Chemotherapy negatively impacts the tumor immune microenvironment in NSCLC: an analysis of pre- and post-treatment biopsies in the multi-center SAKK19/09 study

Background

Over the past few years, immune checkpoint inhibitors have changed the therapeutic landscape of non-small-cell lung cancer (NSCLC). Response to immune checkpoint inhibitors correlates with a pre-existing anti-tumoral immune response. Checkpoint inhibitors have been introduced as second-line therapy and are only very recently used as monotherapy or in combination with chemotherapy as first-line treatment of NSCLC. However, the effect of conventional first-line platinum-based chemotherapy on the immune infiltrate in the tumor is largely unknown.

Methods

We measured the gene expression of a custom set of 201 cancer- and immune-related genes in 100 NSCLC tumor biopsies collected before chemotherapy and 33 re-biopsies after platinum-based chemotherapy at the time point of progression. For 29 patients matched pre- and post-chemotherapy samples could be evaluated.

Results

We identified a cluster of 47 co-expressed immune genes, including PDCD1 (PD1) and CD274 (PD-L1), along with three other co-expression clusters. Chemotherapy decreased the average gene expression of the immune cluster while no effect was observed on the other three cluster. Within this immune cluster, CTLA4, LAG3, TNFRSF18, CD80 and FOXP3 were found to be significantly decreased in patient-matched samples after chemotherapy.

Conclusion

Our results suggest that conventional platinum-based chemotherapy negatively impacts the immune microenvironment at the time point of secondary progression.

Electronic supplementary material

The online version of this article (10.1007/s00262-020-02688-4) contains supplementary material, which is available to authorized users.

Abstract P1-18-01: Incidence of hypocalcemia in patients with metastatic breast cancer under treatment with denosumab: A non-inferiority phase III trial assessing prevention of symptomatic skeletal events (SSE) with denosumab administered every 4 weeks versus every 12 weeks: SAKK 96/12 (REDUSE)

Background

Monthly Denosumab (DN) has shown superiority over zoledronic acid (ZA) in delaying skeletal related events. Randomized trials have shown that ZA given every 12 weeks (q12w) is non-inferior to ZA given every 4 weeks (q4w). The primary endpoint of the REDUSE-trial is non-inferiority for SSE for DN q12w versus q4w. Here we present early data for hypocalcemia (HC), a secondary endpoint.

Methods

Patients with bone metastasis from breast cancer (BC) not pretreated with DN or Bisphosphonates were randomized 1:1 to receive DN q4w (Arm A) versus q12w (Arm B) after a 3-month induction phase with q4w therapy for both arms. All patients received vitamin D 400 U (VitD) and calcium (Ca) 500 mg daily. Measurement of albumin-corrected serum-Ca was mandatory before each DN injection (HC defined as <2.0 mmol/l like in CTCAE V4.0). This safety interim analysis was performed after 3.5 years of accrual. Patients who received at least 1 dose of DN were considered evaluable.

Results

351 BC-patients are currently included (177 in Arm A, 174 in Arm B). HC was the most common side effect with a rate of 20% in the first 16 weeks (during the induction phase with DN q4w for both Arms) and 19% afterwards (combined for Arms A and B). After week 16 HC-prevalence differed between the two arms: while HC was present in 25% in Arm A (q4w), the rate was only 12% in Arm B (q12w). Grade 3 HC (i.e. corrected Ca 1.5 - 1.74 mmol/l or hospitalisation indicated) was rare (0.3%), no grade 4 HC occurred. After 1 year of treatment, the rate of HC compared to the induction phase had decreased in Arm B but not in Arm A (A: 25%, B: 12%). Since HC improved in more patients in Arm B than in Arm A whereas it worsened in more patients in Arm A than in Arm B, a remarkable difference for HC resulted between the two arms.

Rates of hypocalcemia and change of severity after week 16* Arm A (N = 177)Arm B (N = 174)Rates of hypocalcemian (%)n (%)Patients with hypocalcemia at any time49 (28%)46 (26%)Patients with hypocalcemia after week 16*44 (25%)21 (12%)   Change in hypocalcemia grade after week 16*for the 49 patients with hypocalcemiafor the 46 patients with hypocalcemiaWorsening25 (51%)8 (17%)Stable10 (20%)9 (20%)Improving14 (29%)29 (63%)   *week 16: i.e. the time where the schedules of DN begin to differ between Arm A and Arm BArm A: DN q4w for weeks 1 - 12 and likewise thereafter / Arm B: DN q4w for weeks 1 - 12 and q12w thereafter

Conclusions

In our trial up to 20% of all BC patients treated with DN experienced HC in the q4w induction phase despite mandatory supplementation of VitD and Ca. This rate is considerably higher than the numbers reported in the registration trials of DN (where it was 5.5% for BC). After the induction phase, HC is markedly reduced in the q12w arm compared to q4w. This suggests that DN given q12w has a more favorable long-term safety profile in terms of HC compared to DN q4w.

Citation Format: Müller A, Templeton AJ, Hayoz S, Hawle H, Hasler-Strub U, Schwitter M, Pestalozzi BC, Pagani O, Bützberger P, Wehrhahn T, Rauch D, Inauen R, Betticher D, Zaman K, Bodmer A, Popescu RA, Rothschild S, Schardt J, Borner M, Fuhrer A, Schär C, Gillessen S, von Moos R, For the Swiss Group for Clinical Cancer Research (SAKK). Incidence of hypocalcemia in patients with metastatic breast cancer under treatment with denosumab: A non-inferiority phase III trial assessing prevention of symptomatic skeletal events (SSE) with denosumab administered every 4 weeks versus every 12 weeks: SAKK 96/12 (REDUSE) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-18-01.

[Cancer immunotherapy - novel perspectives]

The concept of cancer immune surveillance dates back decades and is based on the hypothesis that the immune system can suppress the development or progression of spontaneous malignancies. Immunotherapy strategies include antitumor monoclonal antibodies, cancer vaccines, adoptive transfer of ex vivo activated T and natural killer cells, and administration of antibodies that either costimulate immune cells or block immune inhibitory pathways. Sipuleucel-T is the first anticancer vaccine that improved overall survival in a randomized clinical study in patients with metastatic castration-resistant prostate cancer. Similarly, ipilimumab, a monoclonal antibody blocking cytotoxic T-lymphocyte antigen 4 (CTLA-4), showed an overall survival benefit and durable tumor responses in pretreated and previously untreated patients with metastatic melanoma. In Switzerland, ipilimumab is approved for second line treatment in metastatic melanoma. These recent positive results of clinical trials with novel immunoactive drugs raised expectations that immunotherapy will play a crucial role in the anticancer treatment of the next decade.

Circulating microRNA profiling in patients with advanced non-squamous NSCLC receiving bevacizumab/erlotinib followed by platinum-based chemotherapy at progression (SAKK 19/05)

OBJECTIVES

Molecular subclassification of non small-cell lung cancer (NSCLC) is essential to improve clinical outcome. This study assessed the prognostic and predictive value of circulating micro-RNA (miRNA) in patients with non-squamous NSCLC enrolled in the phase II SAKK (Swiss Group for Clinical Cancer Research) trial 19/05, receiving uniform treatment with first-line bevacizumab and erlotinib followed by platinum-based chemotherapy at progression.

MATERIALS AND METHODS

Fifty patients with baseline and 24 h blood samples were included from SAKK 19/05. The primary study endpoint was to identify prognostic (overall survival, OS) miRNA's. Patient samples were analyzed with Agilent human miRNA 8x60K microarrays, each glass slide formatted with eight high-definition 60K arrays. Each array contained 40 probes targeting each of the 1347 miRNA. Data preprocessing included quantile normalization using robust multi-array average (RMA) algorithm. Prognostic and predictive miRNA expression profiles were identified by Spearman's rank correlation test (percentage tumor shrinkage) or log-rank testing (for time-to-event endpoints).

RESULTS

Data preprocessing kept 49 patients and 424 miRNA for further analysis. Ten miRNA's were significantly associated with OS, with hsa-miR-29a being the strongest prognostic marker (HR=6.44, 95%-CI 2.39-17.33). Patients with high has-miR-29a expression had a significantly lower survival at 10 months compared to patients with a low expression (54% versus 83%). Six out of the 10 miRNA's (hsa-miRN-29a, hsa-miR-542-5p, hsa-miR-502-3p, hsa-miR-376a, hsa-miR-500a, hsa-miR-424) were insensitive to perturbations according to jackknife cross-validation on their HR for OS. The respective principal component analysis (PCA) defined a meta-miRNA signature including the same 6 miRNA's, resulting in a HR of 0.66 (95%-CI 0.53-0.82).

CONCLUSION

Cell-free circulating miRNA-profiling successfully identified a highly prognostic 6-gene signature in patients with advanced non-squamous NSCLC. Circulating miRNA profiling should further be validated in external cohorts for the selection and monitoring of systemic treatment in patients with advanced NSCLC.

[Chemotherapy for malignant tumors of lung and pleura]

Lung Cancer is the leading cause of cancer-related mortality worldwide, with nearly 1.4 million deaths each year. There has been an overall decrease in the incidence of lung cancer in men, although in women this trend has only been noted very recently in the United States and in many countries in Western Europe. In contrast, in many parts of the world the number of cases and deaths related to lung cancer is on the rise. These increased death rates are in close correlation to smoking habits in the different countries. It is also increasingly becoming a disease of the elderly, with a median age at diagnosis of 70 years. In Switzerland about 2'500 men and 1'200 women are yearly diagnosed with lung cancer. Lung cancer is diagnosed at an advanced stage in a majority of patients, which explains the high mortality rate associated with this disease. In the current review we give on overview on the current treatment practice for small cell lung cancer (SCLC) as well as on non-small cell lung cancer (NSCLC). The main focus is on the novel treatment options for advanced, metastatic NSCLC and the current use of predictive biomarkers in order to personalize therapy. Malignant pleural mesothelioma is a rare cancer occurring mainly in older men who have been exposed to asbestos, although it occurs decades after exposure (20 - 40 years later). The disease is difficult to treat and median overall survival is only about one year.

Application of DNA techniques for identification using human dental pulp as a source of DNA

Dental pulp tissue could be obtained in most cases from materials obtained under experimental conditions and from forensic casework (air accidents, burned and putrefied bodies). Teeth extracted during dental treatment (n = 30) were stored for 6 weeks and 4 years at room temperature. In addition teeth (n = 10) extracted from jaw fragments that had been stored for 15 years at room temperature, and teeth extracted post mortem from actual identification cases (n = 8) were investigated. Following extraction from dental pulp tissue the DNA concentration was measured by fluorometry. The amount of DNA obtained from the dental pulp tissue of a single tooth varied from 6 micrograms to 50 micrograms DNA. In most cases high molecular weight DNA was still present although the major portion consisted of degraded DNA. Genomic dot blot hybridization for sex determination using the biotinylated repetitive DNA probe pHY 2.1 was performed and sex was correctly classified in all cases using 50-100 ng target DNA. PCR typing of the HLA-DQ alpha and ApoB 3' VNTR systems from dental pulp tissue DNA was in agreement with the results obtained from blood, bloodstains, or lung tissue. In addition, Southern blot analysis of selected samples using the single locus VNTR probe pYNH24 was successfully performed. In all cases the DNA recovered from dental pulp was unsuitable for multilocus probe analysis.

Biochemical abnormalities in patients with slipped capital femoral epiphysis and chondrolysis

A prospective clinical and laboratory study was performed in thirty-four patients (twenty-two blacks, ten Puerto Ricans, and two whites) who had slipped capital femoral epiphysis in fifty-two hips. Although the majority of the laboratory studies were normal, all patients showed significant elevations of the serum immunoglobulins and C3 component of complement, with the highest values recorded for IgA. Urinary glycosaminoglycans were elevated in the few patients studied and increased proportionally with the duration of the disease. Nine (25 per cent) of the thirty-four patients had chondrolysis in thirteen hips. The male:female ratio in these nine patients was 0.8:1, compared with the ratio of 1.4:1 in all thirty-four patients. No additional biochemical abnormality was found in the patients with chondrolysis except for a greater elevation of the IgM fraction. These preliminary and tentative data suggest either that slipping of an epiphysis produces an antigen which induces an autoimmune state or that slipping is a localized manifestation of a generalized process resembling some form of connective-tissue disorder or inflammatory state. There is presumably a genetically determined sub-group of patients with this disorder who may have chondrolysis.