Risk of CFTR-related disorders and cystic fibrosis in an Italian cohort of CRMS/CFSPID subjects in preschool and school age

The identification of cystic fibrosis screening-positive, inconclusive diagnosis (CFSPID) in infants is a controversial outcome of newborn screening for cystic fibrosis (CF). Today, despite improvements in the knowledge of CFSPID and the description of several cohorts, little data are available on cohorts with a follow-up period of more than 6 years. In this study, we report the outcomes of an Italian cohort of CFSPID individuals with CFSPID or formerly CFTR-related disorders (CFTR-RD) (CFSPID > CFTR-RD) or diagnosed with CF (CFSPID > CF). This was an observational and multicentre Italian study collecting clinical data on CFSPID born between the period January 1, 2011, and December 13, 2019. A total of 268 participants were included: 243 with persistent CFSPID, 7 with CFSPID > CFTR-RD, and 18 with CFSPID > CF. The trend of sweat chloride (SC) values, percentage of definitive diagnoses, lung function in school-aged children, and development of CF-related complications were evaluated. At the end of the observation period, almost 80% of the individuals with CFSPID did not have a conclusive diagnosis. A total of 29 children (10.8%) transitioned to a diagnosis of CF for pathological SC values (≥ 60 mmol/L) or multi-organ involvement, and 18 (6.7%) to CFTR-RD. Children who were followed up for > 6 years (median age, 7.5 years; range, 6.04-10.5) had normal lung function and were pancreatic sufficient, and the evolution in CF was only present in two cases.

CONCLUSION

Most Italian preschool and school-aged children with CFSPID did not have a conclusive diagnosis, and progression to CF was unlikely in children > 6 years of age. An annual follow-up could be indicated to identify early evolution in clinical features consistent with a CFTR-RD.

WHAT IS KNOWN

• Cystic Fibrosis newborn screening identifies also subjects with an inconclusive diagnosis (CFSPID). • Over time a variable percentage of CFSPIDs will be diagnosed as CF. • Little data is available on CFSPIDs with a follow-up period of more than six years.

WHAT IS NEW

• 80% of Italian preschool and school-age CFSPIDs not have a conclusive diagnosis. • Italian preschool and school-age CFSPIDs have normal lung function and are pancreatic sufficient. • Annual follow-up after 6 years is recommended in CFSPID with abnormal LCI2.5 or with a CF-causing variant in trans with a VVCC.

Associations between sinus tachycardia and adverse cardiovascular outcomes and mortality in cancer patients

Background

Sinus tachycardia in cancer reflects a significant multi-system organ stressor and disease, with sparse literature describing its clinical significance. We assessed cardiovascular (CV) and mortality prognostic implications of sinus tachycardia in cancer patients.

Methods

We conducted a case-control study of 622 cancer patients at a U.S. urban medical center from 2008 to 2016. Cases had ECG-confirmed sinus tachycardia [heart rate (HR) ≥100 bpm] in ≥3 different clinic visits within 1 year of cancer diagnosis excluding a history of pulmonary embolism, thyroid dysfunction, left ventricular ejection fraction <50%, atrial fibrillation/flutter, HR >180 bpm. Adverse CV outcomes (ACVO) were heart failure with preserved ejection fraction (HFpEF), HF with reduced EF (HFrEF), hospital admissions for HF exacerbation (AHFE), acute coronary syndrome (ACS). Regression analyses were conducted to examine the effect of sinus tachycardia on overall ACVO and survival.

Results

There were 51 cases, age and sex-matched with 571 controls (mean age 70±10, 60.5% women, 76.4% Caucasian). In multivariate analysis over a 10-year follow-up period, sinus tachycardia (HR ≥100 vs. <100 bpm) was an independent predictor of overall ACVO (OR 2.8, 95% CI: 1.4–5.5; P=0.006). There was increased incidence of HFrEF (OR 3.3, 95% CI: 1.6–6.5; P=0.004) and AHFE (OR 6.3, 95% CI: 1.6–28; P=0.023), but not HFpEF or ACS (P>0.05) compared with controls. Sinus tachycardia was a significant predictor of overall mortality after adjusting for significant covariates (HR 2.9, 95% CI 1.8–5; P<0.001).

Conclusions

Independent of typical factors that affect cardiovascular disease, sinus tachycardia around the time of cancer treatment is associated with increased ACVO and mortality in cancer patients at 10 years of follow-up.

Abstract 1621: Comprehensive profiling of immune regulatory molecules in baseline sera from advanced stage NSCLC patients receiving anti-PD-1 and anti-PD-L1 immunotherapy: A prognostic potential

Introduction: Immune checkpoint inhibitor (ICI) therapy has shown remarkable benefits in treating non-small-cell lung cancer (NSCLC). However, progress beyond PD-L1 expression has not yielded biomarkers that can better select responders to ICI. This study comprehensively evaluated the prognostic value of soluble immune checkpoints and immune regulators in previously treated lung cancer patients receiving anti PD-L1/PD1 single agents.

Method: We profiled 47 immune checkpoint molecules and regulatory molecules in baseline serum from 135 metastatic NSCLC patients receiving atezolizumab (n=40), pembrolizumab (n=32), durvalumab (n=10), or nivolumab (n=53) after failing frontline therapy. Immune checkpoints and regulators were evaluated via the MILLIPLEX® Human Immuno-Oncology Checkpoint Protein Panels 1 and 2 (MilliporeSigma) using manufacturer-defined protocols. All statistical relationships were determined using the Log-Rank test in relation to overall survival (OS) and progression-free survival (PFS).

Results: The study cohort consisted of 50% males, 72% caucasians, and histologically divided into 72% adenocarcinoma and 25% squamous cell. The median follow-up time was ten months from the time of ICI therapy commencement. The median PFS was 4.1 months, and overall survival was 13.1 months for the entire cohort. Twenty eight molecules were found to be significantly associated (p &lt;0.05) with progression free survival (PFS), out of which the baseline serum levels for circulating CD27, GITR, PD-1, CTLA-4, CD80, CD86, CD40L, B7-H2/ICOSL, E-Cadherin, FGL1/Hepassocin, Galectin-1, and Perforin showed the highest significance (all p-values &lt;0.01). Similarly, twenty-six of the profiled molecules were found to have significant association (p &lt;0.05) with overall survival (OS), with baseline serum levels of PD-1, CTLA-4, CD80, CD86, CD40L, B7-H2/ICOSL, E-Cadherin, FGL1/Hepassocin, Galectin-1, and Perforin being the most highly associated with OS (all p-values &lt;0.01).

Conclusion: We demonstrated the promising value of circulating immune checkpoints and immune regulatory molecules in precision immuno-oncology related to advanced-stage NSCLC. This work requires validation but, with further development, may have implications for single agent anti PD-L1/PD-1 treatment selection in the front-line setting.

Citation Format: Imad Tarhoni, Hita Moudgalya, Sanjib Basu, Wen_Rong Lie, Danielle Pepin, Mary Jo Fidler, Marta Batus, Philip Bonomi, Jeffrey Borgia. Comprehensive profiling of immune regulatory molecules in baseline sera from advanced stage NSCLC patients receiving anti-PD-1 and anti-PD-L1 immunotherapy: A prognostic potential [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1621.

Relationship between circulating tumor-associated autoantibodies and clinical outcomes in advanced-stage NSCLC patients receiving PD-1/-L1 directed immune checkpoint inhibition

BACKGROUND

Durable tumor regressions are observed in a subset of advanced-stage non-small cell lung cancer (NSCLC) patients receiving PD-1/-L1 targeted immune checkpoint inhibitors (or 'immunotherapy') alone or in combination with chemotherapy. However, the majority of advanced NSCLC patients receiving these agents do not experience long-term disease control. Existing methods to identify patients most likely to gain clinical benefit from PD-1/-L1 immunotherapy have limitations, creating a need for improved methods to guide treatment selection, particularly for those likely to benefit from single-agent immunotherapy. Here, we describe the development of a series of novel assays for tumor-associated autoantibodies as part of an exploratory study intended to determine if these biomarkers have potential prognostic value in this setting.

METHOD

A selection of recombinant tumor autoantigens previously characterized for their diagnostic utility were developed and preliminarily evaluated by this study. These include: Fumarate Dehydrogenase (FH), Hydroxysteroid 17-Beta Dehydrogenase 10 (HSD17B10), Inosine Monophosphate Dehydrogenase 2 (IMPDH2), New York Esophageal Squamous Cell Carcinoma-1 (NY ESO-1), Phosphoglycerate Mutase 1 (PGAM1), and Vimentin. Custom Luminex immunobead assays were developed for these targets to quantitatively assess autoantibody levels in individual patient sera. Assays were erected as indirect immunoassays on MagPlex® Microspheres using standard carbodiimide/NHS-based chemistries, utilizing a biotin-conjugated secondary (i.e. anti-human IgG) antibody and R-phycoerythrin-conjugated streptavidin reporter system. Standard curves were created for quantitative purposes using commercially-available anti-antigen antibodies and permitted analytical performance characteristics to be calculated. These assays were used to preliminarily evaluate a series of pretreatment serum samples from stage IV NSCLC patients receiving anti PD-1/-L1 therapy after failure of at least one prior line of therapy (n = 40) and their classification efficiency calculated based on 12 months overall survival (OS) threshold.

RESULTS

Six assays were developed that each showed dynamic ranges of four orders of magnitude and provided more than 90% classification accuracy based on the observed clinical outcome data. Inter- and intra-assay precision was assessed within these standards and overall %CVs of ≤7% and ≤ 10%, respectively, were calculated. Generally, the baseline level of autoantibodies were significantly (p < 0.05) lower in the ≥12 months survival group relative to the <12 months survival groups. Serum titers of FH, HSD170B, NY-ESO-1, and vimentin were significantly correlated with ≥12 month survival (p-value 0.0038, 0.0061, 0.0073, and 0.022, respectively). IMPDH2 and PGAM1 were found to have marginal significance (p-value 0.08 and 0.076, respectively).

CONCLUSION

This study demonstrates an efficient and promising means for assessing circulating autoantibody titers that could be useful in selecting advanced NSCLC patients for PD-1/-L1 directed immunotherapy. Further exploration and validation of this paradigm is warranted to further refine current treatment selection methods for this therapeutic strategy.

Novel Autoantibodies Biomarkers Panel to Prognosticate the Clinical Outcomes in Advanced-stage NSCLC Patients Receiving Anti PD-1/PD-L1 Immunotherapy

Introduction/Objective

Lung cancer is the leading cause of cancer-related deaths worldwide, with a majority of cases detected at a non-resectable advanced stage. Current anti PD-1/-L1 therapy has reformed cancer treatment strategies with remarkable clinical outcomes in non-small cell lung cancer (NSCLC). However, the overall response rate is still marginal, demonstrating the need for biomarkers predictive of response. The objective of this study is to develop a serum based panel to prognosticate clinical response in advanced NSCLC patients receiving anti PD-1/-L1 therapy.

Methods

Pooled sera from two response groups (Poor response, n=20, overall survival &lt; 12 months; Good response, n=20, overall survival &gt; 12 months) were evaluated via the HuProt™ Human Proteome Microarray (CDI laboratories, Baltimore, MD) to identify expressed neoantigens. Recombinant proteins representative to identified neoantigens along with their corresponding antibodies, were commercially acquired to develop a robust 13-plex bead- based immunoassay to evaluate the autoantibodies in pretreatment sera from 125 advanced-stage NSCLC patients. Finally, levels of autoantibodies were correlated to clinical outcome, including progression free survival (PFS), overall survival (OS) and grade III adverse events.

Results

Low baseline levels of ZNF695, MCM4, PRMT2, FGD3, GTF2A1, GLUL, CDCA3, ZNF277, GARS, GBP2, UBL7, and ASNA1 autoantibodies were found to be associated with a longer PFS (all p-values &lt; 0.01), whereas increased levels were associated with a poor PFS outcome (0.06, HR=0.66, 95% CI). Low levels of ZNF695, MCM4, PRMT2, FGD3, GARS, GBP2, and UBL7 autoantibodies were associated with favorable OS (all p-values &lt; 0.01).

Conclusion

In this study we demonstrated that serum autoantibodies have great promise to serve as a prognostic tool for immunotherapy response. We successfully developed a high performance multiplexed serum based assay to evaluate autoantibodies in an advanced NSCLC patients receiving anti PD-1/-L1 therapy.

Adenosine 2A Receptor Blockade as an Immunotherapy for Treatment-Refractory Renal Cell Cancer

Adenosine mediates immunosuppression within the tumor microenvironment through triggering adenosine 2A receptors (A2AR) on immune cells. To determine whether this pathway could be targeted as an immunotherapy, we performed a phase I clinical trial with a small-molecule A2AR antagonist. We find that this molecule can safely block adenosine signaling in vivo. In a cohort of 68 patients with renal cell cancer (RCC), we also observe clinical responses alone and in combination with an anti-PD-L1 antibody, including subjects who had progressed on PD-1/PD-L1 inhibitors. Durable clinical benefit is associated with increased recruitment of CD8⁺ T cells into the tumor. Treatment can also broaden the circulating T-cell repertoire. Clinical responses are associated with an adenosine-regulated gene-expression signature in pretreatment tumor biopsies. A2AR signaling, therefore, represents a targetable immune checkpoint distinct from PD-1/PD-L1 that restricts antitumor immunity. SIGNIFICANCE: This first-in-human study of an A2AR antagonist for cancer treatment establishes the safety and feasibility of targeting this pathway by demonstrating antitumor activity with single-agent and anti-PD-L1 combination therapy in patients with refractory RCC. Responding patients possess an adenosine-regulated gene-expression signature in pretreatment tumor biopsies.See related commentary by Sitkovsky, p. 16.This article is highlighted in the In This Issue feature, p. 1.

Theoretical and Practical Implications of Treating Cachexia in Advanced Lung Cancer Patients

Lung cancer continues to be a major worldwide health issue, with more than 50% of patients having incurable metastatic disease at diagnosis. Fortunately, the advanced lung cancer treatment landscape is changing rapidly as a result of the positive impact of effective inhibitors of tumor driver mutations, and the more recent discovery that immune modulation with anti-PD-1/PD-L1 monoclonal antibodies results in tumor regression and prolonged survival. While a relatively small subset of lung cancer patients are candidates for inhibitors of driver mutations, the majority of advanced lung cancer patients are candidates for an immunotherapy regimen. Many of these patients have cachexia, which is associated with increased cancer therapy toxicity and possibly reduced responsiveness to immunotherapy. Two ongoing cachexia trials, one testing a ghrelin analogue and the other testing a multimodal strategy, have endpoints which assess clinical benefit-weight gain and relief of anorexia/cachexia symptoms. Provided that the trial objectives are achieved, these treatment strategies will provide a way to relieve suffering and distress for cachectic cancer patients. While awaiting the results of these trials, it would be reasonable to consider designing studies testing cachexia treatments combined with first-line immunotherapy and chemotherapy-immunotherapy in stage IV lung cancer patients, with enhanced overall survival being one of the endpoints.

Bioinformatics Model of Serum Biomarkers to Prognosticate the Response to Programmed Death-1/Ligand-1 Targeted Immunotherapy in Metastatic Non–Small Cell Lung Cancer

Introduction

Immune-checkpoint inhibitors revolutionized the therapeutic paradigm for metastatic non–small cell lung cancer (NSCLC). The average response, however, still hovers at 20%, demonstrating the urgent need for biomarkers predictive of response. High-throughput laboratory technology promises to serve as an insightful and robust tool to recognize and select patterns of biomarkers in serum. We applied machine learning on serum immune-checkpoint biomarkers for prognostication of response to immunotherapy in advanced NSCLC.

Method

Pretreatment sera from 106 advanced NSCLC cases who failed frontline chemotherapy were evaluated for 16 soluble immune-checkpoint molecules using the Human Immuno-Oncology Checkpoint Protein Panel (MilliporeSigma). This panel constituted BTLA, CD27, CD28, TIM-3, HVEM, CD40, GITR, GITRL, LAG-3, TLR-2, PD-1, PD-L1, CTLA-4, CD80, CD86, and ICOS. Primary data points were collected and calculated via a Luminex FLEXMAP 3D system (xPONENT v4.0.3 Luminex Corp). The minimum follow-up after treatment was 12 months. Response patterns were categorized based on their overall survival (OS) as long-term responders (>12 months) or short-term responders (<12 months). Values were analyzed with the clinical outcomes using “Survminer” and “survival” R packages to determine the log-rank-based cutoff values associated with overall survival. Finally, machine learning methods were implemented using “caret” and “rpart” R packages to fit a classification model to predict the response pattern. The model was trained and tested on random fractions of the cohort.

Results

BTLA4, HVEM, CD40, GITRL, LAG-3, PD-1, CD80, and CD86 serum levels significantly correlated with OS (all P values ≤.02 and HR of 0.27, 0.5, 4.59, 0.17, 0.12, 0.48, 3.64, and 0.37, respectively). The algorithm composing PD-1, LAG-3, CD86, and CTLA4 predicted the response pattern with PPV of 81%, specificity of 87%, and accuracy of 75%.

Conclusion

The serum immune-checkpoint predictive model might assist in the tissue and gene-based profiling of immune-checkpoints to predict the benefit from immunotherapy.

Abstract 426: Autoantibodies: A promising prognostic tool for immunotherapy response in advanced non-small cell lung cancer

Background: Immune-checkpoint blockade has revolutionized cancer therapy in advanced non-small cell lung cancer (NSCLC). Tissue expression of programmed death protein ligand (PD-L1) remains the gold standard for patient stratification, however, the limited performance of this marker encourages investigations for improved molecular diagnostics. The objective of this study is to identify and evaluate the role of neoantigen-associated autoantibodies to predict the clinical response to anti-PD-1/-L1 in advanced stage NSCLC.

Method: Lung adenocarcinoma A549 and H358 cell lysate proteins were resolved via 2-dimensional electrophoresis, electroblotted onto nitrocellulose, and immunoprobed with pooled, pretreatment sera (n= 4/ group) derived from patients with advanced NSCLC who received PD-1/-L1 directed immunotherapy. These patients have documented disease progression within 12 weeks (“rapid progression”) or demonstrated radiographical stable disease/progression after the first 180 days of therapy (“late progression”). Immunoreactive spots were detected with an HRP-conjugated, anti-human IgG secondary antibody with digital densitometry. A 4-fold cutoff threshold in expression was used to prioritize spots for identification via tandem mass spectrometry. From A549 cells, recombinant proteins were selected for STIP-1, annexin A2, HSPA8, and GAPDH. These proteins were then analyzed via immunoblotting methods using sera from each indicated group (n=4 per group). In addition, identified proteins from H358 cells include FH, HSP70B, IMPDH2, NY ESO-1, PGAM-1, and vimentin. Recombinant versions of a selection of autoantigens identified in this manner were commercially acquired and used to develop custom Luminex immunobead assays to quantitatively assess autoantibody production in individual patient sera (rapid progressors, n=14; late progressors, n=18). Values were statistically compared via Mann-Whitney test.

Results: Series of differentially expressed autoantigens predictive of clinical response to PD-1/-L1 directed immunotherapy were identified. Western blots of neoantigens identified from A549 cells; STIP-1, annexin A2, HSPA8, and GAPDH were significantly able to distinguish between response groups (p-value &lt; 0.001). Six H358 targets resulting from the custom bead-based immunoassay development; FH, HSP70B, IMPDH2, NY-ESO-1, PGAM-1, and vimentin were also able to distinguish between groups (p-values of 0.01, 0.01, 0.022, 0.005, 0.034, and 0.027, respectively).

Conclusion: Our study demonstrates that serum autoantibodies have great promise to serve as a robust tool to prognosticate response for patients receiving PD-1/-L1 directed immunotherapy and potentially aid current treatment selection methods. Additional targets are currently being developed into multiplexed immunobead assays for evaluation across larger cohorts of patients.

Citation Format: Imad Tarhoni, Cristina Fhied, Melissa Pergande, Revathi Kollipara, Connor J. Wakefield, Katherine Gallo, Apoorva Tangri, Marta Batus, Mary Jo Fidler, Philip Bonomi, Jeffrey A. Borgia. Autoantibodies: A promising prognostic tool for immunotherapy response in advanced non-small cell lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 426.

Abstract 404: Prognostic value of soluble and cell surface immune-checkpoint molecules in advanced non-small cell lung cancer (NSCLC) patients receiving anti-PD-1/-L1 immunotherapy

Current methods to stratify immunotherapy candidates, including PD-L1 expression and tumor mutational burden (TMB) profiling, have limitations that hamper their clinical value. This study explores the prognostic potential of soluble and cell-surface immune-checkpoint (IC) molecules as a means to improve treatment selection for NSCLC patients being considered for PD-1/-L1 blockade.

Pretreatment sera from 111 cases of previously-treated advanced NSCLC receiving PD-1/L-1 targeting checkpoint inhibitors (nivolumab, atezolizumab, or pembrolizumab) were evaluated for 16 soluble IC molecules and immune regulators via the MILLIPLEX® MAP Human Immuno-Oncology Checkpoint Protein Panel (MilliporeSigma) using manufacturer-defined protocols. PBMCs from a subset of this cohort (n=28) were profiled on a LSRFortessa™ for cell-surface IC molecules. T-cell subsets (CD4,CD8) were analyzed for CD27\CD28, iCOS, PD-1, CTLA-4, TIM-3, TIGIT, LAG-3, GITR and PD-L1. NK cells (CD56\CD16) were analyzed for CD96, CD94, CD86, CD80, PD-1, CTLA-4, TIM-3, TIGIT, LAG-3 and PD-L1. Classical (CD14++\CD16-), intermediate (CD14++\CD16+) and non-classical (CD14dim\-\CD16++) monocyte subsets were analyzed for these identical markers. All statistical relationships were determined using the Log-Rank test in relation to overall survival (OS) and progression-free survival (PFS). Pearson correlations were calculated between the circulating and PBMCs levels of IC molecules.

Sixteen soluble IC molecules were detectable in patient serum, with twelve of these being prognostic for OS, PFS, or both (see Table). In the 28 patients with PBMCs, a set of cell-surface molecules showed prognostic value, but had no apparent correlation to soluble molecules.

These findings suggest that both soluble and cell-surface IC molecules may have promise for identifying advanced NSCLC patients that may benefit from anti-PD-1/-L1 immunotherapy.

PFSOSp-valueHRp-valueHRSoluble moleculesBMI0.0030.790.0540.75Lymphocyte0.0040.700.0020.60NLR0.0051.69&lt;0.0012.12BTLA0.0140.790.010.90CD270.0020.680.0170.80TIM30.0370.880.0280.93HVEM0.0040.620.0040.53GITR0.0010.003&lt;0.0010.00LAG30.0400.820.030.72GITRL0.0140.100.0070.03PD10.0020.490.0030.34CTLA4&lt;0.0010.180.0020.27CD800.0010.680.0020.67CD86&lt;0.0010.63&lt;0.0010.54iCOS0.0140.840.0470.90PBMCs - cell surface moleculesCD30.0520.660.110.65CD3-CD800.370.990.0051.45CD4-iCOS0.050.740.491.35CD8-CTLA40.020.660.21.34CD8-GITR0.0230.490.30.70CD8-TIGT0.020.630.370.78CD8-LAG30.0160.620.031.18CL-CD860.360.900.050.56CL-CD640.141.330.0151.89NC-CD640.0261.520.0021.74NC-PDL20.0382.840.351.52NC-TIM30.0032.070.041.19

Citation Format: Imad Tarhoni, Mary Jo Fidler, Ibtihaj Fughhi, Connor Wakefield, Revathi Kollipara, Maneet Multani, Marta Batus, Sanjib Basu, Wen-Rong Lie, Donna Russell, Jeffrey Martinson, Alan L. Landay, Timothy M. Kuzel, Philip Bonomi, Jeffrey A. Borgia. Prognostic value of soluble and cell surface immune-checkpoint molecules in advanced non-small cell lung cancer (NSCLC) patients receiving anti-PD-1/-L1 immunotherapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 404.

Phase II Study of Maintenance Pembrolizumab in Patients with Extensive-Stage Small Cell Lung Cancer (SCLC)

OBJECTIVE

The aim of this study was to assess the efficacy of maintenance pembrolizumab in patients with extensive-stage SCLC after treatment with platinum and etoposide.

METHODS

Patients with extensive-stage SCLC with a response or stable disease after induction chemotherapy were eligible. Pembrolizumab at a dose of 200 mg administered intravenously every 3 weeks was initiated within 8 weeks of the last cycle of chemotherapy. The primary end point of the study was progression-free survival (PFS) from study registration, with overall survival (OS) as a key secondary end point. Available tumor tissue was assessed for expression of programmed death ligand 1 (PD-L1) both in the tumor cells and in the surrounding stroma. Blood for circulating tumor cells was collected before the first, second, and third cycles of pembrolizumab.

RESULTS

Of the 45 patients enrolled, 56% were male and 22% had treated brain metastases. The median PFS was 1.4 months (95% confidence interval [CI]: 1.3-2.8), with a 1-year PFS of 13%. The median OS was 9.6 months (95% CI: 7.0-12), with a 1-year OS of 37%. Of the 30 tumors that could be assessed, three had PD-L1 expression (≥1%) in the tumor cells. A total of 20 tumors could be assessed for PD-L1 expression in the stroma. The median PFS in the eight patients with tumors positive for expression of PD-L1 at the stromal interface was 6.5 months (95% CI: 1.1-12.8) compared with 1.3 months (95% CI: 0.6-2.5) in 12 patients with tumors negative for this marker. No unexpected toxicities were observed.

CONCLUSION

Maintenance pembrolizumab did not appear to improve median PFS compared with the historical data. However, the 1-year PFS rate of 13% and OS rate of 37% suggest that a subset of patients did benefit from pembrolizumab.

Abstract 5708: Associations between soluble immune checkpoint molecules and overall survival in advanced non-small cell lung cancer (NSCLC) patients treated with either anti-PD-1/-L1 monoclonal antibodies or single-agent chemotherapy

Background: While several of the KEYNOTE trials showed that NSCLC patients whose tumors expressed high levels of the programmed death ligand-1 (PD-L1) were more likely to have superior survival with pembrolizumab compared to chemotherapy, other trials failed to confirm the predictive value of PD-L1 tissue expression. And with response rates for PD-1/-L1 directed immunotherapy approximating 20%, development of improved molecular diagnostics to accurately identify patients likely to have long-term disease control is needed. The goal of the current study is to evaluate potential relationships between a panel of soluble immune checkpoint molecules and disease control in NSCLC patients treated with PD-1/-L1 monoclonal antibodies. Method: Pretreatment sera from 128 cases of advanced NSCLC that failed frontline chemotherapy were evaluated for 16 soluble checkpoint molecules and immune regulators using the Human Immuno-Oncology Checkpoint Protein Panel (MilliporeSigma). This panel consists of the following targets: BTLA, CD27, CD28, TIM-3, HVEM, CD40, GITR, GITRL, LAG-3, TLR-2, PD-1, PD-L1, CTLA-4, CD80/B7-1, CD86/B7-2, and ICOS. All patients tested received either PD-1/-L1 targeting checkpoint inhibitors (nivolumab, atelizumab, or pembrolizumab; n=79) or single-agent chemotherapy (n=49). All kits were processed according to manufacturer-defined protocols and read using a Luminex® FLEXMAP 3D®. Finally, statistical relationships were determined using the Log-Rank test in relation to overall survival, defined as the interval from diagnosis to last follow up or death. Results: Pretreatment sera from 128 cases of NSCLC were evaluated for 16 soluble checkpoint molecules and immune regulators using the Luminex immunobead platform. In analysis of the cohort, lower levels of CD80/B7-1 were found to have significant association (p=0.0372) with superior overall survival. Patients who received PD-1/L1-directed immunotherapy, however, demonstrated low circulating levels of the T-cell associated molecules CD28 and CD80/B7-1, which were associated with superior overall survival (p=0.0178 and 0.036, respectively), whereas low circulating levels of the tumor-associated molecules LAG-3 and CD86/B7-2 were associated with an inferior overall survival (p=0.009 and 0.0278, respectively). There were no significant associations (all p&gt;0.05) identified in the cohort that received chemotherapy alone. Conclusion: These findings suggest that soluble immune-checkpoint molecules may identify advanced NSCLC patients most likely to benefit from anti-PD-1/-L1 immunotherapy. Prospective study of these biomarkers is planned to determine if they have predictive value for anti-PD-1/-L1 therapy and to explore implications for developing combination immunotherapy regimens.

Citation Format: Imad A. Tarhoni, Ibtihaj Fughhi, David Gerard, Sanjib Basu, Cristina Fhied, Wen-rong Lie, Donna Russell, Marta Batus, Nisha Thakar, Philip Bonomi, Mary Fidler, Jeffrey Borgia. Associations between soluble immune checkpoint molecules and overall survival in advanced non-small cell lung cancer (NSCLC) patients treated with either anti-PD-1/-L1 monoclonal antibodies or single-agent chemotherapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5708.

Molecular and Immune Biomarker Testing in Squamous-Cell Lung Cancer: Effect of Current and Future Therapies and Technologies

Patients with non-small-cell lung cancer, including squamous-cell lung cancer (SqCLC), typically present at an advanced stage. The current treatment landscape, which includes chemotherapy, radiotherapy, surgery, immunotherapy, and targeted agents, is rapidly evolving, including for patients with SqCLC. Prompt molecular and immune biomarker testing can serve to guide optimal treatment choices, and immune biomarker testing is becoming more important for this patient population. In this review we provide an overview of current and emerging practices and technologies for molecular and immune biomarker testing in advanced non-small-cell lung cancer, with a focus on SqCLC.

The serum-based VeriStrat® test is associated with proinflammatory reactants and clinical outcome in non-small cell lung cancer patients

Background

The VeriStrat test is a serum proteomic signature originally discovered in non-responders to second line gefitinib treatment and subsequently used to predict differential benefit from erlotinib versus chemotherapy in previously treated advanced non-small cell lung cancer (NSCLC). Multiple studies highlight the clinical utility of the VeriStrat test, however, the mechanistic connection between VeriStrat-poor classification and poor prognosis in untreated and previously treated patients is still an active area of research. The aim of this study was to correlate VeriStrat status with other circulating biomarkers in advanced NSCLC patients – each with respect to clinical outcomes.

Methods

Serum samples were prospectively collected from 57 patients receiving salvage chemotherapy and 70 non-EGFR mutated patients receiving erlotinib. Patients were classified as either VeriStrat good or poor based on the VeriStrat test. Luminex immunoassays were used to measure circulating levels of 102 distinct biomarkers implicated in tumor aggressiveness and treatment resistance. A Cox PH model was used to evaluate associations between biomarker levels and clinical outcome, whereas the association of VeriStrat classifications with biomarker levels was assessed via the Mann-Whitney Rank Sum test.

Results

VeriStrat was prognostic for outcome within the erlotinib treated patients (HR = 0.29, p < 0.0001) and predictive of differential treatment benefit between erlotinib and chemotherapy ((interaction HR = 0.25; interaction p = 0.0035). A total of 27 biomarkers out of 102 unique analytes were found to be significantly associated with OS (Cox PH p ≤ 0.05), whereas 16 biomarkers were found to be associated with PFS. Thrombospondin-2, C-reactive protein, TNF-receptor I, and placental growth factor were the analytes most highly associated with OS, all with Cox PH p-values ≤0.0001. VeriStrat status was found to be significantly associated with 23 circulating biomarkers (Mann-Whitney Rank Sum p ≤ 0.05), 6 of which had p < 0.001, including C-reactive protein, IL-6, serum amyloid A, CYFRA 21.1, IGF-II, osteopontin, and ferritin.

Conclusions

Strong associations were observed between survival and VeriStrat classifications as well as select circulating biomarkers associated with fibrosis, inflammation, and acute phase reactants as part of this study. The associations between these biomarkers and VeriStrat classification might have therapeutic implications for poor prognosis NSCLC patients, particularly with new immunotherapeutic treatment options.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4193-0) contains supplementary material, which is available to authorized users.

Development of bead based multiplexed immunoassay for evaluation of midkine, syndecan-1, and ANGPTL4 in patient serum

BACKGROUND

Angiogenesis is associated with tumor progression in a range of malignancies. Herein, we develop custom immunobead assays for several mechanistically important targets and evaluated these against sera from cohorts of non-small cell lung cancer (NSCLC) patients.

METHODS

Antigen "capture" antibodies for midkine, syndecan-1, and ANGPTL4 were independently conjugated to MagPlex® Microspheres using standard carbodiimide/NHS-based chemistry. These reagents served as the basis for quantitative sandwich assay assembly using biotinylated detection antibodies and R-phycoerythrin-conjugated streptavidin reporter system. Standard curves were created using dilution series of recombinant target proteins with assay performance characteristics calculated, accordingly. Finally, we evaluated a range of serum samples from NSCLC patients (n = 32) to verify assay performance.

RESULTS

Multiplexed assays for midkine, syndecan-1, and ANGPTL4 were developed with three orders of magnitude in dynamic range, excellent intra- and inter-assay precision, and accuracy parameters (<10%, and <15% variability, respectively). Detection and quantifications limits were suitable for the three assays to efficiently evaluate sera across a range of disease stages with a four-fold dilution factor.

CONCLUSION

We successfully developed and analytically validated a 3-plex immunobead assay for quantifying midkine, syndecan-1, and ANGPTL4 in patient sera. This multiplexed assay will provide an important tool for future studies delineating the role of angiogenesis in lung cancer progression.

Abstract 4665: Induction of receptor tyrosine kinase signaling by sera from patients with lung adenocarcinoma

Background: The objective of this study was to evaluate disease stage-associated differences in receptor tyrosine kinase (RTK) signaling in A549 cells using pretreatment sera from cases of pathologically-confirmed lung adenocarcinoma or control cases derived from a lung cancer screening study. This was accomplished as a means to explore the hypothesis that circulating concentrations of decoy receptors and/or ligands, as well as disease-specific ligand degradation all regulate RTK signaling in vivo.

Methods: Pretreatment peripheral blood were prepared from either from non-cancer control patients (n=30) or those with lung adenocarcinoma, consisting of stage I (T1-2N0M0, n=25); locoregionally progressed (T1-2N1-2M0, n=36) or disseminated, stage IV disease (n=43). All patients were enrolled with written informed consent to our IRB-approved, institutional biorepository. Confluent cultures of A549 cells were stimulated for 10 minutes with patient sera diluted 1:1 in RPMI-1640 followed by immediate whole cell lysate preparation. After protein determinations by BCA, 8.5 µg of each sample was interrogated using the Human RTK (phosphoprotein) kit from MilliporeSigma according to manufacturer’s instructions. After being normalized to the kit-supplied (stimulated) HeLa cell lysates, all resulting data were evaluated by one-way ANOVA (LSD and Tukey post-hoc) for categorical comparisons.

Results: The most commonly observed differences in RTK signaling was noted upon comparing cohorts with locoregional (T1-2N1-2M0) progression and disseminated (stage IV) disease. Levels of in c-Met and insulin receptor (IR) signaling were higher in patients with stage IV disease relative to those with locoregional disease by 24% and 10%, respectively (both p&lt;0.01); whereas induction of c-Kit, VEGFR3, and Tie-1 were reduced by 12.8%, 6.67%, and 17.3%, respectively (all p&lt;0.05). Circulating levels of HGF were previously observed by our group to be 25% higher in stage IV patients relative to those with locoregional progression (p=0.005) - agreeing with our observation in direction of change, though not scale. This is in contrast to levels of VEGF-C and VEGF-D previously being observed elevated 51% and 452% (both p&lt;0.001) in these same cohorts. Also of note was the 1.9 fold decrease in ability of sera from stage I patients to stimulate IGF-1R signaling relative to control patients (p=0.002). We have previously reported a 12% increase in IGF-1 levels between these groups (p=0.002), though we observed no changes in IGF binding proteins that could account for the observed differences in IGF-1R signaling.

Conclusions: We observed an apparent discoupling of certain circulating ligands in patient sera to stimulate their respective RTKs in a disease stage-specific manner. We are currently evaluating levels of circulating ligands, potential disease stage-associated (partial) proteolytic degradation, and decoy receptors to help explain these observations.

Citation Format: Gabriela C. Lobato, Jared D. Fialkoff, Imad Tarhoni, Nicholas Lund, Vineela Chukkapalli, Selina Sayidine, Cristina L. Fhied, Sanjib Basu, Wen-Rong Lie, Michael J. Liptay, Philip Bonomi, Jeffrey A. Borgia. Induction of receptor tyrosine kinase signaling by sera from patients with lung adenocarcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4665. doi:10.1158/1538-7445.AM2017-4665

Efficacy, safety, and biomarker results of trastuzumab emtansine (T-DM1) in patients (pts) with previously treated HER2-overexpressing locally advanced or metastatic non-small cell lung cancer (mNSCLC)

8509

Background: T-DM1 is an antibody-drug conjugate approved for HER2-positive metastatic breast cancer. We report primary results from a fully enrolled, ongoing phase 2 study (NCT02289833) of pts with previously treated HER2-overexpressing mNSCLC who received single-agent T-DM1. Methods: Eligible pts had HER2-overexpressing mNSCLC and were previously treated with platinum-based therapy. Pts received T-DM1 3.6 mg/kg every 3 weeks and were analyzed in 2 cohorts based on centrally determined HER2 status (immunohistochemistry [IHC]2+ vs IHC3+ [≥10% cells stained with 2+ or 3+ intensity, respectively]). HER2 amplification was assessed via ISH (HER2 gene ratio ≥2.0). The primary endpoint is objective response rate (ORR; proportion of pts with confirmed [≥4 weeks] complete or partial response per RECIST v1.1). Results: The clinical cutoff date for this analysis was Oct 26, 2016.Of 393 screened pts, 102 (27%) were IHC2+ and 29 (7%) were IHC3+. In total, 49 pts (IHC2+, n = 29; IHC3+, n = 20) received T-DM1. At cutoff, median follow-up was 16.3 (range 0.9*–22.4; * = censored observation) months. No IHC2+ pt had a response (0%, 95% CI 0–11.9); 4 IHC3+ pts had partial responses (20%, 95% CI 5.7–43.7) with a median duration of response of 7.3 (range 2.9–8.3) months. Median progression-free survival (PFS) in IHC2+ and IHC3+ pts was 2.6 (95% CI 1.4–2.8) and 2.7 (95% CI 1.4–8.3) months, respectively. At 6 months after start of study treatment, 9 pts (IHC2+, n = 4; IHC3+, n = 5) were still at risk for a PFS event. Median overall survival was 12.2 (95% CI 3.8–not estimable [NE]) months in IHC2+ pts and 12.1 (95% CI 9.3–NE) months in IHC3+ pts. Of 16 pts with HER2 amplification (IHC2+, n = 5; IHC3+, n = 11), 3 responded, all in the IHC3+ cohort (27.3%, 95% CI 6.0–61.0). Eleven pts (22%) experienced a grade 3–4 adverse event, with fatigue and dyspnea being the only events reported in > 1 pt (n = 2 each). Conclusions: This is the first study to report on the clinical activity of T-DM1 in HER2-overexpressing mNSCLC. Objective responses were observed in IHC3+ pts. Additional molecular analyses are underway to refine markers for optimal pt selection. Clinical trial information: NCT02289833.

Impact of prior radiation on survival in metastatic lung cancer ECOG-ACRIN trials

9051

Background: Up to 50% of advanced NSCLC patients receive radiation therapy at some point in their course. We sought to determine whether patients with prior radiation demonstrate altered outcomes on subsequent metastatic clinical trials. Methods: We reviewed 8 ECOG-ACRIN advanced non-small cell lung cancer studies conducted between 1993 and 2011 in which information was collected about receipt of prior radiation. Whether radiotherapy was given with curative or palliative intent, or to specific sites was not recorded. Median follow-up among all trials was 66 months. We used the log-rank, Wilcoxon and Fisher’s exact tests to compare patients, and Cox Model and Kaplan-Meier method to calculate survival. Results: 574/3041 (18.9%) patients had received prior radiation. These patients were more likely to be male (64% vs 58%), have squamous histology (20% vs 14%) and have had prior surgery (48% vs 33%) compared to those with no prior radiation. At registration, prior radiation patients were more likely to have an ECOG PS of 1 (66% vs 58%), while they were less likely to have a PS of 0 (24% vs 36%) or have a pleural effusion (23% vs 37%). Patients who received radiation were more likely to have been registered on to studies between 1993-1999 than 2000-2011 (69% vs 31%) (all p < 0.001). Median Overall Survival (OS) for patients with prior radiation was 7.6 months (range 7-8.3) vs 9.5 (9.1-9.8) for those without (p < 0.001). Median Progression Free Survival (PFS) for those with prior radiation was 3.5 months (3-3.9) vs 4.2 (4.1-4.4) for those without (p < 0.001). In multivariable analysis controlling for stage IIIB/IV, sex, PS, histology, and prior surgery, the impact of prior radiation on overall survival remained significant (p = 0.042, HR (95% CI) = 1.11 (1.00, 1.22)). Conclusions: Almost one-fifth of lung cancer patients on systemic therapy trials for advanced disease previously received radiation. They are more likely to be male, have squamous histology, have an ECOG PS of 1 and have had prior surgery. Prior radiation is significantly associated with inferior OS and PFS. For advanced NSCLC clinical trials, documentation of whether curative intent/palliative intent radiation was given and stratification by prior radiation exposure should be considered.

Neutrophil to lymphocyte ratio as predictive of prolonged progression free survival (PFS) and overall survival (OS) in patients with metastatic non-small cell lung cancer (NSCLC) treated with second-line PD-1 immune checkpoint inhibitors

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Background: Baselinehigh neutrophil to lymphocyte ratio (NLR) has been associated with inferior overall survival in patients with stage III/IV NSCLC. Inflammation and neutrophilic infiltrates in the tumor microenvironment appear to inhibit anti-tumor immune response. We suspect that NLR might reflect the level of inflammation in tumor microenvironment. The objectives of this study were to evaluate potential relationships between pretreatment NLR and and PFS and OS in advanced NSCLC patients treated with second-line nivolumab or pembrolizumab. Methods: Patients with stage IV NSCLC who received at least one cycle of nivolumab or pembrolizumab after first-line treatment with a platinum doublet between January 2015 and December 2016 were included. Patient demographics including NLR at baseline, date of starting immunotherapy, and date of progression were recorded. The association between NLR and duration of response was assessed using a Mann-Whitney-Wilcoxon test. A cutoff of NLR of 3.5 and 5.0 based on published data (ref) were analyzed for differences in median overall survival and progression free survival. Results: 113 patients were analyzed: median age 68, male/female 38.9%/61.1%, 15% never smoked. The median PFS for patients with NLR < 5 was 4.14 months vs. 2.27 months in those with NLR > 5 (p = 0.031). Overall survival was also impacted by NLR. There were a total of 29 deaths in the cohort, 24 of these occurred in patients with NLR > 3.5 and 5 were in patients with NLR < 3.5. A lower NLR at baseline was significantly associated with improved overall survival (p = 0.036). Conclusions: A low baseline NLR is associated with superior progression free survival and overall survival in metastatic non-small cell lung cancer patients treated with nivolumab or pembrolizumab. These findings suggest that evaluating mediators of inflammation might help to identify potential therapeutic targets which could enhance effectiveness of PD-1 immune check point inhibitors in advanced NSCLC.

Circulating biomarkers and outcomes in advanced non-small cell lung cancer patients treated with anti-PD1 (program death 1 receptor) monoclonal antibodies

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Background: Current evaluation of immunohistochemical expression of PDL-1 (program death receptor 1 ligand) can select some non-small cell lung cancer (NSCLC) patients who may benefit from anti-PD1 directed therapy. It is an imperfect marker and there is little information about systemic modulation of the immune system on therapy. In this study we explored the prognostic value of baseline circulating immune checkpoint and inflammatory molecules in advanced non-small cell lung cancer (NSCLC) patients receiving anti-PD1 therapy. Methods: Prospectively collected serum from advanced NSCLC patients receiving nivolumab or pembrolizumab were evaluated with the MILLIPLEX Human High Sensitivity T-cell (17-plex) and ProcartaPlex Human Immuno-Oncology Checkpoint (14-plex) panels on our Luminex FlexMAP 3D. Biomarker level cutoffs were optimized and evaluated against progression-free survival (PFS) and overall survival (OS) using log-rank analysis. Results: 21 cases were enrolled in this pilot study: 72% Caucasian, 61% female, 24% never-smokers. IL-10 was found to have a significant association with both PFS (p = 0.0055) and OS (p = 0.024), with levels below 3.32 pg/mL being associated with a superior clinical outcome. We also found IL-2 and IL-6 to have significant associations with PFS (p = 0.033 and 0.040, respectively), again, with low levels being associated with a superior outcome. Neither of these had significant associations with OS. Low circulating levels of the T-cell immunoglobulin and mucin-domain containing-3 (TIM-3) protein were associated with superior PFS (p = 0.036), and a weak trend (p = 0.19) for OS. Conclusions: In this small exploratory pilot study we identified several circulating molecules associated with inflammation and immune system regulation that may have prognostic value for anti-PD-1 therapy. Notably, TIM-3 is a Th1-specific protein associated with macrophage activation and is also a component of T-cell exhaustion along with LAG3 and PD-1. Additional studies to follow up on these findings in larger cohorts are underway.

Association of KRAS mutations detected via liquid biopsy in metastatic non-small cell lung cancer patients with high levels of FDG-PET SUV

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Background: We had previously evaluated the relationship between FDG-PET SUV with TP53 and KRAS mutations in formalin fixed paraffin embedded tissue (FFPE) in non-small cell lung cancers (NSCLC) in which genomic profiling had been performed. Considering FDG-PET SUV as a surrogate of glycolysis, we found TP53 and KRAS mutations were associated with increased glycolytic activity. The aim for this study was to evaluate KRAS and TP53 in circulating tumor DNA (ctDNA) in relation to FDG-PET SUV in a different cohort of NSCLCs in which genomic profiling was performed on peripheral blood. Methods: All stage IV NSCLC patients with genomic analysis from ctDNA and baseline FDG-PET scans between December 2014 and November 2016 were included. Associations between KRAS and TP53 mutations and maximal standard uptake value (SUVmax) were assessed using the Mann-Whitney and Kruskal-Wallis test. A subset analysis studying all KRAS positive patients from FFPE and ctDNA was performed based on the specific KRAS mutation. Results:122 patients had FDG-PET scans and genomic analyses of their circulating tumor cells. 62 (51%) patients had a TP53 mutation, 20 (17%) patients had a KRAS mutation, and 13 (11%) patients had both TP53 and KRAS mutations. Patients with a KRAS mutation had a higher SUVmax with a mean of 12.32 (p = 0.019). The presence of TP53 alone or concurrent TP53/KRAS was not significantly related to SUVmax. Analyzing 48 patients with KRAS mutation from FFPE and ctDNA assay, 16 patients had mutations of G12C and 9 patients had G12V. The presence of the G12C mutation was particularly highly correlated with higher SUVmax with a mean of 17.68 (p = 0.0006). Conclusions: In analyzing ctDNA, a larger cohort, mutations in KRAS had the strongest correlation with increased SUVmax. Targeting glycolysis and cellular metabolism could be a potential therapeutic strategy for patients with KRAS mutations. Although individual numbers are small, KRAS subtype analysis showed the presence of the G12C mutation might have the strongest relationship with SUV max and increased glycolysis.

Differential expression of circulating biomarkers of tumor phenotype and outcomes in previously treated non-small cell lung cancer patients receiving erlotinib vs. cytotoxic chemotherapy

Background

The objective of this study was to identify serum biomarkers capable of predicting clinical outcomes in previously-treated NSCLC patients with wild-type for EGFR activating mutations or insufficient tissue for mutation status determination.

Methods

Sixty-six Luminex immunoassays representative of biological themes that emerged from a re-analysis of transcriptome data from the Cancer Genome Atlas (TCGA) were evaluate against pretreatment serum specimens from previously-treated advanced NSCLC patients received either cytotoxic chemotherapy (n=32) or erlotinib (n=79). Known EGFR mutation positive cases were excluded from analysis. Associations of biomarkers with outcome parameters and their differential interaction with treatment for survival outcomes were assessed using multivariate Cox PH analyses.

Results

Our EMT-based transcriptomic analysis revealed a range of biological processes associated with angiogenesis, apoptosis, cachexia, inflammation, and metabolism emerging as those most highly associated with patient outcome. These processes were evaluated via surrogate serum biomarkers. A treatment-biomarker interaction analysis revealed that higher pretreatment levels of c-Met signaling biomarkers (i.e. HGF levels), pro-inflammatory/ pro-cachexia (e.g. IL-8, sIL-2Rα, FGF-2) processes and a pro-angiogenic (e.g. TGF-α, IL-8, VEGF) milieu were associated with inferior survival (HR=0.35, 0.29, 0.58, 0.50, 0.61, 0.45, respectively; all p<0.05) for patients receiving chemotherapy, relative to erlotinib. In contrast, high levels of decoy receptor for IL-1, sIL-1RII, and a high tissue vimentin/E-cadherin ratio were associated with a poor OS (HR=3.78; p=0.00055) in the erlotinib cohort.

Conclusions

Contemporary precision medicine initiatives that pair patient tumor characteristics with the optimal therapy type may maximize the use of agents targeting EGFR in the treatment of NSCLC.

Relationships between longitudinal neutrophil to lymphocyte ratios, body weight changes, and overall survival in patients with non-small cell lung cancer

Background

There is emerging evidence showing a significant relationship between overall survival (OS) in non-small cell lung cancer NSCLC patients and weight change during chemotherapy or chemoradiation. A high neutrophil/lymphocyte ratio (NLR) at baseline and at follow-up is associated with shorter survival in cancer patients and may be a surrogate for ongoing inflammation, implicated in cancer cachexia and tumor progression. The objective of this study is to explore potential relationships between OS, serial weights, and serial NLRs in advanced NSCLC patients receiving chemotherapy.

Methods

One hundred thirty-nine patients with chemotherapy-naïve NSCLC, predominantly with stage III/IV disease, were treated with first-line platinum doublets from June, 2011 to August, 2012. NLR, tumor response, and body weight were recorded at baseline, 6, and 12 weeks from initiation of therapy and correlated with OS. The association between NLR and OS was assessed using Cox PH (proportional hazards) analysis, the association between NLR and weight change was assessed using a simple regression analysis, and the association between NLR and tumor response was assessed using the Fisher’s exact test.

Results

One hundred thirty-nine patients with median age 68, PS 0-1/2 = 83/17%, male/female = 58%/42%. Median NLR at baseline was 3.6 (range 0.1898 to 30.910), at 6 weeks 3.11 (range 0.2703 to 42.11), and at 12 weeks 3.52 (range 0.2147 to 42.93). A Higher NLR at baseline, 6, and 12 weeks was associated with decreased OS (baseline: HR 1.06, p < 0.001; 6 weeks: HR 1.07, p = 0.001; 12 weeks: HR 1.05, p < 0.001), and longitudinal NLR, as a time-dependent covariate, was also associated with decreased OS (HR = 1.06, p < 0.001). Baseline weight and NLR were inversely related (cor = −0.267, p = 0.001), and weight change and NLR were inversely related at 12 weeks (cor = −0.371, p < 0.001). Longitudinal measurements of weight and NLR were also negatively associated (slope = −0.06, p < 0.001). Using a cutoff of NLR > 5, there was a significant association between progressive disease and NLR > 5 at 6 weeks (p = 0.02) and 12 weeks (p = 0.03).

Conclusions

High baseline and progressive increases in NLRs are associated with progressive disease, inferior OS and weight loss in NSCLC patients. In addition to having prognostic significance, these observations suggest that studying molecular mediators of cachexia/inflammation and their relationships to tumor progression may identify new therapeutic targets in the large subset of NSCLC patients who have cancer cachexia.