Ex Vivo Testing of Patient-Derived Xenografts Mirrors the Clinical Outcome of Patients with Pancreatic Ductal Adenocarcinoma

Image-based ex-vivo drug screening for patients with aggressive haematological malignancies: interim results from a single-arm, open-label, pilot study

Background

Patients with refractory or relapsed haematological malignancies have few treatment options and short survival times. Identification of effective therapies with genomic-based precision medicine is hampered by intratumour heterogeneity and incomplete understanding of the contribution of various mutations within specific cancer phenotypes. Ex-vivo drug-response profiling in patient biopsies might aid effective treatment identification; however, proof of its clinical utility is limited.

Methods

We investigated the feasibility and clinical impact of multiparametric, single-cell, drug-response profiling in patient biopsies by immunofluorescence, automated microscopy, and image analysis, an approach we call pharmacoscopy. First, the ability of pharmacoscopy to separate responders from non-responders was evaluated retrospectively for a cohort of 20 newly diagnosed and previously untreated patients with acute myeloid leukaemia. Next, 48 patients with aggressive haematological malignancies were prospectively evaluated for pharmacoscopy-guided treatment, of whom 17 could receive the treatment. The primary endpoint was progression-free survival in pharmacoscopy-treated patients, as compared with their own progression-free survival for the most recent regimen on which they had progressive disease. This trial is ongoing and registered with ClinicalTrials.gov, number NCT03096821.

Findings

Pharmacoscopy retrospectively predicted the clinical response of 20 acute myeloid leukaemia patients to initial therapy with 88·1% accuracy. In this interim analysis, 15 (88%) of 17 patients receiving pharmacoscopy-guided treatment had an overall response compared with four (24%) of 17 patients with their most recent regimen (odds ratio 24·38 [95% CI 3·99–125·4], p=0·0013). 12 (71%) of 17 patients had a progression-free survival ratio of 1·3 or higher, and median progression-free survival increased by four times, from 5·7 (95% CI 4·1–12·1) weeks to 22·6 (7·4–34·0) weeks (hazard ratio 3·14 [95% CI 1·37–7·22], p=0·0075).

Interpretation

Routine clinical integration of pharmacoscopy for treatment selection is technically feasible, and led to improved treatment of patients with aggressive refractory haematological malignancies in an initial patient cohort, warranting further investigation.

Funding

Austrian Academy of Sciences; European Research Council; Austrian Science Fund; Austrian Federal Ministry of Science, Research and Economy; National Foundation for Research, Technology and Development; Anniversary Fund of the Austrian National Bank; MPN Research Foundation; European Molecular Biology Organization; and Swiss National Science Foundation.

Precision Oncology: The Road Ahead

Current efforts in precision oncology largely focus on the benefit of genomics-guided therapy. Yet, advances in sequencing techniques provide an unprecedented view of the complex genetic and nongenetic heterogeneity within individual tumors. Herein, we outline the benefits of integrating genomic and transcriptomic analyses for advanced precision oncology. We summarize relevant computational approaches to detect novel drivers and genetic vulnerabilities, suitable for therapeutic exploration. Clinically relevant platforms to functionally test predicted drugs/drug combinations for individual patients are reviewed. Finally, we highlight the technological advances in single cell analysis of tumor specimens. These may ultimately lead to the development of next-generation cancer drugs, capable of tackling the hurdles imposed by genetic and phenotypic heterogeneity on current anticancer therapies.

Preclinical Cancer Models and Biomarkers for Drug Development: New Technologies and Emerging Tools

Background and purpose

Predicting the efficacy of anticancer therapy is the holy grail of drug development and treatment selection in the clinic. To achieve this goal, scientists require pre-clinical models that can reliably screen anticancer agents with robust clinical correlation. However, there is increasing challenge to develop models that can accurately capture the diversity of the tumor ecosystem, and therefore reliably predict how tumors respond or resistant to treatment. Indeed, tumors are made up of a heterogeneous landscape comprising malignant cells, normal and abnormal stroma, immune cells, and dynamic microenvironment containing chemokines, cytokines and growth factors. In this mini-review we present a focused, brief perspective on emerging preclinical models for anticancer therapy that attempt to address the challenge posed by tumor heterogeneity, highlighting biomarkers of response and resistance.

Recent findings

Starting from 2-dimensional and 3-dimensional in-vitro models, we discuss how organoid co-cultures have led to accelerated efforts in anti-cancer drug screening, and advanced our fundamental understanding for mechanisms of action using high-throughput platforms that interrogate various biomarkers of ‘clinical’ efficacy. Then, mentioning the limitations that exist, we focus on in-vivo and human explant technologies and models, which build-in intrinsic tumor heterogeneity using the native microenvironment as a scaffold. Importantly, we will address how these models can be harnessed to understand cancer immunotherapy, an emerging therapeutic strategy that seeks to recalibrate the body’s own immune system to fight cancer.

Conclusion

Over the past several decades, numerous model systems have emerged to address the exploding market of drug development for cancer. While all of the present models have contributed critical information about tumor biology, each one carries limitations. Harnessing pre-clinical models that incorporate cell heterogeneity is beginning to address some of the underlying challenges associated with predicting clinical efficacy of novel anticancer agents.

Interventional endoscopic ultrasonography: Where are we headed?

Endoscopic ultrasonography (EUS) is an essential endoscopic tool within the diagnostic and therapeutic armamentarium of gastrointestinal and hepatic diseases. EUS-guided tissue acquisition will develop towards facilitating personalized treatment by obtaining large representative tissue specimens for elaborate immunohistochemical and biomolecular typing of the tumor. Intratumoral or intravascular delivery of drugs potentially offers many advantages over systemic injection. Intratumoral application of radiofrequency ablation and photodynamic therapy show promise but need to be explored further. Appositioning and connecting luminal structures within the gastrointestinal tract using fully covered expandable lumen-apposing stents will expand its indication far beyond the drainage of (infected) fluid collections and EUS-guided gastrojejunostomy is a particularly exciting development that could have significant impact on the management of gastric outlet obstruction.