robust anti-tumor efficacy with attenuated toxicity in murine models. In multiple PBMC-humanized models including A375 melanoma model, HT29 colorectal cancer model, and NCI-H460 NSCLC model, etc., GB268 exhibited significantly better anti-tumor efficacy, compared to PD-1/CTLA-4 bsAb and PD-1/VEGF bsAb, or in the combination of monoclonal antibodies to PD-1, CTLA-4 or VEGF. In arthritis induction model using hPD1/hCTLA4 double KI mice, GB268 had improved tolerance than cadonilimab and at least 20-fold better safety profile than ipilimumab combined with nivolumab. Conclusions: GB268 is a first-in-class anti-PD-1/CTLA-4/VEGF tri-specific antibody with innovative design. Preclinical data demonstrated GB268 is very effective in provoking anti-tumor responses. At the meantime, immune-related AEs is alleviated. Thus, GB268 may emerge as a promising novel therapeutics for cancer treatment. Citation Format: Qinglin Du, Yaxua Lv, Juehua Xu, Fei Peng, Huanhuan Cao, Xueyan Yang, Zhen Qian, Xueqin Li, Yiqi Cao, Qian Ding, Yongcong Tan, Shuhua Han. Development of GB268, a tri-specific antibody targeting PD-1/CTLA-4/VEGF, with enhanced anti-tumor efficacy and reduced toxicity in pre-clinical studies [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2712.

Abstract 3993: A tunable safety switch for solid tumor CAR T-cell therapy

Abstract On-target off-tumor toxicity, cytokine release syndrome (CRS), and immune effector cell-associated neurotoxicity syndrome (ICANS) are severe immune-related adverse events (irAEs) that are frequently associated with Chimeric Antigen Receptor (CAR) T-cell therapy. Current efforts to manage such therapy-related toxicities involve incorporation of an inducible suicide agent within CAR constructs, such as iCaspase-9 or herpes simplex virus type 1 thymidine kinase that can be selectively activated to produce toxic effects within CAR T cells and attenuate their activity. However, while activation of these agents helps to mitigate or overcome such unwarranted toxicities, the therapeutic benefit of CAR T cells anti-tumor activity is also compromised. Therefore, to continue maintenance of CAR T cells’ therapeutic function while minimizing irAEs, an ideal safety switch should 1) rapidly inhibit the activation and proliferation of CAR T cells exposed to the target antigen, 2) reversibly inhibit activity without inducing CAR T cell elimination and 3) be clinically translatable for safe application in patients. Our laboratory investigated one such safety switch to inhibit CAR T-cell activity while maintaining their therapeutic function. We showed that incorporating a mutant variant of c-KIT D816V (KITv) in the intracellular domain of mesothelin-targeting second-generation CAR T cells (M28z-KITv) improved efficacy in solid tumors with low antigen, or an immunosuppressive environment. Herein, we evaluate the use of Dasatinib, a clinically available multitarget (BCR, SRC, c-KIT) tyrosine kinase inhibitor (TKI), as a tunable safety switch to reversibly inhibit M28z-KITv CAR T-cell functional activity. In cohorts of mice established with lung adenocarcinoma, daily administration of Dasatinib starting on day 1 or day 3 after CAR T-cell administration stabilized tumor growth, which otherwise continued to regress in untreated mice, indicating inhibition of CAR T-cell functional activity. Upon discontinuation of Dasatinib, tumors regressed, indicating reversal of CAR T-cell functional activity. In an experiment conducted to investigate functional persistence of CAR T cells upon long-term exposure to Dasatinib (1 month), we noted uninhibited activity of CAR T cells to rechallenged tumors. Dasatinib, thus may act as a tunable safety switch to regulate M28z-KITv CAR T-cell activity without compromising its therapeutic function. Citation Format: Kyohei Misawa, Meriem Taleb, Srijita Banerjee, William-Ray Vista, Navin K. Chintala, Prasad S. Adusumilli. A tunable safety switch for solid tumor CAR T-cell therapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3993.

Abstract 7527: Investigating biomarkers for immune-related adverse events following immune checkpoint inhibitor therapy in recurrent lung cancer patients

Abstract Background: The application of immune checkpoint inhibitors (ICIs) as adjuvant therapy post-lung cancer surgery is expected to confer significant benefits. However, the risk factors for severe immune-related adverse events (irAEs) remain incompletely understood, and managing irAEs may require long-term steroid use. The identification of biomarkers for irAEs in patients with surgically resected lung cancer is an urgent need. Methods: We analyzed 43 lung cancer patients who received ICI treatment for recurrence postoperatively. Macrodissection of lung cancer lesions was performed on FFPE specimens from resected lungs, from which total RNA was extracted. We conducted gene expression analysis of 770 immune-related genes using the PanCancer Immune Profiling Panel (NanoString Technologies, Inc., Seattle, WA, USA). The relationship between gene expression changes and irAEs or the efficacy of ICI treatment was examined. For validation, immunostaining of proteins strongly associated with irAEs was performed to determine their expression status in tissue specimens. Results: Among the 43 patients (30 males, 13 females, median age 68), 28 had adenocarcinoma, and 15 had squamous cell carcinoma. PD-L1 positivity was observed in 36 patients. The treatment regimens included pembrolizumab monotherapy for 18 patients and combination immunotherapy for 25 patients, with 25 patients responding to treatment and 7 developing irAEs. There was a marked difference in gene expression between adenocarcinoma and squamous cell carcinoma, with a notably higher number of tumor-infiltrating lymphocytes (TILs) in adenocarcinoma. An increase in TILs was observed in cases with irAEs across both cancer types. Additionally, an increased CD8/Treg ratio and CD8/exhausted T cell ratio were noted in adenocarcinomas with irAEs. A strong correlation between IRF5 gene expression and the occurrence of irAEs in adenocarcinoma was also confirmed by immunohistochemistry. Conclusion: We have identified tumor immune microenvironments correlated with the onset of irAEs following ICI treatment in patients with postoperative recurrence of lung cancer. This discovery could contribute to perioperative treatment strategies and improve our understanding of tumor immune mechanisms. Citation Format: Yujin Kudo, Jun Matsubayashi, Satoshi Takahashi, Masaru Hagiwara, Masatoshi Kakihana, Toshitaka Nagao, Tatsuo Ohira, Norihiko Ikeda. Investigating biomarkers for immune-related adverse events following immune checkpoint inhibitor therapy in recurrent lung cancer patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 7527.

Abstract 3208: A nano sized system for the treatment of gastrointestinal cancers

Abstract Despite the recent progress in cancer immunotherapies, most patients do not benefit from the currently available immune checkpoint blockers, and many develop severe immune-related adverse events. Therefore, it is urgent to develop alternative, effective immunotherapeutic approaches. An example of non-responsive cancers are gastrointestinal (GI) cancers, which account for 26% of the global cancer incidence and 35% of all cancer-related deaths. In many GI cancers, the failure of immunotherapies to yield clinical response is partially attributed to the inefficient antigen presentation by DC, which results in insufficient T cell stimulation despite their expression of tumor-associated antigens (TAA). To overcome these hurdles, we designed novel polymeric-based nanoparticles (NP) to deliver a combination of GI cancers antigens of CEACAM5 protein and toll-like receptor ligands to DC. We chose to encapsulate CEACAM5 antigens because it is overexpressed in GI cancers, such as gastric cancer, colorectal cancer, and pancreatic cancer. With this approach, we aim to modulate the tumor milieu-immune cell interactions to an anti-cancer phenotype in order to control tumor growth and improve overall survival. Our NP present an average diameter below 200 nm, narrow polydispersity index, slightly negative surface charge, spherical morphology, and high antigens and immune potentiators loading. Cy5-labeled NPs were found to be extensively internalized by DC, which triggered their activation in vivo, shown by the increasing expression of DC-related co-stimulatory molecules such as CD80, CD86, and CD40. Furthermore, we assessed the immunotherapeutic effect of our NP on mouse models and on a human 3D multi-cellular spheroid ex-vivo model, composing the patient’s tumor cells and peripheral blood mononuclear cells (PBMC). We found that the NP successfully induced a potent immune-mediated anti-tumor response against CEACAM5-positive GI tumors, sensitizing the tumor microenvironment to other therapies and decreasing tumor volume, ultimately leading to prolonged survival. Taken together, the developed NP induced a strong antigen-specific immune response and overall sensitized CEACAM5-expressing GI cancers to the clinically relevant treatments in vivo, that so far have shown limited clinical outcomes in addition to a specific T cell anti-tumor activity that was shown on our patient-derived ex vivo model. Citation Format: Daniella Vaskovich, Rita Acúrcio, Ron Kleiner, Barbara Carreira, Ana Matos, Helena Florindo, Ronit Satchi-Fainaro. A nano sized system for the treatment of gastrointestinal cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3208.

Abstract 3861: Associations of intragenic rearrangement burden with immune cell infiltration and response to immune checkpoint blockade in cancer

Abstract While immune checkpoint blockade (ICB) induces durable cancer remission, only a small subset of patients can receive benefits, whereas a substantial portion of patients encounter severe immune-related adverse events. Further, about 4-29% of patients experience dramatic acceleration of disease progression after ICB treatment. Predictive biomarkers of ICB responses are in high demand to ensure patient benefits and avoid tragic clinical outcomes. In addition to PD-L1 tests, several genetic biomarkers are associated with ICB effectiveness, such as tumor mutation burden (TMB), somatic copy number aberrations, indels, and microsatellite instability. However, none of these neoantigen markers are sufficient to discriminate ICB responders in diverse cancer entities of distinct genetic profiles. In particular, TMB fails to predict in the cancer types with low simple mutation rates, such as triple-negative breast cancer (TNBC), ovarian cancer, and esophageal cancers. In TNBC, high TMB only accounts for 5-10% of patients, whereas a much larger proportion of tumors are inflamed (26-50%), which suggests a possible uncharacterized major source of neoantigens. Similarly, TMB is not predictive of ICB response in ovarian cancers according to the IMagyn050 trial. In esophageal cancer, TMB is not associated with T cell infiltration and does not predict ICB response. Our analyses of Pan-cancer whole genomes revealed that intragenic rearrangement (IGR) burden is a pivotal contributor to immune infiltration in breast, ovarian, esophageal, and endometrial cancers, which correlates with increased Macrophage M1 and CD8+ T cell signatures. IGRs result in exon duplications or deletions through rearrangements of a genomic distance of tens of kilobases. Multivariate regression against spatially counted tumor infiltrated lymphocytes in breast, endometrial, and ovarian cancers suggest that IGR burden is a more influential covariate than other genetic aberrations in these cancers. In the MEDI4736 trial evaluating durvalumab in esophageal adenocarcinoma, IGR burden correlates with patient benefits. In the IMVigor210 trial evaluating atezolizumab in urothelial carcinoma, IGR burden increases with platinum exposure and predicts patient benefits for TMB-low, platinum-exposed tumors. Altogether, we demonstrate that IGR burden contributes to T-cell inflammation and predicts ICB benefits in TMB-low, IGR-dominant tumors, or in platinum-exposed tumors. IGRs as a cryptic class of structural variants have been heretofore overlooked in cancer genomics studies. The association of IGRs with ICB response has not been previously reported in cancer in general. The development of IGR burden-based predictive marker could increase effectiveness of ICB therapy, reduce severe side-effects and unnecessary costs. Citation Format: Han Zhang, Sanghoon Lee, Renee R. Muthakana, Binfeng Lu, David N Boone, Daniel Lee, Xiaosong Wang. Associations of intragenic rearrangement burden with immune cell infiltration and response to immune checkpoint blockade in cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3861.

Abstract 3460: Predicting cessation of immune checkpoint inhibitor therapy due to severe adverse events with an integrated autoimmune disease polygenic risk score

Abstract Background: Immune checkpoint inhibitors (ICIs), including anti-PD1/PD-L1 and anti-CTLA4 agents, have changed the landscape of cancer therapy. However, 6-30% of patients treated with ICIs can develop severe immune-related adverse events (irAEs) depending on the type of therapy used, often leading to cessation of treatment. Hundreds of genetic variants have been associated with autoimmune disorders, and recent genetic studies have developed polygenic risk scores (PRS) for composite risk of autoimmune disease (PRSAID). We used data from an ongoing observational study of patients with non-small cell lung cancer (NSCLC) treated with ICIs to evaluate the association between PRSAID and cessation of ICI therapy due to severe irAEs. Methods: Our cohort comprises 1,316 advanced NSCLC patients who received ICI therapy from four institutions between 2009 and 2022. Genotyping was performed using the Affymetrix Precision Medicine Array, and imputation was performed using 1000 Genomes Reference. To evaluate cessation of therapy due to severe irAEs, we conducted a thorough review of electronic health records. We identified permanent discontinuation of ICIs due to irAEs as cessation for at least 6 months without any disease progression. We tested the association of a previously published PRSAID (PMID: 35393596) with cessation of ICI due to any severe irAE. PRSAID was converted to a standard normal distribution. We conducted an unconditional logistic regression model to evaluate the association between a standardized PRSAID and discontinuation of ICI therapy due to severe irAEs. All models were adjusted for age at diagnosis, sex, type of ICI therapy, recruitment site, and 5 ancestry-informative principal components. Results: Of the 1,316 participants with genotype and outcome data, 171 (13.5%) of patients stopped ICI therapy due to severe irAEs. The most common irAEs leading to discontinuation were colitis, hepatitis, and pneumonitis. The PRSAID predicts the cessation of therapy due to severe irAEs with an odds ratio (OR) per standard deviation (SD) of 1.20 (95% confidence intervals [CI]=1.02-1.41, p=0.03). The association was stronger in individuals with high genetic risk (top 25th percentile compared to bottom 75th percentile of the PRSAID) (OR=1.60, 95% CI = 1.11-2.28, p=0.01). When we stratified the analysis by therapy type, we found an OR of 1.17 (95% CI-0.98-1.39, p = 0.08) for the anti-PD1/PD-L1 monotherapy groups and an OR of 1.48 (95% CI=0.94-2.40,p=0.09) for the dual anti-PD1/PD-L1 and anti-CTLA4 therapy group. Conclusions: An integrated PRS for autoimmunity can predict the cessation of ICI therapy due to severe irAEs in patients with advanced cancer. These findings suggest that PRS may help determine which patients may benefit from careful monitoring or even preventative measures for irAEs during ICI therapy. Citation Format: Pooja Middha, Rohit Thummalapalli, Zoe Quandt, Princess Margaret Lung Group, Matthew A. Gubens, Christine M. Lovly, Geoffrey Liu, Melinda C. Aldrich, Adam J. Schoenfeld, Elad Ziv. Predicting cessation of immune checkpoint inhibitor therapy due to severe adverse events with an integrated autoimmune disease polygenic risk score [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3460.

Fulminant myocarditis during postoperative adjuvant chemotherapy for lung cancer with atezolizumab: a case report

BackgroundPostoperative adjuvant systemic therapy with atezolizumab for lung cancer has been reported to be effective. Although myocarditis is a rare immune adverse event associated with atezolizumab, it can have a serious course and should be treated with caution. We herein report a case of fulminant myocarditis during adjuvant systemic therapy with atezolizumab.Case presentationThe patient was a 49-year-old Asian woman. She was diagnosed with pT2aN1M0 stage IIB (Programmed Death Ligand 1(PD-L1), 50%) after surgery for right upper lobe lung adenocarcinoma. Atezolizumab was administered following platinum-based adjuvant chemotherapy. On day 14, the patient was hospitalized because of deterioration in her general condition caused by fever. On day 16, she developed dyspnea, which worsened, and on day 17, she experienced shock. Blood tests, echocardiography, and cardiac catheterization were performed, and the patient was diagnosed with cardiogenic shock due to myocarditis. Initial measures did not improve the patient’s shock state. The patient was transferred to hospital for the use of an assistive circulatory system. Pulse steroid therapy was administered, and myocarditis showed a tendency toward improvement. A retrospective review of the patient’s history revealed a decreased lymphocyte count and an increase in the neutrophil/lymphocyte ratio, which may be useful for detecting severe immune-related adverse events. The troponin levels were elevated, but creatine phosphokinase level remained within the normal range.ConclusionMyocarditis can be fatal due to the rapid progression of symptoms. Close follow-up, a prompt diagnosis, and therapeutic intervention are important. Decreased lymphocyte counts, increased neutrophil/lymphocyte ratios, and the measurement of multiple myocardial biomarkers are considered useful for the early diagnosis of myocarditis.

Association between Immune Checkpoint Inhibitors and Atherosclerotic Cardiovascular Disease Risk: Another Brick in the Wall.

In recent years, immune checkpoint inhibitors have significantly changed the field of oncology, emerging as first-line treatment, either alone or in combination with other regimens, for numerous malignancies, improving overall survival and progression-free survival in these patients. However, immune checkpoint inhibitors might also cause severe or fatal immune-related adverse events, including adverse cardiovascular events. Initially, myocarditis was recognized as the main immune checkpoint inhibitor-related cardiac event, but our knowledge of other potential immune-related cardiovascular adverse events continues to broaden. Recently, preclinical and clinical data seem to support an association between immune checkpoint inhibitors and accelerated atherosclerosis as well as atherosclerotic cardiovascular events such as cardiac ischemic disease, stroke, and peripheral artery disease. In this review, by offering a comprehensive overview of the pivotal role of inflammation in atherosclerosis, we focus on the potential molecular pathways underlying the effects of immune checkpoint inhibitors on cardiovascular diseases. Moreover, we provide an overview of therapeutic strategies for cancer patients undergoing immunotherapy to prevent the development of cardiovascular diseases.

The Efficacy and Safety of Nivolumab Plus mFOLFOX6 in Gastric Cancer with Severe Peritoneal Metastasis

(1) Background: Nivolumab plus chemotherapy is established as a first-line treatment for advanced gastric cancer (AGC). While mFOLFOX6 is commonly used for AGC with severe peritoneal metastasis, the efficacy of nivolumab combined with it remains uncertain. We evaluated the outcomes of nivolumab plus mFOLFOX6 for AGC with severe peritoneal metastasis in clinical practice. (2) Methods: This multicenter retrospective study was conducted between December 2021 and June 2023. We investigated AGC patients with massive ascites or inadequate oral intake due to severe peritoneal metastasis and who received nivolumab plus mFOLFOX6. (3) Results: Among 106 patients treated with nivolumab plus chemotherapy, 21 (19.8%) had severe peritoneal metastasis, with 14 receiving nivolumab plus mFOLFOX6. The median progression-free survival was 7.4 months (95%CI 1.9-10.1), and the median overall survival was 10.7 months (95%CI 5.3-NA), with four patients (28.5%) surviving more than 12 months. Improved ascites and oral intake were observed in 6/14 patients (42.8%) and 10/11 patients (90.9%), respectively. The major grade 3 or more adverse events included leukopenia (28.5%) and neutropenia (21.4%), with no severe immune-related adverse events reported. (4) Conclusions: The safety and moderate efficacy of nivolumab plus mFOLFOX6 were suggested even in AGC patients with severe peritoneal metastasis.

Risk of severe immune-related adverse events in cancer patients with pre-existing autoimmunity receiving immune checkpoint inhibitor therapy

Risk of severe immune-related adverse events in cancer patients with pre-existing autoimmunity receiving immune checkpoint inhibitor therapy

Abstract B025: IL-1 blockade prevents cardiac toxicity and improves immunotherapy efficacy in mouse models of pancreatic cancer

Abstract Background: Immune checkpoint blockers (ICBs) have revolutionized cancer treatment, but they are often associated with severe immune related adverse events (irAEs). These severe irAEs are more often seen in patients with obesity or concomitantly treated with cytotoxic therapies. Methods: We aimed to understand the mechanisms of ICB-induced irAEs, in the context of obesity and ICB/chemotherapy combinations. We developed a mouse model of cardiac irAEs, which is the most fatal type of irAE in ICB-treated cancer patients, with clinically relevant features: (i) an ICB-resistant cancer (pancreatic ductal adenocarcinoma or PDAC), (ii) obesity induced with high-fat diets, and (iii) a combination treatment of ICB (α-PD1 + α-CTLA4) and chemotherapy (FOLFIRINOX). Results: Our FDA and single institution retrospective analyses indicate that patients treated with ICB had greater relative risk of developing myocarditis as compared to other anti-cancer therapies. Mice with orthotopic PDAC and obesity developed irAEs after treatment with ICB and chemotherapy as compared to chow diet. These irAEs recapitulated those observed in patients with cancer and obesity, including cardiac dysfunction consistent with myocarditis, cardiac fibrosis, and increased circulating levels of interleukin-1 beta (IL-1b). IL-1β blockade prevented myocarditis and reduced cardiac fibrosis after immunotherapy. Importantly, IL-1β blockade also enhanced the anti-tumor effects of ICB + FOLFIRINOX combination therapy, and increased mouse survival. Conclusions: We developed a translationally relevant 'triple hit' mouse model and discovered that IL-1β mediates ICB-induced cardiotoxicity. In addition, we found that IL-1β blockers, which are already used in the clinic for cardiology indications, both reduce adverse events and simultaneously enhance the antitumor effects triggered by immunotherapy. Citation Format: Nilesh P. Talele, Heena Kumra, Igor L. Gomes-Santos, Sylvie Roberge, William W. Ho, Patrick Andersson, Sampurna Chatterjee, Marie Siwicki, Dan G. Duda, Mikael J. Pittet, Dai Fukumura, Rakesh K. Jain. IL-1 blockade prevents cardiac toxicity and improves immunotherapy efficacy in mouse models of pancreatic cancer [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Pancreatic Cancer; 2023 Sep 27-30; Boston, Massachusetts. Philadelphia (PA): AACR; Cancer Res 2024;84(2 Suppl):Abstract nr B025.