Personalized, tumor-informed, circulating tumor DNA assay for detecting minimal residual disease in non-small cell lung cancer patients receiving curative treatments

BACKGROUND

Circulating tumor DNA (ctDNA) has emerged as a prognostic and predictive biomarker for detection of minimal residual disease (MRD), monitoring treatment response, and early detection of recurrence in cancer patients. In this study, we explored the utility of ctDNA-based MRD detection to predict recurrence in a real-world cohort of primarily early-stage non-small cell lung cancer (NSCLC) patients treated with curative intent.

METHODS

Longitudinal plasma samples were collected post curative-intent treatment from 36 patients with stage I-IV NSCLC. A personalized, tumor-informed assay was used to detect and quantify ctDNA in plasma samples.

RESULTS

Of the 24 patients with plasma samples available during the MRD window (within 6 months of curative surgery and before adjuvant therapy), ctDNA was detectable in two patients. Patients with ctDNA-positivity during the MRD window were 15 times more likely to recur compared to ctDNA-negative patients (HR: 15.0, 95% CI: 1.0-253.0, p = 0.010). At any time post-curative intent treatment, ctDNA-positivity was associated with significantly poorer recurrence-free survival compared to persistently ctDNA-negative patients (p < 0.0001).

CONCLUSION

Our real-world data indicate that longitudinal, personalized, tumor-informed ctDNA monitoring is a valuable tool in patients with NSCLC receiving curative treatment to identify patients at high risk for recurrence.

Redefining Clinical Hyperprogression: The Incidence, Clinical Implications, and Risk Factors of Hyperprogression in Non-Small Cell Lung Cancer Treated with Immunotherapy

INTRODUCTION

Immune checkpoint inhibitors (ICIs) may be associated with hyperprogressive disease (HPD). However, there is currently no standardized definition of HPD, with its risk factors and clinical implications remaining unclear. We investigated HPD in lung cancer patients undergoing immunotherapy, aiming to redefine HPD, identify risk factors, and assess its impact on survival.

METHODS

Clinical and radiologic data from 121 non-small cell lung cancer (NSCLC) patients with 136 immunotherapy cases were reviewed retrospectively. Three HPD definitions (Champiat et al., HPDc; Saâda-Bouzid et al., HPDs; and Ferrara et al., HPDf) were employed. Additionally, all new measurable lesions on the post-treatment CT scan were incorporated in measuring the sum of longest diameters (SLD) to define modified HPD (mHPD).

RESULTS

Among the 121 patients, 4 (3.3%) had HPDc, 11 (9.1%) had HPDs, and none had HPDf. Adding all new measurable lesions increased HPD incidence by 5%-10% across definitions. Multivariate analysis revealed significantly lower progression-free survival (PFS) and overall survival (OS) for patients with HPDc (HR 5.25, P = .001; HR 3.75, P = .015) and HPDs (HR 3.74, P < .001; HR 3.46, P < .001) compared to those without. Patients with mHPD showed similarly poor survival outcomes as HPD patients. Liver metastasis at diagnosis was associated with HPDs, and a high tumor burden correlated with HPDc.

CONCLUSIONS

The incidence and risk factors of HPD varied with different definitions, but mHPD identified more cases with poor outcomes. This comprehensive approach may enhance the identification of at-risk patients and lead to a better understanding of HPD in lung cancer during immunotherapy.

Deep response to a combination of mTOR inhibitor temsirolimus and dual immunotherapy of nivolumab/ipilimumab in poorly differentiated thyroid carcinoma with PTEN mutation: a case report and literature review

Treating advanced thyroid cancer presents challenges due to its resistance to various treatment modalities, thereby limiting therapeutic options. To our knowledge, this study is the first to report the efficacy of temsirolimus in conjunction with dual immunotherapy of nivolumab/ipilimumab to treat heavily treated advanced PDTC. A 50-year-old female initially presented with a rapidly enlarging mass on her right neck. Subsequent diagnosis revealed poorly differentiated thyroid carcinoma, leading to a total thyroidectomy followed by post-operative radioablation therapy. After four years, an examination for persistent cough revealed a recurrence of the disease within multiple mediastinal nodes. Genetic analysis of blood samples uncovered somatic mutations in the tumor, specifically involving PTEN and TP53. The disease progressed despite palliative radiation, lenvatinib, and nivolumab/ipilimumab therapy. Consequently, temsirolimus, functioning as an mTOR inhibitor, was introduced as an adjunct to the nivolumab/ipilimumab regimen. This combination approach yielded remarkable clinical improvement and disease control for a duration of approximately six months. Temsirolimus likely suppressed the aberrantly activated PI3K/AKT/mTOR signaling pathway, facilitated by the PTEN genetic alteration, thus engendering an effective treatment response. This synergy between targeted agents and immunotherapy presents a promising therapeutic strategy for advanced PDTC patients with limited treatment alternatives. In previous clinical trials, mTOR inhibitors have demonstrated the ability to maintain stable disease (SD) in 65% to 74% for advanced thyroid cancer patients, including those with PDTC. When combined with other targeted therapies, the observed SD or partial response rates range from 80% to 97%. Many of these trials primarily involved differentiated thyroid carcinoma, with diverse genetic mutations. Thyroid cancer patients with alterations in the PI3K/mTOR/Akt appeared to benefit most from mTOR inhibitors. However, no clear association between the efficacy of mTOR inhibitors and specific histologies or genetic mutations has been established. Future studies are warranted to elucidate these associations.

Survival Outcomes After Double-Lung Transplantation for Refractory Lung-Limited Cancers and Incidence of Post-Transplant Lung Cancer

BACKGROUND To evaluate the role of double-lung transplantation (DLT) for lung cancer, the survival outcomes of patients who underwent DLT for lung cancer and the incidence of de novo lung cancer after DLT were assessed. MATERIAL AND METHODS Data from all cases reported in the literature were pooled for analysis and additional data were collected from the Organ Procurement Transplantation Network (OPTN) registry. Recurrence-free survival (RFS), overall survival (OS), and cancer-specific survival (CSS) of patients who underwent DLT for lung cancer were determined. Moreover, the incidence of de novo lung cancer and associated OS in lung transplant recipients were examined. RESULTS Of the 20 cases series and 15 cases from the OPTN registry, the 5-year RFS was 55.0% and 66.7% and the 5-year OS was 55.0% and 26.7%, respectively, and the median CSS was 48.0 (range, 2.0-144.0) and 27.7 (range, 0.2-66.6) months, respectively. In the OPTN data, the incidence of post-transplant lung cancer in patients who underwent DLT for the non-cancerous disease was 0.8% and the 5-year OS was 47.3%. CONCLUSIONS In conclusion, our integrated analysis of the case series and the OPTN registry demonstrated promising survival outcomes for patients with refractory bilateral lung cancer who underwent DLT. Although there are limitations to consider, the results of this study underscore the potential benefits of DLT in managing refractory lung-limited lung cancer.

A Comprehensive Landscape of De Novo Malignancy After Double Lung Transplantation

Although the association between post-transplant malignancy (PTM) and immunosuppressive therapy after organ transplantation has been studied, an integrated review of PTM after lung transplantation is lacking. We investigated the incidence and types of de novo PTM and its impact on survival following double lung transplantation (DLT). The incidence and type of PTM as well as the annual and cumulative risks of each malignancy after DLT were analyzed. The overall survival (OS) of recipients with or without PTM was compared by the Kaplan-Meier survival method and landmark analysis. There were 5,629 cases (23.52%) with 27 types of PTMs and incidences and OS varied according to the types of PTMs. The recipients with PTM showed a significantly longer OS than those without PTM (p < 0.001). However, while the recipients with PTM showed significantly better OS at 3, and 5 years (p < 0.001, p = 0.007), it was worse at the 10-year landmark time (p = 0.013). And the single PTM group showed a worse OS rate than the multiple PTM group (p < 0.001). This comprehensive report on PTM following DLT can help understand the risks and timing of PTM to improve the implementation of screening and treatment.

Current and future role of double-lung transplantation for bilateral lung cancer

Technological advances have progressively enhanced the survival rate of lung transplant recipients and expanded its indications for various diseases, including the recent coronavirus disease 2019 (COVID-19). However, according to the International Society for Heart and Lung Transplantation, lung cancer constituted a mere 0.1% of the indications for lung transplantation over the past two decades. This statistic has remained stagnant, and numerous lung cancer patients continue to be excluded from lung transplantation candidacy. Contrary to the general exclusion of lung cancer patients from transplantation, the post-transplant survival rate for these patients is not inferior to that of patients with non-cancerous diseases. Furthermore, lung transplantation may offer curative treatment for patients with bilateral lung cancer whose respiratory insufficiency has advanced independently of cancer progression. This review aims to elucidate and examine the role of double lung transplantation (DLT) in bilateral lung cancer. We summarize the established indications for lung transplantation, appropriate histologic or molecular subtypes of lung cancer for transplantation, technical advances to minimize recurrence, post-DLT survival outcomes for lung cancer patients, and related translational research. We suggest that although DLT for bilateral lung cancer presents challenges, it may be considered a potential treatment option in select circumstances.

Abstract 5619: Radiomics-based machine learning models to predict progression and biomarker status in non-small cell lung cancer (NSCLC) patients treated with immunotherapy

Background: Radiomics is an emerging tool that involves the extraction of high-throughput features from medical images. These quantitative values can be used to develop predictive models for clinical characteristics and treatment outcomes. We evaluated radiomic features-based models as imaging biomarkers in NSCLC patients.

Methods: 71 patients with NSCLC treated with immunotherapy who had pretreatment CT chest with contrast were retrospectively evaluated. The main tumor and 1cm-thick peritumoral space surrounding the tumor were manually segmented using LIFEx software (IMIV/CEA, Orsay, France) by four physicians. Of 255 radiomic features collected, those with &gt;0.4 of Fleiss’ kappa coefficient were selected. The Random Forest (RF) algorithm with mixed effects was used to develop multi-reader models and assess feature importance. The dataset was divided into a training set (75%) and a test set (25%). Bootstrapping with 1,000 iterations was conducted to estimate the model performance. Durable disease control was defined as having no progression of diseases per RECIST 1.1 up to 24 weeks from starting immunotherapy.

Results: Among 71 patients, 35 (49.3%) are female and 36 (50.7%) are male. The median age was 66. 48 (67.6%) adenocarcinoma, 13 (18.3%) squamous cell carcinoma, and 10 (14.1%) other histologic types were included. 22 radiomic features were included based on importance in the prediction models from both the tumor and peritumoral space. Each model is trained to predict patients’ durable disease control, TTF1 expression, PD-L1 expression, histology (adenocarcinoma or not), and Neutrophils Lymphocyte Ratio (NLR; greater than 5 or not) status. The statistical results from the models to predict clinical outcomes are shown in Table.

Conclusion: The radiomic features-based models lack accuracy in predicting clinical characteristics and outcomes. Further validation with larger cohorts is warranted.

Statistics of radiomics-based models in predicting clinical characteristics and treatment outcomes Durable Disease Control(Yes/No)(n=64) TTF1 expression(Yes/No)(n=62) Histology(Adeno/Other)(n=71) NLR(&gt;=5/&lt;5)(n=71) PD-L1 expression(Yes/No)(n=52) Patient Number(%) 33 (51.56%)/31 (48.44%) 37 (59.68%)/25 (40.32%) 48 (67.61%)/23 (32.39%) 28 (39.44%)/43 (60.56%) 35 (67.31%)/17 (32.69%) Sensitivity (95% CI) 0.63 (0.58, 0.72) 0.62 (0.56, 0.74) 0.69 (0.56, 0.82) 0.55 (0.47, 0.61) 0.57 (0.48, 0.65) Specificity (95% CI) 0.46 (0.37, 0.52) 0.68 (0.58, 0.76) 0.22 (0.12, 0.34) 0.60 (0.56, 0.68) 0.36 (0.30, 0.45) Positive Predictive Value(95% CI) 0.52 (0.49, 0.57) 0.44(0.37, 0.60) 0.62 (0.59, 0.64) 0.69 (0.67, 0.74) 0.72 (0.68, 0.77) Negative Predictive Value(95% CI) 0.58 (0.54, 0.63) 0.79 (0.74, 0.88) 0.28 (0.22, 0.32) 0.46 (0.39, 0.51) 0.25 (0.21, 0.28)

Citation Format: Jisang Yu, Yury Velichko, Hyeonseon Kim, Moataz Soliman, Nicolo Gennnaro, Leeseul Kim, Youjin Oh, Trie Arni Djunadi, Jeeyeon Lee, Liam Il-Young Chung, Sungmi Yoon, Zunairah Shah, Soowon Lee, Cecilia Nam, Timothy Hong, Rishi Agrawal, Pascale Aouad, Young Kwang Chae. Radiomics-based machine learning models to predict progression and biomarker status in non-small cell lung cancer (NSCLC) patients treated with immunotherapy. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5619.

Abstract 783: Systematic review and meta-analysis of the accuracy and applicability of blood-based multi-cancer early detection (MCED) in the general population

Background: Globally, cancer results in 10.08 million deaths per year. A single blood-based screening tool that detects multiple cancer types could greatly reduce cancer burden. We aim to systematically review and statistically examine both the accuracy and applicability of blood-based MCED tests to strategize their utilization in improving cancer detection.

Methods: Original articles were searched from Pubmed, Cochrane, and Embase for blood-based screening tests analyzing multiple cancer types and asymptomatic human subjects. We excluded studies with small sample size (n&lt;30), hypothesis-generating tests, and non-blood based tests. For cell-free DNA (cfDNA) based assays, measurements of diagnostic accuracy were pooled for meta-analysis.

Findings: Of 1,074 records screened, 10 case-control and 6 cohort studies were analyzed, most of which utilized cfDNA-based diagnostic tests. Ten cfDNA studies selected for meta-analysis had a joint sensitivity of 0.66 (95%CI 0.54-0.75) and specificity of 0.98 (0.94-0.99) with an area under the curve of 0.883. For cohort studies, the joint positive and negative predictive values were 0.96 (0.29-1.00) and 0.81 (0.37-0.97) respectively. Sensitivity was higher for advanced staged cancers (III/IV 0.84 (0.84-0.86)) with breast cancer having the lowest sensitivity (0.42 (0.31-0.55)). Sensitivity and specificity were not affected by study type, gender, or assay type. Lastly, accuracy of tumor origin prediction was 0.792 (0.64-0.91) without significant differences across cancer types.

Interpretation: Given high sensitivities and specificities, MCED tests show promise as additional screening tools. Although there exist multiple barriers to their application in clinic, MCED tests may improve patient outcomes for cancers with no conventional screening tools. Future prospective studies with large and diverse populations are warranted.

Summarization of meta-analysis results on cfDNA based multi cancer early detection tests Sensitivity Specificity DOR PPV NPV No. of study included 10 10 10 4 4 Events/Total 5778/10033 14797/15020 Experimental group: 5778/6001 901/1373 10148/11216 Control group: 4202/19052 Proportion (95% CI) 0.652 [0.537; 0.751] 0.978 [0.936; 0.992] 69.290 [25.208; 190.457] 0.961 [0.293; 0.999] 0.812 [0.365; 0.970] Heterogeneity (p value) 98% (&lt;0.01) 97% (&lt;0.01) 96% (&lt;0.01) 99% (&lt;0.01) 100% (&lt;0.01) Abbreviations: CI = confidence interval; DOR = diagnostic odds ratio; PPV = positive predictive value; NPV = negative predictive value

Citation Format: Joo Hee Park, Youjin Oh, Liam Il-Young Chung, Richard Duan, Trie A. Djunadi, Sung Mi Yoon, Zunairah Shah, Chan Mi Jung, Ilene Hong, Leeseul Kim, Young Kwang Chae. Systematic review and meta-analysis of the accuracy and applicability of blood-based multi-cancer early detection (MCED) in the general population [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 783.

The symbiosis of healthcare professionals and patients: Understanding the dynamics of long-term care relationships between healthcare professionals and patients in oncology

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Background: Chronic diseases are a significant source of physical, emotional, mental, and social distress to not only patients but also their friends and family. Healthcare professionals (HCPs) also share in the burden as they strive to provide the best possible care. In particular, cancer patients face great burden as they grapple with the uncertainty of their futures. Given the respective difficulties associated with cancer treatment, fostering a collaborative environment in which patients, caregivers, and HCPs mutually encourage each other becomes necessary to improve the quality of life of everyone involved. This study aims to investigate factors that influence a healthy long-term care relationship between patients and HCPs. Methods: This study is a qualitative analysis of HCPs’ experiences with patients and their caregivers at a large metropolitan academic medical center. This study analyzed reflective essays written by HCPs as part of the Pacemakers initiative at the medical center, which seeks to empower HCPs, patients, and caregivers in creative ways along the management journey. The essays focused on HCPs’ participation in meaningful experiences with patients and caregivers such as patient/caregiver award ceremonies celebrating their resilience and hope. A total of 22 essays ( N = 22) were thematically analyzed by two independent coders to produce meaning-making codes and themes (italicized). Results: The presence of support networks ( n = 10) was very important for the patients and caregivers. Conveying solidarity ( n = 21) was also central in helping patients experience companionship and fellowship in their community with their medical team, family, and friends. It was also noted that little means much ( n = 10); small acts of kindness showing genuine interest led to meaningful interactions that provided encouragement for the patients. Compassion ( n = 19) and patient-centeredness ( n = 17) were important in fostering a receptive environment in which patients and caregivers felt heard. Celebrating and honoring the patients’ resilience ( n = 10) made patients feel recognized, and this process of celebration was also found to bolster a renewed sense of purpose for the HCPs ( n = 11). Conclusions: The results of this study highlight the importance of supporting patients and their caregivers holistically. Understanding and meeting this need through creative encouragement empowers not only the patients and caregivers but also the HCPs. Trust is built and patients are strengthened to pursue their health to the best of their abilities as HCPs show their deep care for their struggles and resiliency. This sacred experience of entrusting one’s life to another builds the best environment for healing and recovery. This study shares a glimpse of how to best support patients as well as HCPs in long-term care relationships.

Preventing healthcare professional burnout in oncology: How creative patient encouragement can go both ways

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Background: Cancer treatment is a difficult process that not only affects the patients themselves, but also their caregivers and healthcare professionals (HCPs). A cancer diagnosis is often a life-changing experience for both patients and caregivers, who may feel vulnerable and stressed in the face of such a complex disease. HCPs in oncology, who are constantly present on the frontline between life and death, often experience emotional and physical exhaustion. Such burnout of HCPs can lead to adverse effects on patient care. Therefore, it becomes important to prevent and manage HCPs’ fatigue to not only improve patient care, but also HCPs’ quality of life. Methods: This study qualitatively examined the experiences of HCPs who collaboratively interacted with patients and caregivers in the clinical setting. The Pacemakers initiative was developed and piloted in a large urban academic medical center with the aim to promote creative encouragement and companionship among HCPs and patients/caregivers. HCPs held ceremonies with personal awards for patients/caregivers during their treatment course, and their experience with the ceremonies was evaluated qualitatively with a survey. A thematic analysis was subsequently performed on the HCPs’ reflective essays ( N = 22) to identify recurring themes (italicized) in their experiences. Results: In general, we found that the HCPs felt that they were benefiting from taking part in the creative patient encouragement ceremonies. Many described the experience as motivating or inspiring ( n = 15), highlighting how such collaboration renews optimism and prevents burnout. The HCPs also reported feeling acknowledged for their behind-the-scenes work and support ( n = 5) and grateful to be given the opportunity to acknowledge their patients and caregivers ( n = 13), as well. Another common theme was that the HCPs felt that they were able to connect emotionally ( n = 14) with the patients and caregivers, describing moments of shared laughter and tears. Lastly, the HCPs reported feeling a sense of togetherness with patients and caregivers ( n = 13), often describing the relationship as akin to a team or family, and many stated that they were able to develop a more personal connection ( n = 15) with patients and caregivers through the ceremonies. Conclusions: Overall, we find that the benefits of encouraging patients and caregivers extend to HCPs. The positive impact of identifying and celebrating small but meaningful joys in the clinical setting is considerable especially upon HCPs, who find such experiences to be rewarding and refreshing. HCP burnout is common in oncology, and the findings of this analysis suggest that inspiring mutual encouragement and fostering collaboration between HCPs, patients, and caregivers are critical in reducing and preventing such fatigue.