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Naqash AR, McCallen JD, Mi E, Iivanainen S, Marie MA, Gramenitskaya D, Clark J, Koivunen JP, Macherla S, Jonnalagadda S, Polsani S, Jiwani RA, Hafiz M, Muzaffar M, Brunetti L, Stroud CRG, Walker PR, Wang K, Chung Y, Ruppin E, Lee SH, Yang LV, Pinato DJ, Lee JS, Cortellini A. Increased interleukin-6/C-reactive protein levels are associated with the upregulation of the adenosine pathway and serve as potential markers of therapeutic resistance to immune checkpoint inhibitor-based therapies in non-small cell lung cancer. J Immunother Cancer 2023; 11:e007310. [PMID: 37852738 PMCID: PMC10603340 DOI: 10.1136/jitc-2023-007310] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Systemic immune activation, hallmarked by C-reactive protein (CRP) and interleukin-6 (IL-6), can modulate antitumor immune responses. In this study, we evaluated the role of IL-6 and CRP in the stratification of patients with non-small cell lung cancer (NSCLC) treated with immune checkpoint inhibitors (ICIs). We also interrogated the underlying immunosuppressive mechanisms driven by the IL-6/CRP axis. METHODS In cohort A (n=308), we estimated the association of baseline CRP with objective response rate (ORR), progression-free survival (PFS), and overall survival (OS) in patients with NSCLC treated with ICIs alone or with chemo-immunotherapy (Chemo-ICI). Baseline tumor bulk RNA sequencing (RNA-seq) of lung adenocarcinomas (LUADs) treated with pembrolizumab (cohort B, n=59) was used to evaluate differential expression of purine metabolism, as well as correlate IL-6 expression with PFS. CODEFACS approach was applied to deconvolve cohort B to characterize the tumor microenvironment by reconstructing the cell-type-specific transcriptome from bulk expression. Using the LUAD cohort from The Cancer Genome Atlas (TCGA) we explored the correlation between IL-6 expression and adenosine gene signatures. In a third cohort (cohort C, n=18), plasma concentrations of CRP, adenosine 2a receptor (A2aR), and IL-6 were measured using ELISA. RESULTS In cohort A, 67.2% of patients had a baseline CRP≥10 mg/L (CRP-H). Patients with CRP-H achieved shorter OS (8.6 vs 14.8 months; p=0.006), shorter PFS (3.3 vs 6.6 months; p=0.013), and lower ORR (24.7% vs 46.3%; p=0.015). After adjusting for relevant clinical variables, CRP-H was confirmed as an independent predictor of increased risk of death (HR 1.51, 95% CI: 1.09 to 2.11) and lower probability of achieving disease response (OR 0.34, 95% CI: 0.13 to 0.89). In cohort B, RNA-seq analysis demonstrated higher IL-6 expression on tumor cells of non-responders, along with a shorter PFS (p<0.05) and enrichment of the purinergic pathway. Within the TCGA LUAD cohort, tumor IL-6 expression strongly correlated with the adenosine signature (R=0.65; p<2.2e-16). Plasma analysis in cohort C demonstrated that CRP-H patients had a greater median baseline level of A2aR (6.0 ng/mL vs 1.3 ng/mL; p=0.01). CONCLUSIONS This study demonstrates CRP as a readily available blood-based prognostic biomarker in ICI-treated NSCLC. Additionally, we elucidate a potential link of the CRP/IL-6 axis with the immunosuppressive adenosine signature pathway that could drive inferior outcomes to ICIs in NSCLC and also offer novel therapeutic avenues.
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Affiliation(s)
- Abdul Rafeh Naqash
- Stephenson Cancer Center, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
- Hematology / Oncology Division, East Carolina University, Greenville, South Carolina, USA
| | - Justin D McCallen
- Department of Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Emma Mi
- Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College London, London, UK
| | - Sanna Iivanainen
- Oncology and Radiation Department, Oulu University Hospital, University of Oulu, MRC Oulu, Oulu, Finland
| | - Mona A Marie
- Hematology / Oncology Division, East Carolina University, Greenville, South Carolina, USA
| | - Daria Gramenitskaya
- Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College London, London, UK
| | - James Clark
- Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College London, London, UK
| | - Jussi Pekka Koivunen
- Oncology and Radiation Department, Oulu University Hospital, University of Oulu, MRC Oulu, Oulu, Finland
| | - Shravanti Macherla
- Hematology / Oncology Division, East Carolina University, Greenville, South Carolina, USA
| | - Sweta Jonnalagadda
- Hematology / Oncology Division, East Carolina University, Greenville, South Carolina, USA
| | - Shanker Polsani
- Hematology / Oncology Division, East Carolina University, Greenville, South Carolina, USA
| | - Rahim Ali Jiwani
- Department of Internal Medicine, East Carolina University, Greenville, NC, USA
| | - Maida Hafiz
- Division of Pulmonary Critical Care, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
- Division of Pulmonary and Critical Care, East Carolina University, Greenville, NC, USA
| | - Mahvish Muzaffar
- Hematology / Oncology Division, East Carolina University, Greenville, South Carolina, USA
| | - Leonardo Brunetti
- Operative Research Unit of Medical Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, Roma, Italy, Italy
| | | | - Paul R Walker
- Hematology / Oncology Division, East Carolina University, Greenville, South Carolina, USA
- Circulogene, Birmingham, Alabama, USA
| | - Kun Wang
- Cancer Data Science Lab, National Cancer Institute, National Institute of Health, Bethesda, Maryland, USA
| | - Youngmin Chung
- Department of Artificial Intelligence, Sungkyunkwan University, Suwon, Reuplic of Korea
| | - Eytan Ruppin
- Cancer Data Science Lab, National Cancer Institute, National Institute of Health, Bethesda, Maryland, USA
| | - Se-Hoon Lee
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
- Department of Health Sciences and Technology, Samsung Advanced Institute of Health Sciences and Technology, Sungkyunkwan University, Seoul, Republic of Korea
| | - Li V Yang
- Hematology / Oncology Division, East Carolina University, Greenville, South Carolina, USA
| | - David J Pinato
- Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College London, London, UK
- Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Joo Sang Lee
- Department of Artificial Intelligence, Sungkyunkwan University, Suwon, Reuplic of Korea
- Department of Precision Medicine, School of Medicine, Sungkyunkwan University, Suwon, Republic of Korea
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology, Sungkyunkwan University, Seoul, Republic of Korea
| | - Alessio Cortellini
- Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College London, London, UK
- Operative Research Unit of Medical Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, Roma, Italy, Italy
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