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.

Evaluation of Major Pathologic Response and Pathologic Complete Response as Surrogate End Points for Survival in Randomized Controlled Trials of Neoadjuvant Immune Checkpoint Blockade in Resectable in NSCLC

INTRODUCTION

Controversy remains as to whether pathologic complete response (pCR) and major pathologic response (MPR) represent surrogate end points for event-free survival (EFS) and overall survival (OS) in neoadjuvant trials for resectable NSCLC.

METHODS

A search of PubMed and archives of international conference abstracts was performed from June 2017 through October 31, 2023. Studies incorporating a neoadjuvant arm with immune checkpoint blockade alone or in combination with chemotherapy were included. Those not providing information regarding pCR, MPR, EFS, or OS were excluded. For trial-level surrogacy, log ORs for pCR and MPR and log hazard ratios for EFS and OS were analyzed using a linear regression model weighted by sample size. The regression coefficient and R2 with 95% confidence interval were calculated by the bootstrapping approach.

RESULTS

Seven randomized clinical trials were identified for a total of 2385 patients. At the patient level, the R2 of pCR and MPR with 2-year EFS were 0.82 (0.66-0.94) and 0.81 (0.63-0.93), respectively. The OR of 2-year EFS rates by response status was 0.12 (0.07-0.19) and 0.11 (0.05-0.22), respectively. For the 2-year OS, the R2 of pCR and MPR were 0.55 (0.09-0.98) and 0.52 (0.10-0.96), respectively. At the trial level, the R2 for the association of OR for response and HR for EFS was 0.58 (0.00-0.97) and 0.61 (0.00-0.97), respectively.

CONCLUSIONS

Our analyses reveal a robust correlation between pCR and MPR with 2-year EFS but not OS. Trial-level surrogacy was moderate but imprecise. More mature follow-up and data to assess the impact of study crossover are needed.

Inflamed immune phenotype predicts favorable clinical outcomes of immune checkpoint inhibitor therapy across multiple cancer types

BACKGROUND

The inflamed immune phenotype (IIP), defined by enrichment of tumor-infiltrating lymphocytes (TILs) within intratumoral areas, is a promising tumor-agnostic biomarker of response to immune checkpoint inhibitor (ICI) therapy. However, it is challenging to define the IIP in an objective and reproducible manner during manual histopathologic examination. Here, we investigate artificial intelligence (AI)-based immune phenotypes capable of predicting ICI clinical outcomes in multiple solid tumor types.

METHODS

Lunit SCOPE IO is a deep learning model which determines the immune phenotype of the tumor microenvironment based on TIL analysis. We evaluated the correlation between the IIP and ICI treatment outcomes in terms of objective response rates (ORR), progression-free survival (PFS), and overall survival (OS) in a cohort of 1,806 ICI-treated patients representing over 27 solid tumor types retrospectively collected from multiple institutions.

RESULTS

We observed an overall IIP prevalence of 35.2% and significantly more favorable ORRs (26.3% vs 15.8%), PFS (median 5.3 vs 3.1 months, HR 0.68, 95% CI 0.61 to 0.76), and OS (median 25.3 vs 13.6 months, HR 0.66, 95% CI 0.57 to 0.75) after ICI therapy in IIP compared with non-IIP patients, respectively (p<0.001 for all comparisons). On subgroup analysis, the IIP was generally prognostic of favorable PFS across major patient subgroups, with the exception of the microsatellite unstable/mismatch repair deficient subgroup.

CONCLUSION

The AI-based IIP may represent a practical, affordable, clinically actionable, and tumor-agnostic biomarker prognostic of ICI therapy response across diverse tumor types.

Abstract 2313: Real-world concordance between tumor mutation burden from blood and tissue

Background: Tissue tumor mutational burden (tTMB) is known to have predictive value for response to immune checkpoint inhibitor treatment of cancer. Utilization of next-generation sequencing of circulating tumor DNA added another data point of blood tumor mutational burden (bTMB). However, the concordance between tTMB and bTMB is not well understood.

Method: A total of 119 patients with solid tumors who had both tTMB and bTMB (collected from 10/2020 to 10/2022) results were included in the analysis. Patients' tTMB and bTMB concordance were analyzed according to the interval between tTMB and bTMB collection, tumor type, and site of tTMB collection using the Pearson correlation coefficient.

Result: Median tTMB was 4.2 mut/Mb and median bTMB was 9.61mut/Mb. bTMB was moderately correlated with tTMB (Pearson r 0.54) in total patient population. The median interval between tTMB and bTMB collection was 27 days (Q1:14, Q3:1834). Concordance did not significantly change when the interval was under 30 days (Pearson r 0.51). Patients with metastatic disease had higher concordance compared to patients without metastasis of cancer (Pearson r 0.58 vs 0.39). bTMB and tTMB were most strongly correlated when tTMB was collected from metastatic lesions (Pearson r 0.92). No significant correlation was observed when tTMB was collected from lymph nodes (Pearson r 0.20). Regarding cancer types, adenocarcinoma of the lung had a moderate correlation between bTMB and tTMB (Pearson r 0.63) while small cell lung cancer did not demonstrate a significant correlation between bTMB and tTMB (Pearson t -0.30).

Correlation between tTMB and bTMB Total study population 119 Interval between bTMB and tTMB collection &lt;30days 64 Pearson R (p value, CI) 0.55 (0.00, 0.41-0.66) Pearson R (p value, CI) 0.52 (0.00, 0.27-0.70) R squared 0.30 R squared 0.27 Patients with metastatic disease 89 Patients without metastatic disease 30 Pearson R (p value, CI) 0.58 (0.00, 0.42-0.70) Pearson R (p value, CI) 0.39 (0.03, 0.04-0.66) R squared 0.33 R squared 0.16 tTMB collected from primary lesion 51 Lung adenocarcinoma 53 Pearson R (p value, CI) 0.52 (0.00, 0.29-0.70) Pearson R (p value, CI) 0.63 (0.00, 0.45-0.77) R squared 0.27 R squared 0.41 tTMB collected from metastatic lesion 29 Lung squamous cell carcinoma 16 Pearson R (p value, CI) 0.92 (0.00, 0.84-0.96) Pearson R (p value, CI) 0.56 (0.02, 0.09-0.82) R squared 0.85 R squared 0.31 tTMB collected from lymph nodes 34 Lung small cell carcinoma 10 Pearson R (p value, CI) 0.20 (0.25, -0.14-0.50) Pearson R (p value, CI) -0.30 (0.38, -0.79-0.40) R squared 0.04 R squared 0.09

Citation Format: Leeseul Kim, Youjin Oh, Jewel Park, Ilene Hong, Lena Chae, Pedro Viveiros. Real-world concordance between tumor mutation burden from blood and tissue [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 2313.

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.

Abstract 3376: Non-small cell lung cancer (NSCLC) with higher blood tumor mutational burden (bTMB)/tissueTMB (tTMB) ratio is associated with inferior survival outcome

Background: High TMB is known to correlate with better response to immune checkpoint inhibitor (ICI) treatment in certain cancers. bTMB is now being used in place of tTMB at times due to difficulty in obtaining enough tissue samples for sequencing. Concordance between bTMB and tTMB values has been reported. However, the prognostic role of bTMB in relation to tTMB is not well understood.

Method: Patients with NSCLC who had both tTMB and bTMB results (collected from 10/2020 to 10/2022) were included. Progression free survival (PFS) and overall survival (OS) were analyzed according to bTMB, tTMB levels (High defined as ≥ 10 Mut/Mb, Low defined as &lt;10 Mut/Mb), and bTMB/tTMB ratio. The Gehan-Breslow-Wilcoxon test was used for survival analysis and the Mantel-Haenszel test was used to calculate the hazard ratio. Survival analysis by bTMB was performed only in 40 patients where bTMB was collected before and within 30 days of treatment initiation.

Results: Among 61 pts,18 pts (29%) received ICI monotherapy, 25 pts (41%) received ICI and chemotherapy combination therapy, 8 pts (14%) received chemotherapy, and 10 pts (16%) received targeted therapy. The median interval between bTMB collection and treatment initiation was 20 days (Q1:11, Q3:47) while 40 pts (66%) had the interval of &lt;30 days. 12 pts (20%) were tTMB high, and 32 pts (52%) were bTMB high. There was no difference in OS between groups with tTMB high and low. Similar findings were seen in OS and PFS of pts who received ICI containing regimen (p-value 0.71, 0.59, and 0.18, respectively). Group with high bTMB showed inferior OS compared to the group with low bTMB(p=0.008, OS HR=4.4) regardless of treatment regimens. Among people treated with ICI containing regimen, a similar trend was seen (p=0.009, OS HR=4.9). The median bTMB/tTMB ratio was 2.49. Patients were divided into three groups according to bTMB/tTMB tertiles (1st: 0.31-1.62, 2nd: 1.71-3.65, 3rd: 3.86-11.48). There was a significant difference in OS among the three groups with the 3rd tertile having the worst prognosis (log-rank test for trend, p=0.04). When divided into two groups (1st+2nd vs 3rd), the 3rd tertile group had a significantly inferior OS (p=0.01, HR 5.58). Among people treated with ICI containing regimen, a trend toward inferior OS was seen in the 3rd tertile group (p=0.12, HR 3.03). However, no significant difference in PFS was seen (p-value 0.77, HR 1.05).

Conclusion: High bTMB/tTMB ratio was associated with inferior OS regardless of treatment regimen in patients with NSCLC. A high bTMB/tTMB ratio may be indicative of increased tumor heterogeneity and/or higher metastatic tumor burden. Further studies are warranted to explore the role of bTMB/tTMB in various cancers.

Citation Format: Leeseul Kim, Jewel Park, Youjin Oh, Young Kwang Chae. Non-small cell lung cancer (NSCLC) with higher blood tumor mutational burden (bTMB)/tissueTMB (tTMB) ratio is associated with inferior survival outcome [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 3376.

Abstract 1985: Ipilimumab and nivolumab induced reactivation of hepatitis B (HBVr) in patient with metastatic squamous cell lung cancer

Background: Unique adverse events caused by immunological perturbation of immune checkpoint inhibitor (ICI) treatment were reported. Recently, it came into light that ICI can increase the risk of HBVr. Immune-mediated adverse events including immune-mediated hepatitis have been widely reported. However, HBVr is an extremely rare adverse event that has been seldom reported. Herein, we report the first case of ipilimumab/nivolumab induced HBVr in metastatic squamous cell lung cancer patient.

Case Presentation: 71-year-old Asian gentlemen with stage IIIB poorly differentiated squamous cell carcinoma of the lung (PD-L1 immunohistochemistry 5-10%) was initially treated with 4 cycles of carboplatin/paclitaxel/pembrolizumab and one dose of maintenance pembrolizumab. The treatment was complicated by immune-related adverse events of thyroiditis and adrenal insufficiency and followed by surgical resection of the tumor. Unfortunately, he developed recurrent metastatic disease of the brain which provoked craniotomy and resection followed by multiple courses of radiation therapy. The patient was then started on treatment with ipilimumab/nivolumab maintenance therapy following 2 cycles of carboplatin/paclitaxel/nivolumab/ipilimumab combined therapy (every 3 weeks). Bevacizumab was added for cerebral edema associated with brain metastasis. The patient was initially noted to be positive for hepatitis B Antigen. However, he was asymptomatic and liver function test (LFT) and liver ultrasound were unremarkable. He had been monitored for LFT at every visit. After 5.5 months from starting the treatment (after seven cycles of ipilimumab/nivolumab and six cycles of bevacizumab), transaminitis was noted and treatment was held. He was admitted for abdominal pain with labs demonstrating hepatocellular injury with ALT 1761 units/L, AST 607 units/L, and total bilirubin 3.3 mg/dL. Hepatitis work-up revealed HBVr (positive for HBs Ag, hepatitis B viral load 11,745). Patient was started on tenofovir daily and LFT was normalized after three weeks without synthetic dysfunction or metabolic encephalopathy. Ipilimumab/nivolumab treatment was held for six weeks and reintroduced without any further significant events.

Conclusion: It has recently been reported that pembrolizumab had a strong signal associated with HBVr. However, to our knowledge, this is the first case report for HBVr in squamous cell carcinoma of lung patient treated with ipilimumab/nivolumab. ASCO recommends universal screening for hepatitis B for patients anticipating systemic anticancer therapy. As illustrated by our case, it is important to have hepatitis B screening before starting systemic therapy including immunotherapy. Additional larger studies are warranted to validate the role of each type of ICI in HBVr.

Citation Format: Leeseul Kim, Horyun Choi, Yeun Ho Lee, Jinah Kim, Young Kwang Chae. Ipilimumab and nivolumab induced reactivation of hepatitis B (HBVr) in patient with metastatic squamous cell lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1985.

Abstract 4121: Durable stable disease with nivolumab, PD-1 inhibitor, and subsequent bevacizumab, Anti-VEGF monoclonal antibody, in long standing recurrent respiratory papillomatosis with lung squamous cell carcinoma

Background: Recurrent respiratory papillomatosis (RRP) is a human papilloma virus (HPV) associated benign disease, which, in rare cases, can develop into lung squamous cell carcinoma. Treatment options are limited with no approved systemic adjuvant therapy and the disease requires frequent surgical resection to prevent airway obstruction. Therefore, expanding available treatment options remains a highly important, but unmet need in RRP. Herein, we present a case of RRP with squamous cell carcinoma of lung that demonstrated durable stable disease with nivolumab and subsequent bevacizumab.

Case presentation: A 48-year-old woman with long standing RRP since teenager, who underwent multiple microsuspension laryngoscopies, debridements including laryngeal lesions, and ultimately, 5 years ago, video assisted thoracic surgery (VATS) resection of right upper lobe mass, confirming squamous cell carcinoma, has been managed with debulking surgery on tracheal lesions by ENT on regular basis. Nivolumab, a programmed death-1 blockade, 3 mg/kg every 2 weeks was started given squamous cell carcinoma of lung. Stable disease (SD) in lung lesions was achieved on nivolumab for one year but she required more frequent debulking of tracheal lesions. After multidisciplinary discussion with Otorhinolaryngology, she was started on bevacizumab, vascular endothelial growth factor inhibitor, 10 mg/kg every 6 weeks. Follow-up CT scans in 10 weeks showed a decrease in size of a left lower lobe mass to 27 mm from 32 mm in the previous image. After one year, administration of bevacizumab was spaced out to every 12 weeks. She requires less debulking surgery and the last debulking surgery was approximately 3 years ago. She maintains SD for over 4 years since starting bevacizumab.

Discussion: Our patient with RRP and squamous cell carcinoma of lung demonstrated SD on nivolumab before she was switched to bevacizumab. In addition, her SD on bevacizumab of more than 4 years with 12 weeks of maintenance interval is encouraging as there is no current standard of care treatment for RRP. Despite difficulty in running clinical trials in RRP due to its rareness, additional studies evaluating the efficacy of PD-1 inhibitor or anti-VEGF monoclonal antibody on RRP are warranted.

Citation Format: Horyun Choi, Jinah Kim, Yeun Ho Lee, Leeseul Kim, Young Kwang Chae. Durable stable disease with nivolumab, PD-1 inhibitor, and subsequent bevacizumab, Anti-VEGF monoclonal antibody, in long standing recurrent respiratory papillomatosis with lung squamous cell carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 4121.

Abstract 4120: Acquired TPM3-NTRK1 fusion resistant to larotrectinib in a non-small cell lung cancer with EML4-ALK fusion progressed on lorlatinib

Background: As oncogenic driver genes have been detected, targeted therapy plays a crucial role in non-small cell lung cancer (NSCLC) with targeted mutation. Lorlatinib, a selective third-generation inhibitor of anaplastic lymphoma kinase (ALK), is a treatment option for ALK-positive NSCLC patients who previously failed on ALK tyrosine kinase inhibitors (TKIs). Larotrectinib, a highly selective tropomyosin receptor kinase (TRK) inhibitor, is a treatment option for NSCLC with neurotrophic tyrosine receptor kinase (NTRK) mutation. Herein, we present an acquired TPM3-NTRK1 fusion resistant to larotrectinib in lung adenocarcinoma with EML4-ALK fusion progressed on lorlatinib.

Case Presentation: A 48-year-old male with stage IV adenocarcinoma of lung with metastatic disease of bone was initially treated with carboplatin, pemetrexed, and pembrolizumab. Follow up CT in 4 months showed numerous hepatic lesions and liver biopsy demonstrated large cell neuroendocrine carcinoma. Upon progression of disease (PD), systemic therapy regimen was switched to combination of carboplatin, paclitaxel, and bevacizumab. After two months since starting the new regimen, a second PD was observed. Follow-up MRI brain demonstrated multiple small metastatic lesions. Subsequently, he was started on alectinib 600 mg twice a day given EML 4-ALK fusion mutation [4.8% of variant allele frequency (VAF)] in circulating tumor DNA (ctDNA) NGS assay. Follow-up CT chest in 5 months showed 5 mm left lower lobe nodule which remained unchanged in size. He maintained SD for 9 months before repeat MRI brain demonstrated PD with new leptomeningeal carcinomatosis. Subsequently, he received whole brain radiotherapy and the treatment regimen was switched to lorlatinib 100 mg daily. In 7-week follow-up CT, the 5 mm nodule in the left lower lobe was stable. Follow-up MRI brain in 16 weeks showed decrease in size and number of numerous enhancing parenchymal and leptomeningeal lesions. Overall SD was maintained for 8 months before follow-up MRI brain showed new punctate lesions. Repeat ctDNA NGS assay revealed new TPM3-NTRK1 fusion (VAF 0.2%) and ALK L1196M (VAF 2.8%), and a decision was made to add larotrectinib 100 mg daily. The 6-week follow-up MRI brain showed new parenchymal brain metastases.

Discussion: It has been reported that the development of ALK resistance mutations may be associated with specific EML4-ALK variants. However, the influence of the specific EML4-ALK variants in NSCLC was not fully investigated. We report the case of acquired TPM3-NTRK1 fusion resistant to larotrectinib and acquired ALK L1196M in lung adenocarcinoma with EML4-ALK fusion progressed on lorlatinib. Further investigations are warranted to explore the mechanism of resistance to ALK TKIs.

Citation Format: Horyun Choi, Jinah Kim, Yeun Ho Lee, Leeseul Kim, Na Hyun Kim, Young Kwang Chae. Acquired TPM3-NTRK1 fusion resistant to larotrectinib in a non-small cell lung cancer with EML4-ALK fusion progressed on lorlatinib [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 4120.

Abstract 1691: The landscape of intra-tumor heterogeneity (ITH) and its association with actionable mutation and blood tumor mutation burden (bTMB) in patients with non-small cell lung cancer (NSCLC) assessed by circulating tumor DNA (ctDNA)

Background: ITH, which is caused by subpopulations of cells with distinct genomic alterations within the same tumor is known to have an impact on the biological profile and natural history of the tumor. However, assessment of ITH is mostly done tissue-based. Herein, we investigated the correlation of ITH assessed by ctDNA with bTMB and the presence of actionable mutations.

Method: Blood samples were collected from consecutive 53 patients with NSCLC seen at Northwestern Memorial Hospital. For each sample, SNV, indel, and CNV results generated by sequencing of all plasma ctDNA (Guardant360) were formatted for PyClone. ITH scores were calculated using the number of clusters identified in the sample divided by the number of variants detected in the sample.

Result: bTMB was evaluable for 22 patients (41%). 7 patients (13%) had actionable mutations associated with FDA-approved therapies. Cluster number was positively correlated with bTMB (Pearson r 0.69, p-value 0.0004, CI 0.38 to 0.86) and was negatively correlated with the presence of actionable mutations (median 2 vs 5, p-value 0.01). ITH scores were not significantly correlated with bTMB (Pearson r 0.03, p-value 0.89, CI -0.39 to 0.44).

Conclusion: Higher cluster number was inversely correlated with the presence of actionable mutations and positively correlated with bTMB. Our study illustrates the importance of utilizing liquid biopsy to assess ITH with tissue-based ITH in clinics for a better understanding of the biological profile of tumor.

Citation Format: Leeseul Kim, Yeun Ho Lee, Hye Sung Kim, Horyun Choi, Jinah Kim, Young Kwang Chae. The landscape of intra-tumor heterogeneity (ITH) and its association with actionable mutation and blood tumor mutation burden (bTMB) in patients with non-small cell lung cancer (NSCLC) assessed by circulating tumor DNA (ctDNA) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1691.

Abstract 5200: The incidence and risk factors of hyperprogressive disease(HPD) in non-small cell lung cancer(NSCLC) treated with immune checkpoint inhibitors(ICI)

Background: HPD is an unexpected rapid acceleration of tumor growth reported for patients treated with ICI. The definition of HPD is not fully established and risk factors are uncertain. Our aim in this study was to find the incidence of HPD as well as its significant clinical and genetic risk factors.

Method: A total of 203 patients with NSCLC who received ICI at Northwestern Memorial Hospital during 2008-2020 were included. Tumor growth kinetics (TGK) on immunotherapy and TGK pre-immunotherapy were collected and TGK ratio (TGKR) was calculated. HPD was defined as TGKR≥2.

Result: HPD was observed in 16% (n=33) of patients. HPD was significantly associated with high ECOG (3-4 vs 1-2) [OR = 4.52, 95% CI = 1.31 to 16.29, P = 0.01], presence of bone metastasis [OR = 2.51, 95% CI = 1.10 to 5.28, P = 0.01], neutrophils/lymphocyte ratio(NLR) ≥5 [OR = 2.68, 95% CI = 1.24 to 5.81 P = 0.01], thrombocytosis (platelet count &gt;450k) [OR = 5.31, 95% CI = 2.07 to 14.70, P=0.0003], and treatment with PD-L1 inhibitor vs PD-1 inhibitor [OR = 2.14, 95% CI= 0.97 to 4.68, P= 0.068]. HPD was inversely associated with positive PD-L1 expression [OR = 0.34, 95% CI = 0.13 to 0.86, P = 0.01], ICI combined with chemotherapy vs ICI monotherapy [OR = 0.24, 95% CI = 0.055 to 0.97, P=0.04], and positive TTF-1 expression [OR = 0.46, 95% CI = 0.21 to 1.02, P=0.057]. HPD was not associated with histology of NSCLC (adenocarcinoma, squamous cell carcinoma, large cell carcinoma, and large cell neuroendocrine carcinoma), age(&lt;70, ≥70), sex, smoking history, number of metastatic lesions (&lt;3, ≥3), brain metastasis, liver metastasis, brain metastasis before treatment initiation, EGFR mutation, TP53 mutation, BRAF mutation, and TNM staging.

Conclusion: The incidence of HPD in NSCLC treated with ICI was consistent with current literature. High NLR and platelet count are suggestive of an immunosuppressive environment that could contribute to the rapid growth of tumors. To our knowledge, this is the first study to report an inverse correlation of PD-L1 expression and TTF-1 expression with HPD. The strength of our study lies in a large number of patients. Further studies on validating risk factors of HPD and exploring their associated mechanisms are warranted.

Citation Format: Hyeonseon Kim, Yeun Ho Lee, Chiwoo Song, Leeseul Kim, Min Jeong Kim, Horyun Choi, Jinah Kim, Young Kwang Chae. The incidence and risk factors of hyperprogressive disease(HPD) in non-small cell lung cancer(NSCLC) treated with immune checkpoint inhibitors(ICI) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5200.

Abstract 3343: Durable response to osimertinib monotherapy as first line treatment in stage IVB lung adenocarcinoma with atypical EGFR L747P mutation

Background: Targeted therapy plays a critical role in NSCLC with a certain type of mutation. Osimertinib is a third generation EGFR tylosine kinase inhibitor (TKI) which is primarily indicated for NSCLC with EGFR exon 19 deletions or exon 21 L858R mutations. Although use of osimertinib is currently limited to patients with common EGFR mutations, it has been reported that patients with NSCLC harboring uncommon EGFR mutations demonstrated response to EGFR TKIs. Herein, we present a case of advanced adenocarcinoma of the lung with atypical EGFR L747P mutation that revealed a noteworthy durable response to osimertinib monotherapy as first line treatment. Case presentation: A 47-year-old woman with no smoking history presented with new-onset hemoptysis and cough. A chest CT scan showed a lobulated, spiculated 38 mm left upper lung mass with innumerable bilateral pulmonary nodules. CT-guided biopsy demonstrated adenocarcinoma of lung with PD-L1 1-2%. Subsequent PET-CT scan revealed hypermetabolic neoplasm in the left lower lobe with scattered area of abnormal focal FDG uptake within the liver. Brain MRI showed unremarkable findings. The patient was diagnosed with stage IVB adenocarcinoma of lung with multiple hepatic metastases. Circulating tumor DNA (ctDNA) NGS assay showed EGFR L747P [0.3% of variant allele frequency (VAF)] and tissue NGS assay revealed EGFR L747P missense variant c.2239_2240delinsCC (22.8% of VAF). The patient was started on osimertinib 80 mg daily. Follow up CT scan in six week demonstrated decrease in size of the left lower lobe lung mass to 32 mm. She has maintained durable SD for six months without any adverse effects. Most recent follow-up CT scan after eight months from the treatment demonstrated SD of the mass in the left lower lobe and less prominent numerous pulmonary nodules. Discussion: It has not been reported that osimertinib monotherapy is used as first line therapy in NSCLC with EGFR L747P mutation. We report the case of durable response to osimertinib in patients with advanced NSCLC with EGFR L747P mutation. Our case highlights the potential efficacy of osimertinib to NSCLC with atypical EGFR mutation. Although there was a clinical trial to explore clinical activity of osimertinib in patients with NSCLC harboring uncommon EGFR mutation, EGFR L747R mutation was not investigated at that time. To date, there are no ongoing clinical trials on the use of osimertinib in NSCLC with EGFR L747P mutation. Further investigations are warranted to confirm the efficacy of osimertinib in this type of mutation.

Citation Format: Horyun Choi, Yeun Ho Lee, Jinah Kim, Leeseul Kim, Na Hyun Kim, Young Kwang Chae. Durable response to osimertinib monotherapy as first line treatment in stage IVB lung adenocarcinoma with atypical EGFR L747P mutation [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3343.

Abstract 4113: Response to amivantamab, a bispecific EGF and MET receptor directed antibody, in a patient with an atypical EGFR mutated (G719X) non-small cell lung cancer (NSCLC) with leptomeningeal disease who progressed on osimertinib

Amivantamab is a bispecific antibody against EGF and MET receptors, approved for patients with locally advanced or metastatic NSCLC harboring EGFR exon 20 insertion after disease has progressed on or after platinum-based chemotherapy. Existing data is insufficient in establishing its efficacy on other rare EGFR mutated subtypes, central nervous system (CNS), or its resistance to 3rd generation tyrosine kinase inhibitor (TKI), osimertinib. Here, we report a case showing a good response on single agent amivantamab in an atypical EGFR mutation (G719A, exon18 substitution) NSCLC that progressed to CNS involvement on osimertinib. A 67-year-old male presented with stage IVB squamous cell carcinoma of lung with osseous metastases. CT chest, abdomen, and pelvis revealed a speculated 7.7 cm right upper lung lesion with hilar and subcarinal lymphadenopathies. MRI brain and spine showed multiple bone metastases without CNS involvement. Tissue biopsy confirmed poorly differentiated squamous cell carcinoma with PD-L1 IHC 75%. Tissue next generation sequencing (NGS) showed EGFR G719A. He was started on osimertinib. Two months later, he was hospitalized for drug-induced pneumonitis which prompted off osimertnib. CT angiogram chest showed new diffuse pericardial thickening and nodularity, suggestive of progressive disease. Two cycles of chemotherapy were delivered followed by immunotherapy with ipilimumab and nivolumab. In 10 weeks, progression of disease was revealed in MRI brain demonstrating new parenchymal and leptomeningeal metastases. Amivantamab monotherapy was initiated with discontinuation of immunotherapy. The patient tolerated amivantamab without major complications. His performance status remained the same before and after amivantamab. He denied fatigue, anorexia, nausea or vomiting, however, endorsed rash, which was managed with hydrocortisone cream. Repeat scans in 6 weeks showed decreased leptomeningeal enhancement, and reduction in the size of parenchymal lesions, lung mass, and lymphadenopathies. The highest variant allele fraction from circulating tumor DNA NGS assay from Guardant360 was significantly improved on amivantamab from 25.6% (EGFR G719A), at time of diagnosis, to non-detectable. Amivantamab monotherapy has shown an encouraging outcome in a patient with an atypical EGFR mutated (G719X) NSCLC with leptomeningeal disease who progressed on osimertinib. Our case has shown significant response on CNS involvements, which is contrary to known poor blood-brain barrier penetration of amivantamab. This supports current trial evaluating the efficacy of amivantamab for NSCLC with rare EGFR mutations such as G719X, and ones progressed on 3rd Gen TKI treatment. Additional studies evaluating the efficacy of amivantamab on CNS metastasis are warranted.

Citation Format: Jinah Kim, Horyun Choi, Yeun Ho Lee, Leeseul Kim, Young Kwang Chae. Response to amivantamab, a bispecific EGF and MET receptor directed antibody, in a patient with an atypical EGFR mutated (G719X) non-small cell lung cancer (NSCLC) with leptomeningeal disease who progressed on osimertinib [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 4113.

Abstract 644: Deep learning-based H&E analyzer reveals distinct immune profiles and clinical outcomes among immune phenotypes in uterine corpus endometrial carcinoma

Introduction: Deep learning-based H&E analyzer can classify the tumor microenvironment as three immune phenotypes: the immune-inflamed, excluded and desert. Our previous study demonstrated a distinct transcriptomic and immunologic landscape amongst the phenotypes in non-small cell lung cancer (NSCLC). However, it has not been fully investigated in other cancers. Here, we explore the immune profiles and clinical outcomes between the three immune phenotypes in uterine corpus endometrial carcinoma (UCEC).

Methods: Tissue H&E slide images, sequencing data, and clinical data were utilized from The Cancer Genome Atlas (TCGA). Lunit-SCOPE IO was trained with multi-cancer 3,166 H&E whole slide images annotated by pathologists. Based on the proportion of tumor infiltrating lymphocytes (TIL) highly conserved either in cancer epithelium (CE) or cancer stroma (CS), Lunit-SCOPE IO classifies tumors as immune-inflamed and excluded, respectively. Also, it classifies tumors with low TIL density in CE and CS as immune-desert.

Results: Among 486 patients with UCEC, the frequency of immune-inflamed, excluded and desert was 174 (35.8%), 160 (32.9%), and 156 (32%), respectively. In the three subgroup comparison, immune-inflamed was associated with the best survival outcome and -excluded was associated with the worst survival outcome (Inflamed vs excluded, HR 0.30 95% CI 0.17-0.55, p&lt;.001; desert vs excluded, HR 0.50 95% CI 0.30-0.84, p=0.009). Likewise, inflamed subtype showed better overall survival (HR 0.43, 95% CI 0.25-0.75, p=0.003) compared to others. In microsatellite instability high (MSI-H) tumors, we observed a similar tendency of improved overall survival in the tumors of inflamed subtype, both compared to the excluded subtype and to a combination of other subtypes. (Inflamed vs excluded, HR 0.18 95% CI 0.05-0.73, p=0.017; inflamed vs others, HR 0.21 95% CI 0.06-0.72, p=0.014). Immune-inflamed had significantly higher cytolytic activity (Inflamed 7.25 vs others 6.34, p&lt;.001) and was associated with higher PD-L1 expression (Inflamed 19.03 vs others 10.7, p=0.003) and CTLA4 expression (Inflamed 60.62 vs others 31.5, p&lt;.001). Immune-inflamed had a higher proportion of CD8 positive T cell (Inflamed 16.7% vs 12.8%, p&lt;.001) and M1 macrophage (Inflamed 3.9% vs others 2.8%, p&lt;.001) and a lower proportion of M2 macrophage (Inflamed 15% vs others 17.9%, p&lt;.001).

Conclusion: The three tissue phenomic subtypes showed distinct immune profiles and clinical outcomes, with immune-inflamed having the best overall survival outcome. In particular, non-inflamed group was associated with worse overall survival even in MSI-H tumors deemed to have more favorable prognosis compared to MSS tumors. Given the definite differences in the survival outcome, tissue H&E based tumor microenvironment classification may serve as a potential prognostic biomarker in UCEC.

Citation Format: Horyun Choi, Leeseul Kim, Jinah Kim, Yeun Ho Lee, Hyung-Gyo Cho, Na Hyun Kim, Gahyun Gim, Sanghoon Song, Gahee Park, Soo Ick Cho, Sergio Pereira, Donggeun Yoo, Kyunghyun Paeng, Chan-Young Ock, Young Kwang Chae. Deep learning-based H&E analyzer reveals distinct immune profiles and clinical outcomes among immune phenotypes in uterine corpus endometrial carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 644.

The incidence and predictive factors of hyperprogressive disease (HPD) in non-small cell lung cancer (NSCLC) treated with immune checkpoint inhibitors (ICI)

e21025

Background: HPD is an unexpected and rapid acceleration of tumor growth in patients following treatment with ICI. The definition of HPD is not fully established and risk factors are uncertain. Our aim in this study was to find the incidence of HPD as well as its significant clinicopathological and genetic predictive factors. Methods: A total of 203 patients with NSCLC treated with ICI at Northwestern Memorial Hospital during 2015-2020 were included. Clinicopathological data were retrospectively gathered and analyzed. Tumor growth kinetics (TGK) of pre-immunotherapy and post-immunotherapy were collected and TGK ratio (TGKr) was calculated. HPD was defined as TGKr≥2. Results: HPD was observed in 16% (33/203) of patients. There was a statistically significant difference in overall survival(OS) between the two groups (non-HPD vs. HPD) [OR = 2.39, P < 0.01]. The progression-free survival(PFS) also showed a statistically significant difference in patients (non-HPD vs HPD) [OR = 3.4, P < 0.01]. The median OS and PFS of patients with HPD were 13.57 months and 2.2 months respectively. The median OS and PFS of patients without HPD were 30.67 months and 7.3 months respectively. HPD was significantly associated with performance status (3-4 vs. 1-2) [OR = 4.52, P = 0.01], presence of bone metastasis [OR = 2.51, P = 0.01], neutrophils/lymphocyte ratio(NLR) ≥5 [OR = 2.68, P = 0.01], thrombocytosis (platelet count > 450k) [OR = 5.31, P < 0.01], and treatment with PD-L1 inhibitor vs. PD-1 inhibitor [OR = 2.14, P = 0.06]. HPD was inversely associated with positive PD-L1 expression [OR = 0.34, P = 0.01], ICI combined with chemotherapy vs. ICI monotherapy [OR = 0.24, P = 0.04], and positive TTF-1 expression [OR = 0.46, P = 0.06]. HPD was not associated with histological subtypes of NSCLC, age(< 70, ≥70), sex, smoking history, number of metastatic lesions (< 3, ≥3), brain metastasis, liver metastasis, brain metastasis before treatment initiation, EGFR mutation, TP53 mutation, BRAF mutation, TNM staging, tumor mutational burden (TMB) (< 10, ≥10), microsatellite stability index (MSI), human leukocyte antigen-1 (HLA-1) heterozygosity, hemoglobin(≤12, > 12), albumin(≤3.5, > 3.5), and LDH(≤240, > 240). Conclusions: The incidence of HPD, 16%, was consistent with current literature. NLR ≥5, platelet count > 450k, poor performance status, presence of bone metastasis, treatment with PD-L1 inhibitor, negative PD-L1 expression, negative TTF-1 expression, and ICI monotherapy were predictors of HPD. To our knowledge, this is the first study to report an inverse correlation of TTF-1 expression, and non correlation of HLA-1 heterozygosity with HPD. The strength of our study is that we analyzed recently emerging next-generation sequencing (NGS) data to find novel predictors of HPD. Further studies on validating risk factors of HPD and exploring their associated mechanisms are warranted.

The inflamed immune phenotype (IIP): A clinically actionable artificial intelligence (AI)-based biomarker predictive of immune checkpoint inhibitor (ICI) outcomes across >16 primary tumor types

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Background: The IIP, defined by enriched intratumoral tumor-infiltrating lymphocytes (TIL), is a potential tumor-agnostic biomarker of responsiveness to ICI therapy. Here, we validate the IIP, as assessed by Lunit SCOPE IO, an AI-powered spatial TIL analyzer that runs on routine H&E-stained whole-slide images (WSI), for clinical outcome prediction in a large, multi-center international cohort of ICI-treated patients, demonstrating its utility as a practical biomarker to guide ICI treatment planning. Methods: Lunit SCOPE IO was developed using 17,849 H&E WSI of multiple cancer types, annotated by 104 board-certified pathologists (13.5 x 109 µm2 area and 6.2 x 106 TIL). IIP+ tumors were defined as those with ≥ 20% of all 1 mm2 tumor tiles in a WSI classified as having a high intratumoral TIL density. We evaluated the correlation between IIP and ICI treatment outcomes (overall response rate (ORR) and progression-free survival (PFS), assessed by RECIST v1.1) in a real-world dataset of 1,806 patients ( > 16 primary tumor types) retrospectively collected from Stanford University Medical Center, Samsung Medical Center, Chonnam National University Hospital, Seoul National University Bundang Hospital, and Northwestern University. IIP status was sub-analyzed by PD-L1 22C3 tumor proportion score (TPS, n = 798), microsatellite status, and tumor mutational burden (TMB, n = 130). Results: The IIP+ phenotype (35.2%, 636 of 1,806) was highly enriched in nasopharyngeal carcinoma (68.0%), melanoma (56.3%), renal cell carcinoma (52.9%), and non-small cell lung cancer (NSCLC, 33.7%). The IIP+ proportion by PD-L1 TPS ( < 1% / ≥ 1%) was 21.6% and 40.7%, respectively. While 33.3% of microsatellite unstable (MSI-H) or TMB-high (≥ 10/Mb) tumors were IIP+, a substantial proportion (26.1%) of microsatellite stable (MSS), TMB-low tumors were IIP+. The ORR in IIP+ patients was significantly higher (26.0% vs. 15.8% in IIP-, p < 0.001). Median PFS for IIP+ was 5.3 months (95% CI 4.6-6.9 m), significantly longer than that for IIP- (3.1 m, 95% CI 2.8-3.6 m), with a hazard ratio (HR) of 0.68 (95% CI 0.61-0.76, p < 0.001). The association held after excluding NSCLC patients (n = 909) (HR 0.69, 95% CI 0.59-0.81, p < 0.001). On subgroup analysis, IIP+ correlated significantly with prolonged PFS, regardless of ICI regimen (mono / combo therapy) or PD-L1 TPS ( < 1% / ≥ 1%). Of note, IIP+ was predictive of favorable PFS only in the MSS, TMB-low group (n = 88, HR 0.56, 95% CI 0.33-0.96), but not in the MSI-H or TMB-high groups. Conclusions: The IIP, as evaluated by Lunit SCOPE IO, may represent a practical, clinically-actionable biomarker predictive of favorable ICI treatment outcomes across diverse cancer patient populations, including those with PD-L1 negative, MSS/TMB-low tumors, in whom predictive biomarkers are urgently needed.

Role of mass spectrometry-based serum proteomics signatures in predicting clinical outcomes and toxicity in patients with cancer treated with immunotherapy

Immunotherapy has fundamentally changed the landscape of cancer treatment. However, only a subset of patients respond to immunotherapy, and a significant portion experience immune-related adverse events (irAEs). In addition, the predictive ability of current biomarkers such as programmed death-ligand 1 (PD-L1) remains unreliable and establishing better potential candidate markers is of great importance in selecting patients who would benefit from immunotherapy. Here, we focus on the role of serum-based proteomic tests in predicting the response and toxicity of immunotherapy. Serum proteomic signatures refer to unique patterns of proteins which are associated with immune response in patients with cancer. These protein signatures are derived from patient serum samples based on mass spectrometry and act as biomarkers to predict response to immunotherapy. Using machine learning algorithms, serum proteomic tests were developed through training data sets from advanced non-small cell lung cancer (Host Immune Classifier, Primary Immune Response) and malignant melanoma patients (PerspectIV test). The tests effectively stratified patients into groups with good and poor treatment outcomes independent of PD-L1 expression. Here, we review current evidence in the published literature on three liquid biopsy tests that use biomarkers derived from proteomics and machine learning for use in immuno-oncology. We discuss how these tests may inform patient prognosis as well as guide treatment decisions and predict irAE of immunotherapy. Thus, mass spectrometry-based serum proteomics signatures play an important role in predicting clinical outcomes and toxicity.

OUP accepted manuscript

The recent, rapid advances in immuno-oncology have revolutionized cancer treatment and spurred further research into tumor biology. Yet, cancer patients respond variably to immunotherapy despite mounting evidence to support its efficacy. Current methods for predicting immunotherapy response are unreliable, as these tests cannot fully account for tumor heterogeneity and microenvironment. An improved method for predicting response to immunotherapy is needed. Recent studies have proposed radiomics—the process of converting medical images into quantitative data (features) that can be processed using machine learning algorithms to identify complex patterns and trends—for predicting response to immunotherapy. Because patients undergo numerous imaging procedures throughout the course of the disease, there exists a wealth of radiological imaging data available for training radiomics models. And because radiomic features reflect cancer biology, such as tumor heterogeneity and microenvironment, these models have enormous potential to predict immunotherapy response more accurately than current methods. Models trained on preexisting biomarkers and/or clinical outcomes have demonstrated potential to improve patient stratification and treatment outcomes. In this review, we discuss current applications of radiomics in oncology, followed by a discussion on recent studies that use radiomics to predict immunotherapy response and toxicity.

269 Utilizing serum proteome to understand response and resistance to immune checkpoint inhibitors in advanced non-small cell lung cancer

Background

Predictive biomarkers are more in need considering that responses and resistance to immune checkpoint inhibition (ICI) are poorly understood. We used a validated serum-based proteomic test, Primary Immune Response (PIR), to predict response and Protein Set Enrichment Analysis (PSEA) scores to elucidate mechanisms of early resistance to ICI in patients with advanced non-small cell lung cancer (NSCLC). (Muller et al., 2020)

Methods

Serum of 43 consented NSCLC patients was collected prospectively at 2 timepoints: baseline (prior to ICI initiation) and 3 weeks after ICI initiation (median 22 days). Blinded samples were classified by the PIR test. Clinical response was evaluated using RECIST. Outcomes, including progression-free survival (PFS) and overall survival (OS), were analyzed by PIR classifications as intermediate/sensitive (not resistant) vs. resistant at baseline and 3 weeks. Multivariable regression was performed. PSEA scores indicating activity of 10 processes of interest (e.g., Type 1 immunity (Th1), complement, interferon-gamma (IFNγ)) were compared between PIR groups.

Results

Of the 43 patients, 28 received chemotherapy with ICI (chemo+ICI) and 15 received ICI alone. 31 of 43 patients (72%) were treatment naïve at baseline blood draw. PIR-resistant patients had worse survival compared to patients classified as not resistant (HR, 10.4; 95%CI, 1.3–81 ; P = 0.025). OS was also significantly lower for patients with PIR resistant result at 3 weeks (HR, 9.1; 95%CI, 1.2–72 ; P = 0.036). The difference in survival between PIR classification groups was consistently observed in the treatment naïve patients treated with chemo+ICI (log rank P = 0.02). No significant differences were observed in PFS. Clinical and pathologic characteristics, including PD-L1 expression, were not significantly associated with PIR result. In multivariable analysis including performance status, line of therapy, and PD-L1 status, PIR resistant remained a significant negative prognostic factor (HR, 8.2; 95%CI, 1.01–67; P = 0.049). PSEA scores at baseline and 3 weeks after ICI initiation showed significantly higher levels of complement, IFNγ, Th1, immune tolerance, and a lower level of wound healing (all P<0.0001) in PIR-resistant vs. PIR-intermediate/sensitive.

Conclusions

These data further validate the utility of the PIR test in predicting patient survival on ICI. Processes associated with PIR resistant result included activation of complement, IFNγ, Th1, and immune tolerance, elucidating early mechanisms of resistance to ICI in a clinical cohort.

631 Deep, durable response to PD-1 inhibitor monotherapy in microsatellite-stable, tumor mutational burden-high colorectal cancer

Background

Immune checkpoint inhibitors have revolutionized care for a number of different cancer types. For colorectal cancer (CRC), a leading cause of cancer-related death in the United States, programmed cell death protein 1 (PD-1) inhibition is a treatment option for certain subsets of patients. High microsatellite instability (MSI-H) tumors are immunogenic, and thus PD-1 inhibition is first-line treatment. Anti-PD-1 therapy is generally not utilized for microsatellite stable (MSS) patients. Tumor mutational burden (TMB) is another predictive biomarker for immunotherapy response in all solid tumors. Here we present the case of a patient with MSS, TMB-H CRC resistant to multiple lines of chemotherapy, who responded to anti-PD-1 monotherapy.

Methods

Case presentation.

Results

A 64-year-old man with a family history significant for colon cancer was diagnosed with colorectal cancer, revealed to be moderately differentiated mucinous adenocarcinoma (stage IIIC) on biopsy. A tissue-based comprehensive genomic profiling of the cancer showed KRASG12D and ERBB2 amplification, microsatellite-stable, and TMB of 11mut/mB (FoundationOne). The patient progressed on multiple lines of therapy with multiple metastatic sites, and was briefly put under home hospice with diffuse abdominal pain and weight loss. The patient was started on pembrolizumab monotherapy, around 3.5 years after initial presentation. After five months on pembrolizumab, imaging showed significant improvement in pulmonary, hepatic, adrenal, and retroperitoneal metastases and the patient demonstrated partial response to treatment according to RECIST 1.1 criteria. The patient's carcinoembryonic antigen (CEA) levels had decreased from 45 ng/mL at treatment initiation to 2.8 ng/mL, and ctDNA analysis showed a blood TMB decrease from 31.58 mut/mB at treatment initiation to .96 mut/mB (figure 1), accompanied by decreases in the variant allele frequencies of the five most prevalent variants at the time of treatment initiation (Guardant 360). The patient's pain had nearly resolved by this point and pain medications were tapered off.

Conclusions

This case demonstrates the existence of a subset of CRC patients who are MSS but TMB-H and may respond to immune checkpoint blockade. Comprehensive genomic profiling must be utilized in order to not miss this subset of patients. The mechanism of response in this subset of patients is unknown but warrants further exploration. Further studies should clarify the mechanism and likelihood of response to immunotherapy in MSS, TMB-H CRC patients, as this is critical to providing effective treatment for this subset.

Consent

Written informed consent was obtained from the patient for publication of this abstract and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.

Abstract 631 Figure 1

Carcinoembryonic antigen (CEA) and blood tumor mutational burden (TMB) levels through six cycles of treatment with pembrolizumab

25 Potential role of serum proteome in predicting immune-related adverse events from immunotherapy in non-small cell lung cancer

Background

Predicting immune-related adverse events (irAEs) in early stage is being emphasized even more. Host response to disease is reflected in serum proteome level and that allows serum proteome level as a new marker to explore response to immunotherapy. With the help of a serum-based proteomics test, Primary Immune Response (PIR), we are accessing the correlations between developing irAEs and immunotherapy in non-small cell lung cancer (NSCLC) patients.

Methods

Data of 48 consented NSCLC patients with baseline PIR test done within one week prior to the start of immunotherapy were collected. Samples were grouped into either sensitive or intermediate/resistant (not sensitive) by PIR classification. We analyzed the durations from the immunotherapy initiation to the first episode of irAE. IrAEs were graded according to Common Terminology Criteria for Adverse Events (CTCAE) v5.0.

Results

Among the 48 NSCLC patients, 19 patients (39%) experienced one or more irAEs with the majority classified as either grade 1 (n=7, 36%) or grade 2 (n=10, 52%). PIR-sensitive group showed no difference in irAE free period compared to PIR-not sensitive (p=0.92, HR=0.95, 95% CI=00.3212 to 2.834). The median ‘Time to first irAE’ were undefined and 24 in PIR-sensitive and PIR-not sensitive, respectively.

Conclusions

Our results demonstrated PIR-sensitive patients are not likely to tolerate immunotherapy longer without developing irAEs.

Association of HLA class I homozygosity with unfavorable clinical outcomes in patients with non-small cell lung cancer treated with chemo-immunotherapy or immunotherapy as first-line therapy

Background

Homozygosity at HLA-I locus has been reported to be an unfavorable predictive biomarker of second-line or beyond immunotherapy in patients with different types of cancer. The linkage between HLA-I zygosity and survival in NSCLC patients treated with first-line immunotherapy with or without chemotherapy has not been reported.

Methods

Next generation sequencing with HLA genotyping was performed on patients with advanced NSCLC treated with immune checkpoint inhibitors with or without chemotherapy as first-line (N = 29). Progression free survival was compared between HLA-I homozygous (defined as homozygosity in at least one locus A, B, or C) and heterozygous patients. Kaplan-Meier curves were built, and log-rank test was used.

Results

Among 29 enrollees, 25 patients (86.2%) were HLA-I heterozygous and four patients (13.8%) were HLA-I homozygous. Treatment response was not available in five patients with HLA-I heterozygosity. Among 20 patients with HLA-I heterozygosity, five patients (20.0%) had partial response, 10 patients (50.0%) had stable disease, two patients (8.0%) had non-complete response/non-progressive disease, and three patients (12.0%) had progressive disease. Among four patients with HLA-I heterozygosity, one patient (25.0%) had partial response, one patient (25.0%) had stable disease, and two patients (50.0%) had progressive disease. The median progression free survival was not reached in heterozygous group and was 2.97 months in homozygous group (Log-rank p = 0.68).

Conclusions

We observed a trend toward an inverse association between HLA-I homozygosity and survival outcomes in patients with NSCLC treated with first-line therapy in conjunction with immunotherapy. Further prospective studies to validate aforementioned relationship are warranted.

Abstract 626: The neoantigen and immune landscape of epithelial mesenchymal transition (EMT) low and high score serous ovarian cancers

Background: Apart from its role in ovarian cancer progression, epithelial-mesenchymal transition (EMT) can promote chemotherapy resistance. We aimed to analyze how the EMT score would affect the tumor microenvironment in ovarian cancer.

Methods: cBioportal was queried to obtain The Cancer Genome Atlas (TCGA) data for the serous ovarian cancer (SOC) cohort (TCGA, 585 patients). The neoantigen prediction data was derived from the CloudNeo pipeline using TCGA mutation calling. EMT scores were calculated by subtracting the average RNA-seq z-scores of three epithelial marker genes from the average RNA-seq z-scores of 13 mesenchymal marker genes as described in the previous study. Patient samples were grouped as either EMT-high (highest 1/3) or EMT-low (lowest 1/3). CIBERSORT was applied to predict the tumor-infiltrating immune cells.

Results: Among the 585 SOC patients, only 256 patients had mutation data available for our analysis. The EMT-low group had a significantly higher mutation count (p value=0.0004) and cytolytic score (p value=0.032) than the EMT-high group. In addition, the EMT-low samples were associated with improved overall survival in SOC patients (HR, 0.55; 95% CI, 0.39-0.78; P &lt; 0.001). The median survival of EMT-low was 57.40, and EMT-high was 41.06 months. Neoantigen counts and PD-L1 express level tended to be higher in the EMT-high group although failed to show statistical significance. The immune cell infiltration rates were not different between both groups.

Conclusions: Our study is the first to describe the association between the EMT potential, neoantigen counts, and cytolytic scores in SOC. In our analyses, tumors with low EMT potential had a significantly higher neoantigen burden and higher cytolytic scores, suggesting that tumors with low EMT potentials tend to be more immunogenic. Further studies are warranted to explore the utility of EMT scores as biomarkers to predict the treatment response to immunotherapy in SOC.

The immunologic characteristics of EMT low and high SOCNumber of patientsNeoantigen countp-valueMutation countp-valueCytolytic scorep-valuePD-L1 expressionp-valueEMT low6088.190.183783.190.0004183.40.032190.0663EMT high5867.7472.7486.3515.52

Citation Format: Won Kyung Hur, Jin Young Hwang, Leeseul Kim, Myungwoo Nam, William H. Bae, Yoonhee Choi, Yeun Ho Lee, Heayoon S. Cho, Emma Yu, Chan Mi Jung, William Cheng, Eugene Kim, Christmann Low, Victor Wang, Jeff Chuang, Young Kwang Chae. The neoantigen and immune landscape of epithelial mesenchymal transition (EMT) low and high score serous ovarian cancers [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 626.

Abstract 520: Potential role of serum proteome in predicting immune-related adverse events from immunotherapy in non-small cell lung cancer

Early recognition of immune-related adverse events (irAEs) of immunotherapy is important. Circulating proteome reflects host response to diseases and is being explored as a marker for response to immunotherapy. We used a serum-based proteomics test, Primary Immune Response (PIR), to explore the associations between developing irAEs and immunotherapy in non-small cell lung cancer (NSCLC) patients.

Data of 38 consented NSCLC patients with baseline PIR test done within one week prior to the start of immunotherapy were collected. Samples were grouped into either sensitive or intermediate/resistant (not sensitive) by PIR classification. We analyzed the durations from the immunotherapy initiation to the first episode of irAE, each individual irAE, and each irAE above grade 1 using log-rank test. IrAEs were graded according to Common Terminology Criteria for Adverse Events (CTCAE) v5.0.

Among the 38 NSCLC patients, 21 patients (55%) experienced one or more irAEs. The total number of irAEs was 33 with the majority classified as either grade 1 (n=18, 55%) or grade 2 (n=11, 33%) (Table 1). PIR-sensitive group showed longer irAE free period with the median ‘Time to first irAE' being 54 weeks compared to 9.5 weeks in PIR-not sensitive (p=0.22, HR=0.56, 95% CI=0.24-1.34). The median ‘Time to each irAE' were 45 weeks and 12 weeks in PIR-sensitive and PIR-not sensitive, respectively (p=0.1, HR=0.55, 95% CI=0.28-1.1). The median ‘Time to each irAE above grade 1' demonstrated similar results with less differences between the two groups with median values of 54 weeks and 30 weeks in PIR-sensitive and PIR-not sensitive, respectively (p=0.28, HR=0.57, 95% CI=0.21-1.56).

Our results demonstrated a trend that PIR-sensitive patients are more likely to tolerate immunotherapy longer without developing irAEs. It implies the potential value of the baseline PIR test in predicting the development of irAEs and selecting subsets of patients who need close monitoring with immunotherapy.

Distribution of irAEs by PIR classificationVariablesSensitiveNot-sensitiveTotal number of patients, n1325Patients without irAE, n (%)7 (54%)10 (40%)Patients with irAE, n (%)6 (46%)15 (60%)Total number of irAEs, n1023Grade 1, n (%)5 (50%)13 (57%)Grade 2, n (%)5 (50%)6 (26%)Grade 3, n (%)02 (8%)Grade 4, n (%)01 (4%)Grade 5, n (%)01 (4%)

Citation Format: Myungwoo Nam, Leeseul Kim, William Cheng, William H. Bae, Jin Young Hwang, Yoonhee Choi, Yeun Ho Lee, Won Kyung Hur, Chan Mi Jung, Heayoon S. Cho, Young Kwang Chae. Potential role of serum proteome in predicting immune-related adverse events from immunotherapy in non-small cell lung cancer [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 520.

Abstract 453: The neoantigen and immune landscape of low and high grade serous ovarian cancers

Background: Within serous ovarian cancer (SOC), high-grade serous carcinoma (HGSC) demonstrates a worse prognosis compared to low-grade serous carcinoma (LGSC). Molecular analysis of SOC has revealed a distinct pattern of mutations found between the two pathologic subtypes, with TP53 as the main driver for HGSC. We analyzed the neoantigen and immune landscape of different SOC subtypes according to pathological grades and mutation status.

Methods: The analysis was done using the SOC cohort of The Cancer Genome Atlas (TCGA). The neoantigen prediction was done through the CloudNeo pipeline. CIBERSORT was applied to derive the tumor-infiltrating immune cells. Patients were grouped by their pathological grades (high vs. low) and the molecular features (type 1 vs. 2). For further subgroup analysis, high-grade samples were stratified by their TP53 mutation status.

Results: Among 585 SOC patients, a subset of 254 patients with available mutation counts and predicted neoantigen counts were included. There was no significant difference in neoantigen count between low and high grades (median 50.50 vs. 62.50, p=0.84). However, there was a trend for differential numbers in the neoantigen count between type 1 and type 2 (median 29 vs. 66.50, p=0.07). No notable differences were detected in immune landscapes of low vs. high grade and type 1 vs. type 2.

Conclusions: Our study is the first to describe the neoantigen and immune landscape of SOC. There were no significant differences in the immune landscape between the subtypes. It seems that molecular subtyping is more related to neoantigen differences than histologic subtyping. It is likely that the neoantigen differences are not defined by the histologic grade but rather by molecular trait.

The immunologic characteristics of EMT low and high SOCNumber of ptientsNeoantigen countp-valueMutation countp-valueCytolytic scorep-valuePD-L1 expressionp-valueLow grade1250.500.84700.8757.120.4812.340.28High grade8062.5085.571.0919.66Type 117290.07114.60.98125.10.7824.940.77Type 222066.50115.3119.526.3High grade(TP53 wild type)744.000.06620.08163.20.0629.770.5High grade(TP53 mutated)7364.0086110.126.47TCGA cohort provided the data of low(GB, G1, G2) and high(G3, G4) grade SOCsType 1: Defined as mutations in KRAS, BRAF, PTEN, PIK3CA, CTNNB1 and ARID1A irrespective of histologic gradeType 2: Defined as mutation in TP53 irrespective of histologic gradeThe samples that had intersecting mutations were excluded in type 1 and type 2.The cytolytic activity score was defined as a geometric mean of mRNA expression of perforin and granzyme.

Citation Format: Won Kyung Hur, Jin Young Hwang, Leeseul Kim, Myungwoo Nam, William H. Bae, Yoonhee Choi, Yeun Ho Lee, William Cheng, Heayoon S. Cho, Emma Yu, Chan Mi Jung, Eugene Kim, Christmann Low, Victor Wang, Jeff Chuang, Young Kwang Chae. The neoantigen and immune landscape of low and high grade serous ovarian cancers [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 453.

Abstract 678: Exceptional response to PD-L1 inhibitor after radiation therapy in a patient with small cell neuroendocrine tumor of the prostate gland refractory to combination treatment with PD-1 and CTLA-4 inhibitors

Background: Immune checkpoint inhibitor (ICI) treatment became the new treatment paradigm of a wide spectrum of cancers in the last decade. However, overcoming unresponsiveness to ICI remains an important high unmet need in the field of immuno-oncology. It is unclear whether another ICI can be an effective treatment option in patients with tumors refractory to combinatorial immunotherapy. Here we describe a case in whom a significant response to a PD-L1 inhibitor was demonstrated when used concurrently with radiation therapy. Notably, this patient was found to be unresponsive to the combined ICI treatment of PD-1 and CTLA-4 inhibitors.

Case Presentation: A 42 y.o. male patient who presented with urinary frequency and hematospermia was diagnosed with stage IV small cell neuroendocrine cancer of prostate gland with osseous metastasis. He was treated with cisplatin plus etoposide for 4 cycles and was subsequently treated with topotecan for 4 cycles given progression of disease (PD). He was given the combination of ipilimumab and nivolumab after another PD. Treatment was discontinued 5 months later due to a lack of response. Two months later, the patient received radiation therapy: 3000 cGy to the prostate and lower pelvis and palliative radiation therapy to the left femur. The patient subsequently underwent multiple lines of treatment with no satisfactory response. Follow up imaging test was concerning for progression with new liver and lung lesions. The treatment was switched to atezolizumab and nab-paclitaxel combination regimen. Concurrently, the patient had stereotactic ablative radiotherapy (4000 cGy) to pelvic region, paraspinal region and para-aortic LNs. Repeated imaging test after two months of the treatment showed an increase in pulmonary nodule size and the treatment was continued despite PD. The repeated scan after 6 weeks revealed an exceptional response that was close to resolution of the metastasized lesion in the liver and significant decrease in size of pulmonary metastatic lesions.

Conclusion:This case illustrates the abscopal effect of targeted radiation treatment when coupled with immunotherapy. Exceptional responses seen in non-radiated lesions including lungs and liver after radiation to pelvic lymph nodes while on PD-L1 inhibitors corroborates the concept of synergistic effect of radiation and immunotherapy. Intriguingly, this concurrent treatment approach maximizing the abscopal effect was effective in this case where combinatorial immunotherapy with nivolumab and ipilimumab was ineffective. Future clinical trials are warranted to validate these findings in a more systematic fashion.

Citation Format: Leeseul Kim, William Cheng, Yeun Ho Lee, Myungwoo Nam, Won Kyung Hur, Jin Young Hwang, Yoonhee Choi, William H Bae, Cyra Y. Kang, Heayoon Shauna Cho, Emma Yu, Chan Mi Jung, Eugene Kim, Christmann Low, Young Kwang Chae. Exceptional response to PD-L1 inhibitor after radiation therapy in a patient with small cell neuroendocrine tumor of the prostate gland refractory to combination treatment with PD-1 and CTLA-4 inhibitors [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 678.

Abstract 452: TGF-β signaling pathway-related gene mutations are associated with increased neoantigen counts, enhanced cytolytic activity, and improved survival outcomes in TP53-mutated endometrial carcinoma

TP53-mutation is a poor prognostic marker for uterine corpus endometrial carcinoma (UCEC). TGF-β is known to promote tumor progression via immune suppression, particularly NK and T cell-mediated cytotoxicity, in the tumor microenvironment. We aimed to analyze the impact of TGF-β signaling pathway-related gene mutation on the immune landscape and survival outcomes in TP53-mutated UCEC patients. cBioPortal was queried to obtain the UCEC The Cancer Genome Atlas cohort data (TCGA, 529 patients). The neoantigen counts were predicted using the CloudNeo pipeline. Survival outcomes were compared in the TGF-β signaling pathway-related gene mutated group, which were defined as genetic variances in TGFBR1, TGFBR2, ACVR2A, ACVR1B, SMAD2, SMAD3, or SMAD4, and the TGF-β signaling pathway-related gene non-mutated group. The cytolytic activity score was defined as a geometric mean of mRNA expression of perforin and granzyme. The duration of overall survival and disease-free survival were also obtained from cBioPortal. Out of the 529 UCEC patients, 192(36.3%) cancer tissues with TP53 mutations were analyzed for this study. 44 patients (22.9%) had more than one mutation in their TGF-β signaling pathway-related genes. TGF-β signaling pathway-related gene mutated group, when compared to a non-mutated group, was associated with significantly increased neoantigen counts (519.3 vs. 20.34 ; p&lt;0.0001) and a significantly enhanced cytolytic activity (407.2 vs. 142.2; p&lt;0.001). But there were no significant differences in PD-L1 expression level. The TGF-β pathway-related gene mutation was associated with improved disease-free survival (HR 0.29; 95% CI 0.13-0.67; p &lt;0.05) and improved overall survival in TP53-mutated UCEC patients (HR, 0.32; 95% CI, 0.17-0.59; P &lt; 0.001). In our analysis, TGF-β pathway-related gene mutations were correlated with significantly increased neoantigen count, higher cytolytic activity, and improved survival outcomes in TP53 mutated UCEC patients. Thus, TGF-β pathway-related gene mutations in TP53 mutated UCEC may be associated with increased cancer immunogenicity. Clinical treatment outcomes of UCEC with TGF-β pathway-related gene mutations should be explored in larger prospective studies.

Citation Format: William H. Bae, Jin Young Hwang, Won Kyung Hur, Myungwoo Nam, Yoonhee Choi, Leeseul Kim, Yeun Ho Lee, William Cheng, Eugene Kim, Emma Yu, Chan Mi Jung, Jeff Chuang, Victor Wang, Young Kwang Chae. TGF-β signaling pathway-related gene mutations are associated with increased neoantigen counts, enhanced cytolytic activity, and improved survival outcomes in TP53-mutated endometrial carcinoma [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 452.

Abstract 451: Immune landscape of endometrial carcinoma and its association with neoantigen landscape and TGF-β signaling pathway related genes mutation status

We aimed to understand how TGF-β signaling pathway related gene mutation affects the tumor neoantigen burden and immune landscape in uterine corpus endometrial carcinoma (UCEC). cBioPortal was queried to obtain the UCEC The Cancer Genome Atlas (TCGA) cohort data (521 patients). TGF-β signaling pathway related gene mutation was defined as genetic variances in TGFBR1, TGFBR2, ACVR2A, ACVR1B, SMAD2, SMAD3, or SMAD4. The neoantigen counts were predicted using CloudNeo pipeline. CIBERSORT was used to predict tumor-infiltrating immune cells. In 521 UCEC patients, 124 had mutations in TGF-β signaling pathway related genes. These tumors with the mutations had significantly higher neoantigen counts, mutation counts, and cytolytic scores (a geometric mean of mRNA expression of perforin and granzyme), and a trend towards higher PD-L1 expression level (Table 1). When subdivided by molecular subtypes, similar patterns were seen in most groups. TGF-β signaling pathway gene mutation was significantly associated with tumor tissue infiltration by CD8 T cells (18.3% vs 10.5%; p&lt; 0.05), active CD4 memory T cells(13.0% vs 7.5%; p&lt;0.001), follicular helper T cells (11.0% vs 7.5%; p&lt;0.001), M1 macrophage(5.8% vs 3.9%; &lt;0.001) and M2 macrophage(12.6% vs 9.8%; p&lt;0.05), but negatively associated with infiltration by plasma cells(2.6% vs 4.4%; p&lt;0.05), naïve CD4T cells (2.3% vs 3.3%; p&lt; 0.05), resting CD4 memory T cells(10.6% vs 15.1%; p&lt;0.001), and Tregs (4.4% vs 5.7%; p&lt;0.05). We first report that the TGF-β-signaling pathway-related gene mutation is significantly correlated with neoantigen burdens, mutations counts, and cytolytic activities in UCEC tissues. Consistently, the mutation was associated with tumor infiltration by CD8T and active CD4 T cells, but negatively associated with infiltration by Tregs. Further studies are warranted to explore the utility of TGF-β pathway mutations as potential favorable biomarkers with immunotherapy in UCEC.

Immune landscape of endometrial carcinoma according to TGF-β pathway related gene mutationnumber of valuesneoantigenmutation countcytolytic scorePD-L1 expressionAll521166.1964.5189.914.1TGF-β pathway related gene nonmutated39652.3219.415813.4TGF-β pathway related gene mutated124528.4**3350.0**293.2*16.3POLEmutAll85741.04925268.619.0nonmutated28158.9941.6183.517.7mutated571027.0**6881.0**310.4*19.6MSI-HAll167297.51455.0251.814.8nonmutated99157.1539.5207.714.7mutated68501.9**2787.0**315.915.0P53abnAll192134.7904.1202.616.8nonmutated14820.390.8142.215.6mutated44519.3**3640.0**407.218.5NSMPAll16111.5254.9131.59.7nonmutated15411.554.6133.39.6mutated712.960.491.612.1Values are expressed as mean.*p&lt;0.05,**p&lt;0.0001.MSI-H, microsatellite instability-high; NSMP, no specific molecular profile

Citation Format: William H. Bae, Jin Young Hwang, Won Kyung Hur, Myungwoo Nam, Yoonhee Choi, Leeseul Kim, Yeun Ho Lee, William Cheng, Eugene Kim, Emma Yu, Chan Mi Jung, Heayoon S. Cho, Jeff Chuang, Victor Wang, Young Kwang Chae. Immune landscape of endometrial carcinoma and its association with neoantigen landscape and TGF-β signaling pathway related genes mutation status [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 451.

Abstract 673: The role of mass spectrometry-based serum proteomics signatures in predicting clinical outcomes in cancer patients treated with immune check point inhibitors (ICI)

The role of mass spectrometry-based serum proteomics signatures in predicting clinical outcomes in cancer patients treated with immune checkpoint inhibitors(ICI)Background Although immune checkpoint inhibitors (ICI) have changed the therapeutic scheme for multiple cancers, only a subset of patients experiences durable benefit. As current tumor markers such as PD-L1 show limited reliability in predicting clinical outcomes, we have explored the predictive role of markers representative of the host immune response on a systemic level present in the circulating proteome. Mass spectrometry allows for analysis of the proteome without the specific identification of individual proteins and protein isoforms. Here, we analyzed the most recent studies using mass spectrometry-based serum proteomics in predicting response to ICI treatment.

Method A systematic literature search on Pubmed and major oncology scientific meetings was conducted up to November 18, 2020.

Result Classifier algorithms trained with data sets from advanced stages of lung cancer (Primary Immune Response, Host Immune Classifier) and melanoma (BDX008, Immune Checkpoint Blockade) were used to stratify patients into groups with favorable and unfavorable treatment outcome. Patients with unfavorable predictive markers had worse prognosis when treated with ICI-single agent therapy. For patients treated with ICI alone or with chemotherapy as frontline or beyond, mass spectrometry-based serum proteomic signatures were shown to be a reliable predictive marker for survival outcomes (hazard ratios 0.15-0.5) independent of PD-L1 expression level.

Conclusion Mass spectrometry-based serum proteomic tests reliably identify patients expected to have a worse prognosis. These patients can benefit from frontline aggressive treatment strategy combining ICI and chemotherapy rather than the standard of care ICI monotherapy.

Cancer type Advanced stage NSCLCTreatmentLine of therapyClassifiernumber of patients included (n)number of patients in each classifier, n(%)Survival outcome (OS, month)HR [95%CI]referenceAdvanced stage NSCLCImmunotherapy (nivolumab)2nd linePIR116Not resistant75 (65%)17.30.48 [0.30-0.77], p=0.002Mirte Muller, et al.Resistant41(35%)6.0Sensitive32 (28%)11.10.58 [0.38-0.87], p=0.009Not sensitive84 (72%)4.3Immunotherapy ± ChemotherapyAll lines First line single agent immunotherapy (pembrolizumab) First line Combination (immunotherapy/chemotherapy) All lineHIC284Hot196 (69%)Not reached0.38 [0.27-0.53], p&lt;0.001R. Brian Mitchell, et al.Cold88 (31%)5.0First line single agent immunotherapy (pembrolizumab)117Hot80 (68%)16.80.36 [0.22-0.58] p&lt;0.001Cold37 (32%)2.8First line Combination (immunotherapy/chemotherapy)161Hot113 (70%)Not reached0.41 [0.26-0.67], p= 0.0003Cold48 (30%)6.4Immunotherapy (either pembrolizumab or nivolumab)All lineHIC47Hot32 (68%)Not reached0.34 [0.10-1.18] p= 0.089YK Chae, et al.Cold15 (32%)16.5Unresectable MelanomaImmunotherapy (nivolumab)2nd lineBDX008119+72 (61%)2-year survival : 55% vs 21 % 3-year survival : 51% vs 14%0.38 [0.19-0.55], p &lt; 0.001J. Weber, et al.-47 (39%)ICB119sensitive34 (29%)2-year survival : 67% vs 33% 3-year survival : 58% vs 28%0.37 [0.19-0.71], p = 0.002J. Weber, et al.resistant85 (71%)PIR (Primary Immune Response) ; Sensitive, Intermediate, Resistant/not resistant = sensitive + intermediate, not sensitive = resistant + intermediate, HIC (Host Immune Classifier) ; Hot, Cold, BDX008 ; +, - ICB (Immune Checkpoint Blockade); sensitive, resistant

Citation Format: Yoonhee Choi, Jin Young Hwang, Won Kyung Hur, Myungwoo Nam, Leeseul Kim, Yeun Ho Lee, William Cheng, Eugene Kim, Emma Yu, Chan Mi Jung, William Han Bae, Young Kwang Chae. The role of mass spectrometry-based serum proteomics signatures in predicting clinical outcomes in cancer patients treated with immune check point inhibitors (ICI) [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 673.

POS0902 EFFICACY AND SAFETY OF INTRAVENOUS GOLIMUMAB IN ANKYLOSING SPONDYLITIS PATIENTS WITH EARLY VS LATE DISEASE THROUGH WEEK 52 OF GO-ALIVE STUDY

Background:

The GO-ALIVE study assessed efficacy and safety of intravenous golimumab (IV GLM) in patients (pts) with ankylosing spondylitis (AS).1,2

Objectives:

In this post hoc analysis, we assessed IV GLM efficacy and safety in AS pts with early disease (ED) vs late disease (LD) based on pt-reported duration of inflammatory back pain (IBP).

Methods:

In this Phase 3, double-blind, placebo (PBO)-controlled trial, pts with active AS were randomized (1:1) to receive IV GLM 2 mg/kg at Week (W) 0, W4, then Q8W or PBO at W0, W4, and W12 with crossover to IV GLM at W16, W20, then Q8W through 52. The primary endpoint was achievement of SpondyloArthritis International Society 20% improvement response (ASAS 20) at W16. In this post hoc analysis, 208 pts were grouped into quartiles based on self-reported duration of IBP symptoms. Efficacy and safety in 60 pts with ED (1st quartile) were compared with 52 pts with LD (4th quartile).

Results:

For the overall study population, mean duration of IBP symptoms was 10.9 yr and mean time since diagnosis was 5.5 yr. For ED pts, the mean duration of IBP symptoms ranged from 2.3 yr (IV GLM) to 2.6 yr (PBO), and for LD pts ranged from 23.5 yr (IV GLM) to 24.4 yr (PBO). At W16, ASAS 20 was achieved by 72% IV GLM vs 32% PBO pts with ED and by 67% IV GLM vs 21% PBO pts with LD. Pts with ED had numerically better response than those with LD in Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), and across more stringent endpoints, including ASAS 40, Bath Ankylosing Spondylitis Disease Activity Index 50% improvement (BASDAI 50), and Ankylosing Spondylitis Disease Activity Score (ASDAS) inactive disease and major improvement (Table 1). Response rates at W16 among IV GLM-treated pts were generally consistent through 1 year in both ED and LD subgroups; also in ED and LD subgroups, pts crossing over to IV GLM at W16 demonstrated response at W52 consistent with pts who started IV GLM at W0. At W16, improvements in enthesitis score were similar for pts with ED (mean change -2.9 for IV GLM vs 0.1 for PBO) and LD (mean change -2.5 for IV GLM vs 0.6 for PBO); improvements were maintained at W52 for ED and LD pts. Treatment-emergent adverse events and serious adverse events through 1 year were 46% and 3% for pts with ED compared with 61% and 2% for pts with LD, respectively.

Conclusion:

While IV GLM provided clinically meaningful improvements in signs and symptoms of AS in pts regardless of disease duration, response generally appeared numerically better in pts with ED than in pts with LD. This supports the principle of prompt diagnosis and early treatment.

References:

[1]Deodhar A, et al. J Rheumatol. 2018;45:341-348.

[2]Reveille J, et al. J Rheumatol. 2019;46:1277-1283.

Table 1.

Efficacy Outcomes

EDLDWeek 16Week 52Week 16Week 52PBO(n=25)IV GLM(n=35)PBO→IV GLM(n=25)IV GLM(n=35)PBO(n=28)IV GLM(n=24)PBO→IV GLM(n=28)IV GLM(n=24)ASAS 2032%71%68%71%21%67%68%63%ASAS 4012%46%56%60%4%42%57%42%BASDAI 5012%40%64%60%7%33%57%42%ASDAS inactive disease (score <1.3)4%17%44%37%0%8%14%4%ASDAS major improvement (decrease ≥2.0)n=244%57%n=2454%51%0%n=2348%46%n=2330%ASDAS clinically important improvement (decrease ≥1.1)n=2429%77%n=2475%77%18%n=2391%61%n=2365%Mean change from baseline (SD) in BASFIn=23-0.4 (2.0)-2.3 (2.1)n=23-2.7 (2.7)-2.8 (2.6)n=27-0.3 (1.8)n=24-2.2 (1.7)n=27-2.4 (2.2)n=23-2.3 (1.7)Mean change from baseline (SD) in BASMIn=23-0.3 (0.7)-0.4 (0.7)n=23-0.6 (0.7)-0.3 (0.5)n=270.01 (0.5)n=21-0.3 (0.6)n=27-0.4 (0.7)n=20-0.3 (0.7)Mean change from baseline (SD) in enthesitis scoren=230.1 (3.6)-2.9 (2.9)n=23-2.0 (4.4)-3.2 (2.5)n=27-0.6 (3.4)n=21-2.5 (3.0)n=27-2.5 (3.1)n=20-3.5 (5.9)

SD=standard deviation

Disclosure of Interests:

Atul Deodhar Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Galapagos, GlaxoSmithKline, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Eli Lilly, GlaxoSmithKline, Novartis, Pfizer, and UCB, Shelly Kafka Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Elizabeth C Hsia Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Kim Hung Lo Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Lilianne Kim Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Stephen Xu Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, John D Reveille Consultant of: Eli Lilly and UCB, Grant/research support from: Eli Lilly and Janssen

Potential role of serum proteome in predicting immune-related adverse events from immune checkpoint inhibitors in non-small cell lung cancer

e21218

Background: Early recognition of immune-related adverse events (irAEs) of immune checkpoint inhibitors(ICI) is important. Circulating proteome reflects host response to diseases and is being explored as a marker for response to immunotherapy. We previously have reported that a serum-based proteomics test, Primary Immune Response (PIR) demonstrated a trend that PIR-sensitive patients are more likely to tolerate ICI treatment longer without developing irAEs in non-small cell lung cancer (NSCLC) patients. The VeriStrat test is another serum-based proteomic assay, which was reported to be predictive of survival outcomes for all treatment regimens and lines of therapy including ICI in NSCLC. We explored the associations between the VeriStrat test and developing irAEs in NSCLC patients treated with ICI. Methods: Data of 70 consented NSCLC patients treated with any regimens and lines of therapy including ICI were collected. Samples were grouped into either VeriStrat ‘Good’(VS-G) or VeriStrat ‘Poor’(VS-P). We analyzed the durations from the immunotherapy initiation to each episode of irAE and each irAE above grade 2 using log-rank test. IrAEs were graded according to Common Terminology Criteria for Adverse Events (CTCAE) v5.0. Results: Among the 70 patients, 18 patients (25%) experienced one or more irAEs. There was no significant difference in ‘Time to first irAE’ between VS-G and VS-P (p = 0.72, HR = 0.82, 95% CI = 0.29-2.32). Among 48 VS-G patients, 12(25%) had one or more irAE and 5(10%)had irAE graded over 2. Among 22 VS-P patients, 6(27%) had one or more irAE and 2(9%) had irAE graded over 2. There was no significant difference between VS-G and VS-P groups in the development of irAE and irAE graded over 2. Conclusions: There was no statistically significant association between the VeriStrat test and the development of irAEs. Further studies are warranted to investigate proper serum based proteomic assay to predict the development of irAE.

Real-world concordance between tumor mutational burden (TMB) from blood (circulating tumor DNA) and tissue in lung cancer

e20522

Background: Tumor mutational burden (TMB) level is associated with response to immunotherapy in lung cancer. However, tissue TMB can be difficult to obtain, as tissue samples obtained from biopsies may be insufficient. Circulating tumor DNA-based TMB has been developed in order to complement or replace tissue TMB, but there is limited real-world data on their concordance. Here, we investigate the landscape and concordance between blood and tissue TMB, along with clinical traits of the concordant and discordant groups. Methods: Tumor mutational burden (TMB) was calculated using Tempus (tissue) and Guardant Health (blood) next generation sequencing (NGS) platforms from October 2020 to January 2021. There were 33 patients who had both Tempus and Guardant TMB data. Under the assumption that tissue TMB (tTMB) correlates with blood TMB (bTMB) at a ratio of 1:1.6, the patients were divided into concordant and discordant groups. The concordant group patients had bTMB/tTMB ratios between 1.3 and 1.9. The discordant group was divided into two subgroups: over 1.9 (Group B) and less than 1.3 (Group C). Among the 33 patients, 9 patients were excluded due to their non-evaluable bTMB levels. Treatment response was evaluated using RECIST criteria. Results: Of the remaining 24 patients, 7 patients in the concordant group and 21 patients in the discordant group were analyzed according to their clinical manifestations [Blood TMB (n = 24): range [1.46, 44.01], median = 9.57], [Tissue TMB (n = 24), range [1.3, 18.4], median = 4.5]. We compared the clinical presentations (number of metastatic organs and metastatic sites) between the two discordant groups (Groups B and C). Among the 24 patients, 13% (n = 3) had small cell lung cancer, 50% (n = 12) had adenocarcinoma, and 29% (n = 7) had squamous cell lung carcinoma. Patients with higher bTMB than tTMB (Group B) had more squamous cell carcinoma cases (71%, n = 5) compared to remaining groups (Groups A and C) (29%, n = 2). Among the discordant group, 6% of the patients (n = 1) had small cell lung cancer, 47% (n = 8) had adenocarcinoma, and 35% (n = 6) had squamous cell carcinoma. Further, 58% (n = 14) of the patients had higher bTMB than tTMB levels. Among the concordant and discordant groups, tumor burden as reflected by the number of metastatic sites and metastatic lesions and the sum of the largest diameters of tumor lesions using RECIST had no significant difference (p = 0.10, 0.68, 0.54, respectively). The concordant and discordant groups showed no significant difference in objective response (33% vs. 20%, p = 0.60) or clinical benefit rate (100% vs. 60%, p = 0.33). Conclusions: The majority of the patients had higher blood TMB than tissue TMB (Group A), with a concordance rate as low as 28%. Further studies are warranted to understand the biology behind the difference between blood and tissue TMB, including intertumoral heterogeneity.

Addition of selpercatinib to overcome osimertinib resistance in non-small cell lung cancer (NSCLC) with acquired RET fusion detected in ctDNA at very low allele frequency

3046

Background: Osimertinib, a highly selective third generation EGFR tyrosine kinase inhibitor (TKI) became the standard front-line therapy for EGFR-mutant NSCLC. However, therapeutic options are limited for TKI resistance which commonly occurs. Therefore, overcoming acquired resistance to osimertinib remains an important high unmet need in the field of precision oncology. Herein, we present the first case of advanced adenocarcinoma of the lung that showed notable response with the addition of selpercatinib after acquired resistance to osimertinib monotherapy. Methods: Case presentation. Results: A 37-year-old woman with stage IVB adenocarcinoma of lung with osseous, hepatic and brain metastases initially received one cycle of carboplatin, pemetrexed and pembrolizumab. Based on the EGFR exon19 deletion detected from ctDNA NGS assay (Guardant 360) [variant allele frequency (VAF) 62.7%], the treatment regimen was changed to osimertinib monotherapy (80mg PO daily). Bevacizumab was empirically added given CNS involvement. She maintained overall stable disease for 10 months before subsequent CT showed disease progression. The treatment regimen was switched to atezolizumab, bevacizumab, paclitaxel and carboplatin combination therapy. She tolerated 6 cycles of the regimen in 4 month before a subsequent brain MRI revealed progression of the metastatic brain disease with new leptomeningeal disease. Whole brain radiotherapy was performed and decision was made to start combination TKI treatment of selpercatinib (120mg BID) added to the osimertinib (80mg daily) monotherapy based on her repeat ctDNA NGS assay result showing concurrent acquired CCDC6RET fusion (VAF 0.05%) and EGFR exon 19 deletion (VAF 10.0%). The 6 week follow-up CT demonstrated significant decrease in the largest lung mass (33.95*24.22mm->32.50*16.07mm). Repeat ctDNA NGS assay at one week after selpercatinib use showed disappearance of RET fusion and significant decrease in EGFR clone (VAF 10.0% to 0.05%). Conclusions: It has been reported that co-occurring RET fusions in NSCLC patients with EGFR mutations may contribute to acquired resistance to EGFR inhibitors. Several successful cases of cabozantinib, a non-selective RET inhibitor, or pralsetinib, a selective RET inhibitor combined with EGFR inhibitor, have been reported to aid in overcoming the acquired resistance to EGFR inhibitors. To date, there has been no report of clinical benefit in adding a RET inhibitor based on ctDNA detection of RET fusion with minute variant allele frequency. We for the first time report the case of overcoming acquired resistance to osimertinib by adding selpercatinib, a selective RET inhibitor in NSCLC patients with acquired RET fusion detected in ctDNA at VAF of 0.05%.

Blood transfusions may adversely affect survival outcomes of patients with lung cancer: a systematic review and meta-analysis

Background

Despite common use in clinical practice, the impact of blood transfusions on prognosis among patients with lung cancer remains unclear. The purpose of the current study is to perform an updated systematic review and meta-analysis to evaluate the influence of blood transfusions on survival outcomes of lung cancer patients.

Methods

We searched PubMed, Embase, Cochrane Library, and Ovid MEDLINE for publications illustrating the association between blood transfusions and prognosis among people with lung cancer from inception to November 2019. Overall survival (OS) and disease-free survival (DFS) were the outcomes of interest. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were computed using the random-effects model. Study heterogeneity was evaluated with the I² test. Publication bias was explored via funnel plot and trim-and-fill analyses.

Results

We included 23 cohort studies with 12,175 patients (3,027 cases and 9,148 controls) for meta-analysis. Among these records, 22 studies investigated the effect of perioperative transfusions, while one examined that of transfusions during chemotherapy. Two studies suggested the possible dose-dependent effect in accordance with the number of transfused units. In pooled analyses, blood transfusions deleteriously influenced both OS (HR=1.35, 95% CI: 1.14–1.61, P<0.001, I²=0%) and DFS (HR=1.46, 95% CI: 1.15–1.86, P=0.001, I²=0%) of people with lung cancer. No evidence of significant publication bias was detected in funnel plot and trim-and-fill analyses (OS: HR=1.26, 95% CI: 1.07–1.49, P=0.006; DFS: HR=1.35, 95% CI: 1.08–1.69, P=0.008).

Conclusions

Blood transfusions were associated with decreased survival of patients with lung cancer.

Abstract 5791: Blood transfusions may adversely affect survival outcomes of patients with lung cancer: A systematic review and meta-analysis

Background: Lung cancer has the highest mortality rate among tumor entities in the United States. Patients with lung cancer may require transfusions due to blood loss during surgery or bone marrow suppression caused by chemoradiation. Despite common use in practice, however, the impact of blood transfusions on prognosis among patients with lung cancer remains unclear. There have been long-standing concerns on the associated risk, including possible contamination by undetected malignant cells. The concept of transfusion-related immunomodulation (TRIM) has also been highlighted, which hypothesizes that transfusions may suppress the anti-tumor immune surveillance and promote growth of cancer cells. In spite of these concerns, scholarly efforts elucidating the relationship between transfusions and cancer recurrence have focused primarily on other cancers such as colorectal cancer. We thus performed an updated systematic review and meta-analysis to evaluate the influence of blood transfusions on survival outcomes of lung cancer patients.

Methods: We searched PubMed, Embase, Cochrane Library, and Ovid MEDLINE for publications illustrating the association between blood transfusions and prognosis among people with lung cancer from inception to 11/28/2019. Overall survival (OS) and disease-free survival (DFS) were the outcomes of interest. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were computed using the random-effects model. Study heterogeneity was evaluated with the I2 test. Publication bias was explored via funnel plot and trim-and-fill analyses.

Results: We identified 843 citations initially and four studies were added after reviewing references of the searched articles. By assessing titles and abstracts, we excluded 393 duplicates and 414 irrelevant articles. 16 studies were removed given that they were review or correspondence articles or lacked the outcome of interest. As a result, 24 cohort studies with 13,036 patients (3,098 cases and 9,938 controls) were included for meta-analysis. Among these records, 23 studies investigated the effect of perioperative transfusions, while one examined that of transfusions during chemotherapy. Two studies suggested the possible dose-dependent effect in accordance with the number of transfused units. In pooled analyses, blood transfusions deleteriously influenced both OS (HR=1.36, 95% CI=1.14-1.62, P=0.0005, I2=0%) and DFS (HR=1.46, 95% CI=1.16-1.84, P=0.0013, I2=0%) of people with lung cancer. No evidence of significant publication bias was detected in funnel plot and trim-and-fill analyses (OS: HR=1.26, 95% CI=1.07-1.48, P=0.0052; DFS: HR=1.36, 95% CI=1.10-1.69, P=0.0053).

Conclusion: Blood transfusions were associated with decreased survival of lung cancer patients.

Citation Format: Sukjoo Cho, Jonghanne Park, Misuk Lee, Dongyup Lee, Horyun Choi, Gahyun Gim, Leeseul Kim, Cyra Y. Kang, Young Kwang Chae. Blood transfusions may adversely affect survival outcomes of patients with lung cancer: A systematic review and meta-analysis [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5791.

Abstract 6684: Association of human leukocyte antigen (HLA) homozygosity with unfavorable clinical outcomes in patients with non-small cell lung cancer (NSCLC) treated with PD-L1 inhibitors as frontline therapy

Background: High polymorphic diversity in HLA class I (HLA-I) is essential for successful immunologic control of cancer. Lung cancer patients with maximal HLA-I heterozygosity treated with single-agent PD-L1 inhibitors as their second-line or beyond were reported with longer overall survival. However, the role of HLA heterozygosity for patients with NSCLC who received single-agent immunotherapy with or without chemotherapy as their first-line has not been reported.

Methods: Patients with unresectable stage III or IV NSCLC who underwent next-generation sequencing with HLA typing were enrolled in our study (N=27). HLA genotypes were determined using DNA sequencing data. They received either pembrolizumab (N=5) or pembrolizumab plus chemotherapy (N=22) as their first-line treatment. Kaplan-Meier curves were constructed to compare survival outcomes according to HLA (homozygous vs. heterozygous) and tumor mutation burden (TMB, above vs. below median) status. A log-rank test was applied to compare Kaplan-Meier curves between groups. Hazard ratios were derived from the Cox-proportional hazards model with adjustment for baseline characteristics including age, sex, and TMB.

Results: We determined HLA-I genotypes consisting of two alleles in 27 patients with NSCLC. Among these enrollees, 23 patients (85.2%) were heterozygous at every HLA-I locus and four patients (14.8%) were homozygous at more than one HLA-I locus. Response Evaluation Criteria in Solid Tumors (RECIST) evaluable patients were 19. In the HLA-heterozygous group (N=15), three patients (20%) had partial response (PR), eight patients (53.3%) had stable disease, and four patients (26.7%) had progressive disease (PD), whereas in the HLA-homozygous group (N=4), one (25%) had PR, one (25%) had SD, and two (50%) had PD. The disease control rates (CR, PR, and SD) were 73.3% in the HLA-heterozygous group and 50% in the HLA-homozygous group. Homozygosity at HLA-I genes seemed to be associated with shorter progression-free survival (PFS, HR=3.2, 95% CI=0.71-15, p=0.13) compared with heterozygosity at HLA-I genes. The HLA-heterozygous group had longer median PFS than the HLA-homozygous group (19 vs. 9.5 months, Log-rank p=0.11). When we controlled the effect of HLA homozygosity on PFS for age, sex, and TMB, the adjusted HRs were 4.4[0.82-23], 3.1[0.69-14] and 1.9[0.36-9.8] respectively.

Conclusion: No data exists on the effect of HLA homozygosity on clinical outcomes of patients treated with immunotherapy with or without chemotherapy as frontline treatment. We for the first time report that in such setting HLA homozygosity may be associated with worse outcomes.

Citation Format: Dongyup Lee, Jonghanne Park, Horyun Choi, Gahyun Gim, Sukjoo Cho, Leeseul Kim, Cyra Y. Kang, Pedro Viveiros, Young Kwang Chae. Association of human leukocyte antigen (HLA) homozygosity with unfavorable clinical outcomes in patients with non-small cell lung cancer (NSCLC) treated with PD-L1 inhibitors as frontline therapy [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 6684.

Abstract 5527: Serum proteomic scores for understanding the mechanisms of immune-related adverse events (irAEs) in non-small cell lung cancer

Background:

Understanding of biological processes associated with irAEs for patients treated with immune checkpoint inhibitors (ICI) is limited. We used serum-based, proteomic scores at baseline and after treatment initiation to explore mechanisms of irAEs for patients with non-small cell lung cancer (NSCLC) treated with ICI.

Methods:

Under an ongoing clinical protocol, 43 patients with advanced NSCLC were consented and serum samples were prospectively collected at two timepoints: baseline and approximately 3 weeks after treatment initiation with ICI (median 22 [IQR, 21 - 26] days). Samples were analyzed, blinded to clinical data, using MALDI-ToF mass spectrometry. Protein Set Enrichment Analysis (PSEA) approach applied to mass-spectral data was used to assign biological scores characterizing activation of 10 processes of interest (e.g., Type 1 immunity, complement, interferon (IFN)-gamma). irAEs after initiation of ICI with or without chemotherapy were classified per standard definitions. Patients were classified into two groups based on irAEs of any grade: irAE positive and negative.

Results:

Of the 43 participants, 28 received ICI with chemotherapy and 15 received monotherapy. 18 of 43 patients (42%) were determined to have irAEs. These included the following: 9 pneumonitis, 3 thyroiditis, 3 adrenal insufficiency, 1 arthritis, 1 flare of pre-existing psoriasis, 1 mucositis, 1 colitis, 1 myocarditis, and 1 hepatitis (2 patients had both thyroiditis and adrenal insufficiency, 1 patient had both mucositis and pneumonitis). The median timeframe between treatment initiation and development of irAEs was 105 days [IQR, 42 - 169 days]. PSEA scores measured at 3 weeks after initiation of systemic therapy showed significant differences between irAE positive and negative groups in the following processes: extracellular matrix remodeling, complement activation, IFN-gamma signaling, and immune tolerance (P&lt;0.05 for PSEA scores of each pathway identified). These processes did not show any significant differences in PSEA scores at baseline. However, the changes in PSEA scores of all processes analyzed from baseline to 3 weeks after treatment initiation were not significantly different between the two groups.

Conclusions:

Our findings demonstrate that serum-based, proteomic scores can provide insight into understanding early mechanisms for the development of irAEs in patients treated with ICI. In particular, we identified several mechanisms associated with the development of irAEs, including extracellular matrix remodeling, complement activation, IFN-gamma signaling, and immune tolerance. These associations were not present at baseline and were only observed after treatment initiation, suggesting that early changes in the blood may provide insight into prediction of irAEs.

Citation Format: Andrew A. Davis, Jonghanne Park, Leeseul Kim, Gahyun Gim, Wade T. Iams, Michael S. Oh, Robert W. Lentz, Heinrich Roder, Joanna Roder, Senait Asmellash, Lelia Net, Julia Grigorieva, Nisha Mohindra, Victoria Villaflor, Young Kwang Chae. Serum proteomic scores for understanding the mechanisms of immune-related adverse events (irAEs) in non-small cell lung cancer [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5527.