Immune suppressive microenvironment in liver metastases contributes to organ-specific response of immunotherapy in advanced non-small cell lung cancer

Recent advances in biomarkers for predicting the efficacy of immunotherapy in non-small cell lung cancer

Lung cancer continues to be the primary cause of cancer-related deaths globally, with non-small cell lung cancer (NSCLC) accounting for approximately 85% of all instances. Recently, immune checkpoint inhibitors (ICIs) have transformed the treatment approach for NSCLC, however, only a subset of patients experiences significant benefits. Therefore, identifying reliable biomarkers to forecast the efficacy of ICIs is crucial for ensuring the safety and effectiveness of treatments, becoming a major focus of current research efforts. This review highlights the recent advances in predictive biomarkers for the efficacy of ICIs in the treatment of NSCLC, including PD-L1 expression, tertiary lymphoid structures (TLS), tumor-infiltrating lymphocytes (TILs), tumor genomic alterations, transcriptional signatures, circulating biomarkers, and the microbiome. Furthermore, it underscores the pivotal roles of liquid biopsy, sequencing technologies, and digital pathology in biomarker discovery. Special attention is given to the predictive value of TLS, circulating biomarkers, and transcriptional signatures. The review concludes that the integration of multiple biomarkers holds promise for achieving more accurate efficacy predictions and optimizing personalized immunotherapy strategies. By providing a comprehensive overview of the current progress, this review offers valuable insights into biomarker-based precision medicine for NSCLC and outlines future research directions.

Perspectives on the role of "-Omics" in predicting response to immunotherapy

The annual Immuno-Oncology "Think Tank" held in October 2023 in Siena reviewed the rapidly evolving systems-biological approaches which are now providing a deeper understanding of tumor and tumor microenvironment heterogeneity. Based on this understanding opportunities for novel therapies may be identified to overcome resistance to immunotherapy. There is increasing evidence that malignant disease processes are not limited to purely intracellular or genetic events but constitute a dynamic interaction between the host and disease. Tumor responses are influenced by many host tissue determinants across different cellular compartments, which can now be investigated by high-throughput molecular profiling technologies, often labelled with a suffix "-omics". "Omics" together with ever increasing computational power, fast developments in machine learning, and high-resolution detection tools offer an unrivalled opportunity to connect high-dimensional data and create a holistic view of disease processes in cancer. This review describes advances in several state-of-the-art "-omics" approaches with perspectives on how these can be applied to the clinical development of new immunotherapeutic strategies and ultimately adopted in clinical practice.

Clinical and dynamic circulating cytokines profile features of long-term progression-free survival benefit to immune checkpoint inhibitors in advanced non-small cell lung cancer

BACKGROUND

Immune checkpoint inhibitors (ICIs) offer durable progression-free survival (PFS) benefit in a subset of patients with advanced non-small cell lung cancer (NSCLC). However, the predictors of long-term PFS (LTPFS) remain unclear.

METHODS

Advanced NSCLC patients receiving first-line ICIs monotherapy at Guangdong Lung Cancer Institute between December 2017 and August 2022 were identified. Predictive value of different characteristics was evaluated in LTPFS (PFS ≥ 24 months) compared with short-term PFS (STPFS, PFS ≤ 3 months). Circulating cytokine levels were evaluated in paired peripheral blood samples collected before and after ICIs treatment.

RESULTS

Among 202 patients identified and 171 included (median follow-up: 41.0 months), 44 (25.7%) experienced LTPFS, associated with a 5-year overall survival (OS) rate of 81.2%. Squamous NSCLC, intermediate or poor lung immune prognostic index (LIPI) score, and liver metastases, were negatively associated with LTPFS. High tumor mutational burden (TMB, ≥ 10 mutations/megabase) was enriched in LTPFS compared to STPFS (P = 0.002). Patients with both high TMB and PD-L1 demonstrated the greatest survival benefit from first-line ICIs monotherapy (median PFS: 24.5 months, median OS: 67.0 months). Thirty-eight peripheral blood samples were collected before and after ICIs treatment from 10 patients with LTPFS and 9 with STPFS, which revealed increased CCL11 (P = 0.013) and decreased IL1RA (P = 0.001) and IL17A (P = 0.003) levels in LTPFS after ICIs treatment.

CONCLUSION

Distinct clinical characteristics, including TMB, PD-L1, pathologic subtypes, LIPI score, number of organs involved, metastatic sites, and dynamic circulating cytokines profile features, can distinguish NSCLC patients achieving LTPFS from those with STPFS following first-line ICIs monotherapy.

Organ-specific immune-related adverse events and prognosis in cancer patients receiving immune checkpoint inhibitors

BACKGROUND

Patients who developed immune-related adverse events (irAEs) could benefit more from treatment with immune checkpoint inhibitors (ICIs) than those who did not develop irAEs. This study was designed to assess whether the occurrence of irAEs or their characteristics are correlated with survival in advanced patients treated with ICIs.

METHODS

This retrospective cohort study enrolled a panel of cancer patients who received ICIs at a single institute. Kaplan‒Meier curves were generated to describe progression-free survival (PFS) and overall survival (OS) in patients with irAEs or specific irAE characteristics.

RESULTS

A total of 238 patients were enrolled, 83 (34.9%) of whom developed at least one irAE. Overall, irAE development was associated with prolonged OS (not reached vs. 17.8 months, P < 0.001), PFS (8.7 vs. 4.8 months, P = 0.003), and an improved objective response rate (24.1% vs. 10.3%, P = 0.005). Furthermore, only skin or endocrine toxicities were associated with improved OS and PFS. On the basis of the results from organ-specific irAEs, the first development of skin or endocrine toxicities as protective irAEs rather than other irAEs was an independent indicator for predicting OS (P < 0.001) and PFS (P < 0.001). A protective irAE burden score based on organ-specific irAEs was further developed to show the significant protective effect of total irAEs on patient outcomes.

CONCLUSIONS

Not all irAEs are associated with prolonged survival. The identification of organ-specific irAEs is useful for stratifying patients who actually respond to and benefit from ICIs across different cancer types.

From Images to Genes: Radiogenomics Based on Artificial Intelligence to Achieve Non-Invasive Precision Medicine in Cancer Patients

With the increasing demand for precision medicine in cancer patients, radiogenomics emerges as a promising frontier. Radiogenomics is originally defined as a methodology for associating gene expression information from high-throughput technologies with imaging phenotypes. However, with advancements in medical imaging, high-throughput omics technologies, and artificial intelligence, both the concept and application of radiogenomics have significantly broadened. In this review, the history of radiogenomics is enumerated, related omics technologies, the five basic workflows and their applications across tumors, the role of AI in radiogenomics, the opportunities and challenges from tumor heterogeneity, and the applications of radiogenomics in tumor immune microenvironment. The application of radiogenomics in positron emission tomography and the role of radiogenomics in multi-omics studies is also discussed. Finally, the challenges faced by clinical transformation, along with future trends in this field is discussed.

Dissociated response and treatment outcome with immune checkpoint blockade in advanced cancer

Immune-related dissociated response (DR) has been recently recognized and have become a subject of ongoing interest. The purpose of the present study was to evaluate the frequency, treatment outcome, and predictors of DR in cancer patients with immune checkpoint inhibitors. We retrospectively collected clinicopathological data from a cohort of patients with cancer who received PD-1/PD-L1 inhibitor-based monotherapy or combination therapy at a single institution (developing cohort). An independent cohort of advanced non-small cell lung cancer (NSCLC) patients treated with immunotherapy at two institutions was used as the validating cohort. Progression-free survival (PFS) and overall survival (OS) were used as outcome measures. The pantumor cohort included 177 patients. DR were observed in 12 (6.8%) patients. The median PFS and OS were significantly longer in patients with atypical response versus nonresponse but shorter versus true response. Patients with DR had a longer median PFS and OS than those with true progressive disease (PD). Local treatment seemed to have a positive influence on DR patient outcomes, with a median OS of 32.3 months versus 21.9 months for no local treatment. No clinical characteristics remained significant predictors for DR. In the NSCLC cohort, DR was observed in 10 (12.5%) patients. Inferior PFS and OS were validated in patients with real PD when compared with patients with DR. Patients who experience DR exhibit a relatively favorable prognosis. Some patients with DR may benefit from the continuation of ICI administration and local treatment to the growing lesions and achieve a longer survival.

Epithelial-Mesenchymal Transition in Non-Small Cell Lung Cancer Management: Opportunities and Challenges

Lung cancer, the leading cause of death worldwide, is associated with the highest morbidity. Non-small cell lung cancer (NSCLC) accounts for 80-85% of lung cancer cases. Advances in the domain of cancer treatment have improved the prognosis and quality of life of patients with metastatic NSCLC. Nevertheless, tumor progression or metastasis owing to treatment failure caused by primary or secondary drug resistance remains the cause of death in the majority of cases. Epithelial-mesenchymal transition (EMT), a vital biological process wherein epithelial cancer cells lose their inherent adhesion and transform into more invasive mesenchymal-like cells, acts as a powerful engine driving tumor metastasis. EMT can also induce immunosuppression in the tumor environment, thereby promoting cancer development and poor prognosis among patients with NSCLC. This review aims to elucidate the effect of EMT on metastasis and the tumor immune microenvironment. Furthermore, it explores the possible roles of EMT inhibition in improving the treatment efficacy of NSCLC. Targeting EMT may be an ideal mechanism to inhibit tumor growth and progression at multiple steps.

Treatment Options for Patients with Non-Small Cell Lung Cancer and Liver Metastases

Lung cancer represents the most common cause of cancer-related death. Patients with non-small cell lung cancer (NSCLC) and liver metastases have worse prognosis, with an overall survival (OS) from three to six months. The majority of them have a poor response to chemotherapy, and the data are controversial regarding the response to immunotherapy. This could be because the liver is considered to be an immune-tolerant organ, which is characterized by T-cell anergy and immunosuppressive signals. This review evaluates current treatment options for patients with NSCLC and liver metastases. Combination therapies might be a better treatment option for this subgroup of patients. The addition of radiotherapy to immunotherapy could also be an option in selected patients. The resection of single liver metastasis should also be considered.

Role of immunotherapy in gastric cancer with liver metastasis

Gastric cancer continues to be a significant issue for public health, marked by its widespread occurrence and high mortality rates, even as the incidence of the disease shows a declining trend. The liver is the primary site for metastatic spread, with the peritoneum, lungs, and bones also being common targets. With the advent of biologic treatments and the introduction of immunotherapy for patients with metastatic conditions, the options to treat metastatic gastric cancer have expanded. This diversified therapeutic approach is designed to enhance patient quality of life and prolong survival, showcasing the progress in treatment modalities for individuals with gastric cancer and liver metastases.

Long-Term Outcomes in Patients with EGFR Positive Lung Adenocarcinoma and Subgroup Analysis Based on Presence of Liver Metastases

Lung cancer represents the most common cause of cancer related death. Patients with non-small cell lung cancer (NSCLC) and liver metastases (LM) have worse prognosis with an overall survival (OS) of three to six months. The aim of this study was to investigate long-term outcomes in patients with EGFR mutated (EGFRmut) lung adenocarcinoma as well as the presence of LM. (A total of 105 patients were included in the analysis). They were divided into two groups based on the presence of LM. OS was 13 months for the whole group and also 13 months for patients with and without LM. The 9-year survival rate for patients with and without LM was 12.5% and 3.4%, respectively. Further, the 9-year survival rate for the whole group of patients was 4.8%. There are few data about survival rates beyond 5 years for patients with locally advanced and metastatic EGFRmut NSCLC, mainly because patients with lung cancer rarely live for such a long time. Regarding patients with liver metastases, the results of our study showed similar outcomes compared to patients without LM. As these patients represent a significant number of patients, we need a wider range of therapeutic options. It might be that combination therapies represent a better therapeutic option.

DNA repair-dependent immunogenic liabilities in colorectal cancer: opportunities from errors

Colorectal cancer (CRC) remains one of the major causes of cancer death worldwide. Chemotherapy continues to serve as the primary treatment modality, while immunotherapy is largely ineffective for the majority of CRC patients. Seminal discoveries have emphasized that modifying DNA damage response (DDR) mechanisms confers both cell-autonomous and immune-related vulnerabilities across various cancers. In CRC, approximately 15% of tumours exhibit alterations in the mismatch repair (MMR) machinery, resulting in a high number of neoantigens and the activation of the type I interferon response. These factors, in conjunction with immune checkpoint blockades, collectively stimulate anticancer immunity. Furthermore, although less frequently, somatic alterations in the homologous recombination (HR) pathway are observed in CRC; these defects lead to genome instability and telomere alterations, supporting the use of poly (ADP-ribose) polymerase (PARP) inhibitors in HR-deficient CRC patients. Additionally, other DDR inhibitors, such as Ataxia Telangiectasia and Rad3-related protein (ATR) inhibitors, have shown some efficacy both in preclinical models and in the clinical setting, irrespective of MMR proficiency. The aim of this review is to elucidate how preexisting or induced vulnerabilities in DNA repair pathways represent an opportunity to increase tumour sensitivity to immune-based therapies in CRC.

Site-Specific Response and Resistance Patterns in Patients with Advanced Non-Small-Cell Lung Cancer Treated with First-Line Systemic Therapy

Patients with advanced NSCLC have heterogenous responses to immune checkpoint inhibitors (ICIs) with or without chemotherapy. In NSCLC, the impact of the distribution of metastatic sites and the response to systemic therapy combinations remain poorly understood. In a retrospective cohort study of patients with unresectable stage III/IV NSCLC who received first-line systemic therapy, we sought to assess the association between the site of metastases with patterns of response and progression. Data regarding demographics, tumour characteristics (including site, size, and volume of metastases), treatment, and outcomes were examined at two cancer care centres. The endpoints included organ site-specific response rate, objective response rate (ORR), progression-free survival (PFS), and overall survival (OS). Two-hundred and eighty-five patients were included in the analysis. In a multivariate analysis, patients with bone metastases had a reduced ORR, PFS, and OS. Primary resistance was also more likely in patients with bone metastases. Patients with bone or liver metastases had a shorter OS when receiving ICIs with or without chemotherapy, but not with chemotherapy alone, suggesting an immunological basis for therapeutic resistance. A directed assessment of the tumour microenvironment in these locations and a deeper understanding of the drivers of organ-specific resistance to immunotherapy are critical to optimise novel combination therapies and sequencing in these patients.

Poor efficacy of immune checkpoint inhibitor treatment in advanced thymic carcinoma patients with liver metastases

Background

Although immune checkpoint inhibitor treatment for advanced thymic carcinoma exhibits promising efficacy, factors that affect the efficacy and prognosis, including metastases sites, remain uncertain.

Objectives

Our study aimed to investigate the determinants of survival among patients with advanced thymic carcinoma who underwent immunotherapy in real-world settings, with implications for clinical practice.

Designs

Different therapy regimens of immunotherapy were produced to analyze the influence of liver metastases on survival and prognosis for advanced thymic carcinoma patients.

Methods

Data for advanced thymic carcinoma patients receiving immunotherapy and their metastases sites were collected for analysis from seven different hospitals between January 2015 and January 2023. Progression-free survival (PFS) and overall survival (OS) analyses were performed using the Kaplan-Meier method. Cox analysis was used to evaluate factors influencing survival.

Results

The present study analyzed 136 advanced thymic carcinoma patients from seven different hospitals.The PFS for all patients receiving immunotherapy was 6.4 months, while the OS was 24.0 months. The objective response rate was different for patients with liver and non-liver metastases (11.9% versus 37.2%, p = 0.003). The disease control rate values were also different between the two groups (47.6% versus 80.9%, p = 0.037). The PFS for patients with liver metastases demonstrated poor immunotherapy efficacy compared to patients with non-liver metastases (3.0 versus 8.0 months, p < 0.0001). The OS was also significantly different between these two patient groups (16.1 versus 29.1 months, p = 0.009).

Conclusion

Immunotherapy had poor efficacy in advanced thymic carcinoma patients with liver metastases.

Combined Stereotactic Body Radiation Therapy and Immune Checkpoint Inhibition for Liver Metastases: Safety and Outcomes in a Pooled Analysis of 3 Phase 1 Trials

PURPOSE

Stereotactic body radiation therapy (SBRT) safely and effectively controls liver metastases (LMs), but its safety and efficacy when combined with immune checkpoint inhibitors (ICIs) are not well characterized. This analysis of 3 phase 1 trials of combination SBRT and ICI evaluates whether LM-SBRT increases the risk for hepatotoxicity when combined with ICI and explores efficacy endpoints.

METHODS AND MATERIALS

Data were analyzed from 3 phase 1 trials of combination SBRT and ICI for patients with metastatic solid tumors conducted between 2016 and 2020. ICI was administered per trial protocol with LM-SBRT delivered to 45 Gy in 3 fractions with mean liver dose <16 Gy and ≥700 cc of normal liver spared 17.1 Gy. Hepatic adverse events (HAEs) were defined as hepatic failure, autoimmune hepatitis, or elevation of aspartate transaminase, alanine transaminase, bilirubin, or alkaline phosphatase using Common Terminology Criteria for Adverse Events version 4.0. Cumulative incidence of HAEs and local failure were modeled with death as a competing risk. Competing risk regression was performed using Fine-Gray modeling. Survival was estimated via the Kaplan-Meier method.

RESULTS

Two hundred patients were analyzed, including 81 patients with LM, 57 of whom received LM-SBRT. The 12-month rate of any grade ≥2 HAE was 11% and 10% in LM-SBRT and non-LM-SBRT patients, respectively non-significant (NS). Radiographic evidence for liver disease and dual-agent ICI was significantly associated with HAEs on univariable and multivariable analysis, but liver dose metrics were not. Patients with LM had significantly worse progression-free and overall survival compared with those without, and local failure of treated LM was significantly higher than for treated extrahepatic metastases (28% vs 4% at 12 months, P < .001).

CONCLUSIONS

Combination LM-SBRT and ICI did not significantly increase the risk for HAEs compared with ICI without LM-SBRT, suggesting hepatotoxicity is largely driven by factors other than liver radiation therapy, such as choice of ICI. LM is associated with worse overall survival and local control outcomes.

PD-(L)1 inhibitors plus bevacizumab and chemotherapy as first-line therapy in PD-L1-negative metastatic lung adenocarcinoma: a real-world data

BACKGROUND

Chemotherapy combined with immune checkpoint inhibitors (IC), bevacizumab (BC), or both (IBC) is the preferred first-line therapy for PD-L1-negative and oncogenic-driver wild-type metastatic lung adenocarcinoma. However, the optimal strategy is still undetermined.

METHODS

This retrospective study enrolled PD-L1-negative metastatic lung adenocarcinoma patients from four cancer centers between January 1, 2018 and June 30, 2022. All the patients received IC, BC, or IBC as the first-line therapies. The efficacy and safety were evaluated.

RESULTS

A total of 205 patients were included, with 60, 83, and 62 patients in IC, BC, and IBC groups, respectively. The baseline characteristics among three groups were well balanced. Patients treated with IBC had the highest objective response rate (ORR) (43.5%) and disease control rate (DCR) (100%) relative to those treated with IC (40.4%, 84.2%) or BC (40.5%, 96.2%) (ORR: P = 0.919, DCR: P < 0.01). Compared with the IC (6.74 m) or BC (8.28 m), IBC treatment significantly improved median progression-free survival (mPFS) (9.53 m, P = 0.005). However, no difference in overall survival (OS) was observed. When stratified by different clinical and molecular information, we found that male gender, ever smoking, wild-type genes mutations, and adrenal metastasis predict superior PFS benefit when treated with IBC. In patients with liver metastasis, IBC or BC treatment displayed better PFS compared with IC. No additional adverse reactions were observed in IBC group compared with other two groups.

CONCLUSION

Combined IBC treatment achieved superior DCR and PFS compared with IC or BC in patients with PD-L1-negative metastatic lung adenocarcinoma, while did not increase the adverse events.