Association between neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, and survival in undifferentiated pleomorphic sarcoma (NLR, PLR, and overall survival in UPS)

BACKGROUND AND OBJECTIVES

Cancer-related inflammation has been shown to be a driver of tumor growth and progression, and there has been a recent focus on identifying markers of the inflammatory tumor microenvironment. Neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) are inflammatory indices that have been identified as prognostic biomarkers in various malignancies. However, there is limited and conflicting data regarding their prognostic value in soft tissue sarcoma (STS) and specifically in undifferentiated pleomorphic sarcoma (UPS).

METHODS

This was a retrospective review of patients who underwent surgical treatment for primary UPS from 1993 to 2021. Cutoff values for NLR and PLR were determined by receiver operating curve analysis. Cox proportional hazards regression was used to determine prognostic factors on univariate and multivariate analysis.

RESULTS

Eighty-six patients were included. The optimal cutoff value was 3.3 for NLR and 190 for PLR. Both high NLR (HR 2.44; 95% CI 1.29-4.63; p = 0.005) and high PLR (HR 1.99; 95% CI 1.08-3.67, p = 0.02) were associated with worse OS on univariate analysis. On multivariate analysis, metastasis at presentation and radiotherapy were independently predictive of OS, but high NLR (HR 1.30; 95% CI 0.64-2.98; p = 0.41) and high PLR (HR 1.63; 95% CI 0.82-3.25; p = 0.17) were not predictive of survival.

CONCLUSIONS

High pre-treatment NLR and PLR were associated with decreased overall survival but were not independent predictors of survival in patients undergoing resection for UPS. Until additional prospective studies can be done, survival outcomes are best predicted using previously established patient- and tumor-specific factors.

Four-Phase, Definitive Chemoradiation for a Real-World (Poor Risk and/or Elderly) Patient Population With Locally Advanced Non-small Cell Lung Cancer

Introduction With the incorporation of modernized radiotherapy, chemotherapy, and immunotherapy, treatment outcomes have improved for patients with locally advanced, unresectable diseases. Elderly or poor performance status patients comprise more than half of non-small cell lung cancer (NSCLC) patients, but they are often underrepresented or excluded in clinical trials. Split-course concurrent chemoradiotherapy can be an effective treatment, showing good adherence and a favorable toxicity profile for unresectable, locally advanced NSCLC. Method We identified locally advanced NSCLC cancer patients via a single institution retrospective study. Patients were treated using a four-phase, split-course external beam radiotherapy approach with concurrent chemotherapy. The primary endpoints analyzed were completion rate, incidence, and severity of treatment-related toxicities, progression-free survival (PFS), and median overall survival (OS). Results Thirty-nine locally advanced lung cancer patients were treated with split-course chemoradiation (CRT). The median age at diagnosis was 73 years old. Seventeen patients had an Eastern Cooperative Oncology Group (ECOG) performance score of 2. Twenty-three patients had a clinical diagnosis of chronic obstructive pulmonary disease (COPD), and 10 patients were on home oxygen at the time of diagnosis. All patients completed 6000 centigrays (cGy) of radiation, and 95% of the patients completed at least three cycles of concurrent chemotherapy. No patients experienced grade 3 to 5 acute thoracic toxicities. Overall median survival was 12.7 months, and PFS was 7.5 months. Conclusion Our retrospective analysis of 39 poor risk and/or elderly patients with locoregional NSCLC treated with concurrent CRT via a split-course regimen suggests favorable oncologic outcomes and superb treatment completion rates and toleration.

Gender and weight change, skeletal muscle index(SMI) change, and survival in advanced non-small cell lung cancer(NSCLC) patients(pts.) receiving platinum chemotherapy

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Background: Significantly longer OS has been reported in advanced NSCLC pts. who gained weight or maintained (skeletal muscle mass) SMI during treatment with platinum containing chemotherapy. None of these studies evaluated the relationship between OS and both weight and SMI. Sex specific distributions are described for cachexia and muscle wasting. Methods: The objective of this retrospective study was to evaluate the relationships between OS and both weight gain and SMI maintenance during front line chemotherapy in advanced NSCLC pts. Weight and SMI measurements(cm2/m2) were done at baseline and at 6, 12, & 24 weeks. OS was estimated using the Kaplan-Meier method. The associations of weight and SMI with overall survival were assessed using Kaplan-Meier, log-rank test and proportional hazards regression. Results with p < 0.05 were reported as significant. Results: Characteristics for the 88 patients were: median age – 64 years, women – 57%, caucasian – 68%, black – 25%, and adenocarcinoma histology – 63%. Weight gain (i.e., > 0%) and > 5% weight gain were observed in 50% and 11.3% of the patients, respectively. For all 88 patients the hazard ratio(HR) for OS in patients with > 0% vs < 0% weight change was 0.544 (p = 0.0164), and the HR for OS for weight > 5% vs < 5% was 0.469 (p = 0.099). The HR for OS in men for > 0% vs < 0% weight gain was 0.421(p = 0.031), and HR for OS > 5% vs < 5% weight gain was 0.421 (p = 0.031). The same analyses in women showed no significant differences. Increases in SMI > 0% and > 5% SMI were found in 48% and 35% of patients, respectively. Maintenance of SMI defined as > - 1.3% was observed in 25% of pts. The HR for OS in men with SMI maintenance versus loss was 0.230 (p = 0.031), and the HR for OS in men with SMI increase > 5% vs < 5% was 0.219 (p = 0.0267). Neither SMI gain nor maintenance were significantly related to OS in the entire patient group or in women. Conclusions: In patients treated with first line platinum doublet, as a group there were no significant relationships between weight changes or SMI changes and OS. The observation that either weight gain or SMI maintenance was associated with longer OS in men only is based on data from a small number of patients. However, if larger studies show similar results, these findings could have implications for clinical and translational research in cachexia.

Clinical and laboratory parameters associated with rapid progression in advanced NSCLC patients treated with second or third-line single agent immune checkpoint inhibitors (ICIs)

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Background: While laboratory parameters including PDL1 expression and NLR are associated with outcomes in patients with metastatic NSCLC treated with ICIs, these measures have not identified patients with rapid progression (RP) defined as progressive disease within 30 days. Clinical factors including patient age and weight loss have been associated with cancer outcomes in general. Identifying clinical correlates for NSCLC patients who experience RP on ICI therapy would be useful. Methods: The objective of this retrospective study was to evaluate relationships between pre-treatment cachexia and inflammation and RP in NSCLC patients who received 2nd- or 3rd- line single agent ICIs. Associations of age, race, gender, smoking status, and longitudinal changes in weight and NLR (from at least 6 weeks prior to treatment initiation) with RP were analyzed by univariate and multivariate statistical (Kaplan-Meier and related) methods. Results: 195 patients were included: 59% female, 18% Black, and 78% current or former smokers. 14% of patients had RP. Black race was associated with RP (HR = 2.32, p = 0.03). 191 patients had pretreatment weight available. 63% had weight loss prior to ICI, 25% with > 5% loss. Any weight loss and weight loss > 5% over the time period ≥6 weeks prior to treatment initiation were associated with RP (HR = 3.19 and 6.40, p = 0.03 and < 0.01). 188 patients had pretreatment NLR values, 63% and 42% had NLRs > 3.5 and > 5, respectively. Pre-treatment NLR > 5 and higher baseline NLR were associated with increased risk of RP (p = 0.03 and p < 0.01). In multivariate analysis adjusted by age, smoking status and weight change, higher pre-treatment NLR is found to differentially increase RP risk for black patients (interaction HR = 1.27, p = 0.03). A model with these 5 variables provided 84.5% AUC of ROC curve (80% sensitivity, 75% sensitivity) for prognosticating RP. Conclusions: This retrospective study identified clinical variables including pre-treatment NLR > 5, weight loss > 0% & > 5%, black race, smoking status, and age that were associated with RP in previously treated advanced NSCLC patients receiving single agent ICIs. Though this requires validation with racially diverse data sets, these clinical parameters may be useful in identifying patients at high risk of RP on 2nd or 3rd line ICI therapy. Future directions include evaluating clinical characteristics and laboratory parameters in NSCLC patients treated with ICIs combined with chemotherapy and novel immunotherapy regimens, as well as single agent ICIs in the first line setting. If these clinical characteristics are associated with frequent RP in the setting of first line ICI treatment, it would be reasonable to consider novel immune strategies in this patient subset.

NRG-DT001 phase Ib trial of neoadjuvant navtemadlin (previously AMG232 and KRT232) concurrent with preoperative radiotherapy in wild-type p53 soft tissue sarcoma of the extremity and body wall

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Background: NRG-DT001 is a phase Ib trial evaluating neoadjuvant navtemadlin with preoperative radiation therapy (RT) in patients (pts) with wild-type (WT) p53 soft tissue sarcoma (STS). The primary objective is to evaluate the safety and tolerability of the MDM2 inhibitor navtemadlin in combination with standard-dose RT in STS in two cohorts (A, extremity or body wall; B, abdomen/pelvis/retroperitoneum) to determine the maximum tolerated dose/recommended phase II dose (MTD/RP2D) of navtemadlin in combination with RT. This report contains the results for cohort A. Methods: Eligible pts had grade 2-3 STS ≥ 5 cm, age ≥ 18, and Zubrod performance status 0-1. Dose levels were 120 mg 2x/week (DL-1), 120 mg 3x/week (DL1), 4x/week (DL2), and 5x/week (DL3) 1 week prior to and during RT (50Gy/5 weeks). Surgery was 5-8 weeks after RT. A 3+3 design was used to make dose escalation/de-escalation decisions at each dose level. Five additional pts were enrolled to the MTD to ensure safety (expansion cohort) with a dose limiting toxicity (DLT) rate of ≤ 1/5 considered safe. The DLT observation period was from the start of navtemadlin until 4 weeks after completion of drug+RT. Tumor Tp53 mutation status was determined by NGS sequencing. All eligible and treated p53 WT pts who experienced DLT or completed the observation period were considered DLT-evaluable. DLT included all grade 4-5 AE definitely, probably, or possibly related to navtemadlin. Any grade 3 AE definitely, probably, or possibly related to navtemadlin was also considered DLT if any of the 2 following situations occurred: a delay of treatment > 2 weeks or ≥ 2 dose reductions due to the grade 3 AE. The decision to escalate or de-escalate was made by consensus of the study team in accordance with the protocol. Results: Between 11/3/2017 and 9/10/2021, 4 (3 WT), 7 (4 WT) and 7 (4 WT) pts were enrolled at DL1, DL2, and DL3 respectively. An additional 9 (5 WT) pts were enrolled on DL3 expansion cohort. Preoperative RT was completed for all except 1 pt (pt refusal/DL3). On DL1 and DL2, 100% of pts completed navtemadlin. On DL3 (including expansion cohort), 78% (7/9) completed navtemadlin (1 AE, 1 pt refusal). On DL1, DL2, and DL3, 3/3, 3/4 (1 disease progression), and 5/6 (1 consent withdrawal; 3 pending) completed surgery. There were no DLTs in any dose level (DL1 0/3, DL2 0/4, DL3 0/9), establishing DL3 as the MTD/RP2D. Tumor necrosis rates will be reported at the time of presentation. Conclusions: Neoadjuvant navtemadlin concurrent with standard dose preoperative RT is well tolerated in patients with WT p53 STS at extremity or body wall, and the 120 mg PO daily of navtemadlin, 5 days per week dose should be used to design future trials of RT with extremity STS. Incorporating NGS sequencing results as an integral biomarker in a clinical trial of neoadjuvant radiotherapy and a radiosensitizer is feasible. Clinical trial information: NRG-DT001 NCT03217266.

What is the clinical impact of staging and surveillance PET-CT scan findings in patients with bone and soft tissue sarcoma?

BACKGROUND AND OBJECTIVES

Positron emission tomography-computerized tomography (PET-CTs) are becoming increasingly utilized in sarcoma care, workup, and surveillance. This study aimed to describe additional PET-CT findings as well as subsequent workups and changes in the clinical course due to those results.

METHODS

Patient records were retrospectively reviewed, and the additional workups and evaluations triggered by PET-CT findings were qualitatively analyzed to document their results. Additional changes in the clinical course were documented.

RESULTS

A total of 183 bone and soft tissue sarcoma patients underwent PET-CT as part of staging or surveillance. Additional workup was performed in 31.5% (n = 41 of 130) patients who had positive PET-CT findings. Among these, 36.6% (n = 15 of 41) patients had clinically significant findings that altered the clinical course. Overall, 14.8% (n = 27 of 183) experienced a change in the clinical course due to PET-CT.

CONCLUSION

PET-CT often highlights lesions of potential clinical importance. Additional workup, as well as changes in the clinical course, were not infrequent. Future, multi-institutional studies should address the value of PET-CT in sarcoma care.

The clinical utility of next-generation sequencing for bone and soft tissue sarcoma

Background: Sarcomas are a rare and heterogeneous tumor group composed of a variety of histologic subtypes. Targeted next-generation sequencing (NGS) of bone and soft tissue sarcomas is a nascent field with limited evidence for its use within clinical practice. Therefore, further research is needed to validate NGS in sarcoma and assess the clinical utility of these techniques with the hope of improving treatment options.Methods: Comprehensive molecular profiling with NGS was performed on 136 tumors (116 soft tissue, 20 bone) using two commercial vendors. Patient records were retrospectively reviewed, and the clinical impact of NGS-related findings were qualitatively analyzed to determine actionable mutations and number of changes in treatment.Results: The median age was 55.0 years (IQR 42-67 years), and most patients were non-metastatic at presentation (80.9%, n = 110). Prior to performing NGS, 72.1% (n = 98) were treated with a mean 1.1 ± 1.2 lines of systemic chemotherapy. NGS identified 341 putative alterations with at least one mutation present in 89.7% (n = 122) of samples. In a subset of 111 patients with available TMB data, 78.7% (n = 107) had a low (<6 m/Mb) mutational burden. Among all 136 cases, 47.1% (n = 64) contained clinically actionable alterations, and 12 patients had a change in medical treatment based on NGS. Those who underwent a treatment change all had metastatic or recurrent disease; three of these patients experienced a clinical benefit.Conclusion: Most bone and soft tissue sarcomas harbor at least one genetic alteration, and it appears a sizeable number of tumors contain mutations that are clinically actionable. While a change in treatment based off NGS-related findings occurred in 12 cases, three patients experienced a clinical benefit. Our data provide further proof-of-concept for NGS in sarcoma and suggest a clinical benefit may be observed in select patients.

Pulmonary metastasectomy in bone and soft tissue sarcoma with metastasis to the lung

 

OBJECTIVES

This study investigated the outcomes of sarcoma patients with lung metastases who underwent pulmonary metastasectomy (PM), compared to patients who underwent medical management alone. The secondary objective was to compare survival after PM between variables of interest.

METHODS

This was a retrospective review of 565 sarcoma patients with confirmed, isolated pulmonary metastasis identified from the Surveillance, Epidemiology and End Results database between 2010 and 2015. 1:4 propensity score matching was used to select PM and non-PM groups. The multivariable Cox proportional hazards model was used to analyse prognostic factors of disease-free survival (DFS).

RESULTS

Of the eligible 565 patients, 59 PM patients were matched to 202 non-PM patients in a final ratio of 3.4. After propensity matching, there were no significant differences in baseline characteristics between PM and non-PM patients. The median DFS after PM was 32 months (interquartile range 18–59), compared to 20 months (interquartile range 7–40) in patients without PM (P = 0.032). Using a multivariable Cox proportional hazards model, metastasectomy (hazard ratio 0.536, 95% confidence interval 0.33–0.85; P = 0.008) was associated with improved DFS. In a subset analysis of patients who underwent PM only, the median DFS was longer in males compared to females (P = 0.021), as well as in bone sarcoma compared to soft tissue sarcoma (P = 0.014).

CONCLUSIONS

For sarcoma patients with metastatic lung disease, PM appears to improve the prognosis compared to medical management. Furthermore, there may be a survival association with gender and tumour origin in patients who underwent PM. These data may be used to inform the surgical indications and eligibility criteria for metastasectomy in this setting.

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.

Outcomes of brain metastasis in high-grade bone and soft tissue sarcoma: An analysis of clinicopathological characteristics and survival data

Brain metastases in sarcoma are exceedingly rare, with few published series documenting ranges from 1% to 8%. This study investigated the outcomes of sarcoma patients with brain metastases using a population-based analysis. This was a retrospective review of 5933 patients with high-grade sarcoma identified from the Surveillance, Epidemiology, and End Results database between 2010 and 2015. Of the eligible 5933 patients, 0.7% (n = 44) had brain metastasis. Kaplan–Meier was used to estimate survival and follow-up (reverse Kaplan–Meier), and a multivariable Cox proportional hazards model analyzed prognostic factors of disease-free survival (DFS). Median (IQR) follow-up of all eligible patients was 28 months (12; 47). Patients who developed brain metastasis had a higher proportion of N1 stage disease (p < 0.001), as well as synchronous metastasis to bones, liver, and lungs compared to those without brain metastasis (all p < 0.001). The median (IQR) DFS with brain metastasis was 6 months (2; 12), and survival with brain metastasis was significantly worse than DFS in patients without brain metastasis (p < 0.001). Among those with brain metastasis only, there was no difference in DFS with respect to sex, race, primary tumor origin, T stage or N stage disease, synchronous metastasis to bone, liver or lung, nor with respect to chemotherapy or radiation for treatment of the primary tumor (all p > 0.05). For sarcoma patients with brain metastasis, the outcomes are poor and do not appear to differ by clinicopathologic factors. However, patients with certain histologies and synchronous metastases may warrant more frequent surveillance as there was an association of brain metastasis with these factors.

Associations between longitudinal pretreatment BMI and neutrophil/lymphocyte ratio(NLR) and progression-free(PFS) and overall survival(OS) in advanced NSCLC patients treated with single agent anti-PD-1/anti-PDL1 monoclonal antibodies(mAbs)

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Background: Several parameters that have been associated with outcomes in patients with metastatic NSCLC treated with anti-PD1/PDL1 mAbs include tumor PD-L1 expression, tumor mutational burden, and baseline NLR. Further investigation into clinical correlates of benefit with immune checkpoint inhibitors remains an unmet need. Methods: The objective of this retrospective study was to examine the potential influence of pretreatment cachexia and chronic inflammation in patients with NSCLC that received second- or third- line single agent anti-PD1/PDL1 mAbs. Weight, BMI, and NLR, as well as longitudinal changes in these variables from at least six-weeks prior to initiation of treatment were correlated with progression-free and overall survival (PFS/OS). These associations were assessed using statistical methods for time-to-event analysis. Results: 192 patients were included: 59% female, 72% Caucasian, 18% African American, 79% current or former smokers. 185 patients had pretreatment NLR values and 63% and 42% had NLR ratios > 3.5 and > 5, respectively. 187 patients had pretreatment weight and BMI available. Of these, 63% had a loss in BMI prior to initiation of anti-PD1/PDL1 mAbs, 29% with > 5% loss. Any BMI loss as well as BMI loss > 5% over the time period prior to treatment initiation were associated with shorter PFS (p < 0.01, 2.1 vs 4.37 mos for loss > 5% vs ≤ 5%) and change in BMI assessed in continuous scale was also associated with PFS (HR = 0.94, p < 0.05). Similarly, any BMI loss and BMI loss > 5% were associated with shorter OS (p < 0.01. 7.33 vs 12.23 mos for loss > 5% vs ≤ 5%) and change in BMI and baseline BMI assessed in continuous scale were additionally associated with OS (HR = 0.97 and 0.94, p < 0.05). Baseline NLR > 5 was associated with shorter PFS (p < 0.01) and baseline NLR assessed in continuous scale was negatively associated (HR = 1.01, p < 0.05). Moreover, pre-treatment NLR > 5 and baseline NLR > 3.5 were associated with shorter OS (p < 0.05). Pre-treatment NLR, baseline NLR, and %change in NLR, assessed in continuous scale, were negatively associated with OS (HR = 1.04, 1.02, 1.12, p < 0.01). Conclusions: This retrospective study identified clinical features of NLR and BMI at treatment initiation and in the immediate pre-treatment period that were associated with PFS and OS on anti-PD1/PDL1 mAbs therapy. These parameters can easily be investigated in the front-line population. They may also have utility in identifying patients that would benefit from therapeutic strategies to reverse weight loss and inhibit immunosuppressive effects associated with elevated NLR in order to increase the effectiveness of immunotherapy.

Psychosocial distress in patients with driver-mutant lung cancer

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Background: Project PRIORITY, a collaborative research study between The EGFR Resisters and the LUNGevity Foundation, found that 29% of United States respondents had clinical depression. While tyrosine kinase inhibitors (TKI) prolong lives, the impact of an oncogene driven lung cancer diagnosis on emotional well-being is not well studied nor are resource utilization and potential contributing factors to psychosocial distress. Methods: Our primary objective was to study cancer related distress in patients (pts) with newly diagnosed oncogene driver lung cancer. The secondary objective was to correlate distress with neutrophil to lymphocyte ratio (NLR) and body mass index loss (BMI) as a surrogate for cancer cachexia/precachexia to gauge the relationship to psychosocial distress. We retrospectively reviewed pts treated with TKI between 1/1/2008 and 2/1/2021. Sample size was based on estimates of depression in this population. A diagnosis of depression or anxiety was defined by documentation in the visit problem list, and active symptoms were based on progress note documentation. Depression and anxiety were recorded at 6 time points from diagnosis to progression on TKI, and their associations with treatment toxicities, progression free survival (PFS) and overall survival (OS) were assessed. Association with serial BMI and NLR were assessed using longitudinal statistical models. Results: We studied 78 pts: 71.8% female, 62.8% Caucasian, 15.4% African American, 15.6% Hispanic/LatinX, and 11.5% Asian. 94.9% had an EGFR mutation, and 5.1% had an ALK mutation. Prevalence of depression at diagnosis and progression was 11.5% and 25%, with anxiety prevalence 28.2% and 40.6%, respectively. Of these pts, 22.2% had active depression symptoms and 54.5% had active anxiety symptoms at diagnosis, although symptoms were not addressed in 33.3% and 22.7%, respectively. At progression, 68.8% had active depression symptoms and 46.2% had active anxiety symptoms, but symptoms were not addressed in 6.3% and 26.9%, respectively. At diagnosis and progression, 24.4% and 35.9%, respectively, were on treatment for anxiety and/or depression. Social work and psychology evaluated 12.8% and 10.3% of all pts at diagnosis and 10.9% and 17.2% at progression. NLR > 3.5 and > 5 were not associated with depression or anxiety. A more rapid longitudinal decrease in BMI was associated with depression. Grade ≥3 toxicities were not associated with depression or anxiety. Shorter PFS and OS were associated with higher rates of depression, but not anxiety. Conclusions: In this retrospective study of an ethnically diverse patient group at an academic medical center, we found a prevalence of depression and anxiety consistent with the Project PRIORITY findings. We saw an association between depression and more rapid weight loss but did not see correlation with NLR. Prospective evaluation with accurate documentation is needed to better address these questions in future studies.

Neutrophil-to-Lymphocyte Ratio Is a Predictive Biomarker in Patients with Epidermal Growth Factor Receptor (EGFR) Mutated Advanced Non-Small Cell Lung Cancer (NSCLC) Treated with Tyrosine Kinase Inhibitor (TKI) Therapy

BACKGROUND

First-line treatment for patients with non-small cell lung cancer (NSCLC) with a sensitizing epidermal growth factor receptor (EGFR) mutation is a tyrosine kinase inhibitor (TKI). Despite higher response rates and prolonged progression free survival (PFS) compared with platinum doublet chemotherapy, a subset of these patients do not receive prolonged benefit from these agents. We investigate if the neutrophil-to-lymphocyte ratio (NLR) and other markers of cachexia and chronic inflammation correlate with worse outcomes in these patients.

METHODS

This study is a retrospective review of 137 patients with advanced EGFR-mutated NSCLC treated with TKIs at Rush University Medical Center and University of Chicago Medicine from August 2011 to July 2019, with outcomes followed through July 2020. The predictive value of NLR and body mass index (BMI) was assessed at the start of therapy, and after 6 and 12 weeks of treatment by univariable and multivariable analyses.

RESULTS

On univariable analysis, NLR ≥ 5 or higher NLR on a continuous scale were both associated with significantly worse PFS and overall survival (OS) at treatment initiation, and after 6 or 12 weeks of treatment. On multivariable analysis, NLR ≥ 5 was associated with increased risk of death at 12 weeks of therapy (HR 3.002, 95% CI 1.282-7.029, p = 0.011), as was higher NLR on a continuous scale (HR 1.231, 95% CI 1.063-1.425, p = 0.0054). There was no difference in PFS and OS and amongst BMI categories though number of disease sites and Eastern Cooperative Oncology Group (ECOG) performance status was associated with worse PFS and OS.

CONCLUSIONS

Patients with NLR ≥ 5 have a worse median PFS and median OS than patients with NLR < 5. NLR may have value as a predictive biomarker and may be useful for selecting patients for therapy intensification in the front-line setting either at diagnosis or after 12 weeks on therapy. NLR needs to be validated prospectively.

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.

RNA pathway enrichment in serum-based mass spectroscopy prognostic analyses

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Background: Veristrat(VS) good and poor labels were found to be prognostic in the front-line NSCLC setting with or without immune checkpoint inhibitors. Little is known about RNA expression data corresponding to these good and poor prognostic labels. Methods: Raw RNA seq expression data was obtained from TEMPUS XP RNA analysis. Sequences were filtered for allowing only genes that had an overall count of at least 20 across all samples. Samples were then processed through the EdgeR analysis in the R programming environment. Along with a Z-scored heatmap, PCA plot was also generated. Differential abundance analysis was done further filter out the genes. Benjamini-Hochberg correction was done and only genes with corrected p-value of < 0.05 were selected for further pathway analysis. 242 genes with corrected p-value < 0.05 were used. Pathway analysis was performed using the Broad Institute GSEA (Gene Set Enrichment Analysis) and DAVID (Database for Annotation, Visualization and Integrated Discovery). The gene list was ran using KEGG database in GSEA and using KEGG, BioCarta and Reactome pathway databases. Functional analyses against the KEGG and REACTOME database were reported out to determine the enriched pathways in the VS poor and VS good groups. Kaplan-Meier and Logrank were used to compare overall survival in the poor vs. good label cohorts of patients. Results: 26 patients had VS label and RNA expression data available. Nine patients had VS poor label and 17 had veristrat good label. 6(66%) VS poor 13(76%) VS good patients received anti PD1 agents during the course of their therapy. Overall survival was not significantly different between good and poor label groups in this small series. 242 genes had significantly different abundance in the VS poor vs good patients with the majority (211) over expressed in the poor label patients. Significant pathways enriched in the VS poor group included the intrinsic pathway of fibrin clot formation, platelet degranulation (DAVID), steroid hormone biosynthesis and dilated cardiomyopathy (KEGG). Systemic lupus erythematous pathway was enriched in the VS good group (KEGG). Conclusions: In this small set of front-line patients with RNA pathway analyses and known VS poor or good labels, differential expression of acute phase reactants was found in VS poor patients. DAVID and KEGG pathways were differentially enriched and may reveal potential targets to mitigate prognosis in poor risk NSCLC.

IMpower150: Exploratory efficacy analysis in patients (pts) with bulky disease

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Background: In the Ph 3 IMpower150 study (NCT02366143), 1L treatment (tx) with atezolizumab (A) + bevacizumab (B) + carboplatin + paclitaxel (CP; ABCP) significantly improved PFS and OS vs B + CP (BCP) in pts with chemotherapy-naive metastatic (met) nsq NSCLC. As pts with high tumor burden or large size (bulky disease) have poor survival outcomes, an exploratory analysis was conducted to determine whether pts with bulky disease in IMpower150 could derive benefit from ABCP. Methods: 1202 pts (ITT population) were randomized 1:1:1 to ABCP, atezo + CP (ACP) or BCP arms. Doses were given q3w: A, 1200 mg; B, 15 mg/kg; C, AUC 6 mg/mL/min; P, 200 mg/m2. Disease burden subgroups (high or low) were defined using the 3rd quartile of the sum of the longest diameter (SLD) of the target lesions or median number (no.) of met sites at baseline (BL). Exploratory efficacy analyses included PFS, OS, ORR, time to response (TTR) in these subgroups; safety was also assessed. Outcomes are reported for pts enrolled in the ABCP vs BCP arms. Results: Per 3rd quartile SLD (108 mm), 91 ABCP and 85 BCP pts had high disease burden. Per median no. of met sites (median = 2), 210 ABCP and 190 BCP pts had high disease burden. BL characteristics were generally balanced between ABCP and BCP in high disease burden subgroups. With a minimum follow-up of 32.4 mo (data cutoff: Sep 13, 2019), ABCP showed improved OS, PFS and ORR vs BCP in pts with high and low disease burden (Table). High disease burden did not impact TTR. The safety profile of ABCP was comparable between ITT-WT (no EGFR or ALK alterations) pts and high disease burden subgroups. Conclusions: A tx effect for OS, PFS and ORR was seen in pts with and without bulky disease when ABCP vs BCP was compared, regardless of the method used to define “bulky”; TTR was not affected in high disease burden pts. ABCP had a comparable safety profile in bulky disease and ITT-WT pts. ABCP may be a 1L tx option for pts with nsq NSCLC who have high disease burden. Clinical trial information: NCT02366143. [Table: see text]

The prognostic value of neutrophil-to-lymphocyte ratio in patients with epidermal growth factor receptor mutated advanced non-small cell lung cancer (NSCLC)

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Background: An elevated neutrophil-to-lymphocyte ratio (NLR) indicates a poor prognosis across multiple cancers, including non-small cell lung cancer (NSCLC). Our study aims to validate these findings in EGFR-mutated NSCLC patients receiving tyrosine kinase inhibitor (TKI) therapy, and to evaluate other factors that may impact NLR. Methods: We retrospectively analyzed 95 patients with advanced EGFR-mutated NSCLC treated with TKIs at Rush University Medical Center and The University of Chicago Medical Center from August 2011 to August 2018. The prognostic value of NLR was assessed at the start of therapy, and after 6 and 12 weeks of treatment. The median progression free survival (mPFS) and median overall survival (mOS) were calculated by the Kaplan-Meier method and compared with the log rank test. Spearman rank correlation was used to correlate number of disease sites with NLR at diagnosis. T test analysis compared mean NLR between patients with high grade (≥ 3) toxicity versus low or no (grades 0-2) toxicity. The relationship between NLR and body mass index (BMI) changes were analyzed using Pearson correlation. Results: At therapy start, patients with NLR < 5 (n = 57) had a mPFS of 15.3 months and a mOS of 56.7 months, while those with NLR ≥ 5 (n = 35) had a mPFS of 13.8 months ( p= 0.024) and mOS of 40.0 months ( p= 0.0056). After 6 weeks of treatment, patients with NLR < 5 (n = 69) had a mPFS of 14.6 months and mOS of 56.2 months, while those with NLR ≥ 5 (n = 23) had a mPFS of 10.0 months ( p= 0.052) and a mOS of 37.74 months ( p= 0.049). After 12 weeks of treatment, patients with NLR < 5 (n = 66) had a mPFS of 14.2 months and mOS of 54.8 months, while those with NLR ≥ 5 (n = 17) had a mPFS of 3.0 months ( p= 0.0016) and a mOS of 22.4 months ( p= 0.0012). Patients who had a decrease in NLR did not have significantly better mPFS or mOS compared to patients whose NLR increased at either 6 or 12 weeks. Baseline number of disease sites and BMI did not correlate with NLR at diagnosis. Changes in BMI did not correlate with a change in NLR at 6 weeks or at 12 weeks. There was no significant difference in NLR between patients with high grade (≥ 3) versus no or low grade (0-2) drug toxicities. Conclusions: NLR can be used as a prognostic factor to predict which EGFR mutated NSCLC patients on TKI therapy may have worse PFS or OS outcomes. Closer monitoring and potential therapeutic escalation may be beneficial in patients with elevated NLR ≥ 5. Further work studying NLR in patients being treated with a larger osimertinib cohort is ongoing.

Heart dose and coronary artery calcification in patients receiving thoracic irradiation for lung cancer

Background

Thoracic irradiation (TIR) is associated with an increased risk of coronary artery disease (CAD) and coronary-related death. Lung cancer patients receive considerable doses of TIR, making them a high-risk population that may benefit from post-therapy surveillance. Coronary artery calcium (CAC) is a known biomarker of CAD development and may serve as a useful indicator of disease progression in this population. We hypothesized greater CAC progression in lung cancer patients subjected to higher whole heart radiation doses.

Methods

CAC progression (pre- and >2 years post-TIR) from chest CT scans of lung cancer patients were evaluated. A 2:1 matched control population was established controlling for age, gender, race, and CT scan interval. Vessel-specific CAC presence, progression, and extension in pre- and post-interval CT studies was evaluated by two blinded reviewers using the ordinal method. Dosimetric treatment files were restored and contours of the whole heart and proximal left anterior descending artery (LAD) were created within existing plans to compute radiation doses (Pinnacle Treatment Planning Software). Binary logistic regression analysis identified factors predictive for CAC development. Multiple logistic regression analysis with hierarchal method was used to assess covariates.

Results

Thirty-five patients and 65 controls (50% female) were evaluated; mean age 57 years, mean follow-up post-radiation 4.9±2.2 years. Average mean and maximum left anterior descending coronary artery (LAD) radiation doses were 19.9 Gy (95% CI, 14.1–25.7) and 30.7 Gy (95% CI, 23.8–37.5), respectively; 91.6% inter-observer variability. There was greater incidence of coronary calcification in irradiated patients (48.6% vs. 24.6%; P=0.01). In interval CT scans, a greater proportion of radiated patients demonstrated new coronary calcification (P=0.007) and extension within the LAD (P=0.003). Radiation exposure was the only independent predictor of new calcification (OR 3.1; 95% CI: 1.09–9.2).

Conclusions

We identified both an increase in the development and progression of CAC in lung cancer patients receiving TIR. Future studies utilizing alternative cancer populations and larger sample sizes are necessary to further correlate radiographic and dosimetric observations to cardiovascular events.

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.

Changes in skeletal muscle mass during PD-1 and PD-L1 checkpoint inhibitor therapy in advanced-stage non-small cell lung cancer patients

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Background: Severe skeletal muscle loss (sarcopenia) is a principle property of cancer cachexia and is found to be a hallmark of poor prognosis in patients with advanced non-small cell lung cancer (NSCLC). With the latest advancements of PD-1 and PD-L1 checkpoint immunotherapy, we aim to examine changes in sarcopenia before and after treatment with these agents. Methods: : In this study, patients with stage IIIB/IV NSCLC receiving PD-1 and PD-L1 immune checkpoint inhibitors were evaluated. CT images obtained before and after treatment were used for skeletal muscle analyses with the SliceOmatic software (Tomovision) at the level of the first lumbar vertebra. Skeletal muscle index (SMI) was assessed by measuring the cross-sectional muscle area, normalized to patient height. Height, weight, disease progression status, and overall survival (OS) was extracted from EPIC under an IRB-approved protocol. Data was then compared with baseline and clinical outcome was used for survival analysis. Results: In 100 pre-treatment subjects (48% women, mean age of 68), patients with < 32 cm2/m2 SMI had a significantly lower OS (median OS = 1.41 mo, n = 16) compared to those with SMI > 32 cm2/m2 (median OS = 9.44 mo, n = 84, p = 0.024). In 74 patients with pre- and post-treatment data, (avg 2.66 mo interval) an increase of > 5% SMI from baseline occurred in 17 (23%) patients, while a decrease of > 5% SMI from baseline occurred in 26 (35%) patients. Mean reduction in SMI from pre- to post-immunotherapy was 0.921 cm2/m2 while median reduction in SMI was 1.087 cm2/m2. Conclusions: Patients with high pretreatment SMI had a significantly greater overall survival when compared to those with low pretreatment SMI. Two-thirds of patients experienced stability or increase in SMI during immunotherapy. These results suggest that immune checkpoint inhibitors may dampen mechanisms of cancer cachexia in some patients.

Mature, real world progression-free survival (PFS) and overall survival (OS) milestones in stage IV, non-squamous, non-small cell lung cancer patients (nsqNSCLC) treated with first line pemetrexed(Pem)/platinum(Plat) followed by pem+/-bevacizumab(Bev) maintenance

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Background: Pemetrexed maintenance therapy is associated with superior survival in stage IV nsqNSCLC patients. We have observed long term disease control in some patients treated with at least one cycle of Pem/Plat with potential for maintenance pem. There are no reports of data regarding long term PFS and OS in patients treated with Pem regimens. The objectives of our retrospective analysis are to determine the frequency of long term disease control on Pem maintenance and to identify parameters associated with longer PFS/OS. Methods: We included all patients with Stage IV nsqNSCLC who received at least one cycle of pem/plat between May 2010 and Nov 2013. We identified 240 patients from our database and analyzed their demographics, lab values, dates of therapy, and dates of progression. PFS/OS was estimated by the Kaplan-Meier method and associations with patient characteristics were assessed by log-rank tests and Cox proportional hazards analysis. The shortest potential follow up was 5 years. Results: Median age was 66 years, 60% were female, and 72% were Caucasian. Baseline ECOG performance status was 0(22%), 1(50%) and ≥ 2(22%). Median PFS was 6.2 months. At 1, 2, 3, 4, and 5 years of follow up absence of disease progression was seen in 33%, 14%, 7.5%, 4%, and 3%, respectively. Additionally, in terms of OS at 1-5 years, we observed 54.5%, 35%, 21%, 14%, and 11%. Lower baseline neutrophil: lymphocyte ratio (NLR) was strongly associated with improved PFS when using NLR≤5 vs > 5 (median PFS 13.2 mo vs 5.6 mo) Additionally, baseline Hemoglobin (mean = 12.03 g/dL, HR = .904, p = .0046) and Albumin (mean 3.3 g/dL, HR = .7722, p = .024) were associated with better PFS. Conclusions: The similarity in median PFS in our patients (6.2 mo) and clinical trial data suggests that our group of real world patients did not have uniquely favorable baseline characteristics. However, the patients most likely to reach long PFS/OS milestones had favorable baseline prognostic indicators suggesting that this patient subset might also be most likely to benefit from the recently approved regimen which combined Pembrolizumab with Pemetrexed/Carboplatin.

Real-world tumor response (rwTR) to ramucirumab plus docetaxel (R+D) post platinum-based (Pt) and immune checkpoint inhibitor (ICI) therapy in advanced non-small cell lung cancer (aNSCLC) patients (pts)

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Background: In REVEL, adding ramucirumab to docetaxel improved response rates among Pt-treated aNSCLC pts. This observational study evaluated rwTR in aNSCLC pts treated with R+D after Pt & ICI or other (non-ICI) therapies. Methods: Adult aNSCLC pts receiving 2L/3L R+D between 3/1/15 & 6/30/18, after 1L/2L Pt therapy, with ≥ 1 documented rwTR assessment, & ≥ 3 months of potential follow-up were selected from the Flatiron Health EHR-derived de-identified database (n = 172). Based on prior ICI exposure, pts were assigned to either the R+D post-ICI or the R+D post non-ICI [other] unmatched cohort. Study endpoints during R+D therapy included real-world (rw) objective response rate [rwORR], rw disease control rate [rwDCR], rw time to first response [rwTTFR], rw duration of response [rwDOR] & rw best response [rwBR]. Results: Overall, median age was 66.0 years and most pts were male (54.7%), white (70.3%), treated in the community (99.4%), had nonsquamous histology (79.7%), were stage IV at diagnosis (70.9%), had a low (≤ 1) Charlson comorbidity index (90.7%) & ECOG ≤ 1 (57.6%). Among tested pts, most were negative for EGFR (93.0%), ALK (94.9%) ROS1 (96.6%), or PD-L1 (75.0%). Baseline characteristics were similar between cohorts. Table shows significant differences in rwBR & rwDCR when stratified by cohort. Conclusions: Pts receiving R+D in the post-ICI setting had improved rwDCR compared to the R+D post-Other group, driven by a greater proportion of rwPR & a higher rate of rwSD as rwBR. The proportion of rwPD as rwBR was lower in R+D post-ICI pts. rwTR rates were generally similar to tumor response outcomes reported in REVEL. Understanding impact on OS is warranted given the increasing use of ICIs in earlier lines of therapy. [Table: see text]

Correlating the effects of VeriStrat result, anti-PD1 therapy, and neutrophil-to-lymphocyte ratio (NLR) on progression-free survival (PFS) in patients with stage IV non-small cell lung cancer (NSCLC)

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Background: Biodesix VeriStrat (VS) is a mass spectrometry assay found to be prognostic in previously treated and front-line NSCLC patients. A label assigns a “good” or “poor” result and is believed to in part represent host inflammatory reaction to tumor. This study looks to correlate VS good (VS-G) or poor (VS-P) label with the neutrophil to lymphocyte ratio (NLR) and outcomes in front-line NSCLC patients who were screened for actionable mutations as part of a companion diagnostic. Methods: Retrospective chart review was conducted of 76 patients with advanced NSCLC who had pretreatment VS testing. Included patients had at least 3-month follow up. Chi squared analysis was used to correlate VS label with patient characteristics and Cox proportional hazards was used to correlate PFS with VS label, NLR and other baseline characteristics in patients receiving anti-PD1 targeted therapy as part of their first treatment. Results: Median PFS was 6.31 months (follow up range 3-17 months). Of 76 tested patients, 23 never received treatment and 47 received anti-PD1 therapy. 51 had VS-G and 23 had VS-P (2 indeterminate). Using two standard NLR cutoffs of 3.5 and 5, 29 and 47, and 42 and 34 had values above and below the cutoff, respectively. VS-G vs VS-P correlated with performance status (PS) as well as NLR at both cut points and on a continuous scale. (P = 0.031, 0.043, 0.045, and 0.056 respectively, VS-G correlating with good PS and low NLR). There was no correlation with PDL1 or body mass index. On multivariate analysis VS label and NLR were also associated with PFS and OS (P = < 0.001 and P = 0.046). Among a subset of 47 patients treated with ICIs, VS-G and NLR < 5 were associated with longer PFS (P = 0.010 and 0.010) though PDL1 result was not. Conclusions: This is the first description of the performance of the VS mass spectrometry assay in front-line patients whose regimen included an anti-PD1 agent. The VS label was able to predict for PFS in this patient population despite relatively short follow up. VS-G label also correlated with low NLR by multiple methods analyzed. Further evaluation of the impact of cytotoxic chemotherapy to anti-PD1 is warranted.

Real-world economic burden of rapid disease progression (RDP) in patients (pts) with advanced/metastatic non-small cell lung cancer (aNSCLC)

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Background: RDP on initial therapy imposes significant clinical burden among pts with aNSCLC. This retrospective claims study provides estimates of the economic burden associated with RDP during subsequent therapy following RDP v non-RDP on platinum-based (Pt) therapy. Methods: Adult Medicare Advantage or commercially insured aNSCLC pts receiving a subsequent line of therapy (LOT) from 03/2015 to 08/2017 after initial Pt therapy were identified in the Optum Research Database and assigned to unmatched RDP & non-RDP cohorts based on Pt treatment duration (≤ 12 and > 12 weeks, respectively) as a surrogate. All-cause healthcare costs were inflation adjusted to 2017 US$ and computed as per patient per month (PPPM) during the subsequent LOT. Total costs were the sum of medical (inpatient, ambulatory, ER, and other costs) and outpatient pharmacy costs. Results: Patient characteristics were similar between RDP (n = 751) and non-RDP (n = 1,304) cohorts, with mean age of 68 years for the total study sample (n = 2,055). Overall, nivolumab was the most common subsequent regimen post Pt; 40% of the total study sample. While duration of subsequent LOTs was shorter for RDP pts (Kaplan-Meier median, 167 v 192 days and log rank test P = 0.03), mean systemic therapy drug costs were similar ($10,516 v $9,642, P = 0.14) during the LOT and PPPM total costs for RDP pts were $4,103 higher than those for non-RDP pts, driven by higher PPPM costs for inpatient stays and ambulatory visits (Table). Conclusions: This study sheds light on the significant economic burden of aNSCLC that rapidly progresses, and may inform management strategies to improve outcomes and lower downstream costs for RDP pts. Future research should continue to explore unmet needs for RDP pts, including underlying cost drivers, to provide context for the rapidly changing aNSCLC treatment landscape.[Table: see text]

Real-world (rw) clinical outcomes for advanced/metastatic non-small cell lung cancer (aNSCLC) patients (pts) treated with second line (2L) ramucirumab plus docetaxel (R+D) post frontline (1L) platinum based chemotherapy plus immune checkpoint inhibitors (Pt + ICI)

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Background: R+D is approved for use in pts with aNSCLC after Pt chemotherapy. With recent approvals, ICI can now be added to Pt chemotherapy (Pt + ICI) in 1L. This retrospective observational study provides an exploratory view of baseline characteristics and rw clinical effectiveness outcomes for pts receiving 2L R+D post 1L Pt + ICI. Methods: All adult pts treated with 2L R+D after 1L Pt + ICI therapy between 03/01/2015 and 06/30/2018, with ≥ 3 months follow up, were selected from the Flatiron Health EHR-derived de-identified database (n = 15). Rw clinical endpoints during R+D therapy included rw objective response rate (rwORR), rw disease control rate (rwDCR), rw best response, as well as Kaplan-Meier estimates of rw time to first response & rw duration of response. Results: Median age was 62 years, 10 pts (66.6%) were aged < 65 years, 11 (73.3%) were men, 3 (20.0%) had no history of smoking, 14 (93.3%) had non-squamous histology, 4 (26.7%) were EGFR positive, 3 (20.0%) were KRAS positive and 6 (85.7%) were PD-L1 negative. Of the 8 pts with a documented rw tumor response assessment, 3 (37.5%) had partial response (PR), 3 (37.5%) had stable disease (SD), & 2 (25.0%) had progressive disease as their rw best response. The rwORR (PR or complete response [CR]) & rwDCR (PR, CR, or SD) were 37.5% and 75.0%, respectively. Among responding pts, median time to first response was 2.2 months (95% CI, 1.3 - not reached [NR]) & median duration of response was 2.3 months (95% CI, 1.5 - NR). Patient numbers were too small (n = 15) and duration of follow-up was too short (3.4 months [IQR, 0.7 - 5.4]) to make robust estimation of overall survival or rw progression free survival. Conclusions: Data from this small patient cohort in US community practice are not conclusive and should be considered exploratory, but do show high rates of rw objective response and rw disease control rates during 2L R+D following 1L Pt + ICI. Data with larger sample sizes and additional follow-up are needed to better understand outcomes of R+D following the addition of ICI to 1L Pt chemotherapy regimens.

Real-world clinical burden of aggressive disease (AD) in advanced/metastatic non small cell lung cancer (aNSCLC)

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Background: Clinical trials have shown that aNSCLC patients (pts) with AD, including those with rapid disease progression (RDP) on initial therapy (time to progression ≤ 12 weeks), have poor prognosis. This retrospective study evaluates the real world clinical burden associated with AD, defined as the difference in clinical effectiveness outcomes during subsequent treatment following RDP v non-RDP on platinum-based (Pt) therapy. Methods: Adult aNSCLC pts receiving standard post-Pt progression therapy (immune checkpoint inhibitors, single agent chemo, ramucirumab) between 03/01/2015 and 06/30/2018, after Pt therapy, with ≥ 3 months of potential follow up, were identified in the Flatiron EHR-derived deidentified database and assigned to RDP (n = 158) and non-RDP (n = 518) cohorts. Real-world tumor response (rwTR) was collected using technology-enabled abstraction. Overall survival (OS) from start of 1L, and real-world (rw) progression free survival (PFS) & rw tumor response outcomes (rw objective response rate [rwORR], rw disease control rate [rwDCR], rw time to first response [rwTTFR], rw duration of response [rwDOR] & rw best response [rwBR]) during post-Pt progression therapy were estimated. Results: Of 676 eligible pts, 23% had RDP. Clinical outcomes in the RDP and non-RDP cohorts are shown in table. Conclusions: Findings from this real world cohort underscore the clinical burden & unmet medical need for more effective treatment strategies in pts with aggressive aNSCLC pts who rapidly progress on initial therapy. As the treatment landscape evolves, characterization of these pts is warranted to identify potential risk factors. [Table: see text]

Associations between baseline serum biomarker levels and cachexia/precachexia in pretreated non-small cell lung cancer (NSCLC) patients

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Background: We previously reported associations of pretreatment serum biomarkers with clinical outcomes in a cohort of advanced NSCLC patients that progressed on front-line therapy. This study aims to elucidate mechanisms underlying cancer cachexia/ pre-cachexia by evaluating relationships between baseline serum biomarker values and sequential changes in body weight, body mass index (BMI), and neutrophil/lymphocyte ratio (NLR) in NSCLC patients. Methods: We used Luminex immunobead assays to survey 101 protein biomarkers in sera from advanced NSCLC (n = 138) collected prior to their salvage regimen. Serial parameters associated with cancer cachexia included body weight, BMI, and NLR. Outcome variables (progression-free survival (PFS) and overall survival (OS)) were extracted with full IRB-approval. Biomarkers were evaluated as continuous variables with the cachexia surrogates using Pearson correlations, whereas associations of PFS and OS were accomplished with the Cox PH test. Results: High baseline values of BMI and low baseline NLR were associated with both OS and PFS (each p < 0.05), though weight failed to reach significance. PFS and OS were similarly associated with percent changes (relative to baseline) in weight (p < 0.01), BMI (p < 0.01), and NLR (p < 0.001). Thirteen biomarkers were found to be associated (p < 0.05) with baseline BMI values, including positive correlations with leptin, sol.VEGFR2, and c-peptide and inverse correlations with adiponectin, ferritin, ghrelin, IGFBP-1 and IL-8; fifteen biomarkers were associated with baseline NLR (all p < 0.05), including positive correlations with visfatin, insulin, and serum amyloid A and inverse correlations with IGF-II. Fifteen biomarkers were found to be associated (p < 0.05) in common with percent weight and BMI changes, including positive correlations with IGFBP-3 and inverse correlations with insulin, FGF-2, TNF-alpha, and resistin. Only prolactin and placental growth factor were found to be associated (p < 0.05) with percent change in NLR. Conclusions: A series of circulating protein biomarkers primarily connected with metabolic regulation and systemic inflammation/ acute phase response were found to be associated with cachexia/ pre-cachexia in NSCLC patients. Additional cohorts are currently being tested to verify these findings.

Real-world characterization of advanced/metastatic non-small cell lung cancer (aNSCLC) patients (pts) with rapid disease progression (RDP)

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Background: Despite advances in therapy, recent observational data shows that aNSCLC pts with RDP continue to have a poor prognosis. This retrospective, observational study characterizes the demographic, molecular, & treatment profile of pts with RDP. Methods: Adult aNSCLC pts receiving first-line (1L) platinum-based (Pt) therapy between 01/2014 - 12/2018 were identified in the COTA Real-World Evidence database and assigned to RDP (n = 280) & non-RDP (n = 1,212) cohorts based on time to progression during 1L Pt therapy (≤ 12 and > 12 weeks, respectively). Results: Of 1,492 eligible pts, the incidence of RDP was 19%. Mean age (±SD) was 64.6 (10.9) and 66.1 (10.2) in the RDP and non-RDP group, respectively (p = 0.04). Data showed RDP patients had higher percentage of stage IV disease at diagnosis (77 v 72, p < 0.01), higher histologic grade G3/G4 (37 v 29, p = 0.01), and PD-L1 negative (< 1% expression) status (p = 0.01). Table shows molecular profiling across cohorts. No notable difference in treatment patterns across 1L and 2L was observed. Conclusions: This study identifies stage IV disease at diagnosis, higher grade, & PD-L1 negative ( < 1% expression) as potential risk factors for RDP. A better understanding of this poor prognosis cohort may offer an opportunity to better optimize therapies & outcomes. [Table: see text]

Decreasing BMI/weight immediately prior to starting anti-PD-1/PDL-1 monoclonal antibodies for treatment for stage IV non-small cell lung cancer is associated with shorter progression-free survival

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Background: Currently, prognostic markers associated with immunotherapy treatment outcomes in patients with metastatic NSCLC include PDL-1 expression, tumor mutational burden (TBM), and neutrophil to lymphocyte ratio (NLR). In this study we examine the influence of pretreatment changes in weight, BMI, and NLR in 237 patients treated with anti-PD-1/PDL-1 therapy (ICI) at our institution. Methods: This was a retrospective analysis of previously-treated stage IV NSCLC patients who received ICI. Pretreatment (≥ 6 weeks before starting therapy) values of weight, BMI, and NLR were compared to baseline values and NLR was analyzed as continuum and according to standard cutoffs of 3.5 and 5. The same variables were correlated with progression-free survival (PFS) and overall survival (OS) using the Log-Rank test. Results: 237 patients were analyzed: 45% were male, 73% were Caucasian, 72% were former smokers, and 25% were age ≥ 75 years. 148 patients had pretreatment NLR values. Of these, 32% had a ratio < 3.5 and 54% had ratio < 5. 34% had increased NLR at baseline, the majority of which (48/77) had a > 5% increase. 187 patients had pretreatment weight and BMI. Of these, 14% had a pretreatment BMI < 20. 71% had a negative change in BMI and 29% had a > 5% decrease in BMI. 65% had a negative change in weight and 26% had a > 5% decrease in weight. BMI decrease greater than 5% (p = 0.0039), negative weight change (p = 0.0371), and pretreatment NLR > 5 (p = 0.0136) were associated with shorter PFS. Change in NLR trended towards decreased PFS but was not statistically significant (p = 0.07) though only 77 of 237 patients had both values available. There was no statistical PFS difference between patients less than or ≥ 75 years old. Conclusions: The results suggest that decrease in pretreatment BMI and weight along with high baseline NLR are associated with significantly shorter PFS in NSCLC treated with anti-PD-1/PDL-1 therapy. If confirmed, these observations raise the possibility that specific treatment which reverses cancer associated weight loss might enhance effectiveness of immunotherapy.

Clinical benefit of next generation sequencing in soft tissue and bone sarcoma: Rush University Medical Center’s experience

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Background: The overall survival for metastatic sarcoma has remained at only 18-20%. In the era of next generation sequencing (NGS), much research is ongoing on identifying optimal treatments. The MULTISARC trial aims to determine if NGS can lead to improved overall survival by randomizing patients with metastatic STS to receive NGS (followed by possible NGS-guided therapy) or not. We present our center’s experience with NGS in sarcomas patients. Methods: Patients with soft tissue and bone sarcomas at Rush that had the Foundation Medicine assay sent on tumor samples between August 2017 and August 2018 were analyzed retrospectively. The impact of NGS on clinical decision making was determined based on patients being prescribed off-label FDA-approved therapy targeting identified mutation. Results: Thirty-four patients with bone/soft tissue sarcomas that had NGS sent on specimens were identified. Median age at diagnosis: 43 (18-78 years); 18 males, 16 females. Histologic subtypes: synovial sarcoma, myxofibrosarcoma, leiomyosarcoma, chondrosarcoma, sclerosing epitheloid fibrosarcoma, PEcoma, pleomorphic undifferentiated sarcoma, MPNST, liposarcoma- well and de-differentiated, angiosarcoma, osteosarcoma. 16/34 patients had targetable mutations with approved therapies in tumor types other than sarcoma. Four of these patients had therapy changed based on NGS results, 1 patient with metastatic chondrosarcoma (PTEN mutation, everolimus added), 1 patient with metastatic liposarcoma (CDK4 mutation, palbociclib added), 1 patient with metastatic osteosarcoma (CCD1/CDK4 and a PDGFRA mutation for which palbociclib followed by imatinib was added), and 1 patient with metastatic pleomorphic undifferentiated sarcoma (CDK4 mutation, palbociclib added). Targetable mutations for which clinical trials are available were identified in 25/34 (73%) of the cases. Conclusions: NGS was readily able to identify actionable mutations in close to 50% of patients with clinical trial opportunities in close to 75%. Four patients had therapy changed as a result of NGS testing. Although our study size is small, our data show potential for the use of genomic profiling to identify actionable targets, tailor therapy, and hopefully improve outcomes. [Table: see text]

Treatment of soft tissue sarcoma with a novel cold plasma jet

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Background: Soft tissue sarcoma is a malignant tumor that most often develops in adults, but can occur in children as well. Treatment with radiation, en bloc surgical resection and chemotherapy have achieved long-term survival rates up to 65% to 80% in non-metastatic disease. Local microscopic tumor cells can still exist despite complete R-0 surgical excision of the tumor. A novel technology Cold Atmospheric plasma (CAP) is an emerging technology that has shown promising anticancer effects i.e anti-mitotic and less effective on non-cancerous tissue. A new field has developed in medicine Plasma Onco-therapeutics. CAP treatment has the potential to improve the outcome of osteosarcoma patients. Methods: CAP was generated using a US Medical Innovations LLC (USMI) SS-601 MCa high-frequency electrosurgical generator (USMI, Takoma Park, MD, USA) integrated with Canady Cold Plasma Conversion Unit and connected to a Canady Helios Cold Plasma Scalpel. Three types of human sarcoma cells, synovial sarcoma (SW982), connective tissue fibro sarcoma (HT-1080), and rhabdomyosarcoma (RD) were used in this study to test the effect of the CAP generated by the Canady Cold Plasma Conversion System. Cells were treated with various CAP settings including different helium flow rates (1 and 3 LPM) and power settings (20-120p) in order to establish an optimal treatment condition for each cell line. Viability was performed on the cells using MTT assay 48 hours after CAP treatment. Student t test was performed on the data (*p < 0.05). Results: The reduction of the viability of all three sarcomas were dose-dependent and significantly reduced at various time and power combinations tested (Figure 1-3). Helium flow alone did not significantly impact cell viability. The decrease in viability of the sarcoma cells when using 1 LPM required a higher dose. About 20 to 40% of viability reduction was seen on the three cell lines. With 3LPM, viability was reduced to 20% using 80p 2 min for SW982 and HT-1080, and 100p 2min for RD. Conclusions: Our data demonstrates that CAP reduced sarcoma cell viability in a time- and power-dependent manner. With optimal dosage for each cancer type, this study provides a promising treatment for future therapeutic interventions for soft tissue sarcomas.